CMHC Pulse Blog

November is National Diabetes Month, and with the increasing overlap between type 2 diabetes (T2D) and metabolic dysfunction-associated steatohepatitis (MASH), it’s critical to focus on integrating liver health into the management of cardiometabolic patients. This two-part series breaks down key treatment approaches for MASH, helping healthcare providers stay informed and deliver evidence-based care. 

Case Study: A Common Clinical Scenario 

This case study highlights the complex relationship between metabolic disease and liver health. 

Patient Overview: 

• Age: 60-year-old female 

• Comorbidities: Obesity (BMI: 36), hypertension, hyperlipidemia, 15-year history of T2D 

• Liver markers: Abnormal liver enzymes (ALT of 92, AST of 80) with elevated aminotransferases for several years 

• Lifestyle: No alcohol consumption, struggles with weight loss despite limiting calories and carbohydrates. 

• Current medications: Metformin, amlodipine, enalapril, atorvastatin (discontinued due to concerns over elevated liver enzymes) 

Additional Workup: 

• Non-invasive testing: 

• FIB-4 score of 2.4 (indeterminate fibrosis) 

• Vibration-controlled transient elastography (FibroScan) showing liver stiffness of 16 kPa, indicating high risk of advanced fibrosis. 

• Liver biopsy results: Confirmed a diagnosis of MASH with F3 fibrosis (bridging fibrosis) and no cirrhosis. The biopsy revealed significant liver inflammation and fibrosis, with no other causes of elevated liver enzymes, such as viral hepatitis. 

This patient’s case presents a common and challenging scenario in primary care and endocrinology, where T2D, obesity, and metabolic dysfunction intersect with liver disease. 

Why MASH and Diabetes Are Closely Linked 

Metabolic dysfunction-associated steatotic liver disease (MASLD), including its severe form known as metabolic dysfunction-associated steatohepatitis (MASH), is closely linked to type 2 diabetes (T2D). Patients with T2D often experience insulin resistance and chronic inflammation, both of which contribute to fat accumulation in the liver. Over time, this can lead to liver inflammation and fibrosis, key features of MASH, making T2D patients more susceptible to developing liver-related complications.

MASH is more than liver fat accumulation; it involves liver inflammation and scarring, which can progress to more severe conditions like cirrhosis and liver failure. The combination of T2D and MASH creates a dangerous cycle where metabolic dysfunction worsens liver health, and liver damage exacerbates insulin resistance. This underscores the importance of early detection and management of both conditions to prevent severe outcomes.

One of the most significant risks for patients with both T2D and MASH is cardiovascular disease (CVD), which is the leading cause of death in this population. This connection highlights the need for a holistic treatment approach that not only targets blood sugar control but also focuses on improving liver health and reducing cardiovascular risks. Comprehensive care is essential to reduce the progression of these interrelated conditions

Management of MASH: A Multidisciplinary Approach To Cardiometabolic Health

Managing MASH requires collaboration among multiple subspecialties, with primary care and endocrinology playing key roles. The management process begins with initial assessments and risk stratification by primary care providers, who can perform non-invasive tests like the FIB-4 score or transient elastography. These assessments allow for risk evaluation before referring the patient to specialists such as hepatology or gastroenterology for advanced workup and treatment recommendations. 

Lifestyle Modifications: The Foundation of Treatment 

Lifestyle changes are the cornerstone of MASH management. Nearly all patients with MASH can benefit from interventions that focus on weight management and dietary changes. 

• Diet: Caloric reduction of 750–1,000 kcal/day is recommended to help manage weight and insulin resistance. Sustained weight loss of 7–10% is associated with improvement in MASH and even reversal of fibrosis. Patients should limit fructose intake, particularly from sugary beverages, and consume at least 2 cups of caffeinated coffee per day, as it may offer liver-protective effects. Alcohol should be limited or eliminated. 

• Exercise: Moderate physical activity is essential for weight management and potentially improving liver fat levels. Patients should aim for 150 minutes of moderate-intensity exercise per week. While the effect of exercise on liver fibrosis is still under study, its cardiovascular and metabolic benefits are well-documented, making it a critical aspect of MASH treatment. 

Stay tuned for Part 2, where we’ll dive into current pharmacotherapy options, new developments on the horizon for MASH treatment, and practical takeaways for managing MASH in patients with cardiometabolic disease.