We read with interest “Approach to steatotic liver disease in the office. Diagnosis, management, and proposed nomenclature” by Szilagyi and Hilzenrat in the April 2025 issue of Canadian Family Physician.1 The increasing burden of metabolic risk factors is an important issue in primary care. However, we are concerned by the potential impact of broad recommendations surrounding screening and testing for metabolic dysfunction–associated steatotic liver disease (MASLD), despite lacking evidence this has an effect on patient-oriented outcomes.

We were surprised the article did not more transparently acknowledge the absence of high-quality data supporting many of its proposed diagnostic and management strategies. Recommendations that shift clinical attention toward routine detection and staging—particularly with tests like the Fibrosis-4 (FIB-4) Index for Liver Fibrosis or elastography—risk drawing time and resources away from higher-value care that meaningfully impacts patient outcomes. As family physicians, we are increasingly aware of the time needed to treat2 and the potential downstream effects of devoting energy to interventions of uncertain benefit.

The article suggests liver stiffness measurement and FIB-4 scoring are important for determining clinical management. However, it remains unclear how the FIB-4 test meaningfully alters clinical management, given the lack of treatments specifically tailored to fibrosis stage. The cornerstone interventions for MASLD—lifestyle counselling, glucagon-like peptide-1 agonists, reducing alcohol intake, and vaccination for hepatitis A and B—can be indicated regardless of fibrosis stage. Although advanced fibrosis correlates with poorer outcomes, robust evidence is lacking to demonstrate early staging improves these outcomes. Evidence on that regard should be available before advocating for a change in practice as recommended in the Wilson and Jungner principles for screening.3 Available evidence thus far suggests diagnosing patients with steatotic liver disease does not help them modify their lifestyles.4

We also respectfully disagree with the statement that “… other causes [of steatosis] need to be ruled out in every case.”1 This contradicts the 2023 American Association for the Study of Liver Diseases guidelines5 that recommend consideration—not systematic exclusion—of rare causes. As is the case for any other investigation done in low-prevalence settings, such over-investigation may increase the risk of false positive results and associated patient harms.6 We are also concerned by the recommendation to repeat blood work and FIB-4 scoring annually for low-risk patients with steatotic liver disease. This recommendation does not consider implementation costs (eg, financial, time, opportunity costs). With no strong evidence of benefit, such a recommendation for the general population cared for by family physicians goes against thoughtful resource stewardship.

We agree with several key points made by the authors. MASLD is becoming increasingly common and warrants assessment of underlying cardiometabolic risk factors, alongside counselling on weight, diet, alcohol intake, and physical activity. We also recognize that MASLD is contributing to the need for liver transplants. However, no studies to date show screening changes this important outcome. We also agree that when confronted with atypical clinical profiles it is appropriate to consider alternate causes.

We urge clinicians to remain prudent, conservative, and evidence-based in the evaluation and management of MASLD. As guidelines evolve, they must balance potential benefits of new diagnostic pathways against the clinician time and opportunity costs required to implement them. Given the limited evidence and high prevalence of metabolic risk factors, we urgently need sustainable, evidence-based guidelines focused on interventions that meaningfully improve patient-oriented outcomes.