EASL expert guidance on fatty liver (SLD): who gets tested where, and who treats how?

In short: The European Association for the Study of the Liver (EASL), together with other societies, has published a guidance document on fatty liver. It describes how family doctors, diabetes and obesity clinics and liver specialists should work together: test people with risk factors, treat according to severity, refer on when scarring is present. About one in three adults is affected ¹.

Status of the evidence: This is a consensus statement by 36 experts, not a study with new data and not a systematic analysis. EASL commissioned it in 2024; the statements were presented at the EASL steatotic liver disease summit in Estoril on 23 January 2025. Received 20 January 2026, accepted 24 February 2026, online since 25 February 2026, printed in September 2026 in JHEP Reports (volume 8). Article written on 4 October 2026. Newer recommendations are not covered.

What is this about?

Fatty liver (steatotic liver disease, SLD) is very common worldwide. Usually metabolism is behind it (MASLD), sometimes alcohol or both. For a long time it causes no symptoms. What matters is whether scar tissue (fibrosis) forms. The guidance follows the path of those affected, from prevention through finding people at risk to treatment ¹.

Who should be tested?

Testing the whole population for liver fat is not recommended. People with risk factors such as type 2 diabetes, overweight, metabolic problems or hazardous alcohol use should be checked, as well as anyone with abnormal liver values. In diabetes clinics, an analysis of 28 studies with more than 10,000 people found about 20% had raised liver stiffness ¹.

How is testing done?

The first step is FIB-4, a score calculated from age, liver values and platelets:

• Below 1.3: No advanced scarring. Improve risk factors and recheck every 3 to 5 years.
• 1.3 to 2.67: Unclear. Improve risk factors and retest after 6 months, or measure liver stiffness (e.g. FibroScan, abnormal from roughly 8 to 12 kPa).
• Above 2.67: High risk. Referral to a liver specialist.

For alcohol, the guidance recommends short questionnaires (AUDIT-C) and, where needed, a blood test for alcohol (PEth), because consumption is often underreported ¹.

How is it treated?

For non-advanced fatty liver the family doctor remains responsible. The basis is lifestyle: Mediterranean diet, less sugar, processed food and alcohol, and at least 150 minutes of exercise per week. For related conditions, GLP-1 drugs, SGLT2 inhibitors or, in selected cases, pioglitazone can be used. In one semaglutide trial, inflammation resolved in 62.9%. Follow-up every 1 to 3 years. With FIB-4 of 1.3 or above or stiffness of 8 kPa or above, people go to a liver specialist. If cirrhosis is suspected (stiffness above 10 kPa), a check for liver cancer every 6 months makes sense ¹.

What applies in advanced scarring (cirrhosis)?

In cirrhosis, liver specialists take over. If liver function is still good (Child-Pugh A), most drugs, including statins and metformin, are generally safe. Painkillers such as ibuprofen (NSAIDs) are strongly discouraged because of kidney and bleeding risks; paracetamol is possible short term up to 2 to 3 g per day. In type 2 diabetes with severely impaired liver function (Child-Pugh C), only insulin is started. Weight-loss drugs should not be used in cirrhosis for lack of evidence; in one trial, semaglutide improved neither scarring nor inflammation in cirrhosis. Sleeve gastrectomy is an option only without portal hypertension and is ruled out in decompensated cirrhosis. Before liver transplantation the heart is examined thoroughly, and a BMI below 40 is desirable.

Where are the limits?

The guidance rests on expert opinion and existing literature. Whether this cooperation produces better results in everyday care is not proven. Depending on country and resources, tests are not available everywhere. For cirrhosis, few drugs have proven benefit so far. The work received no funding. Many authors, however, report ties to the pharmaceutical industry (consulting, speaker fees, research grants, occasionally shareholdings), mostly outside this work; details are in the original text.

What does this mean for me?

If you have type 2 diabetes, overweight or hazardous alcohol use, raise the topic of your liver with your family doctor (FIB-4). The values can usually be calculated from a normal blood test. Whether and how to treat is decided by your doctor.

This article does not replace medical advice.