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Metabolic dysfunction-associated steatotic liver disease (MASLD) now affects roughly 4 in 10 older US adults, and the medications used to control its cardiometabolic drivers can accumulate faster than clinicians or payers tend to track. A retrospective cohort study published in the Journal of General Internal Medicine, drawing on National Health and Nutrition Examination Survey (NHANES) data from 2017 to 2020, measured that burden and found it concentrated in the oldest patients.
Researchers analyzed 1,756 adults aged 65 years and older who had transient elastography data, representing an estimated 42 million Americans. MASLD was defined as hepatic steatosis plus at least one cardiometabolic risk factor, and polypharmacy as five or more prescription medications. About 39.8% of the group met MASLD criteria. Compared with peers without the disease, patients with MASLD had higher rates of diabetes and obesity across every age band and carried more cardiometabolic comorbidities overall, while lipid-lowering agents were the most commonly used drug class throughout.
Polypharmacy tracked steadily upward with age among patients with MASLD, from 36.9% of those 65 to 69 years to 60.3% of those 75 years and older (P = 0.002). At 75 and older, patients with MASLD were more medicated than their peers without it (60.3% vs 42.7%, P = 0.005). After adjustment for cardiometabolic conditions, the oldest group had more than three times the odds of polypharmacy compared with those 65 to 69 years (adjusted odds ratio 3.12, 95% CI 2.21 to 4.42). The load came from the breadth of multimorbidity rather than intensified treatment of any single condition, and it reflected cardiometabolic drugs rather than sedatives or anticholinergics.
For plans managing this population, the authors describe the results as a clinical fault line. Tight control of diabetes, hypertension, and lipids slows liver disease progression and lowers non-liver mortality, yet the same regimens raise the risk of falls, drug interactions, and reduced adherence in frail patients. The authors also flag a guideline gap: liver disease guidance sets no age-specific glycemic target, while the American Diabetes Association recommends looser hemoglobin A1c goals for older adults. Whether patients 75 and older with MASLD and diabetes benefit from de-intensifying glycemic control, they write, should be decided case by case.
The authors conclude that age-appropriate medication review, deprescribing, and goal-concordant care are central to managing this high-risk and expanding group.
