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This discussion on ways to improve MASH patient management comes from the early July roundtable on "Major Issues of the First Six Months of 2025." As a reminder, that roundtable included the three co-hosts (Louise, Jörn Schattenberg and Roger Green)

Roger drives this conversation, focusing on two very different, yet very important issues: the first is the increasing dynamism of the in-office scanning market, with leader Echosens developing new products and services, while companies like e-Scopics, Sonic Incytes, and Mindray (Hepatus) are introducing new devices with competing profiles. Roger discusses the idea that some scanners keep all data resident in the machine, while others send it immediately to the cloud. Louise suggests that while we should welcome any reliable scanning device to the market, Echosens has a significant advantage in terms of data richness and depth when compared to all competitors. (NOTE: This benefit became clearer when Echosens submitted a Letter of Intent to the FDA to qualify liver stiffness measurement (LSM) using VCTE, as found in FibroScan, as a reasonably likely surrogate endpoint in clinical trials for MASH.

Separately, he lists some concerns about how the Trump Administration's focus on cutting services to the poor, coupled with Robert F. Kennedy Jr.'s distrust of pharmaceuticals and mainstream health research, might limit the number of Americans with access to healthcare and the kinds of care they can access.

At the end of this conversation, Roger asks Jörn and Louise what they consider major issues for the next six months.

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Last month, The Lancet posted online an article from Stine Johansen, Fredrik Åberg, Emmanuel Tsochatzis and Aleksander Krag, titled "Screening for Advanced Liver Disease." The article aims to update the Wilson and Jungner criteria, initially developed in 1960, to address modern needs and issues. In this conversation, Professor Krag and Dr. Johansen join Roger Green to discuss their article.

There are many nuances and high points to cover in this thoughtful, fairly lengthy conversation, but one key point is that screening a mass population for HCC or cirrhosis has an entirely different set of issues and criteria compared to the screening usually discussed on this podcast, which involves identifying a population at increased risk for MASLD or MASH and screening them. Also, healthcare is far more expensive than it was in 1960 with a plethora of high-cost ways to diagnose, treat and manage patients.

As a result, the authors started with the 10 Wilson and Jungner criteria and added eight more. During this conversation, Stine emphasizes the need for a comprehensive clinical trial on this issue, and all panelists agree that LiverAIM is likely to serve as the study.

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This discussion on ways to improve MASH patient management comes from the early July roundtable on "Major Issues of the First Six Months of 2025." As a reminder, that roundtable included the three co-hosts (Louise, Jörn Schattenberg and Roger Green)

Louise drives this conversation based on two related issues she sees emerging: (i) increasing opportunities for motivated patients to manage their own health and (ii) managing the total patient in an environment where people may be taking incretin agonists as if they are consumer drugs. With increased access to scanning, providers can monitor patients (and patients can self-monitor) more closely. However, some of the issues a provider might find are tricky: patients who undertake what Louise describes as "the sneaky areas patients think are normal, but are probably contributing to disease" due to miseducation or no education on healthy eating and lifestyle, or patients purchasing and using incretin agonists through consumer channels, but possibly at subtherapeutic doses. Vigilance and probing are key here, but health systems will need to train more people on the types of probing that uncover underlying issues and behaviors that patients mistakenly believe to be healthy.

The discussion also extends to the role of NITs in diagnosis and patient management, and how providers need to shift the paradigm away from describing a patient by fibrosis stage and instead focus on the amount of fat in the liver and its overall suppleness.

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00:00:00 - Surf's Up: Season 6 Episode 13
Louise Campbell, Jörn Schattenberg and Roger Green continue their discussion of some major issues from earlier this year, while co-authors Aleksander Krag and Stine Johanset join Roger to discuss their recent publication in The Lancet, titled "Screening for Advanced Liver Disease."

00:04:45 - Major Issues of the First Six Months: Integrated Patient Management

Louise drives this conversation based on two related issues she sees emerging: (i) increasing opportunities for motivated patients to manage their own health and (ii) managing the total patient in an environment where people may be taking incretin agonists as if they are consumer drugs. With increased access to scanning, providers can monitor patients (and patients can self-monitor) more closely. However, some of the issues a provider might find are tricky: patients who undertake what Louise describes as "the sneaky areas patients think are normal, but are probably contributing to disease" due to miseducation or no education on healthy eating and lifestyle, or patients purchasing and using incretin agonists through consumer channels, but possibly at subtherapeutic doses. Vigilance and probing are key here, but health systems will need to train more people on the types of probing that uncover underlying issues and behaviors that patients mistakenly believe to be healthy.

00:21:02 - Newsmakers: Aleksander Krag and Stine Johansen discuss Screening for Advanced Liver Disease

Last month, The Lancet posted online an article from Stine Johansen, Fredrik Åberg, Emmanuel Tsochatzis and Aleksander Krag, titled "Screening for Advanced Liver Disease." The article aims to update the Wilson and Jungner criteria, originally developed in 1960, to address modern needs and issues. In this conversation, Professor Krag and Dr. Johansen join Roger Green to discuss their article.

There are many nuances and high points to cover in this thoughtful, fairly lengthy conversation, but the key point is that screening a mass population for HCC or cirrhosis has an entirely different set of issues and criteria compared to the screening usually discussed on this podcast, which involves identifying a population at increased risk for MASLD or MASH and screening them.

00:54:42 - Major Issues of the First Six Months: Changes in US Health Policy and Potential for Dynamism in the In-Office Scanning Market

Roger drives this conversation, focusing on two very different, yet very important issues: the first is the increasing dynamism of the in-office scanning market, with leader Echosens developing new products and services, while companies like e-Scopics, Sonic Incytes, and Mindray (Hepatus) are introducing new devices with competing profiles. Roger discusses the idea that some scanners keep all data resident in the machine, while others send it immediately to the cloud. Louise suggests that we should welcome any reliable scanning device to the market.

Separately, he lists some concerns about how the Trump Administration's focus on cutting services to the poor, coupled with Robert F. Kennedy Jr.'s distrust of pharmaceuticals and mainstream health research, might limit the number of Americans with access to healthcare and the kinds of care they can access.

At the end of this conversation, Roger asks Jörn and Louise what they consider major issues for the next six months.

01:11:40 - Business Report and Wrap-Up

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Key Opinion Leaders Manal Abdelmalek, Naim Alkhouri, Scott Isaacs and Zobair Younossi join Roger Green to discuss the FDA's approval of semaglutide for patients with non-cirrhotic MASH. This conversation centers on the roles that new technologies and an expanded APP population will play in MASLD and MASH management in the US, and concludes by exploring how care might look different 12 months from now, and then in subsequent years.

As panelists identify some of the changes they foresee if we are to manage the tsunami of undiagnosed MASLD patients, many comments touch on themes discussed earlier in this episode. A couple are unique. Zobair and Scott discuss the increased role that artificial intelligence and big data analytics will play in identifying high-risk patients and improving clinical pathways. Additionally, Zobair notes that we must remember that the vast majority of MASLD patients will never develop MASH. Manal foresees a more sophisticated approach to selecting pharmacotherapies as prescribers have a broader set of options, each with its own benefits and drawbacks. Scott anticipates a "paradigm shift" in which endocrinologists view MASH similarly to how they view retinopathy, neuropathy and retinopathy. Naim suggests that one year will not look tremendously different from today, but that five years from now will be an entirely different picture, which he describes in some detail.

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Key Opinion Leaders Manal Abdelmalek, Naim Alkhouri, Scott Isaacs and Zobair Younossi join Roger Green to discuss the FDA's approval of semaglutide for patients with non-cirrhotic MASH. This conversation focuses on how the US healthcare system must adapt to handle the growing number of MASH and MASLD patients who might seek treatment, given likely increases in publicity and education.

The conversation starts with a focus on the implications of semaglutide approval for hepatologists. Naim states that many hepatologists are currently uncomfortable managing patients on GLP-1 agonists. This will need to change. Manal points out that providers must check for cirrhosis when testing for MASH and understand how to respond accordingly. An increase in the number of providers having access to in-office scanning devices will facilitate this process.

Zobair shifts to a larger point: even if all related specialists integrate MASH into their practices, the actual patient care demand will require alternative pathways in which the responsibility for patient care will rest with specialist APPs. The number of APPs necessary to handle this load and trained to do so does not currently exist in the US. Increased APP training must, and will, become an area for increased investment and focus.

After Naim Alkhouri describes some of the differences between resmetirom and semaglutide in terms of practical treatment decisions, the discussion focuses on why MASLD and MASH will create unique challenges for hepatology practices. Manal views the issue as a matter of time; practices cannot absorb large numbers of new, non-urgent patients. Naim suggests that the real issue is the business question: specialists today do not profit simply from treating patients. Zobair agrees with Naim and notes that the challenge is not unique to hepatology. He expresses the hope that AI and efficient database management will make it easier to target, screen, diagnose and treat patients...given sufficient providers (mostly APPs) to treat them.

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Key Opinion Leaders Manal Abdelmalek, Naim Alkhouri, Scott Isaacs and Zobair Younossi join Roger Green to discuss FDA's approval of semaglutide for patients with non-cirrhotic MASH. This conversation focuses on benefits for patients and ways that having two drugs with different modes of action will change pharmacotherapy choices.

This conversation starts with the group describing the sense of "enthusiasm" and "fulfillment" hepatology drug developers feel to see two drugs approved in the US and many other major changes to come (more drug approvals, FDA acceptance of a path to approval that is not based on liver biopsy). One interesting takeaway is that while the approval of semaglutide will likely change the number of patients treated with MASH pharmacotherapy, the greater impact of this approval will be on public awareness of MASH and the accompanying demand for treatment. In terms of actual drug use, the first major change will come among patients living with obesity but not Type 2 diabetes. Most of these patients previously saw their semaglutide prescriptions rejected for payment by health insurers. However, many of these patients will be living with MASH, and they are likely to see their prescriptions approved.

Instead, the largest impact may involve increased education and awareness. Scott pointed out that endocrinologists, who frequently prescribe incretin agonists, will have reason to learn how to diagnose and manage MASH in patients they already treat. Zobair noted that an array of companies, starting with pharmaceutical manufacturers and scanning companies, will dramatically increase investments in prescriber and patient education.

Another important benefit may come in terms of coverage. Scott points out that most patients living with obesity but not diabetes are unlikely to have their semaglutide prescriptions covered by commercial insurers. Those living with non-cirrhotic MASH are likely to have semaglutide covered. A separate but related point: Naim reports that ~30% of the MASH patients he sees are taking an incretin agonist at the time of initial visit.

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00:00:00 - Surf's Up, Season 6, Episode 12
This week's episode is a special three-part roundtable on the implications of the FDA's recent approval of semaglutide. Naim Alkhouri, Manal Abdelmalek, Scott Isaacs and Zobair Younossi join Roger Green in a discussion that focuses less on specifics of pharmacotherapy and more on how having two drugs available will change MASH management in the US.

00:08:45 - Part I: How Will The Semaglutide Approval Affect Patient Treatment and Pharmacotherapy?
The group starts by describing the sense of "enthusiasm" and "fulfillment" hepatology drug developers feel to see two drugs approved in the US and many other major changes to come (more drug approvals, FDA acceptance of a path to approval that is not based on liver biopsy). One interesting takeaway is that while the approval of semaglutide will likely change the number of patients treated with MASH pharmacotherapy, the greater impact of this approval will be on public awareness of MASH and the accompanying demand for treatment. In terms of actual drug use, the first major change will come among patients living with obesity but not Type 2 diabetes. Most of these patients previously saw their semaglutide prescriptions rejected for payment by health insurers. However, many of these patients will be living with MASH, and they are likely to see their prescriptions approved.

Instead, the largest impact may involve increased education and awareness. Scott pointed out that endocrinologists, who frequently prescribe incretin agonists, will have reason to learn how to diagnose and manage MASH in patients they already treat. Zobair noted that an array of companies, starting with pharmaceutical manufacturers and scanning companies, will dramatically increase investments in prescriber and patient education.

00:25:30 - Part II: How the Structure of Medical Practice Is Likely To Change
Naim states that many hepatologists are currently uncomfortable managing patients on GLP-1 agonists. This will need to change. Manal points out that providers must check for cirrhosis when testing for MASH and understand how to respond accordingly. An increase in the number of providers having access to in-office scanning devices will facilitate this process. Zobair states that even if all related specialists integrate MASH into their practices, the actual patient care demand will require alternative pathways in which the responsibility for patient care will rest with specialist APPs.

After Naim Alkhouri describes some of the differences between resmetirom and semaglutide in terms of practical treatment decisions, the discussion focuses on why MASLD and MASH will create unique challenges for hepatology practices. Manal views the issue as a matter of time; practices cannot absorb large numbers of new, non-urgent patients. Naim suggests that the real issue is the business question: specialists today do not profit simply from treating patients. Zobair agrees with Naim and notes that the challenge is not unique to hepatology. He expresses the hope that AI and efficient database management will make it easier to target patients, screen, diagnose and treat them.

00:44:17 - Part III: What Happens Next?
In this final section, panelists identify some of the changes they foresee if we are to manage the tsunami of undiagnosed MASLD patients. Many of the comments touch on themes discussed earlier in this episode, but a couple are unique. Zobair states we must remember that the vast majority of MASLD patients will never develop MASH. Manal foresees a more sophisticated approach to selecting pharmacotherapies as prescribers have a broader set of options, each with its own benefits and drawbacks. Scotts anticipates a "paradigm shift" in which providers come to view MASH similarly to how they view diabetic comorbidities.