Metabolic dysfunction-associated steatohepatitis, or MASH, is gaining attention across the medical community, but for many patients it remains a largely silent disease. Closely linked with obesity, type 2 diabetes and other cardiometabolic risk factors, MASH can progress along a disease spectrum that includes fibrosis, cirrhosis and MASH-related hepatocellular carcinoma, often before patients or clinicians recognize the seriousness of the condition. As awareness grows and new treatment options emerge, the challenge is not only to define MASH more clearly, but to identify at-risk patients earlier and support them with effective, multidisciplinary care. We spoke with Professor Helena Cortez-Pinto, MD, PhD, a gastroenterology and hepatology specialist with deep expertise in steatotic liver disease, nutrition, and public health, about unmet needs, recent developments, and the future of MASH care.

How can we increase awareness about MASH?

Dr Cortez-Pinto: We need to raise awareness about metabolic dysfunction-associated steatohepatitis (MASH) with both generalist and specialist doctors. The first step is including additional information in medical training curricula.

We also need to better inform practicing doctors (both general practitioners as well as specialists) about the disease and the associated risk factors. Awareness is rising slowly and we are starting to see coverage of MASH in guidelines for Obesity, Diabetes, etc.

Patients also are generally aware of cardiovascular risks associated with diseases such as diabetes, obesity and hypertension, but tend to be less knowledgeable about MASH. We should aim to educate high risk patients about MASH, both the risk factors and possible complications.

What is the primary unmet clinical need in MASH?

Dr Cortez-Pinto: The capacity to identify the patients that have a more serious disease and may progress to cirrhosis or liver cancer. In the specialist gastroenterology/hepatology clinics, doctors see patients with liver steatosis. However they are also present in the wider population, and it remains difficult to identify them and implement effective strategies (including lifestyle interventions).

Patients with cardiovascular risk factors should be tested for MASH. The ongoing development of non-invasive tests will be very useful in this aspect for more widespread screening, with genetic testing possibly in the future.

Furthermore, stratifying high risk patients is key. Some high-risk patients will not go on to develop cirrhosis, while others will – right now it is difficult to know which of the high-risk patients should be more closely monitored.

What would most improve treatment of patients with MASH?

Dr Cortez-Pinto: The availability of effective drugs that simultaneously treat cardiovascular risk factors and MASH is key, and we are certainly on track to reach this. It is also very important to provide access to patients for coaching on how to implement the lifestyle changes that are so important, whether they be diet or exercise or both. Ideally a physical exercise specialist and nutritionist are part of the team treating these patients, as well as a psychologist for patient support. In Dr Cortez-Pinto’s Steatotic Liver Disease Clinic in Portugal, they are fortunate to have these types of allied health specialists treating patients wholistically.

What are the most exciting recent developments in MASH?

Dr Cortez-Pinto: Having worked in the field for close to 30 years, Dr Cortez-Pinto is delighted with the recent flurry of activity (including a multitude of clinical trials testing a range of possible treatments) over the last few years. Helena also believes that the nomenclature change from NASH (non-alcoholic steatohepatitis) to MASH, as well as the umbrella term of steatotic liver disease (SLD) was very important in raising awareness, removing the word alcohol and highlighting the metabolic elements. Semaglutide and other incretin-based therapies are very exciting, offering the possibility of treatment for the more advanced forms of the disease, even if cirrhotic patients unfortunately do not have such effective treatments yet.

What does pharma/biotech need to bring to the picture?

Dr Cortez-Pinto: Foremost effective treatments! This of course is also their focus, however cost is always a consideration and the industry needs to find ways of improving access to treatments. As mentioned earlier, treatments that improve both MASH and cardiovascular aspects at the same time is very important. There is some preliminarily evidence that drugs such as Semaglutide can mitigate alcohol addiction, implicated in some forms of steatotic liver disease.

Furthermore, there is a role for biotechs in particular regarding the development of biomarkers and devices that can identify and classify liver diseases which are less expensive and/or invasive than current options. There is a lot going on in this space.

Is there another issue you would like to bring to the forefront?

Dr Cortez-Pinto: I am interested in the interplay of alcohol consumption with steatotic liver disease. For example, how do we categorize patients, when alcohol consumption varies over a lifetime and is notoriously difficult to realistically measure it? Stratification is important as alcohol consumption can impact risk factors as well as the rate of liver disease progression. It would be very helpful to have more availability of direct biomarkers of alcohol consumption, such as serum measurements of Phosphatidylethanol (PEth).

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