Who needs liver monitoring on GLP-1 therapy?
MJA September 2025 consensus recommends FIB-4 screening for patients with metabolic risk factors. In GLP-1 prescribing populations, this is the majority of patients. Specific triggers:
- Type 2 diabetes — every patient
- BMI ≥ 30
- Metabolic syndrome
- Persistently elevated ALT or GGT at any visit
- Imaging-detected hepatic steatosis
- Family history of advanced liver disease
In practice, almost every patient considering Wegovy or Mounjaro meets at least one criterion.
The FIB-4 → elastography pathway
- Order or note FIB-4 from baseline LFT + platelet panel
- FIB-4 < 1.3 (or < 2.0 if patient is 65+): Low risk. Routine annual LFTs. Reassure.
- FIB-4 1.3–2.67: Indeterminate. Refer for elastography to clarify fibrosis stage.
- FIB-4 > 2.67: High risk. Refer to hepatology. Elastography supports the referral but does not replace it.
Elastography kPa thresholds (MASLD context)
- kPa < 8: F0–F1. Reassure. Annual LFTs.
- kPa 8–12: F2–F3. Significant fibrosis. Continue GLP-1 therapy with rationale; repeat elastography in 12 months.
- kPa > 12: F3–F4. Hepatology referral. Consider HCC surveillance if cirrhosis confirmed.
Monitoring schedule on GLP-1 therapy
- Baseline: LFTs, FIB-4, weight, BMI, BP, lipids. Elastography if FIB-4 indeterminate or high.
- Month 3: LFTs. Expect modest ALT/AST reductions.
- Month 6: LFTs, weight, BP, clinical review.
- Month 12: Full repeat: FIB-4, LFTs, lipids, weight. Repeat elastography if previously indicated.
- Annual: Continuing pattern while on long-term therapy.
What counts as meaningful response on elastography?
Baveno VII criteria define a kPa change of ≥5 kPa between measurements as clinically meaningful in chronic liver disease. In GLP-1 trial data:
- Mean kPa reduction in semaglutide responders: 4–7 kPa at 12 months (ESSENCE)
- Tirzepatide trial data (SYNERGY-NASH) similar or larger
- CAP/UAP grade improvements common — one full S-stage drop in many responders
- Histological MASH resolution rates of 60%+ in pivotal trials
When to refer to hepatology
- FIB-4 > 2.67 at any visit
- Elastography kPa > 12
- Established cirrhosis on imaging or clinical features
- Persistent ALT > 3× ULN with no clear cause
- Suspected drug-induced or autoimmune component
- HCC screening consideration for cirrhotic patients
Practical referral workflow
Elastography is available at participating clinics across Australia. Most accept GP referrals; some accept self-referral. A typical appointment is 10–15 minutes, with the result returned to the referring GP within days.
Frequently asked questions
What's the MJA 2025 pathway for GLP-1 patients?
FIB-4 screening for all patients with metabolic risk factors. Elastography for indeterminate FIB-4 (1.3–2.67). Specialist referral for FIB-4 > 2.67 or elastography kPa > 12. Repeat at 12 months on therapy.
When should I refer a GLP-1 patient for elastography?
Whenever FIB-4 is in the indeterminate range (1.3–2.67), or when LFTs remain abnormal beyond 6 months on therapy. Baseline elastography before starting is reasonable in patients with multiple metabolic risk factors.
Is semaglutide approved for MASH in Australia?
FDA-approved August 2025. TGA approval for the MASH indication is anticipated but not yet finalised. Ozempic (T2D) and Wegovy (weight management) cover most eligible patients through standard channels.
How does GLP-1 therapy change FIB-4 over time?
ALT and AST typically fall as liver fat reduces, which lowers FIB-4 over 6–12 months. A baseline FIB-4 before starting gives a clean reference for tracking.
Refer your GLP-1 patients for elastography
Search participating clinics by suburb to send patients close to home. Reports return to the referring GP within days.
This page is educational and not medical advice. Always discuss your GLP-1 treatment and liver monitoring with your GP.