In patients with F2/F3 fibrosis, would you start Resmetirom if they had normal liver enzymes?   

Yes, it would be reasonable, especially if you can prove that they still have significant steatosis (such as a CAP of >300 db/m) or active MASH on liver biopsy, as Resmetirom works by directly removing fat from the liver. The lack of liver enzyme elevation is not a reliable sign to rule out steat...

The goal is to downstage fibrosis by 1-2 stages and along reduce steatosis. We know that patients may have normal enzymes but do have steatosis and fibrosis that may progress. So, if I am convinced that the F2-F3 fibrosis is due to metabolic disease, I would use Resmetirom in this case scenario.

I think I would and use it for about 12 months before a reassessment. We know that liver enzymes are not the perfect surrogate marker for disease activity in MASLD, as noted below.