In a patient with low (or normal) BMI but findings of steatosis on imaging, no cardiometabolic comorbidities, and very elevated CAP scores, what are your next diagnostic and therapeutic steps to identify the cause of their steatosis and subsequent management?

In addition to knowing the level of steatosis, liver stiffness values would be of most interest.

Alcohol use should stop if there is any level of fibrosis. Lifestyle modifications (dietary/exercise) should be part of recommendations, but with a goal of around 5 % weight loss. If they have F2-3 fibrosis would strongly consider the use of resmetirom. If diabetes is present, would also consider a GLP-1 to help with both conditions, but again weight loss goal should be modest. Although BMI is considered in this scenario, need to know that for Asians, normal BMI is around 21-23, and therefore a BMI of 25 should be considered abnormal. Also, I would measure abdominal girth.

I have never prescribed pioglitazone or vitamin E in these cases. Need to...