For most of the time this site has covered semaglutide, the scarring form of fatty liver disease had no approved drug treatment at all. That has changed. An international expert panel writing in Gut on 11 September 2026 has published a clinical practice update for the two therapies now conditionally approved by the FDA for MASH with significant fibrosis — resmetirom, sold as Rezdiffra, and semaglutide, sold as Wegovy. For anyone already taking a GLP-1 drug for weight, the panel’s stated remit includes a question that applies directly to them: what to do with patients who are on one already.
What the panel covers
MASH — metabolic dysfunction-associated steatohepatitis — is the inflammatory, scarring form of fatty liver disease. The approvals cover patients with significant fibrosis, staged F2 to F3, who do not yet have cirrhosis. The panel describes this as the first time clinicians have had any pharmacological therapy for that group.
The two drugs work through different routes, which is the panel’s starting point for choosing between them. Resmetirom is a liver-directed thyroid hormone receptor-beta agonist, acting on the liver itself. Semaglutide is a GLP-1 receptor agonist with, in the panel’s words, a broad spectrum of metabolic effects — the same drug most readers here know for weight and blood-sugar control, now carrying a liver indication as well.
The update consolidates phase III trial data, the FDA labels and early clinical experience into a single document covering the whole care pathway: diagnosing MASH with significant fibrosis using non-invasive tests rather than biopsy, selecting and starting treatment, monitoring during treatment, and assessing response. The authors say they set out practical recommendations for tailoring therapy to patient phenotype, for managing patients already receiving GLP-1 drugs, and for defining what counts as response, what counts as non-response, and what would justify switching between the two agents or combining them.
What is not settled
This is expert opinion, not new evidence. No trial was run here. The panel synthesises existing phase III results and label information, and says plainly that its framework is intended to evolve as long-term outcomes data emerge and further MASH therapies become available. Conditional approval means roughly what it sounds like: the long-term outcome data that would confirm the benefit is not yet in hand.
The disclosures deserve attention, and to the journal’s credit they are published in full and in public alongside the paper. Panel members report extensive financial relationships with both manufacturers whose products they are advising on — Madrigal, which makes resmetirom, and Novo Nordisk, which makes semaglutide — as well as with most of the companies developing competing MASH drugs. The corresponding author reports research grants from a list that includes Novo Nordisk and Madrigal, and consulting fees from a longer one. Of the eleven authors, only the first reports nothing to disclose. That is close to unavoidable in a field this small, and it is not a reason to dismiss the guidance. It is a reason to read it as what it is: the considered view of many of the people who ran the trials, rather than an independent appraisal of them.
One practical note for anyone wanting to check it themselves. The abstract and the full funding and competing-interest statements are freely readable, but the recommendations themselves sit behind the journal’s subscription — so the detail summarised above is the panel’s own description of its scope, not our reading of the individual recommendations.
Sources: Mironova M, Ratziu V, Rinella ME, et al. “International expert panel review for the use of resmetirom and semaglutide in the management of MASH-related fibrosis: clinical practice update.” Gut, 11 September 2026, doi:10.1136/gutjnl-2026-340031 · PubMed record, PMID 42728029.
