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 noninvasive 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.[40] Liver biopsy should not be repeated routinely, but may be considered on a case-by-case basis.[3]​​[40]

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).[173] 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 noninvasive testing. The American College of Dermatology recommends patients with psoriasis undergo fibrosis-4 serologic testing and transient elastography at baseline and yearly during treatment if they are at risk for hepatotoxicity.[174] 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.[30] 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 noninvasive testing, should be offered screening for hepatocellular carcinoma.​[32][166]​​ Screening is initially performed with ultrasound, with or without serum alpha-fetoprotein.[175]

All patients with cirrhosis should also undergo surveillance for portal hypertension with esophagogastroduodenoscopy when cirrhosis is first diagnosed.​[176] Patients with varices should be treated with prophylactic measures.

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

Use of this content is subject to our disclaimer