Review of new treatment approaches for MASH (fatty liver inflammation): which drugs exist and who do they help?

In short: A review in the Zeitschrift für Gastroenterologie summarises how the treatment of fatty liver inflammation (MASH) is changing. With resmetirom, a drug designed specifically for MASH has been approved in Europe since 2025. Other drugs such as semaglutide, tirzepatide and FGF21 analogues show in trials that liver inflammation and scarring can regress. The foundation, however, remains a healthy lifestyle ¹.

Status of the evidence: The paper was submitted on 7 April 2026, accepted after revision on 12 June 2026 and published online on 23 September 2026 (Z Gastroenterol 2026; 64: 1250–1260). Approval information runs up to March 2026. Article written on 4 October 2026. Newer studies and approvals are not covered.

What is this about?

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects more than 30% of people worldwide. In some, it develops into liver inflammation called MASH. This can lead to scarring (fibrosis), cirrhosis and liver cancer. The stage of scarring is decisive for the outlook. Until 2025 there was no approved drug for MASH in Europe, only lifestyle changes and treatment of related conditions ¹.

What remains the foundation?

Lifestyle remains the basis. Losing at least 5% of body weight reduces liver fat, 7 to 10% improves inflammation, and 10% or more can reverse scarring. Recommended are a Mediterranean diet, few sugary drinks and at least 150 minutes of moderate exercise per week. Even at normal weight, exercise reduces liver fat ¹.

Which drugs exist?

• Resmetirom (a tablet that acts on a thyroid hormone receptor in the liver): In the MAESTRO-NASH trial with 966 patients, inflammation resolved without worsening of scarring in 25.9 to 29.9%, versus 9.7% on placebo. Scarring improved in 24.2 to 25.9%, versus 14.2% on placebo. The most common side effects were diarrhoea and nausea at the start. It has been approved in the EU since August 2025 for MASH without cirrhosis and with moderate to advanced scarring (stage F2 to F3).
• Semaglutide (given by injection, originally for diabetes and obesity): In the ESSENCE trial with 1,197 participants, inflammation resolved after 72 weeks in 62.9% (placebo: 34.3%). Scarring improved in 36.8% (placebo: 22.4%). Weight fell by 10.5% on average. Approved in the USA since August 2025 and conditionally approved in Europe since March 2026.
• Tirzepatide and survodutide (dual agonists): In smaller phase 2 trials, inflammation resolved clearly more often than on placebo, while differences in scarring were not clear. Not yet approved for MASH.
• FGF21 analogues (e.g. efruxifermin, pegozafermin): Promising phase 2 results, including in cirrhosis. Still in development.
• Lanifibranor: In a phase 2b trial with 247 patients, inflammation resolved in 49% (placebo: 22%). Phase 3 results are pending.
• SGLT2 inhibitors and pioglitazone: They are approved for diabetes and other conditions. According to the guidelines they are not a MASH-specific therapy.

Who is treatment for?

Mainly people with “at-risk” MASH, meaning inflammation with at least moderate scarring (stage F2 or higher). This can be assessed with gentle methods such as liver stiffness measurement (e.g. FibroScan) or blood scores. A simple blood value such as FIB-4 alone is not enough. In cirrhosis, resmetirom is not approved. Trials with more than 700 patients are under way ¹.

Where are the limits?

Some of the figures come from interim analyses or smaller phase 2 trials. Long-term data on deaths, liver transplants and liver cancer are still missing. The authors report consulting fees from several pharmaceutical companies ¹.

What does this mean for me?

If you have fatty liver, overweight or type 2 diabetes, talk to your family doctor about your liver and have your scarring risk checked. Whether a drug is an option is decided by a liver specialist after measuring the scarring. Drugs do not replace lifestyle change, they add to it.

This article does not replace medical advice.