Pooling seven trials and just 110 patients on SGLT2 inhibitors, this single-arm meta-analysis found significant improvement from baseline in liver fat (CAP, SMCR -0.56), liver stiffness (SMCR -0.58), biopsy NAFLD Activity Score (SMCR -1.18), and in steatosis, ballooning and fibrosis on histology. Waist circumference, ferritin, systolic blood pressure and liver enzymes also fell, and tolerability was consistent. Heterogeneity was substantial for stiffness and histological outcomes.
The direction fits what larger MASLD meta-analyses and randomized data on empagliflozin and dapagliflozin have suggested, but the design here is weak. With no control arms, every effect is a before-and-after change, so regression to the mean, concurrent weight loss, lifestyle advice and the placebo response in biopsy scoring are all baked in. Paired biopsies are notoriously variable, and the wide confidence interval on NAS (-2.29 to -0.06) barely excludes zero. Because SGLT2 inhibitors cause modest weight loss, it is hard to separate a liver-specific effect from general metabolic improvement. Still, for adults with type 2 diabetes and fatty liver, who already have reasons to consider these drugs for cardiovascular and kidney protection, liver benefit looks like a plausible bonus rather than a reason to start one alone. Resmetirom and semaglutide now carry stronger MASH-specific trial evidence. Treat this as confirmatory and hypothesis-generating, and discuss options with a clinician rather than self-directing therapy.