Georgetown University School of Medicine’s Zobair Younossi, MD, highlights the need for routine fibrosis screening in primary care to detect metabolic dysfunction–associated steatohepatitis (MASH) early, preventing its progression to cirrhosis or liver cancer. Younossi notes that MASH is frequently diagnosed at advanced stages, with significant gaps in identifying patients at risk, showing the importance of improved screening and awareness in primary care settings.
Younossi explains that the lack of awareness about MASH at all levels of care is a significant problem, and many patients present with advanced disease or liver cancer. He notes that MASH is the most common liver disease in the world and the second indication for liver transplantation in both Europe and the United States.
To address this issue, Younossi recommends using risk stratification algorithms to identify patients who are at risk for progressive liver disease. He suggests that patients with diabetes, complicated obesity, or raised liver enzymes should undergo a FIB-4 score test, and if the score is high, they should receive further testing, such as a transient elastography or an ELF test.
Younossi also discusses the use of resmetirom and semaglutide, two drugs that differ in mechanism, administration, and cost. He explains that he chooses between the two drugs based on whether a patient has obesity or diabetes and notes that starting both drugs at the same time is not currently recommended due to a lack of data.
Future of MASH Treatment
Younossi believes that future trials should address the development of better noninvasive tests (NITs) and the use of combination therapy. He also thinks that the treatment of MASH will be based on personalized medicine, using clinical data, laboratory data, genomic data, and environmental data to create a profile of each patient.
Younossi notes that an ideal coverage framework for MASH therapies would involve a health system approach, where electronic health records are connected to the first-line assessment of at-risk patients. He suggests that payers should cover the cost of risk stratification and treatment, and that patients should be connected to the right provider experienced in managing and treating MASH.
According to Younossi, the number of liver transplants due to hepatitis C has plummeted substantially since the introduction of effective treatments, and he hopes to see similar improvements in MASH treatment and outcomes in the next 5 to 10 years. He emphasizes the importance of raising awareness about MASH and dedicating resources to better manage the disease.
Personalized Medicine Approach
Younossi’s approach to MASH treatment is centered on early intervention and personalized medicine. He believes that by using risk stratification and combination therapy, patients can receive more effective treatment and improve their outcomes. As Younossi explains, the goal is to calm the disease down and then maintain the response or improvement achieved, which may involve using at least one drug long-term, possibly lifelong.
In terms of coverage, Younossi thinks that payers should buy into a package payment approach, where patients who are at risk are risk stratified for liver disease and connected to the right provider. He notes that this approach has been successful in managing diabetes and could be applied to MASH treatment, with the goal of improving outcomes and reducing complications.
The metabolic dysfunction-associated steatohepatitis is a complex condition that requires a detailed approach, and Younossi’s insights provide valuable guidance for healthcare providers and policymakers.
Risk Stratification Tools
According to Younossi, the FIB-4 score test is a useful tool for identifying patients who are at risk of progression.
Younossi’s comments on the importance of risk stratification and treatment highlight the need for further research and development of new therapies for MASH. He notes that current treatments have shown promise, but more work is needed to develop effective combination therapies and to improve patient outcomes, with a FIB-4 score of more than 1.3 indicating the need for further testing.