Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver

Updated 2026 Guidelines for Drug Treatment of Metabolic-Related Fatty Liver Disease and Liver Inflammation

Updated

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) has become the leading cause of chronic liver disease worldwide.

  • Prevalence of MASLD is increasing in general and high-risk populations, especially among individuals with type 2 diabetes, obesity, and metabolic syndrome.
  • Progression from simple liver fat accumulation to more severe conditions like steatohepatitis and advanced fibrosis significantly raises the risk of cirrhosis and liver cancer.
  • New regulatory pathways have expedited the development of therapies, with Resmetirom and Semaglutide showing histological efficacy in Phase 3 trials for steatohepatitis with moderate to severe fibrosis.
  • The AISF STEPS-MASH framework offers a systematic method for identifying and monitoring patients who could benefit from emerging treatments.
  • Recommendations are provided for integrating new pharmacological strategies into clinical practice in Italy, focusing on both high-risk and broader metabolic patient populations.

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Funding

Competing interests

Declaration of competing interest AAg: speaking and/or advisory board for Gilead, Ipsen, BMS, Novo Nordisk, Madrigal, AbbVie. AAr: speaking for Novonordisk, Sanofi, Echosense. EB: speaking and/or advisory board for AstraZeneca, Boheringer, Eli Lilly, Inventiva, MSD, Novo Nordisk. GC: speaking and/or advisory board for Eisai, Ipsen, AstraZeneca, MSD, Roche, Gilead. MC: consultant/speaker bureau for Advanz, Alentis, Albireo, Alfasigma, Amgen, Calliditas, Echosense, Genetic spa, GSK, Ipsen, Intercept, Kowa, Mayloly, Mirun, Perspectum, Zydus; scientific board advisor for Advanz/Intercept, Falk, Gilead, GSK, Ipsen, Kowa, Mirum, Cymabay, Moderna. RD: speaking, teaching and advisory board for Gilead Science and AbbVie; consultant and advisory board for Madrigal. AD speaking and/or advisory board for Astrazeneca, Eisai, MSD, Novonordisk and Roche. SDC: speaking and/or advisory board for AbbVie, Alfasigma. AG: consultant and advisory borad for for Roche, Ipsen, Novonordisk, MSD, BMS, AstraZeneca, Alfasigma, Actial, Wellmicro. GG: speaking, consulting fee fees and/or travel fees for Chiesi, Alfasigma, Ipsen, Biotest, Novartis. SG: speaking and/or advisory board for Gilead. MI: consultant for Roche, Roche Diagnostic, Eisai, MSD, AstraZeneca; speaking for Roche, AstraZeneca, Ipsen, Eisai, MSD, Gilead; Travel fees from Roche; research funding by Gilead, Astrazeneca, Roche Diagnostic. FM: consultant and/or speaking and/or advisory board and/or travel grant for Aòfasigma, AstraZeneca, Biomarin, Boehringer Ingelheim, Gilead, Gore, Ipsen, Madrigal, MSD/Eisai, Novo Nordisk, Roche. GM: speaking for MSD-Eisai, Chiesi, Kedrion, Ipsen, Alfasigma. MM: speaking and/or advisory board for Gilead, Ipsen, Novo Nordisk, Alfasigma, AbbVie, Mirum. LM: speaking and advisory board for Alexion, Boheringer-Ingelheim, Echosens, GSK, Madrigal, MSD, Mirum, Novonordisk, Reslis Pharma, Siemens Healthineers. GP: speaking and/or advisory board and/or consultant for Novo Nordisk, Echosense, Advanz Pharma, Madrigal. SP: speaking and/or advisory board for Boeringher, Echosens, Madrigal, Novonordisk, Resalis. FRP: speaking and/or consultant and/or travel grant from AstraZeneca, Ipsen, Roche, AbbVie, Gilead, Alfasigma, Mirum. FR: research support by Boheringer Ingelheim, Ely Lilly; travel grant by Novo Nordisk; speaking for Novo Nordisk, Eli Lilly, Echosense. FPR: speaking, travel grant and advisory board for Gilead, Biotest, Grifols, AbbVie, GSK, Novonordisk. FT: consultant for Astrazeneca, Roche, Eisai, BMS, Ipsen; LV: speaking for Viatris, Novo Nordisk, GSK; consulting for Novo Nordisk, Pfizer, Boehringer Ingelheim, Resalis, GSK, Almac, AIRNA; travelling by Novo Nordisk. UVG: speaking and/or advisory board and/or funding for research by Advanz, Gilead, Ipsen, Mirum, Novo Nordisk, Madrigal, Astra Zeneca. MV: speaking and teaching for Gilead, Ipse, AbbVie, Novo Nordisk, Eli Lilly, Kedrion.
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