In patients with Met-ALD, how do you approach their treatment plan?

This is a complicated question as Met-ALD is not a homogeneous disease state. This means that some patients will have ethanol-predominant disease, whereas others will have more metabolic issues. However, for all patients whom I suspect have significant alcohol use, I start by asking them to eliminate all alcohol for 2 weeks and repeating labs to gauge if there is improvement in their AST/ALT as a triage strategy. If the AST/ALT fall precipitously, then I focus on alcohol first; if they do not, I consider metabolic therapy with mitigation of alcohol use.