# Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: AASLD Practice Guidance on MASLD 2023 · EASL-EASD-EASO Clinical Practice Guidelines for MASLD 2021 · Egyptian National Drug Formulary - Endocrine System 2024 (pioglitazone monograph); indication per Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - StatPearls (NCBI Bookshelf NBK541033) - https://www.ncbi.nlm.nih.gov/books/NBK541033/: "pioglitazone, which improves steatohepatitis without clear fibrosis regression" · Egyptian National Drug Formulary - Endocrine System 2024 (semaglutide monograph, oral dosing) · Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - disease-level clinical article (fatty-liver-disease-masld-full.txt) · REZDIFFRA (resmetirom) tablets US prescribing information, section 1 Indications and Usage, section 2 Dosage and Administration, section 5 Warnings and Precautions and section 8 Use in Specific Populations (DailyMed SetID e67ea09f-a840-439c-86c8-f98585f978b2) - Verified date: 2026-08 ## Verified against - AASLD Practice Guidance on MASLD 2023 - Egyptian National Drug Formulary - Endocrine System 2024 (pioglitazone monograph); indication per Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - StatPearls (NCBI Bookshelf NBK541033) - https://www.ncbi.nlm.nih.gov/books/NBK541033/: "pioglitazone, which improves steatohepatitis without clear fibrosis regression" - Egyptian National Drug Formulary - Endocrine System 2024 (semaglutide monograph, oral dosing) - Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - disease-level clinical article (fatty-liver-disease-masld-full.txt) - REZDIFFRA (resmetirom) tablets US prescribing information, section 1 Indications and Usage, section 2 Dosage and Administration, section 5 Warnings and Precautions and section 8 Use in Specific Populations (DailyMed SetID e67ea09f-a840-439c-86c8-f98585f978b2) ## Treatment metadata - Vitamin E — 400 mg — oral.solid - Pioglitazone — 30 mg — oral.solid - Semaglutide — 7 mg — oral.solid - Resmetirom — oral.solid - Metformin — 500 mg — oral.solid ## Complete treatment card ```text METABOLIC DYSFUNCTION-ASSOCIATED STEATOTIC LIVER DISEASE (MASLD) Sources: AASLD Practice Guidance on MASLD 2023 · EASL-EASD-EASO Clinical Practice Guidelines for MASLD 2021 · Egyptian National Drug Formulary - Endocrine System 2024 (pioglitazone monograph); indication per Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - StatPearls (NCBI Bookshelf NBK541033) - https://www.ncbi.nlm.nih.gov/books/NBK541033/: "pioglitazone, which improves steatohepatitis without clear fibrosis regression" · Egyptian National Drug Formulary - Endocrine System 2024 (semaglutide monograph, oral dosing) · Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - disease-level clinical article (fatty-liver-disease-masld-full.txt) · REZDIFFRA (resmetirom) tablets US prescribing information, section 1 Indications and Usage, section 2 Dosage and Administration, section 5 Warnings and Precautions and section 8 Use in Specific Populations (DailyMed SetID e67ea09f-a840-439c-86c8-f98585f978b2) Review status: REVIEWED against 5 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Most patients have no symptoms; when present, fatigue is one of the most frequent complaints [fatigue] - Sharp or dull upper abdominal aching, thirst, bloating, and disturbed sleep can occur [abdominal distension · abdominal pain] - Once cirrhosis or end-stage disease develops, nausea, vomiting, jaundice, itching, fluid retention, memory trouble, easy bruising or bleeding, and poor appetite can appear [bleeding · bruising · cirrhosis · itching · jaundice · nausea · oedema · poor appetite · vomiting] - MASH is the progressive form: the liver is inflamed and its cells injured, with or without fibrosis - The metabolic risk factors that define it are obesity, diabetes mellitus, dyslipidaemia and high blood pressure [hypertension · obesity] SIGNS - what you find (2) - Mild to moderate liver enlargement is the most common exam finding - Advanced disease can show jaundice, spider angiomas, palmar redness, caput medusae, breast enlargement in men, Dupuytren contracture, ascites, and petechiae [ascites · jaundice · petechiae · redness] TESTS (9) - Mild transaminase elevation is the main lab abnormality, though most patients have normal levels, and the AST-to-ALT ratio stays below 1 - A raised GGT flags higher mortality risk, and worsening disease brings low albumin, high bilirubin, low platelets, and a prolonged clotting time - Abdominal ultrasound is the routine screening tool, but liver biopsy remains the gold-standard diagnostic test - A FIB-4 score under 1.3 means low fibrosis risk needing recheck only every 1 to 3 years; a score of 1.3 to 2.67, or above 2.0 past age 65, calls for elastography or a year of lifestyle treatment before repeat testing - Elastography techniques - transient, shear-wave, or MRI-based - measure liver stiffness noninvasively to stage fibrosis - Alpha-fetoprotein is added to ultrasound for liver cancer surveillance in high-risk patients, since ultrasound alone often misses early tumors - MASLD means 5% or more steatosis in the liver with at least one cardiometabolic risk factor, no other cause, and little or no alcohol - under 20 g a day in women, under 30 in men - MetALD is that same picture with moderate drinking - 20 to 50 g a day in women, 30 to 60 in men - and it sits between the metabolic and the alcoholic ends of the spectrum - Above that it is alcohol-associated liver disease: over 50 g a day in women and over 60 in men, where a standard drink holds about 14 g IF NOT THIS - what else fits (4) - Alcoholic liver disease and hepatitis C, particularly genotype 3, are also considered - Wilson disease and drugs such as amiodarone, methotrexate, tamoxifen, steroids, or valproate can also cause a fatty liver - Reye syndrome and mitochondrial hepatopathies are rarer causes on the differential - Kwashiorkor and anorexia nervosa are nutritional causes of steatosis to consider Source StatPearls "Metabolic Dysfunction-Associated Steatotic Liver Disease (MΑSLD)" - disease- level clinical article Status traced to the source above Rx: Main treatment | GLP-1 receptor agonist - added glucose control, or metformin unsuitable | Thyroid hormone receptor-beta agonist for staged MASH with F2-F3 fibrosis - hepatology-initiated MAIN TREATMENT - choose one, plus any add-on marked below 1. VITAMIN E [1st line] Adult 800 IU (approx 530 mg) once daily x 6-12 months under monitoring Peds Specialist pediatric hepatology evaluation required Source AASLD Practice Guidance on MASLD 2023 Why Antioxidant therapy recommended by AASLD for non-diabetic adults with biopsy-proven NASH Caution Primary therapeutic intervention is weight loss (7-10%) via diet and aerobic exercise. Avoid high-dose Vitamin E in patients with prostate cancer or heavy haemorrhagic risk. Not recommended in diabetic MASLD without specialist advice. Egypt TOCO 400MG 20 CAPS. SEDICO 13.20 EGP (0.66/unit) VITAMIN E 400 MG 24 S.G. CAPS. SAFE PHARMA >... 50.00 EGP 2. PIOGLITAZONE [2nd line] Adult 15 mg or 30 mg once daily, increased to 45 mg once daily if needed - Review response at 3-6 months and discontinue if there is no adequate response Peds Safety and efficacy in children have not been established. NICE restricts pharmacological therapy for children with advanced fibrosis to vitamin E in tertiary care. Source Egyptian National Drug Formulary - Endocrine System 2024 (pioglitazone monograph); indication per Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - StatPearls (NCBI Bookshelf NBK541033) - https://www.ncbi.nlm.nih.gov/books/NBK541033/: "pioglitazone, which improves steatohepatitis without clear fibrosis regression" Why 19 live products. NICE NG49 says 'Consider pioglitazone or vitamin E for adults with advanced liver fibrosis, whether they have diabetes or not' - the vitamin E half of that sentence is already the line 1 row here and the pioglitazone half is missing. The dose comes from the Egyptian formulary because NG49 does not state one. Caution NICE restricts pioglitazone in this disease to adults with ADVANCED liver fibrosis and to secondary or tertiary care - it is not a primary-care initiation for a fatty liver on ultrasound. Not licensed for fatty liver disease anywhere - the marketing authorisation is for type 2 diabetes only. CONTRAINDICATED in cardiac failure or any history of it (NYHA I to IV), in hepatic impairment, in diabetic ketoacidosis, and in current or previous bladder cancer or uninvestigated macroscopic haematuria. Hepatic impairment is a contraindication, which cuts across this very indication - it is for fibrosis, not for decompensated disease. Causes fluid retention, oedema in up to 27%, weight gain, and distal fractures in women. NICE advises stopping pioglitazone and considering vitamin E instead if the ELF test score has risen. Stop if there is no adequate HbA1c or clinical response by 3-6 months. Egypt GLITAZEN 30 MG 30 TABS. EL-OBOUR MODE... 33.00 EGP (1.10/unit) HI-GLITAZONE 30MG 30 TAB. HI-PHARM 33.00 EGP (1.10/unit) GLUSTAZON 30MG 21 TAB. CHEMIPHARM 28.50 EGP (1.36/unit) DIABETIN 30 MG 10 TABS. UNIPHARMA 35.00 EGP (3.50/unit) DIABETIN 30 MG 30 TABS. UNIPHARMA 105.00 EGP (3.50/unit) PIOJET 30MG 10 TAB. EUROPEAN EGYP... 37.00 EGP (3.70/unit) GLUSTIN 30MG 7 TAB. TAKEDA 55.50 EGP (7.93/unit) ACTOS 30MG 30 TAB. ARAB PHARMACE... 372.00 EGP (12.40/unit) 3. METFORMIN [add-on - not a substitute] Adult 500 mg twice daily with meals, titrate to 1000 mg twice daily - long-term Peds Specialist endocrinology use Source AASLD Practice Guidance on MASLD 2023 Why Targeted at underlying insulin resistance and metabolic risk factors in patients with MASLD and prediabetes/T2DM Caution Metformin improves glycemic control but does NOT reverse liver histology/fibrosis directly in MASLD per AASLD 2023. Monitor renal function (eGFR) and serum B12. Contraindicated in severe hepatic impairment or eGFR <30 mL/min. Egypt METFORMIN-EL NASR 500MG 200 TAB. EL NASR 26.00 EGP (0.13/unit) DIAPHAGE 500MG 20 TAB. PHAROPHARMA 4.00 EGP (0.20/unit) AMOPHAGE 500MG 30 TAB. AMOUN 10.50 EGP (0.35/unit) CIDOPHAGE 500 MG 10 TAB. CID 11.00 EGP (1.10/unit) GLUCOPHAGE 500 MG 50 F.C.TABS. MINA PHARM > ... 60.00 EGP (1.20/unit) KELVAMET MR 500 MG 30 TABS. BIOMED 54.00 EGP (1.80/unit) ANDOGLYCEMIC XR 500MG 30 EXT. REL. TABS. ANDALOUS PHARMA 24.00 EGP METIANORMIN 500 MG 30 EXT. REL. F.C.TABS. WADI ELNEEL BENTA 54.00 EGP GLP-1 RECEPTOR AGONIST - ADDED GLUCOSE CONTROL, OR METFORMIN UNSUITABLE 4. SEMAGLUTIDE [2nd line] Adult Initially 3 mg once daily for 1 month, then increased to 7 mg once daily for at least 1 month, and then increased if necessary to 14 mg once daily, taken on an empty stomach Peds The formulary states adult dosing only for this indication. Not for paediatric use here. Source Egyptian National Drug Formulary - Endocrine System 2024 (semaglutide monograph, oral dosing) Why An earlier review refused this because the formulary indicates GLP-1 receptor agonists for type 2 diabetes and for weight management, never for fatty liver. Under the August 2026 ruling that silence is not prohibition, and with the indication claim coming from the card's own article, it stands. The article's reasoning: metformin is first-line for type 2 diabetes, while pioglitazone and the GLP-1 receptor agonists - liraglutide, semaglutide - are reasonable alternatives where more glucose control is needed or metformin cannot be taken, and may improve liver histology into the bargain. Semaglutide rather than liraglutide because the Egyptian register carries 14 semaglutide products against 3 liraglutide, including the oral tablets dosed here. The metformin and pioglitazone rows are the same shape and stay: the same article names both by name. Caution CONTRAINDICATED on the formulary's own list: hypersensitivity to semaglutide or to anything else in the product; medullary thyroid carcinoma, whether in the patient or in the family, and thyroid C-cell tumours; and multiple endocrine neoplasia type 2 (MEN 2). The formulary's indication is diabetes, not fatty liver: it licenses the drug in type 2 diabetes, alongside diet and exercise, to bring the blood glucose under better control in adults. The liver indication comes from the disease article, which is also honest about the limit of the benefit - a GLP-1 agonist can clear the steatohepatitis while leaving the fibrosis where it was. The formulary also gives a subcutaneous regimen: initially 0.25 mg once weekly for 4 weeks, then doubled at 4-week intervals up to 1 mg once weekly if necessary. The oral regimen is on this row because the card's other options are oral and both forms are registered in Egypt. Cost is a real barrier in Egypt - the oral tablets and the pens are among the most expensive items on this card by a wide margin. Weight loss and sustained lifestyle change remain the primary treatment for MASLD; a drug does not replace them. Egypt RYBELSUS 7 MG 30 TABS. NOVO NORDISK ... 3150.00 EGP (105.00/unit) RYBELSUS 7 MG 10 TABS. NOVO NORDISK ... 1575.00 EGP (157.50/unit) THYROID HORMONE RECEPTOR-BETA AGONIST FOR STAGED MASH WITH F2-F3 FIBROSIS - HEPATOLOGY-INITIATED 5. RESMETIROM [3rd line] Adult Dosed by actual body weight, taken once daily. Per the US label: below 100 kg the dose is 80 mg by mouth once daily, and at 100 kg or above it is 100 mg once daily. It can be taken with or without food; swallow tablets whole - they must not be divided, crushed or chewed. Combined with a moderate CYP2C8 inhibitor - clopidogrel is the label's example - dosing drops to 60 mg once daily under 100 kg and 80 mg once daily at 100 kg or above. StatPearls gives the same two weight-based doses. - Long-term, on an approval that is itself provisional. US label verbatim: "This indication is approved under accelerated approval based on improvement of MASH and fibrosis. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials." Liver tests are monitored throughout rather than checked once. Peds Not a paediatric prescription. US label verbatim: "The safety and effectiveness of REZDIFFRA have not been established in pediatric patients." Source REZDIFFRA (resmetirom) tablets US prescribing information, section 1 Indications and Usage, section 2 Dosage and Administration, section 5 Warnings and Precautions and section 8 Use in Specific Populations (DailyMed SetID e67ea09f-a840-439c-86c8-f98585f978b2) Why StatPearls names the drug, the fibrosis stage and the dose. Resmetirom, a thyroid hormone receptor-beta agonist, is licensed for MASH with F2-F3 fibrosis in patients who have not achieved significant weight loss; people with cirrhosis were excluded from the pivotal trials, and safety in that group is still under study. The doses given are 80 mg once daily under 100 kg and 100 mg once daily at 100 kg or above. The US label's indication matches the same disease and stage: adults with noncirrhotic MASH and moderate-to-advanced fibrosis (stage F2-F3), used alongside diet and exercise. It is the only drug licensed for MASH itself, rather than for the metabolic disease driving it, and the card carried none. Egypt has no registered resmetirom product, so no local brand or price can be shown; the row exists so a prescription started abroad can be recognised, with the fibrosis stage that gates it clearly stated. Caution It is not for cirrhosis, and that is the boundary the whole row turns on. US label verbatim: "Avoid use of REZDIFFRA in patients with decompensated cirrhosis (consistent with moderate to severe hepatic impairment)." and "The safety and effectiveness of REZDIFFRA have not been established in patients with MASH cirrhosis." A patient with ascites, varices or a low platelet count needs hepatology, not this tablet. RED FLAG - it can itself injure the liver. US label verbatim: "Hepatotoxicity has been observed with use of REZDIFFRA." and "Monitor patients during treatment with REZDIFFRA for elevations in liver tests and for the development of liver-related adverse reactions. Monitor for symptoms and signs of hepatotoxicity (e.g., fatigue, nausea, vomiting, right upper quadrant pain or tenderness, jaundice, fever, rash, and/or eosinophilia [>5%]). If hepatotoxicity is suspected, discontinue REZDIFFRA and continue to monitor the patient." One reported case reached 58 times the upper limit of normal for ALT. Gallstones and their complications. US label verbatim: "In clinical trials, cholelithiasis, acute cholecystitis, and obstructive pancreatitis (gallstone) were observed more often in REZDIFFRA-treated patients than in placebo-treated patients. If an acute gallbladder event is suspected, interrupt REZDIFFRA treatment until the event is resolved." It raises statin levels, and most of these patients are on one. US label verbatim: "An increase in exposure of atorvastatin, pravastatin, rosuvastatin and simvastatin was observed when concomitantly administered with REZDIFFRA, which may increase the risk of adverse reactions related to these drugs. Dosage adjustment for certain statins is recommended. Monitor for statin-related adverse reactions including but not limited to elevation of liver tests, myopathy, and rhabdomyolysis." Two drug groups the disease article singles out. Resmetirom is not to be given with an OATP 1B1/1B3 inhibitor - ciclosporin is the example it gives - nor with a strong CYP2C8 inhibitor such as gemfibrozil. The label takes the same line on gemfibrozil, advising against REZDIFFRA alongside a strong CYP2C8 inhibitor. It does not replace the weight loss. The label ties it to diet and exercise, and the article frames it as being for MASH where significant weight loss has not happened - the patient who can lose 7% of body weight does not need it. Egypt no Egyptian brand matched - prescribe by generic name Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)