Juan Pablo Arab, MD, is a transplant hepatologist and an associate professor of Medicine at the Division of Gastroenterology at Western University.

Juan Pablo Arab, MD

Arab and Banerjee discuss how new therapies change discussions around screening, management of MASH

How New Therapies Change Discussions Around Screening, Management of MASH

In the final part of our 5-part video series, Arab and Banerjee discuss how an approval for MASH, such as resmetirom might shift discussions about the need for screening from reactive to proactive. The pair conclude the overall discussion by highlighting the importance of implementing screening strategies for asymptomatic patients with suspected liver disease. Banerjee outlines that establishing outpatient community diagnostic centers, where patients undergo blood tests and scans to determine their eligibility for treatment, will be critical in the UK and elsewhere. He highlights the role of primary care providers in prescribing medications based on recommendations from specialist clinics.

Arab also emphasized the importance of preventive medicine and the need to allocate resources effectively to target high-risk populations. He discusses the triage process in Ontario, Canada, where patients are assessed based on their risk of advanced liver disease and referred for further testing accordingly. Later, the pair agree on the necessity of non-invasive assessments, such as transient elastography, to identify patients who may benefit from treatment.

Before concluding the conversation, Arab and Banerjee touch on the scalability of screening programs, with Banerjee mentioning the increasing accessibility of diagnostic tests like MRI and fibroscan. Both experts commented on the availability of these technologies and emphasize the importance of tailoring screening strategies to each health system's resources and population needs.

Editor’s Note: This conversation was recorded on March 14, 2024 prior to the FDA’s approval of resmetirom.

Arab has no relevant disclosures to report. Banerjee’s disclosures include Perspectum Ltd.

Articles

In the final installment in our 5-part video series, our pair of experts in hepatology touch upon how an approval for MASH would impact conversations around screening for asymptomatic patient populations. 

 How New Therapies Change Discussions Around Screening, Management of MASH

JP Arab, MD, and Rajarshi Banerjee, MD, PhD, MSc, discuss how the study population of MAESTRO-NASH compares to MASH population in real-world settings. 

Comparing MAESTRO-NASH to Real-World MASH Populations

In this portion of the discussion, Arab and Banerjee address how the population and inclusion criteria for MAESTRO-NASH compare to that of real-world populations with MASH, with a specific focus on fibrosis levels. To begin the discussion, Arab notes a substantial proportion of patients in the MAESTRO study had advanced fibrosis (F3 or higher), which may influence the perspectives of clinicians entering the field. Banerjee emphasizes that the distribution of fibrosis severity can vary depending on the clinical setting, with primary care offices likely seeing more patients with early-stage fibrosis (F1 or F2) and liver transplant centers dealing with more advanced cases.

Regarding treatment targets, Banerjee suggests focusing on patients with higher fibrosis scores (F2 or F3) as they are at greater risk of adverse outcomes and may derive the most benefit from treatment. Arab concurs with this sentiment, suggesting an approach targeting this population could help prevent disease progression and associated complications, such as cirrhosis.

When discussing thresholds for initiating treatment, Banerjee mentions the use of transient elastography (Fibroscan) to assess fibrosis levels. He suggests using thresholds such as less than 8 for non-significant fibrosis (F0-F1) and greater than 12 for significant fibrosis (F2-F3), with patients falling between 8 and 12 potentially deriving the greatest magnitude of benefit from treatment.

Editor’s Note: This conversation was recorded on March 14, 2024 prior to the FDA’s approval of resmetirom. 

Videos

In part 4 of our 5-part video series, Arab and Banerjee discuss how the study population of MAESTRO-NASH compares to MASH populations in real-world settings. 

Real-World MASH Populations Compared to MAESTRO-NASH

JP Arab, MD, and Rajarshi Banerjee, MD, PhD, discuss MAESTRO-NASH and how it informs use of resmetirom in NASH. 

Understanding Resmetirom's Potential Based on MAESTRO-NASH

The discussion highlights how the advent of an approved therapy for MASH, formerly known as NASH, might impact the management of the disease. Recorded prior to the approval of resmetirom, the discussion centers around how the MAESTRO-NASH trial might inform use of the agent in real-world settings.

The trial results, recently published in the New England Journal of Medicine, indicate significant improvements in key clinical outcomes compared to a placebo, with around 25% of patients experiencing improvement and even higher rates with higher doses of the medication. The conversation also touches on the practical aspects of prescribing and monitoring patients on the medication. Both Arab and Banerjee agree that when the drug becomes available, they would consider prescribing it, especially for high-risk MAFLD populations

Later, the pair discuss the importance of monitoring for both efficacy and side effects, including gastrointestinal symptoms and muscle-related issues. Monitoring liver enzymes, liver function tests, and non-invasive fibrosis assessments like transient elastography are recommended, with consideration for potential changes in cardiovascular outcomes over time. Additionally, Arab and Banerjee emphasize the need for long-term follow-up given the gradual nature of fibrosis improvement.

In part 3 of our 5-part discussion, Arab and Banerjee dive into the results of the pivotal MAESTRO-NASH trial and how it can inform use of resmetirom in real-world settings. 

JP Arab, MD, and Rajarshi Banerjee, MD, PhD, discuss the challenges and recommendations for screening of liver disease.

Challenges, Recommendation Updates in Screening for MASH/MASLD

This portion of our 5-part peer-to-peer discussion focuses on optimal screening practices for MASH. The conversation delves into the challenges of recognizing and diagnosing MASH, with Arab emphasizing the need to screen high-risk patients due to the nonspecific symptoms of the disease. He suggests targeting populations with known high prevalence rates, such as those with diabetes, obesity, metabolic syndrome, or other metabolic dysfunctions, as they are more likely to develop and progress to advanced liver disease.

Following up on Arab’s statements, Banerjee adds to the discussion by highlighting the association between MAFLD and cardiovascular outcomes, citing research that suggests liver CT can predict cardiovascular risk. He notes regional differences in MAFLD prevalence, with higher rates observed in certain populations, such as those in South America with specific genetic polymorphisms. Both doctors emphasize the importance of tailoring screening and intervention strategies to high-risk populations while making diagnostics more accessible and less reliant on invasive procedures like biopsies.


In part 2 of this 5-part video series, our experts in hepatology discuss the challenges, pitfalls, and recommendations for screening of MASH/MASLD in real-world settings. 