Role of anti-diabetic medications in the management of MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD) poses a significant global health challenge due to its rising prevalence and strong association with metabolic syndrome and type 2 diabetes mellitus (T2D). Effective management requires a comprehensive approach, emphasising aggressive treatment of obesity and T2D. While lifestyle modifications remain central, anti-diabetic medications such as pioglitazone, glucagon-like peptide-1 receptor agonists, the dual glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide receptor agonist tirzepatide, and sodium-glucose transporter 2 inhibitors have demonstrated benefits in improving liver parameters and slowing disease progression. These medications not only improve glycaemic control but also reduce hepatic steatosis, liver enzyme levels, and inflammation, with some potential to address fibrosis. Additionally, they offer cardiovascular benefits, which are important for patients with MASLD at heightened cardiovascular risk. However, the histological benefits of metformin and the effects of dipeptidyl peptidase-4 (DPP-4) inhibitors and sulfonylureas remain unclear. Insulin therapy has been shown to reduce hepatic steatosis and improve liver enzyme levels, though its impact on fibrosis is not well documented. A multifaceted treatment strategy targeting metabolic, hepatic and cardiovascular health is essential for effectively managing MASLD and preventing its progression to advanced liver disease.