JAAPA Podcast: MASLD Screening and Management

Date: March 27, 2026
Host: JAAPA
Guest: Annie Geary, Assistant Professor at Butler University and GI/Hepatology PA at Hendricks Regional Health

Episode Overview

This episode of the JAAPA Podcast focuses on Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), formerly known as NAFLD and often referred to as "masled." The discussion is led by Annie Geary, PA-C and academic, who reviews prevalence, screening, diagnostic criteria, and evolving management strategies, including new pharmacological therapies. The episode emphasizes the key role of physician assistants in early detection and collaborative management of this highly prevalent but frequently silent disease.

Key Discussion Points and Insights

Annie Geary’s Journey into Hepatology and Academics

• Annie shares her background, including her transition from clinical GI/hepatology practice to academia, driven by her passion for discussing sensitive health topics and mentoring future PAs.
  Key Quote (01:30):
  "I've always practiced in GI and now I get the opportunity to teach that to future PAs. So it's a really rewarding career and I'm glad I'm doing it." — Annie Geary

MASLD: Epidemiology and Significance

• MASLD affects nearly 30% of the global population, making it a significant public health concern.
• Complications include cirrhosis and hepatocellular carcinoma (HCC).
• PAs play a critical role in early detection and management.
  [02:20]

Case-Based Learning: Introducing Mr. Smith

• 56-year-old male with obesity (BMI 42), hypertension, dyslipidemia, mild transaminase elevation, and metabolic risk factors.
• Annie illustrates her approach to suspected MASLD:

Initial Clinical Approach

• Metabolic risk factors: Central obesity, hypertension, elevated glucose—high suspicion for MASLD even before evaluating transaminases.
• Liver enzyme interpretation:
  • AST/ALT = ‘the house’ (hepatocellular injury).
  • Alk phos/bilirubin = ‘the pipes’ (cholestatic/biliary disease).
  • Mr. Smith has a hepatocellular pattern (AST/ALT elevation).

Analogous Quote (04:08):
"I really teach interpreting liver enzymes as an analogy between a house and the pipes in your house... if you have a problem with your pipes, sometimes your flooring gets ruined too..." — Annie Geary

• Always ask about alcohol use and screen for viral hepatitis, regardless of metabolic risk profile.

• Consider secondary causes for enzyme elevation (e.g., hypothyroidism).

• Use initial conversations to address common misconceptions and reduce stigma:
  Quote (07:52):
  "Liver disease isn't just from alcohol use. I talk about how fat can be toxic to the liver just like alcohol." — Annie Geary

• Even modest weight loss (3–5%) can reduce hepatic steatosis.

Evolution of Disease Nomenclature

• NAFLD → MASLD:
  • Shifted from defining by absence of alcohol to presence of metabolic dysfunction.
  • Reduces stigma by removing "alcoholic" and "fatty" from the name.
  • Allows for recognition of patients with both metabolic risk and moderate alcohol intake (now termed MetALD).
  • Severity now classified by fibrosis staging (F0–F4). Quote (11:02):
    "We've really flipped the way we think about this disease process... we’re defining the name with the driving factor, which is metabolic dysfunction." — Annie Geary

Physical Exam and Laboratory Findings

• Most patients with MASLD have little to no distinctive physical findings outside of typical metabolic syndrome features (central obesity, hypertension).
• Initial labs often normal—especially in diabetic patients.
• Late-stage findings suggest cirrhosis (jaundice, ascites, spider angiomata, hepatic encephalopathy).
• Only bilirubin and INR truly reflect liver function; AST/ALT elevations may not. Quote (15:36):
  "Labs and physical exam all may be completely normal. And that's why this is so easy to not think about when you're seeing your patients in family practice." — Annie Geary

Non-Invasive Risk Stratification for Fibrosis

• FIB-4 Index:

  • Non-invasive, uses age, AST, ALT, platelet count.
  • <1.3 (ages 35–65): Low risk—monitor and treat metabolic syndrome.

  • 2.67: High risk—refer to GI/hepatology, further evaluate with elastography.

  • 1.3–2.67: Indeterminate—proceed to transient elastography (FibroScan) or MR elastography.
  • Cutoffs differ in age extremes. Quote (18:00):
    "The FIB4 is a great way to triage patients and then kind of restratify them." — Annie Geary

• [19:47]: Real-life application: Mr. Smith's FIB4 = 2.46 (indeterminate); next step is advanced fibrosis assessment.

Diagnostic Criteria for MASLD

• Diagnosis requires evidence of hepatic steatosis (histology, imaging, or strong clinical suspicion) AND at least one cardiometabolic risk factor.
• Abnormal transaminases are NOT required for diagnosis; diabetics commonly have normal liver enzymes.
• Always exclude other causes (hepatitis B/C). Quote (22:05):
  "Absolutely not required. In fact, normal liver enzymes are very common in somebody who has MASLD." — Annie Geary

Management: Lifestyle and New Pharmacologic Treatments

• Lifestyle is first-line:

  • Weight loss (≥3–5%) improves steatosis.
  • Mediterranean-style diet, regular exercise, management of comorbidities (diabetes, hypertension).

• New Pharmacotherapies:

  • Resmetirom (approved 2024):
    • Thyroid hormone receptor β agonist.
    • Indicated for non-cirrhotic patients with F2–F3 fibrosis.
    • Given based on imaging (elastography) without need for biopsy.
  • Semaglutide:
    • GLP-1 agonist, now approved at higher (2.4 mg) dose for MASLD with F2–F3 fibrosis (not diabetes dose).

Quote (25:30):
"First line therapy is still lifestyle modification... But now we have pharmacotherapy, which we didn’t have in the past." — Annie Geary

• Early intervention improves long-term outcomes.

Safety and Monitoring with New Therapies

• Resmetirom:
  • Check AST/ALT at 12 weeks; early transient increase is possible.
  • Baseline TSH for overall management.
  • Reassess liver stiffness after ~12 months.
  • Key drug interactions:
    • Avoid with gemfibrozil.
    • Dose reduction with clopidogrel.
    • Statin maximum doses: simvastatin (20mg), atorvastatin (40mg).

Quote (28:00):
"We’ve got to monitor really for both... How are they doing on the drug itself and what’s the safety profile?" — Annie Geary

Hepatocellular Carcinoma (HCC) Screening

• Only patients with established cirrhosis require HCC screening (ultrasound & alpha-fetoprotein [AFP] every 6 months).
• Patients with F2 or F3 fibrosis (pre-cirrhosis): HCC screening not currently recommended.

Quote (31:00):
"All cirrhotic patients should be surveilled for hepatocellular carcinoma... regardless of the cause." — Annie Geary

Notable Quotes & Memorable Moments

• "Liver disease isn’t just from alcohol use. I talk about how fat can be toxic to the liver just like alcohol." (07:52)
• "Labs and physical exam all may be completely normal. And that’s why this is so easy to not think about when you’re seeing your patients in family practice." (15:36)
• "First line therapy is still lifestyle modification... But now we have pharmacotherapy, which we didn’t have in the past." (25:30)
• "If you suspect they have risk factors for MASLD, go ahead and calculate a FIB4... allows you to risk stratify them very easily." (33:17)
• "MASLD is common and it’s quiet." (32:29)

Final Takeaways & Actionable Points

• MASLD is common, often silent, and generally underdiagnosed.
• Think MASLD in patients with metabolic syndrome (obesity, diabetes, hypertension, dyslipidemia), even with normal liver enzymes.
• Utilize FIB4 scoring to risk stratify patients—it's quick, easy, and non-invasive.
• Focus on lifestyle interventions, but consider newly approved medications early for those with significant fibrosis.
• Ensure appropriate HCC screening for all cirrhotic patients.
• Don’t be deterred by normal labs—be vigilant for subtle signs and risk factors.
• Early intervention is key to preventing serious liver complications.

Timestamps for Important Segments

• 00:53 – Annie Geary’s background and entry into hepatology
• 02:20 – MASLD prevalence, public health importance
• 03:46 – Approach to suspected MASLD: case intro and interpreting labs
• 09:56 – Nomenclature evolution: NAFLD/NASH to MASLD
• 13:46 – Physical/lab findings in MASLD
• 17:31 – Non-invasive fibrosis assessment: FIB4
• 20:11 – Case application: indeterminate FIB4 and next steps
• 21:57 – Diagnostic criteria; role of abnormal transaminases
• 24:23 – Weight loss and new pharmacological management options
• 27:46 – Resmetirom monitoring, drug interactions
• 30:49 – HCC surveillance: who needs it and how often
• 32:29 – Final thoughts and call to action

Conclusion

This episode underscores the importance of awareness and early detection of MASLD by physician assistants and primary care clinicians. It reviews practical approaches—FIB4 scoring, diagnostic clarity, updated terminology, and new therapeutic avenues—all with actionable tips for everyday practice. Annie Geary’s teaching analogies and recommendations equip listeners to be proactive in screening and management of this increasingly common yet insidious disease.