When noninvasive tests are discordant (e.g., low FIB-4 but elevated VCTE and ELF), what is your decision algorithm for initiating a GLP-1 receptor agonist for MASH, and what specific discordance threshold makes you revert to biopsy?

I rely more on vibration-controlled transient elastography (VCTE) than the Fibrosis-4 (FIB-4) index or the Enhanced Liver Fibrosis (ELF) score. I use FIB-4 as more of a screening tool to inform next steps rather than a definitive diagnostic assessment of fibrosis. If I am wary of my VCTE results, I ...

I would proceed with MRE, especially if there is a risk for doing a liver biopsy (on anticoagulation, elderly, and patient’s hesitation).