Steatotic liver disease is the commonest chronic liver disease, and the 2023 nomenclature carved out a middle category — metabolic dysfunction- and alcohol-associated liver disease (MetALD) — for patients who have both cardiometabolic risk and meaningful alcohol intake. This AGA Clinical Practice Update offers best-practice advice for it.
The practical core: classify a patient by their cardiometabolic risk factors and their weekly alcohol intake (roughly 140–350 g/week in women and 210–420 g/week in men defines the MetALD band); ask about alcohol at diagnosis and at least yearly, using questionnaires or biomarkers; and stage fibrosis with a tiered non-invasive strategy — start with the Fibrosis-4 index, then move indeterminate or high-risk patients to elastography or the Enhanced Liver Fibrosis test. Advise abstinence, treat cardiometabolic risk, replace folate, thiamine and vitamin D, and avoid bariatric surgery here for want of safety data. GLP-1-based drugs may help both the liver and alcohol cravings, but are untested in MetALD specifically.
For India, where fatty liver and alcohol use frequently coexist, the message is to stop treating these as separate diagnoses and to quantify both the metabolic and the alcohol contribution in every patient.
- Classify steatotic liver disease by cardiometabolic risk and weekly alcohol intake, not one or the other.
- Ask about alcohol at diagnosis and at least annually, using questionnaires or biomarkers.
- Stage fibrosis with FIB-4 first, escalating indeterminate or high-risk patients to elastography or ELF.
- Avoid bariatric surgery in MetALD for lack of safety data; treat cardiometabolic risk and advise abstinence.
Why it matters
It stops metabolic and alcohol-related fatty liver being managed as separate problems when they commonly coexist.
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