Review Article: An Update on Non-Invasive Tests for Steatotic Liver Disease - Insights From the ESSENCE Phase 3 Trial and Longitudinal Studies

Background: Metabolic dysfunction-associated steatohepatitis (MASH) is increasingly common globally and is associated with significant morbidity and mortality, necessitating effective treatments to stop its progression. Multiple pharmacologic treatments have been developed for MASH, targeting patients most likely to experience major adverse liver outcomes (MALO). It is therefore of utmost importance to accurately identify patients with at-risk MASH, those with the greatest likelihood of developing cirrhosis and other related MALO who would benefit from these treatments. Aims: The goal of this review is to summarize expert opinion on the pharmacologic treatment of MASH following the recent approval of semaglutide for this condition in the United States. Methods: An expert panel was convened as part of the Desert Liver Conference (Scottsdale, AZ, USA) in March 2025 to provide recommendations regarding guidelines for selecting patients who would benefit from MASH pharmacotherapy. Results: The ESSENCE trial studied the safety and efficacy of 2.4 mg semaglutide in patients with biopsy-confirmed MASH, but liver biopsy is not widely deployed in clinical practice. Non-invasive tests (NITs) can be used to identify patients who are likely to have at-risk MASH. The panel recommended targeting patients with controlled attenuation parameter ≥ 280 dB/m and AST ≥ 17 IU/L (females) or ≥ 20 IU/L (males) for additional confirmatory testing, such as vibration-controlled transient elastography, magnetic resonance elastography, enhanced liver fibrosis score and/or combination imaging-serum biomarker tests. Conclusions: Pharmacologic treatment for MASH, including semaglutide, should be offered to patients with at-risk MASH who are at the highest risk of MALO.