MASH-Cirrhosis and Obesity: Transforming Care with Shared Medical Appointments

For patients with compensated metabolic dysfunction-associated steatohepatitis (MASH) cirrhosis and obesity, the clinical path is fraught with complexity. These patients face a "dual burden"—progressive liver disease compounded by severe metabolic dysfunction driven by obesity and diabetes. While clinicians know that weight loss and metabolic optimization are essential to prevent hepatic decompensation, achieving these goals in patients with cirrhosis has historically been a significant challenge.

The evolving landscape and the sarcopenia risk

The treatment landscape changed with the advent of glucagon-like peptide-1 (GLP-1) receptor agonists such as semaglutide (Wegovy^®/Ozempic^®) and tirzepatide (Zepbound^®/Mounjaro^®), which offer powerful metabolic benefits.

“In fact, semaglutide was recently FDA-approved for use in non-cirrhotic, fibrotic MASH patients, but there is very limited efficacy and safety data for these drugs in cirrhosis,” explains Sobia Laique, MD, Director of the Multidisciplinary MASLD Clinic at Cleveland Clinic.

However, simply prescribing these medications to patients with cirrhosis presents a new, critical danger: sarcopenia.

“Weight loss in this population requires a delicate balance,” Dr. Laique notes. “We cannot simply prescribe a medication and walk away. Without safeguards, there is a legitimate risk of muscle wasting, or sarcopenia, which is already a significant predictor of poor outcomes in cirrhosis. We must ensure patients are losing fat mass, not lean muscle.”

A new delivery model launched in March 2025

To bridge this gap, Dr. Laique and her team piloted the MASH Cirrhosis and Obesity Shared Medical Appointment program in March 2025. Presented at the recent American Association for the Study of Liver Disease (AASLD) Liver Meeting, the model utilizes a robust multidisciplinary framework designed to optimize healthcare delivery while mitigating clinical risk.

The program operates as a three-part monthly series that functions as a comprehensive medical encounter rather than a simple educational class. Each session is co-led by a specialist facilitator and a physician (hepatologist or endocrinologist), allowing for concurrent medical follow-up. While patients receive group education, they also undergo individual medical reviews with the physician during the same visit. This integrated structure ensures that while lifestyle behaviors are being modified, pharmacotherapy is actively managed, labs are monitored and doses are titrated safely.

Keren Zhou, MD, Research Director, Department of Diabetes, Endocrinology and Metabolism, emphasizes that the model also solves a financial barrier: it grants patients access to vital support services, such as nutrition counseling, exercise physiology and behavioral health, that are frequently not covered by insurance when sought as standalone appointments.

A comprehensive three-month curriculum

The curriculum utilizes the SBIRT (Screening, Brief Intervention, and Referral to Treatment) framework, systematically addressing a different clinical pillar each month.

To directly counter the risk of muscle loss, the first month focuses exclusively on nutrition and sarcopenia prevention. Registered dietitians provide targeted counseling on high-protein diets, educating patients on specific types of proteins, optimal meal timing and portion sizes to ensure adequate substrate for muscle preservation while in a caloric deficit. Crucially, every patient leaves with a "nutrition prescription" tailored to their needs.

The second month focuses on physical activity and reducing frailty. Led by exercise physiologists, the session helps patients understand the benefits of movement and develop a realistic, personalized activity plan, whether at a gym, outdoors, or at home. Recommendations are tailored to each patient’s physical abilities and body composition, and patients leave with an individualized FITT-VP exercise prescription (Frequency, Intensity, Time, Type, Volume, and Progression) designed to build strength and endurance safely.

The third month is led by a behavioral psychologist and focuses on the mental and emotional factors that affect long-term weight management. The session addresses stress, emotional eating, and weight-related stigma, and includes screening for conditions such as depression and anxiety that can interfere with progress. Through guided group discussion, patients learn practical coping strategies and build confidence to maintain lifestyle changes, with referrals for individual support when needed.

Efficiency, engagement and outcomes

The pilot cohort represented a clinically complex population typical of tertiary hepatology centers: 25 patients with a mean BMI of 38, of whom 75% had diabetes. Despite this complexity, the SMA model proved highly feasible. The cohort was fully enrolled within four weeks, and patient engagement was exceptional for a lifestyle intervention, with 94% overall attendance.

A key driver of success was the program’s ability to solve the "access problem," says Dr. Zhou. Through coordinated insurance navigation and prior authorization support, the team successfully optimized medication therapy for 85% of the group. Nearly half of the participants were newly initiated on incretin therapies, such as tirzepatide or semaglutide, while others were switched to more effective agents or titrated to therapeutic doses. This support translated directly into real-world adherence: while discontinuation is common in standard practice, the SMA cohort achieved 100% adherence to prescribed therapy throughout the program.

The combination of medication management and lifestyle modification delivered potent results. Participants achieved a mean 9.4% total body weight loss (approximately 10.5 kg). Most importantly, this weight loss was achieved safely. There were no hepatic decompensations or serious adverse events, validating the efficacy of the model’s nutritional and frailty safeguards.

“We have demonstrated that this value-based framework is feasible and scalable,” Dr. Laique concludes. “By streamlining care into a supportive, multidisciplinary environment, we can provide high-risk patients with the infrastructure they need to safely lose weight, preserve muscle, and improve their long-term survival”.

Due to the program's initial success, it is now rapidly expanding to accommodate a growing patient census.