MASH Academy: Advanced Care Strategies for Metabolic Dysfunction-Associated Steatohepatitis

Summary

This on-demand teaching session by Dr. Blanca Lizaola-Mayo is essential for medical professionals dealing with patients with metabolic dysfunction-related steatohepatitis. The session covers advanced care strategies for this specific form of nonalcoholic fatty liver disease (NAFLD), informed by two-year global research involving 56 countries and 275 panelists. It delves into the newly established protocols and nomenclature for diagnosing NAFLD, offering a simple yet detailed approach adaptable to both adults and children. The teaching session also covers important aspects like the correlation between menopause and the disease, the implications of alcohol intake, and the risk factors to look out for. Furthermore, the session explores diagnosis and screening methods, treatment options, and significant lifestyle modifications. Sign up to gain a deeper understanding of this modern epidemic affecting about 25% of the global population.

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Description

This program is funded by an independent grant from Novo Nordisk. This online education program has been designed solely for healthcare professionals in the USA. The content is not available for healthcare professionals in any other country.

This accredited On Demand teaching session is presented by MASH expert Dr Blanca Lizaola-Mayo and focuses on developing advanced care strategies that leverage a multidisciplinary approach to improve patient outcomes. (Further sessions can be found here)

Advanced Multidisciplinary Care

Get the latest updates and clinical trial results supporting the importance of a multidisciplinary care approach, discussing the roles of various specialists, including dieticians, exercise therapists, and endocrinologists, in the management of MASH, including case studies that highlight successful multidisciplinary interventions.

Diet, Nutrition & Excercise

The nutritional management segment will cover latest updates and clinical trials to give evidence-based dietary interventions specifically for MASH patients, alongside strategies for effective collaboration with dieticians to optimize patient outcomes. It will also address the critical role of exercise and physical activity in managing MASH, focusing on developing individualized exercise plans in partnership with exercise therapists.

Patient Education

Patient education and support programs will be another key focus, where we will discuss the design of patient education materials and programs, as well as techniques to improve patient adherence to treatment plans.

Who is this course for

This online education program has been designed solely for healthcare professionals in the USA. The course provides continuing education for:

✅ Gastroenterologists

✅ Hepatologists

✅ Other Healthcare Professionals

Faculty

Blanca Lizaola-Mayo, MD

Dr. Blanca Lizaola-Mayo, MD, is a leading Transplant Hepatologist at Mayo Clinic Arizona, where she oversees the Liver Transplant Center as the Medical Director. She also contributes to the academic field as the Associate Program Director of the Transplant Hepatology Fellowship and serves as an Assistant Professor of Medicine at Mayo Clinic College of Medicine. In her role as a Senior Associate Consultant in the Division of Gastroenterology & Hepatology, Dr. Lizaola-Mayo's research interests include fatty liver disease, health disparities, and outcomes following liver transplants. She co-founded the Fatty Liver Clinic at Mayo Clinic Arizona, providing specialized, multidisciplinary care for patients with Nonalcoholic Fatty Liver Disease.

Continuing Education Information

This continuing education activity is provided by AffinityCE and MedAll. This activity provides continuing education credit for physicians, physician assistants, nurses, and nurse practitioners and pharmacists. A statement of participation is available to other attendees.

Disclosures

No relevant financial relationships with ineligible companies to disclose.

Intends to discuss non-FDA uses of drug products and/or devices and their unlabeled indications. The discussion relates to GLP-1 in the context of MASH and will be disclosed to the audience when this discussion takes place.

AffinityCE staff, MedAll staff, as well as planners and reviewers, have no relevant financial relationships with ineligible companies to disclose.

Mitigation of Relevant Financial Relationships

AffinityCE adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CME activity, including faculty, planners, reviewers, or others, are required to disclose all relevant financial relationships with ineligible companies. Relevant financial relationships were mitigated by the peer review of content by non-conflicted reviewers prior to the commencement of the program.

Activity Accreditation for Health Professions

Physicians This enduring activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and Medall. AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring activity for a maximum of 0.75 _AMA PRA Category 1 Credits_™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physician Assistants This enduring activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and MedAll AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring activity for a maximum of 0.75 _AMA PRA Category 1 Credits_™. Physician assistants should claim only the credit commensurate with the extent of their participation in the activity.

Nurse Practitioners This enduring activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AffinityCE and MedAll. AffinityCE is accredited by the ACCME to provide continuing medical education for physicians.

AffinityCE designates this enduring activity for a maximum of 0.75 _AMA PRA Category 1 Credits_™. Nurse practitioners should claim only the credit commensurate with the extent of their participation in the activity.

Nurses Continuing Nursing Education is provided for this program through the joint providership between MedAll and AffinityCE. AffinityCE is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation (ANCC). This enduring activity provides a maximum of 0.75 hours of continuing nursing education credit.

Criteria for Claiming CNE Credit: Participants must have registered and attended the entire program. Attendance is monitored online for participation in the entire activity.

Pharmacists AffinityCE is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education (CPE).

UAN: 0829-9999-24-156-L01-P

Activity Type: Knowledge-based

CEUs: 1.5

No cost to participate.

Participant CE records will be electronically communicated to CPE Monitor.

Pharmacist Learning Objectives

At the conclusion of this web conference, participants should be able to:

Develop comprehensive care strategies for patients with MASH, emphasizing a multidisciplinary approach:

Foster collaboration with dietitians, exercise therapists, and other specialists to address the complex needs of MASH patients.
Create and implement patient education and support programs to enhance treatment adherence and improve overall health outcomes.

Criteria for Claiming CPE Credit: Participants must have registered and attended the entire program. Attendance is monitored online for participation in the entire activity.

System Requirements

Mobile device (e.g., large-format smart phone; laptop or tablet computer) or desktop computer with a video display of at least 1024 × 768 pixels at 24-bit color depth, capable of connecting to the Internet at broadband or faster speeds, with a current version Internet browser and popular document viewing software (e.g., Microsoft Office, PDF viewer, image viewer) installed. Support for streaming or downloadable audio-visual materials (e.g., streaming MP4, MP3 audio) in hardware and software may be required to view, review, or participate in portions of the program

Other Health Care Professionals All other health care professionals completing this continuing education activity will be issued a statement of participation indicating the number of hours of continuing education credit. This may be used for professional education CE credit. Please consult your accrediting organization or licensing board for their acceptance of this CE activity.

Participation Costs

There is no cost to participate in this program.

CME Inquiries

For all CME policy-related inquiries, please contact us at ce@affinityced.com.

How to Earn CE Credit

At the end of the live session participants will be sent an email with a feedback form. On completion of the feedback form participants with be issued a certificate with their CE credit.

How to Earn CE Credit: Pharmacists Only

Diagnostic Updates in Metabolic Dysfunction-Associated Steatohepatitis

Registration for the Activity does not establish an account in the CE Center or automatically provide continuing education credit. You must sign into the CE Center site and evaluate the content of the activity to earn CE credit.

1.Please use the private evaluation link provided to you to access the CE Center.

IMPORTANT: You must use this link every time you access the CE Center for this activity.

2. Select the activity: Diagnostic Updates in Metabolic Dysfunction-Associated Steatohepatitis

3. Enter an e-mail address and password to begin setting up your profile. Select “I Forgot My Password” if you need to reset the password you set up.

4. Verify, correct, or add your information.

5. Participants claiming Pharmacist CE credits will need to supply their Date of birth and NABP e-Profile ID. Pharmacy CE records will be electronically communicated to CPE Monitor.

6. Complete the post-activity evaluation after attending the entire program.

7. After completing the activity evaluation, you will be able to download your CE certificate. Your CE record will also be stored here for later retrieval.

8. The website is open for completing your evaluation until July 24, 2025.

9. After the website has closed, you can come back to the site at any time to download your certificate, but you will not be able to add any evaluations.Please send any customer service requests to cds_support+medall@affinityced.com.

Learning objectives

Understand the new nomenclature of non-alcoholic fatty liver disease (NAFLD) and Metabolic Dysfunction-Associated Steatohepatitis (MASH) as well as how they are diagnosed and treated.
Recognize the risk factors and prevalent demographics for Metabolic Dysfunction-Associated Steatohepatitis (MASH), including male, Hispanic, obese, type 2 diabetic, and hypercholesterolemic individuals.
Learn how to identify and screen patients who are at risk for metabolic dysfunction-associated steatohepatitis using available diagnostic tools, such as BMI, waist circumference, blood glucose levels, blood pressure, triglyceride levels, and HDL levels.
Understand how to interpret and use prediction tests, such as the NAFLD Fibrosis Score, Aspartame Aminotransferase to Platelet Ratio Index (APRI), and the Fibrosis-4 Index (FIB-4).
Recognize the importance of a multidisciplinary care approach, including lifestyle modifications, medications, and potential bariatric surgery, in the treatment of patients with metabolic dysfunction-associated steatohepatitis.

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Blanca Lizaola-Mayo, MD MASH Academy Advanced Care Strategies for Metabolic Dysfunction-Associated SteatohepatitisNew NAFLD NomenclatureNAFLD Nomenclature • 2-year global consensus process • 56 countries • 275 panelists EASL 2023 (Vienna, Austria) aasld.orgNomenclature that is affirmative and non-stigmatizing • Simple, readily available with easily measurable parameters • Well established cardiometabolic risk factors • Also adapted to the pediatric population aasld.orgMASLD Resources www.aasld.org aasld.orgMASLD ResourcesNew SLD nomenclature Updated - FLD New New Metabolic Dysfunction- Associated Steatohepatitis Same (MASH) Updated Updated NAFLD NASHMetabolic Dysfunction Associated Steatotic Liver Disease • Hepatic steatosis with 1/5 cardiometabolic risk factors: • BMI >25 or waist circumference >94 → men and >80in → females • FSG >100 mg/dL or 2hr blood glucose >140 or HgbA1c >5.7% or T2DM dx • Blood pressure >130/85mmHg or antihypertensive medications • Triglycerides >150 mg/dL or anti-lipid medications • HDL < 40 mg/dL or anti-lipid medications aasld.orgMETALD MASLD and increased alcohol intake Females • 20-50 g/day • 140-350 g/week Males • 30-60 g/day • 210-420 g/week Standard drink: 6 fl oz or 14 grams of pure alcoholMASLD EpidemiologyPrevalence of Chronic Liver Disease • Male Factors • Hispanic • Male • Obesity • Hispanic • Type 2 diabetes • Obesity • Hypercholesterolemia • Type 2 diabetes • Hypertension • Hypercholesterolemia • Hypertension Younossi, et al.Gut 2020;69:564-568.MASLD numbers: Epidemiology The Global Prevalence of nonalcoholic Fatty Liver Disease (NAFLD) • Global fatty liver disease prevalence → 25% • US 30% of the population South America 30.45% • More common in men NorthAmerica 23.71% 24.13% • Children 7-10% Middle East • 2nd leading cause for liver transplantation 31.79% • Leading cause of death: Cardiovascular Africa SouthAmerica 13.48% 30.45% GastYounossi et al. J Hepatology2019. Menopause and MASLD • Higher MASLD prevalence in post- menopausal women • Hypoestrogenism, dyslipidemia and insulin resistance • Increase risk to MASH progression Journal of Hepatology. Vol. 79 Issue 6 Endocrinology, 2020, Vol. 161, No. 10, 1–12.Bariatric surgery and AUD • Patients who undergo bariatric surgery are at greater risk alcohol misuse problems in the early years following bariatric procedures. • Effect more pronounced in women Liver Int. 2021 May; 41(5): 1012–1019.MASLD Diagnosis & ScreeningSteatotic liver Disease definition Accumulation of fat in the liver MASLD MASH • ≥5% Hepatic steatosis by imaging or • ≥5% Hepatic steatosis and inflammation histology, and with hepatocyte injury • Lack of secondary causes of hepatic fat accumulation N Engl J Med 2017; 377:2063-2072New nomenclature of non-alcoholic fatty liver disease MASLD = hepatic steatosis + 1 of 5 cardiometabolic risk factors MASH = presence of inflammation and cellular injury Cardiometabolic risk factors: • BMI >25 or waist circumference >94in in men and more than 80 in females • FSG >100 mg/dL or 2hr blood glucose >140 or HgbA1c >5.7% or T2DM dx • Blood pressure >130/85mmHg or antihypertension medications • Triglycerides >150 mg/dL or anti-lipid medications • HDL < 40 mg/dL or anti-lipid medicationsNatural History of Nonalcoholic Fatty Liver Disease Cirrhosis 20-30% 20% stage3 Over 3 years Fibrosis over2 years 60-80 million 15-20 million 13-16 Americans Americans million Stage 1-3 1-2 million Hepatocellular carcinoma Gastroenterology 2020;158:1851–1864 Aliment PhaCell. 2021 May 13;184(10):2537-2564159In which patients should we suspect SLD? ≥2 Metabolic Risk Factors • Central obesity • Prediabetes • Insulin resistance • Hypertension • High triglycerides Type 2 Diabetes Screen for NAFLD with Advanced Fibrosis Liver Steatosis • US, CT or MRI Elevated Aminotransferases • Men >40 U/L • Women >30 U/L Gastroenterology 2021; 161:1657-1669Prediction T ests • NAFLD Fibrosis Score • Aspartame Aminotransferase to Platelet Ratio Index (APRI) • Fibrosis-4 Index (FIB-4) Cutoff Fibrosis stage <1.45 F0-F2 -1.45 to 3.25 Indeterminate >3.25 F3-F4 ClinGastroenterology 2020;158:1851–18641112 Hepatology 2007;45:846-854Imaging • Ultrasound • Computed tomography • Transient elastography (kPa) • Most widely used • Predicts risk of decompensation Kilopascals (kPa) < 2.5= No fibrosis • Accurate in detecting advanced 2.51-7= Stage 1 fibrosis 7.1-9.5= Stage 2 • Magnetic resonance* 9.51-12.4 = Stage 3 • Stiffness cutoff 3.63 kPa > 12.5 = Cirrhosis • Sensitivity 0.86, specificity 0.91 Hepatology 2016;64:2234-2243 Radiographics 2016;36:1987-2006Who to refer to GI or Screening Hepatology • Indeterminate or high risk based • Patients with pre-DM/T2DM, or ≥2 on fibrosis risk stratification metabolic risk factors → FIB-4 every 1–2 years. • Evidence of advance liver disease • Abnormal liver enzymes for > 6 • No T2DM and <2 metabolic risk months factors → Every 2-3 yearsMASLD TreatmentTreatment – Team Approach • Multidisciplinary care • Personalized approach • Lifestyle modifications • Medications • Bariatric Surgery and Endobariatrics Image Copyright Getty ©2024 Mayo Foundation for Medical Education and Research | WF902700-24Medications and body weight • Antidepressants: monoamine oxidase inhibitors, • Anticonvulsants: topiramate, zonisamide, tricyclic antidepressants (nortriptyline, amitriptyline, lamotrigine doxepin), paroxetine, citalopram, escitalopram, • Antidepressants: bupropion, venlafaxine, imipramine, mirtazapine desvenlafaxine • Antipsychotics: thioridazine, olanzapine, risperidone, clozapine, quetiapine • Antipsychotics: ziprasidone • Attention deficit hyperactivity disorder: • Diabetes: insulin, sulfonylureas, thiazolidinediones, methylphenidate, amphetamine, i meglitinides dextroamphetamine e • Glucocorticoids o s • Hormonal agents: progestins, b medroxyprogesterone O • Anti-seizure medications: divalproex • Neurological agents and mood stabilizers: lithium, carbamazepine, gabapentin, valproate • Antihistamines: cyproheptadine • Alpha-blockers: terazosin Ann Intern Med 2013; 159:ITC3-1 • Beta-blockers: propranolol Circulation 2012; 125:1695Lifestyle Modifications Weight loss • 3-5% → Improve steatosis • 7% → Improve the histological characteristics of MASH • 10% → Fibrosis Therap Adv GastroenGoogle image9(1):113-120.Diet • Calorie restriction 500-1000/day • Limit red meat, processed and high-fructose foods • Caffeinated coffee reduces the risk of liver fibrosis in MASH • Avoid any herbal supplements or dietary teas Hepatology. 2018;67(1):328-357Diet Compensated cirrhosis • Recommend losing 5-10% weight • Hypocaloric diet (1200-1500 kcal/d Kcal/kg/día Protein or decrease of 500 kcal/d) gr/kg/day Decompensated cirrhosis Normal 35 1.2-1.5 • Avoid prolonged fasting Obese 15-20 >1.5 • Focus on improving nutrition and muscle mass • High-protein diet • Nightly snack high in protein J Hepatology. 2017;67:829-846 Hepatology. 2018;67(1):328-357Diets Diet Liver Weight Metabolic Steatosis FibrosisCardiovascular risk enzymes parameters Mediterranean ✓ ✓ ✓ ✓ ✓ ✓ Low HCO ✓ ✓ ✓ +/- +/- ✓ Keto ✓ ✓ ✓ +/- Intermittent ✓ ✓ +/- +/- ✓ fasting Plan based ✓ ✓ ✓ ✓ Hepatology. 2018;67(1):328-357Exercise • 150 to 180 min of moderate-intensity exercise/week or 75-150 min of intense exercise per week in 3-5 sessions • Decompensated cirrhosis • Exercise is NOT contraindicated (low impact) J Hepatology. 2017;67:829-846 Hepatology. 2018;67(1):328-357Weight loss interventions The Adv Gastrointest Endosc. 2022 Jun 7:15.AACE.comN Engl J Med 2024; 390:497-509Phase 2 Trial • F2-F3 fibrosis (biopsy) • 5mg, 10mg or 15 mg for 52 weeksWhat happens when it stops?STEP 4 • Study Type: Phase 3a, Randomized, Double Blind, withdrawal study • Participants: N 902, BMI > 30 or BMI > 27 + comorbidity • Exclusion: diabetes • Intervention: after 20 weeks of treatment, randomize again to cont txt or placebo • Duration: The study lasted 68 weeks (16 months). Add citation hereSTEP 4 - Results Continuation group vs Withdrawal group • TBWL: - 7.9% vs + 6.9% • Waist Circumference: -9.7 cm • Systolic Blood Pressure: - 3.9 mm • Physical Function Survey: + 2.5 Add citation hereSTEP 1 Trial Extension • Aim: To explore changes in body weight and cardiometabolic risk factors after treatment withdrawal in the STEP 1 trial extension. • Participants: See STEP 1. N = 327 (232 txt, 101 placebo) • Intervention: Discontinue txt (semaglutide & LM) at 68 weeks • Duration: 52 weeks (after discontinuation) Add citation hereSTEP 1: Trial Extension Results Add citation hereSTEP 1: Trial Extension Results Add citation hereCan we use it long term? What happens if we do?STEP 5 Study Type: Phase 3, Randomized, Double Blind, Placebo controlled Participants: N 304, BMI > 30 or BMI > 27 + comorbidity Exclusion: diabetes Intervention: semaglutide 2.4 mg or placebo (1:1) Duration: 104 weeks NATURE MEDICINE, AUGUST 2022 Unapproved product related discussions: GLP1 in the context of MASH STEP 5 - Results Add citation here Unapproved product related discussions: GLP1 in the context of MASH TIRzepatide Approved in Nov 2023 • MOA: GLP-1 Receptor Agonism AND GIP • Route: SubQ • Dose: 2.5mg wk. Increase by 2.5 mg q4wk. Max dose 15 mg qwk. • Efficacy: 15 to 26% • Side Effects • GI: N/V, Diarrhea, Constipation, Abdominal Pain, Pancreatitis • Other: Injection Site Rxn, Depression & SI, hypoglycemia • Contraindications: PFHx of Medullary Thyroid Carcinoma, MEN2, pancreatitis, severe DKA Add citation hereCONCLUSIONS • # 1 chronic liver disease in the world • Screen those patients at high risk • Stage 2 fibrosis is associated with liver- related outcomes • Treatable disease • Multidisciplinary aggressive treatment Thank you! lizaola-mayo.blanca@mayo.edu @Blankmd22