This AGA Clinical Practice Update provides Best Practice Advice (BPA) on the diagnosis, staging, and treatment of metabolic dysfunction– and alcohol-associated liver disease (MetALD), a newly defined category under the 2023 multisociety consensus nomenclature for steatotic liver disease (SLD).
Nine BPA statements were issued, covering: classification of MetALD by alcohol intake thresholds (≈140–350 g/wk in women, 210–420 g/wk in men) plus cardiometabolic risk factors; annual alcohol screening; abstinence counseling; tiered noninvasive fibrosis assessment starting with FIB-4; cautious interpretation of elastography during active drinking; micronutrient repletion and exercise; preliminary GLP-1/GIP receptor agonist data suggesting reduced alcohol cravings; pharmacotherapy for alcohol use disorder; and avoidance of bariatric/endobariatric surgery due to insufficient safety data.
Systematic reviews were not performed, so BPA statements carry no formal evidence quality ratings or strength-of-recommendation grades. FDA-approved MASLD treatments (resmetirom, semaglutide) have not been formally studied in MetALD populations, leaving a key therapeutic gap.
Classify SLD patients into MetALD using the 140–350 g/wk (women) and 210–420 g/wk (men) alcohol thresholds, screen at least annually with validated tools, and use a tiered FIB-4–first strategy for fibrosis staging. Advise complete alcohol abstinence, replete micronutrients, prescribe aerobic exercise, and offer alcohol use disorder pharmacotherapy for moderate-to-severe AUD; avoid bariatric surgery in MetALD patients.
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