August 06, 2025 New Clinical Practice Guidelines Released for MASLD

Diabetes Canada has released new guidelines for the care and management of metabolic dysfunction-associated steatotic liver disease (MASLD) in adults with diabetes.  

These new guidelines, published in the Canadian Journal of Diabetes, were developed through a rigorous and transparent process, including the review, appraisal, and synthesis of thousands of published research studies, as well as an evaluation and grading of their relevance and quality. The result is a set of recommendations that help guide practice, inform general patterns of care, and support better outcomes for those living with diabetes.  

Given the significant impact of MASLD on health outcomes and the health-care system, as well as its high prevalence in people living with type 2 diabetes (T2D), this guideline aims to raise awareness of MASLD and provide practical recommendations for its screening, diagnosis, and management. 

MASLD affects about 70% of people living with T2D, and this guideline offers background information on the pathophysiology, risks, and outcomes of MASLD; its diagnosis and screening; health behavior and pharmacologic interventions; key messages for both health-care providers and people living with diabetes; and recommendations to aid health-care providers in their daily clinical care of people living with MASLD and diabetes.   
 

Highlights for health-care providers

• Liver fibrosis is the primary determinant of the hepatic and nonhepatic adverse outcomes of people living with MASLD. 
• Consider screening for MASLD-related liver fibrosis in all individuals living with prediabetes or type 2 diabetes by using the Fibrosis-4 Index (FIB-4) score, which can assist in ruling out the likelihood of advanced liver fibrosis. 
• If the FIB-4 score is <1.3, then the management of metabolic syndrome, especially diabetes and weight, should be done in the primary care clinic. 
• Additional tests may be required if the FIB-4 score is between 1.3 and 2.67.  
• If the FIB-4 score is >2.67, then referral to hepatology is warranted due to the high risk of advanced fibrosis. 
• Sustained weight reduction of at least 5% to 10% is recommended, but, if possible, weight loss of >10% is preferred as it can assist with reversing liver fibrosis. 
• Pioglitazone and subcutaneous semaglutide may be considered to improve glycemia and may reduce the liver fat content and progression of liver fibrosis. 
• Cardiovascular protection is crucial in people living with MASLD, as most people with MASLD have cardiovascular disease. Therefore, statins can be continued to be used unless decompensated cirrhosis is developed. 

Highlights for people living with diabetes 

• MASLD affects more than just the liver. Although it can cause liver damage over time, most people with MASLD are more likely to have heart disease, which is the leading cause of illness within this group. 
• Everyone with prediabetes or T2D should be checked for liver scarring (also called fibrosis), which is a key predictor of complications. A simple calculation called the FIB-4 score, based on age and routine blood tests, can help rule out serious damage. 
• Weight loss is one of the best treatments. Losing at least 5% to 10% of body weight can reduce fat in the liver. A 10% reduction in body weight may even help reverse some liver scarring. 
• Some diabetes medications may help the liver. Certain treatments for diabetes may also reduce liver fat and slow down liver damage. 
• Heart health matters too. Because heart disease is common in people with MASLD, statins (cholesterol-lowering medications) are usually safe and should be continued — except for cases of advanced liver disease like decompensated cirrhosis. 
• MASLD, formerly known as nonalcoholic fatty liver disease (NAFLD), is the most common liver condition, particularly among people living with T2D.  
• Globally, 69% of people with T2D have MASLD, and 37% have metabolic-associated steatohepatitis (MASH), highlighting the complex nature of this disease. In contrast, MASLD affects approximately 22% of people living with type 1 diabetes mellitus.  
• The primary drivers of MASLD are T2D and obesity. 
• Most people living with MASLD are seen in primary care or endocrinology settings, where the condition often goes undiagnosed and untreated. 

For more information, please contact:
info@diabetes.ca