Assess fibrosis and treat metabolic risk

I assess metabolic risk, alcohol and coexisting liver disease, then interpret fibrosis tests alongside the examination and liver-test trend. Treatment starts before symptoms or advanced fibrosis develop.

Guidance behind this advice

GP consultation tool

Use the FIB-4 navigator

Calculate FIB-4, check whether it fits the clinical context and prepare a plan for FibroScan, metabolic treatment and reassessment. Includes weight goals and GP notes.

1. Assess metabolic and liver risk

Prioritise type 2 diabetes, obesity with metabolic risk, steatosis on imaging and persistently abnormal liver enzymes. Review weight, HbA1c, blood pressure, lipids, alcohol, medicines and supplements.

Check for coexisting liver disease, including hepatitis B/C and iron disorders, with other tests guided by the findings.

2. Calculate FIB-4 from stable results

FIB-4 uses age, AST, ALT and platelets. AST is not included in every routine liver-function panel, so request it separately when needed. The Auckland laboratory guide, updated August 2026, uses these age bands.

Auckland FIB-4 interpretation
Age	Action
Below 36	Use an alternative fibrosis assessment; FIB-4 is unreliable.
36–59	Below 1.3 suggests low risk. At or above 1.3, consider elastography or further assessment.
60 and over	Below 2.0 suggests low risk. At or above 2.0, consider elastography or further assessment.

3. Clarify elevated or concerning results

Arrange FibroScan or another accepted second-stage test. In MASLD, reliable stiffness below 8 kPa generally suggests low risk of advanced fibrosis; at or above 8 kPa warrants further assessment.

Refer directly for ascites or portal-hypertension features, such as splenomegaly or other features on ultrasound, persistent unexplained thrombocytopenia, low albumin or an elevated INR without another cause. Review discordant or technically inadequate tests with a specialist.

4. Treat metabolic risk and plan reassessment

Support sustainable dietary change, activity, weight management and alcohol reduction. Treat diabetes, hypertension and dyslipidaemia. Weight loss of at least 5% can reduce liver fat; 7–10% can improve inflammation, with greater fibrosis benefit around 10% or more.

Use diabetes and obesity medicines when indicated. Emerging data suggest semaglutide can improve MASH activity and metabolic risk and has not raised new liver-safety concerns in selected patients with compensated liver disease; its fibrosis benefit in compensated cirrhosis remains uncertain.

Use it within an approved diabetes or weight-management indication, and refer if there is advanced or uncertain disease, decompensation or concern about treatment.

Repeat FIB-4 in one to two years with diabetes or several metabolic risks, or two to three years in lower-risk patients. Reassess earlier if clinical findings change.

Clinical pearls

Around two-thirds of people with type 2 diabetes have fatty liver (MASLD); normal aminotransferases still do not exclude advanced fibrosis.
A low FIB-4 has a high negative predictive value and can exclude advanced fibrosis with a high degree of confidence in the appropriate age group and clinical setting.
AST is not included in every routine liver-function panel, so request it separately when calculating FIB-4. The score is unreliable during acute illness and can be distorted by non-hepatic platelet abnormalities.

Information to share with your patient

Fatty liver: what does my scan mean?

MASLD: assessing fibrosis risk in primary care