Jan 15, 2026 at 10:33 PM#2
In my community hepatology practice, here's my real-world workflow:
Referral triage:
- I receive referrals and calculate FIB-4 from the labs they send. If <1.3, I often manage by phone with recommendations and don't bring them in for a visit.
- Everyone who comes in gets a FibroScan at the first visit.
Baseline assessment for new MASH patients:
- FibroScan (stiffness + CAP)
- FIB-4 calculation
- Comprehensive metabolic panel, CBC with platelets
- Lipid panel, HbA1c, fasting insulin
- If available and insurance covers: ELF score
- If FibroScan >12.5 or diagnostic uncertainty: liver biopsy
Monitoring on GLP-1 therapy:
- ALT/AST every 3 months for first year
- FIB-4 every 6 months (calculated from routine labs)
- FibroScan every 6-12 months depending on fibrosis stage
- ELF at baseline and 12 months (when insurance covers it)
The problem with ELF: It's excellent as a test but the logistics are terrible. Quest and LabCorp both run it, but it requires a special order, costs $300-500, and many insurance plans don't cover it. Medicare does cover it now (as of 2024), which helps for older patients. But for my under-65 patients, it's often out-of-pocket.
The problem with FibroScan in the community: I have a FibroScan machine in my office, but most GI practices don't. The nearest FibroScan for many of my patients is a 45-minute drive. This creates a huge access barrier for monitoring.
We need FibroScan to be as ubiquitous as ultrasound. Until then, FIB-4 is doing a lot of the heavy lifting in primary care, despite its limitations.
39 9mike.trainer_LA, sarah_nash92, FitDadDave and 36 others
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