Diabetes Core Update – Special Edition: MASH Part 3 – Cases Jan 2026

Podcast Date: February 17, 2026
Host: Dr. Neil Skolnick
Guests: Dr. Alina Allen (Mayo Clinic, Hepatology), Dr. Susan Kucera (Jefferson Health, Family Medicine)
Podcast Focus: Clinical case-based discussion on Metabolic dysfunction Associated Steatohepatitis (MASH), screening practices, diagnostic challenges, and management strategies, specifically oriented toward the needs and realities of primary care.

Episode Overview

This episode, the third of a special three-part series, takes a case-based approach to integrating the latest guidelines, diagnostic tools, and evolving treatments for MASH (formerly known as NAFLD-related steatohepatitis). The conversation addresses real-world issues in screening, risk stratification, and management, with a particular focus on helping primary care clinicians adapt to an increasingly complex landscape. The dialogue draws on both hepatology and primary care perspectives, aiming to give practical, usable guidance for frontline providers.

Key Discussion Points

1. The State of MASH Screening & Primary Care Realities

[03:27]

• Scope of the Problem:
  • Prevalence of MASLD (the precursor to MASH): 30% of adults, up to 65% of patients with T2DM in the US.
• Screening Recommendations Recap:
  • Should screen those with overweight/obesity + metabolic risk factors, all patients with T2DM, or elevated LFTs.
  • Main goal: Identify MASH with advanced fibrosis (F2/F3), where intervention can have a meaningful impact.
• Primary Care Uptake:
  • Dr. Kucera notes screening is "not something that's happening regularly" ([04:15]), with most diagnoses in practice arising from incidental findings (e.g., LFTs on routine panels or imaging for unrelated issues).
• Barriers in Primary Care:
  • Overwhelming number of things to screen for in diabetic patients (A1c, B12, microalbumin, eye/foot exams, heart failure, etc.); hard to “add one more thing.”
  • “If we're going to impact overall longevity, morbidity, mortality, we've got to add it to the list.” – Dr. Kucera ([05:53])

2. Case 1: The Asymptomatic At-Risk Patient

Case Details:

• 55-year-old male, 10 years T2DM, obesity, hypertension, hyperlipidemia.
• LFTs normal; AST 33, ALT 37, platelets 155.
• Routine FIB-4: 1.93.

FIB-4 Interpretation and Next Steps

[07:13]

• FIB-4 Cutoffs:
  • <1.3 = low risk; >1.3 = evaluate further (generally via liver stiffness measurement).
  • Age sensitivity: For those 65+, the cutoff is 2.0.
• Diagnostics After FIB-4:
  • Primary care commonly orders an elastography-based test (e.g., FibroScan).
  • Newer, more accessible tests: ELF (Enhanced Liver Fibrosis) test, a blood-based tool.
    • Caveat: Exact actionable cutoffs are evolving, but current guidance is ELF ≥9-9.5 signals need for further evaluation ([08:16], Dr. Allen).
    • Pros: May assist where elastography is unavailable, or when patients struggle with follow-up appointments.

Practical Considerations

[10:28]

• Tests are probabilistic, not binary—require clinical judgment.
• Not all patients in practice will follow-up on extra imaging orders; convenience of blood-based options is valuable in some populations.
• “Cutoffs always need to be used with clinical judgment.” – Dr. Skolnick ([10:28])

Elastography Results & Clinical Integration

• Elastography <8 kPa:

  • Low risk for advanced fibrosis.
  • Management: Lean into metabolic risk reduction, lifestyle, and rescreen in 1-2 years (timing individualized to risk) ([14:41], Dr. Kucera).

• Platelet Nuances:

  • Platelet count of ~155 may be “normal,” but warrants attention—could signal more advanced disease despite normal function tests ([15:56], Dr. Allen).
  • Always assemble the big picture, not just isolated test results: “Liver disease estimation is a puzzle, the pieces … put together in a nice symphony.” ([17:31], Dr. Allen)

If Elastography ≥8 kPa or ELF ≥9.2

[18:43]

• Indicates clinically significant fibrosis (stage 2 or higher).
• Next: Rule out cirrhosis (use imaging—CT, ultrasound—for morphology and look for portal hypertension, splenomegaly, and check platelets).
• If cirrhosis is excluded, initiate treatment for moderate-advanced fibrosis MASH.

3. Case 2: Patient With Mild LFT Elevations

Case Details:

• 61-year-old woman, obesity, hypertension, hyperlipidemia, prediabetes.
• On atorvastatin and lisinopril, A1C 5.9, AST 62, ALT 70, normal AlkPhos and bilirubin, platelets 155.
• FIB-4: 2.92.

[21:37]

• Common, complex presentation:
  “We see this at least once a week, maybe more. This is how we tend to stumble upon metabolic associated liver disease...” – Dr. Kucera
• Differential diagnosis is broader:
  • Consider statin effect, viral hepatitis, other medications, autoimmune liver diseases, hemochromatosis, in addition to MASLD/MASH.
• Initial Workup:
  • Exclude other chronic liver disease (especially viral hepatitis, alcohol use).
  • Non-invasive fibrosis assessment if available; otherwise refer to hepatology.
• Primary Care Role:
  • If tools are available, pursue noninvasive staging before referral.
  • Hepatology prefers patients to arrive with chronic liver disease exclusions and noninvasive fibrosis assessment; allows for more targeted care ([23:02], Dr. Allen).

4. Evolving Treatment: What’s Available Now and What’s Coming

[26:01]

• Two FDA-Approved MASH Medications (2024 & 2025):

  • Resmetirom (Resdifra):
    • Thyroid hormone mimetic, liver-directed, weight-neutral, improves steatosis/inflammation/fibrosis, also reduces LDL.
  • Semaglutide (Wegovy):
    • Familiar to primary care, approved for MASH with moderate/advanced fibrosis, also indicated for weight loss and T2DM. Multiple metabolic benefits.
  • Effectiveness: Roughly similar; side effects mainly GI in nature.
  • Patient-centered choice: Consider comorbidities, coverage, and patient priorities.
  • “In primary care … you can either use [semaglutide] … for the liver indication.” – Dr. Allen

• In the Pipeline:

  • More GLP-1 agents (retatutride, tirzepatide), dual-acting agents, FGF21 agents, all in phase 3 trials.

5. Special Considerations: Cirrhosis

[31:15]

• Why care about cirrhosis before starting MASH-directed therapy?
  • No phase III data or FDA approval for these drugs in MASH-cirrhosis.
  • Not contraindicated if indicated for diabetes/obesity, but be cautious about risk for sarcopenia and frailty:
    • Counsel on protein intake and resistance exercise ([31:15], Dr. Allen).
• Diagnosing Cirrhosis:
  • High elastography values: FibroScan ≥12-15 kPa, MRE ≥4.6-5 kPa, ELF ≥11.3.
  • Use imaging (US/CT) to detect nodular liver, spleen size, and portal hypertension.
  • Platelet count, FIB-4, and imaging—“constellation of findings.”

Notable Quotes & Memorable Moments

• On Barriers to Screening:

  “Primary care, the things we need to screen for—that list is like, longer by the minute… sometimes it's really hard to add one more thing to the list.”
  — Dr. Susan Kucera ([04:59])

• On Test Interpretation:

  “We often think of tests as binary… they're not. They're all probability based. And I love the way that you discussed that…”
  — Dr. Neil Skolnick ([10:28])

• On Platelets as a Clue:

  “Platelets have a very strong voice when it comes to fibrosis estimation. Although [a] platelet value of 155 may be considered normal, it always catches our hepatology eye...”
  — Dr. Alina Allen ([15:56])

• On Multimodal Assessment:

  “Liver disease estimation is a puzzle. It's the pieces that have to be put together... platelets are a big part of that symphony…”
  — Dr. Alina Allen ([17:31])

• On the Excitement for New Therapies:

  “It is a very exciting time for hepatology… we have two drugs and… several in the pipeline… for liver disease if they prove their safety and effectiveness.”
  — Dr. Alina Allen ([26:01])

• Vision for the Future:

  “My hope… is that liver will need to deserve its own space, just like the eyes and the kidneys and the nerves… that we will celebrate this achievement in the next few years—is liver is a quality measure in patients who have diabetes.”
  — Dr. Alina Allen ([34:51])

Important Timestamps

• Introduction, importance of MASH – [00:02]
• Barriers to screening in primary care – [04:59]
• Case 1: FIB-4, ELF, and age-related interpretation – [07:13]
• Factoring in platelets and “test symphony” – [15:56], [17:31]
• Elastography thresholds and re-screening intervals – [14:41]
• Case 2: Mildly abnormal LFTs, workup approach – [21:37]
• Current and upcoming treatments – [26:01]
• Cirrhosis: why and how to rule out – [31:15], [33:10]
• Dr. Allen’s vision for liver as a quality measure in diabetes care – [34:51]

Final Takeaways

• Screening for MASH with modern risk tools should become routine, especially in T2DM and those with metabolic syndrome.
• Diagnostics must be tailored: Use age-appropriate FIB-4 cutoffs, leverage ELF where imaging is impractical, and always view all labs/imaging in the context of the whole patient.
• Platelet count “gray zone” demands nuance and may signal a need for more aggressive assessment.
• Treatment for MASH is real and expanding: Resmetirom and semaglutide are options for moderate-to-advanced fibrosis. Watch for new approvals.
• Don’t treat blindly—exclude cirrhosis before initiating MASH-targeted drugs.
• Primary care clinicians need practical, streamlined pathways and should collaborate with hepatology when feasible.
• The future will position liver health alongside kidneys, eyes, and nerves as a quality surrogate in diabetes management.

For more information:
Visit www.diabetesjournals.org

[End of Summary: Covers Core Content, Clinical Pearls, Cases, and Actionable Guidance]