Recognizing, Treating Alcohol as an Additive Risk Factor in MASLD

In this segment of Liver Lineup, hosts Nancy Reau, MD, and Kimberly Brown, MD, focus on one of the most challenging, and often underappreciated, aspects of managing metabolic dysfunction-associated steatotic liver disease (MASLD): accurately assessing and addressing alcohol use.

Check out the full episode here.

Reau highlights data examining patient reluctance to disclose alcohol consumption, using phosphatidylethanol (PEth) testing as an objective biomarker. Even at a relatively low cutoff, PEth identified alcohol use in a substantial proportion of patients who reported little or no drinking during clinic visits. Of note, many patients who stated they abstained entirely showed biochemical evidence of alcohol exposure, reinforcing a reality many clinicians recognize: self-reported alcohol use is often inaccurate, whether due to stigma, reluctance, or misunderstanding of what constitutes meaningful intake.

The conversation then turns to how PEth testing can be integrated into practice. Reau emphasizes transparency, explaining that she routinely tells patients when PEth is being ordered, framing it as a tool to support honest, nonjudgmental conversations about liver health.

Brown contrasts this with a more routine testing strategy, likening PEth to other standard laboratory assessments. For her, she says the value lies in using objective data to educate patients, showing that even amounts they perceive as minimal may still be harmful in the context of MASLD. She also notes the implications for clinical trials, pointing out that many study populations likely include patients with overlapping metabolic disease and alcohol use, given the limitations of self-reporting.

Both experts emphasize the clinical importance of another study discussed in the segment, which demonstrated that even modest alcohol consumption, including levels considered lower risk by public health standards, was associated with increased fibrosis in patients with MASLD. This risk was compounded by the presence of multiple metabolic factors, with alcohol acting as another “layer” of risk that accelerates disease progression.

Reau and Brown agree that for patients with MASLD, particularly younger individuals with decades of disease risk ahead, no amount of alcohol is truly safe, and addressing this openly is essential to long-term outcomes.

Editors’ note: Relevant Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal.

References

1. Daugherty T, Roepke E, Caviness D, et al. Real-world use of PEth in a MASLD Clinic. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

2. Duseja A, Verma N, De A, et al. Any amount of alcohol intake increases the risk of significant fibrosis and fibrotic MASH in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) - Insights from 7189 patients from Indian Consortium on MASLD (ICOM-D). Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.