In 2023, MetALD was officially introduced as a disease entity, as part of a broader international, multisociety consensus process. MetALD is a new medical classification for liver disease combining metabolic risk factors (such as obesity and diabetes mellitus) with moderate-to-high alcohol consumption. This represents a middle-ground category between metabolic dysfunction-associated steatotic liver disease (MASLD; purely metabolic)—the term that replaced nonalcoholic fatty liver disease—and alcohol-associated liver disease (purely alcohol-driven). This month’s issue of Gastroenterology & Hepatology places a spotlight on MetALD in an interview with Dr Paul Y. Kwo. In our Advances in Hepatology column, he discusses the importance of this new nomenclature, how hepatic steatosis can be detected, and how alcohol consumption can be quantified using questionnaires and phosphatidylethanol levels. Dr Kwo also discusses the management of MetALD, including lifestyle interventions involving diet and decreased alcohol intake, the role of pharmacotherapies such as acamprosate and naltrexone, and emerging data on the use of glucagon-like peptide-1 (GLP-1) receptor agonists in this patient population.
Our review article this month explores therapeutic options for primary biliary cholangitis (PBC). Dr Mariam Alamgir, Dr Sheena Bhushan, Dr Aalam Sohal, and Dr Kris V. Kowdley examine first-line treatment with ursodeoxycholic acid and the need for second-line therapeutic options. The authors review the recent withdrawal of obeticholic acid owing to safety concerns and lack of confirmed benefit in advanced disease, the potential role of fibrates, and the recent approval of the selective peroxisome proliferator-activated receptor (PPAR) agonists elafibranor and seladelpar. Additionally, the authors examine upcoming medications in clinical trials such as saroglitazar and pemafibrate, advanced PPAR agonist–based therapies aimed at managing dyslipidemia and liver disease, and propose an algorithm for managing PBC patients who do not have cirrhosis.
Our MASH in Focus column highlights recent guidance from the American Association for the Study of Liver Diseases on pediatric MASLD/metabolic dysfunction-associated steatohepatitis (MASH). Dr Stavra A. Xanthakos discusses why separate pediatric practice guidance was needed, which children should be screened for MASLD and using which tools, when liver biopsy should be performed, and the importance of multidisciplinary lifestyle management. Her discussion also covers the roles of pharmacotherapies such as GLP-1 receptor agonists and bariatric surgery, as well as differences from the adult MASH recommendations.
Janus kinase (JAK) inhibitor–associated acne is the focus of our Advances in IBD column. Associate Professor Britt Christensen discusses acne rates in inflammatory bowel disease patients taking JAK inhibitors, the typical clinical presentation of affected patients, and how patients should be counseled upon initiation of JAK inhibitor therapy. Also discussed are therapeutic approaches involving topical, combination, and oral antibiotic therapies; when to refer patients for dermatologic consultation; and whether JAK inhibitor therapy should be discontinued or reduced.
Our Advances in IBS column features an interview with Dr Brennan Spiegel on artificial intelligence (AI) in disorders of gut-brain interaction (DGBIs), including irritable bowel syndrome (IBS). He discusses potential uses of AI to transform the care of these patients, including in microbiome analysis, the prediction of IBS development, the investigation of functional dyspepsia, and the management of gastrointestinal symptoms. Other topics of discussion include the effectiveness of AI-driven interventions for DGBIs and the challenges of integrating AI into routine clinical practice.
Finally, Dr Brian E. Lacy presents the case of a patient who has IBS with constipation (IBS-C) in our Case Study Series section. He offers helpful teaching points and discusses how to speak with IBS-C patients about various important issues such as how to reassure that a confident symptom-based diagnosis is possible, how to explain the multifactorial pathophysiology and chronic nature of the disease, and how to discuss the approved IBS-C medications with different mechanisms of action.
I hope that this issue provides valuable insights for your clinical practice.
Sincerely,
Gary R. Lichtenstein, MD, FACG, AGAF, FCCF, FACP