How do you approach methotrexate management in patients with rheumatoid arthritis and moderate NASH but no fibrosis per FibroSURE?

In this scenario of a patient with defined NASH by Fibrosure or alternative biomarker or predictive index of fibrosis, I would refer for baseline Fibroscan (transient elastography) to determine the degree of steatosis and presence/degree of fibrosis. NAFLD is common in our population with an estimated 10 to 20% progression to NASH and 15 to 20% of patients with NASH will progress to cirrhosis. (Bassal et al., PMID 36355154)

If no fibrosis is seen and the patient has had good efficacy with methotrexate, I would continue treatment with methotrexate. Progression to cirrhosis is dependent on many factors but particularly BMI and counseling on the importance of weight reduction is critical.

A recent large study of 520 patients with rheumatic disea...