Monitoring

The optimal follow-up for patients with metabolic dysfunction-associated steatotic liver disease (MASLD) has not yet been determined. Monitoring should include routine biochemistry, assessment of comorbidities, and non-invasive monitoring of fibrosis. European guidelines advise that patients with metabolic dysfunction-associated steatohepatitis (MASH), without worsening of metabolic risk factors, should be monitored at 2- to 3-year intervals. Patients with MASH and/or fibrosis should be monitored annually, and those with MASH cirrhosis at 6-month intervals.[41] Liver biopsy should not be repeated routinely, but may be considered on a case-by-case basis.[3]​​[41]

Given its association with the development of SLD and fibrosis, there are various recommendations for monitoring when long-term methotrexate treatment is required. The American College of Rheumatology recommends laboratory monitoring at baseline and then at regular intervals during treatment (every 2-4 weeks for the first 3 months, every 8-12 weeks for 3-6 months, every 12 weeks after 6 months).[170] They also recommend restricting the use of methotrexate in patients with suspected MASLD to those who have normal liver biochemistry and do not have advanced fibrosis, as detected by non-invasive testing. The American College of Dermatology recommends patients with psoriasis undergo fibrosis-4 serological testing and transient elastography at baseline and yearly during treatment if they are at risk for hepatotoxicity.[171] Laboratory monitoring at baseline and every 3-6 months is recommended, with liver biopsy used in case of abnormal transient elastography results or persistently abnormal liver biochemistry findings.[31] Transient elastography and/or liver biopsy are also recommended once 3.5 to 4.0 g of cumulative methotrexate exposure has been reached.

Patients with cirrhosis, and patients who have evidence of advanced fibrosis or cirrhosis on non-invasive testing, should be offered screening for hepatocellular carcinoma.​[33][163]​​ Screening is initially performed with ultrasound, with or without serum alpha-fetoprotein.[172]

All patients with cirrhosis should also undergo surveillance for portal hypertension with oesophogastroduodenoscopy when cirrhosis is first diagnosed.​[173] Patients with varices should be treated with prophylactic measures. 

All patients with MASH cirrhosis should be referred to a transplant centre after the development of the first complication of liver disease (ascites, encephalopathy, variceal bleeding, and primary liver cancer).

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