An AGA Clinical Practice Update in Clinical Gastroenterology and Hepatology (22 September 2026) gives nine best practice advice statements on metabolic dysfunction- and alcohol-associated liver disease (MetALD) — steatotic liver disease with cardiometabolic risk and moderate alcohol intake. It is expert opinion from a literature review, without formal evidence grading.
MetALD is defined by about 140-350 g of alcohol a week in women and 210-420 g in men, ideally over three months or more. All patients with steatotic liver disease should have alcohol use assessed at diagnosis and at least annually, by interview, questionnaire or biomarkers, and be advised to stop drinking. Fibrosis should be staged with FIB-4 first and elastography or ELF for indeterminate or high results — with caution, because active drinking raises liver stiffness. Management includes diet, exercise, micronutrient replacement (folate, thiamine, vitamin D), cardiometabolic risk treatment and alcohol use disorder pharmacotherapy where needed. Resmetirom and semaglutide have not been studied in MetALD, and bariatric surgery is not advised.
For gastroenterologists and hepatologists, the practical shift is making alcohol quantification in grams a routine part of every steatotic liver assessment.
- Record alcohol intake in grams per week for every patient with steatotic liver disease
- Reassess alcohol use at least yearly, with AUDIT-C or biomarkers where history is uncertain
- Stage fibrosis with FIB-4 first, then elastography or ELF for indeterminate or high scores
- Interpret a high liver stiffness cautiously in a patient still drinking
- Replace folate, thiamine and vitamin D, and treat alcohol use disorder with medication where indicated
Why it matters
It gives structured advice for the large group whose liver disease has both metabolic and alcohol drivers, who fall between existing guidelines.
Don't overread it
These are expert-opinion best practice statements without formal evidence grading.
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