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<journal-meta>
<journal-id journal-id-type="publisher-id">Front. Med.</journal-id>
<journal-title-group>
<journal-title>Frontiers in Medicine</journal-title>
<abbrev-journal-title abbrev-type="pubmed">Front. Med.</abbrev-journal-title>
</journal-title-group>
<issn pub-type="epub">2296-858X</issn>
<publisher>
<publisher-name>Frontiers Media S.A.</publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="doi">10.3389/fmed.2026.1763185</article-id>
<article-version article-version-type="Version of Record" vocab="NISO-RP-8-2008"/>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Review</subject>
</subj-group>
</article-categories>
<title-group>
<article-title>Glucagon-like peptide-1 and dual/triple receptor agonists in the treatment of metabolic dysfunction-associated steatotic liver disease: advances in mechanistic research</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname>Lu</surname>
<given-names>Xinyi</given-names>
</name>
<xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<uri xlink:href="https://loop.frontiersin.org/people/3309146"/>
<role vocab="credit" vocab-identifier="https://credit.niso.org/" vocab-term="Writing &#x2013; original draft" vocab-term-identifier="https://credit.niso.org/contributor-roles/writing-original-draft/">Writing &#x2013; original draft</role>
<role vocab="credit" vocab-identifier="https://credit.niso.org/" vocab-term="Writing &#x2013; review &#x0026; editing" vocab-term-identifier="https://credit.niso.org/contributor-roles/writing-review-editing/">Writing &#x2013; review &#x0026; editing</role>
</contrib>
<contrib contrib-type="author" corresp="yes">
<name>
<surname>Yang</surname>
<given-names>Li</given-names>
</name>
<xref ref-type="aff" rid="aff2"><sup>2</sup></xref>
<xref ref-type="corresp" rid="c001"><sup>&#x002A;</sup></xref>
<role vocab="credit" vocab-identifier="https://credit.niso.org/" vocab-term="conceptualization" vocab-term-identifier="https://credit.niso.org/contributor-roles/conceptualization/">Conceptualization</role>
<role vocab="credit" vocab-identifier="https://credit.niso.org/" vocab-term="Writing &#x2013; review &#x0026; editing" vocab-term-identifier="https://credit.niso.org/contributor-roles/writing-review-editing/">Writing &#x2013; review &#x0026; editing</role>
<role vocab="credit" vocab-identifier="https://credit.niso.org/" vocab-term="Writing &#x2013; original draft" vocab-term-identifier="https://credit.niso.org/contributor-roles/writing-original-draft/">Writing &#x2013; original draft</role>
</contrib>
</contrib-group>
<aff id="aff1"><label>1</label><institution>The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University</institution>, <city>Guangzhou</city>, <state>Guangdong</state>, <country country="cn">China</country></aff>
<aff id="aff2"><label>2</label><institution>Department of Endocrinology, Zhujiang Hospital, Southern Medical University</institution>, <city>Guangzhou</city>, <state>Guangdong</state>, <country country="cn">China</country></aff>
<author-notes>
<corresp id="c001"><label>&#x002A;</label>Correspondence: Li Yang <email xlink:href="mailto:yangli19762009@163.com">yangli19762009@163.com</email></corresp>
</author-notes>
<pub-date publication-format="electronic" date-type="pub" iso-8601-date="2026-02-12">
<day>12</day>
<month>02</month>
<year>2026</year>
</pub-date>
<pub-date publication-format="electronic" date-type="collection">
<year>2026</year>
</pub-date>
<volume>13</volume>
<elocation-id>1763185</elocation-id>
<history>
<date date-type="received">
<day>08</day>
<month>12</month>
<year>2025</year>
</date>
<date date-type="rev-recd">
<day>20</day>
<month>01</month>
<year>2026</year>
</date>
<date date-type="accepted">
<day>26</day>
<month>01</month>
<year>2026</year>
</date>
</history>
<permissions>
<copyright-statement>Copyright &#x00A9; 2026 Lu and Yang.</copyright-statement>
<copyright-year>2026</copyright-year>
<copyright-holder>Lu and Yang</copyright-holder>
<license>
<ali:license_ref start_date="2026-02-12">https://creativecommons.org/licenses/by/4.0/</ali:license_ref>
<license-p>This is an open-access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="https://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License (CC BY)</ext-link>. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.</license-p>
</license>
</permissions>
<abstract>
<p>Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) has emerged as a prevalent and severe global hepatic disorder, necessitating the development of effective therapeutic strategies. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), along with glucose-dependent insulinotropic polypeptide (GIP) and glucagon (GCG) dual or triple receptor agonists that modulate multiple metabolic pathways, have attracted significant scientific interest due to their multifaceted roles in metabolic regulation. This review provides a comprehensive overview of the mechanistic insights into the effects of GLP-1RAs and dual or triple receptor agonists on the pathophysiology of MASLD, with a focus on hepatic lipid metabolism, inflammatory responses, and fibrosis progression.</p>
</abstract>
<kwd-group>
<kwd>fibrosis</kwd>
<kwd>glucagon-like peptide-1 receptor agonists</kwd>
<kwd>inflammation</kwd>
<kwd>metabolic dysfunction-associated steatohepatitis</kwd>
<kwd>metabolic dysfunction-associated steatotic liver disease</kwd>
</kwd-group>
<funding-group>
<funding-statement>The author(s) declared that financial support was not received for this work and/or its publication.</funding-statement>
</funding-group>
<counts>
<fig-count count="1"/>
<table-count count="0"/>
<equation-count count="0"/>
<ref-count count="58"/>
<page-count count="7"/>
<word-count count="6090"/>
</counts>
<custom-meta-group>
<custom-meta>
<meta-name>section-at-acceptance</meta-name>
<meta-value>Gastroenterology</meta-value>
</custom-meta>
</custom-meta-group>
</article-meta>
</front>
<body>
<sec sec-type="intro" id="sec1">
<label>1</label>
<title>Introduction</title>
<p>Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly referred to as non-alcoholic fatty liver disease (NAFLD), has become the most prevalent chronic liver condition worldwide, affecting approximately one-third to nearly 40% of the adult population globally, with projections indicating an increase to over 55% by 2040 (<xref ref-type="bibr" rid="ref1">1</xref>, <xref ref-type="bibr" rid="ref2">2</xref>). The clinical spectrum of MASLD spans from simple steatosis, which is often benign and potentially reversible, to metabolic dysfunction-associated steatohepatitis (MASH), a progressive and inflammatory condition that may lead to hepatic fibrosis, cirrhosis, and hepatocellular carcinoma (HCC) (<xref ref-type="bibr" rid="ref2">2</xref>, <xref ref-type="bibr" rid="ref3">3</xref>). There is a critical unmet need for effective pharmacotherapies that target the underlying metabolic and inflammatory mechanisms driving MASLD. Resmetirom, a selective liver thyroid hormone receptor <italic>&#x03B2;</italic> (THR-&#x03B2;) agonist, received approval from the FDA in 2024 for the treatment of adult patients with F2-F3 MASH (<xref ref-type="bibr" rid="ref4">4</xref>).</p>
<p>Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have gained considerable attention in recent years as promising therapeutic agents for MASLD, particularly owing to their well-established efficacy in treating type 2 diabetes mellitus (T2DM) and obesity, conditions closely implicated to MASLD pathogenesis (<xref ref-type="bibr" rid="ref2">2</xref>, <xref ref-type="bibr" rid="ref5">5</xref>). Clinical trials, including phase 2 and 3 studies, have reported significant improvements in liver histology, including MASH resolution and decreased hepatic fat content, with GLP-1RA therapy (<xref ref-type="bibr" rid="ref6">6</xref>, <xref ref-type="bibr" rid="ref7">7</xref>). Subsequently, in August 2025, semaglutide, a representative drug of GLP-1RAs, also obtained FDA approval, targeting the same indications as Resmetirom (<xref ref-type="bibr" rid="ref8">8</xref>). Building on the therapeutic success of GLP-1RAs, recent pharmacological developments have introduced GLP-1 with glucose-dependent insulinotropic polypeptide (GIP)/glucagon (GCG) dual or triple receptor agonists simultaneously target multiple incretin pathways, offering a novel multi-targeted approach to MASLD treatment.</p>
<p>This review aims to systematically summarize the mechanistic insights and clinical advances of GLP-1with dual or triple receptor agonists in MASLD treatment, thereby promoting a more profound comprehension and facilitating their application in clinical practice (<xref ref-type="fig" rid="fig1">Figure 1</xref>).</p>
<fig position="float" id="fig1">
<label>Figure 1</label>
<caption>
<p>The mechanistic insights of GLP-1 with GIP/GCG dual or triple receptor agonists in MASLD treatment. Created with <ext-link xlink:href="http://BioRender.com" ext-link-type="uri">BioRender.com</ext-link>. Top right illustration: GLP-1RAs regulate hepatic lipid metabolism via indirect systemic effects. Left panel: Lipid metabolism regulation within hepatocytes: GLP-1 RA, by activating the AMPK/SIRT1 pathway, promote fatty acid oxidation (<italic>&#x03B2;</italic>-oxidation) and inhibit lipogenesis (via suppression of SREBP-1c/FAS), thereby fundamentally reducing lipid accumulation in hepatocytes. Middle panel: Anti-inflammation and immune regulation within immunity microenvironment: GLP-1 RAs inhibits the NF-&#x03BA;B signaling pathway, a key mediator of inflammation, thereby reducing the production of pro-inflammatory cytokines such as TNF-<italic>&#x03B1;</italic> and IL-6 by macrophages in macrophage (M1) and other immune cells. Concurrently, it enhances the expression of anti-inflammatory factors, including IL-22/IL-10 in Treg and macrophage (M2), contributing to the mitigation of hepatic inflammation and oxidative stress. Right panel: Anti-fibrotic and protective effects within HSCs: GLP-1RAs directly inhibit hepatic stellate cell activation, reducing the TGF-&#x03B2;/Smad/PPAR&#x03B3; signaling pathway, resulting in decreased collagen deposition and delayed progression of fibrosis. MASH, Metabolic Dysfunction-Associated Steatohepatitis; MASLD, Metabolic Dysfunction-Associated Steatotic Liver Disease; GLP-1 RAs, Glucagon Like Peptide-1 Receptor Agonists; GIP, Glucose-dependent Insulinotropic Polypeptide; GCG, Glucagon; AMPK/SIRT1, AMP-activated Protein Kinase/Sirtuin-1; SREBP-1c/FAS, Sterol Regulatory Element-Binding Protein 1c/Fatty Acid Synthase; NF-&#x03BA;B, Nuclear Factor kappa-B; TNF-&#x03B1;, Tumor Necrosis Factor alpha; IL-1&#x03B2;/6/10/22, Interleukin-1&#x03B2;6/10/22; Treg, Regulatory T cell; Macrophage1/2, M1/M2; TGF-&#x03B2;/Smad, Transforming Growth Factor-beta; PPAR&#x03B3;, Peroxisome Proliferator-Activated Receptor gamma; ECM, Extracellular Matrix.</p>
</caption>
<graphic xlink:href="fmed-13-1763185-g001.tif" mimetype="image" mime-subtype="tiff">
<alt-text content-type="machine-generated">Flowchart illustrating mechanisms to alleviate MASLD/MASH by improving liver function. Hepatocytes increase fatty acid oxidation and decrease lipogenesis, reducing lipid accumulation. Immune microenvironment changes include macrophage activation, reducing hepatic inflammation via anti-inflammatory factors. Hepatic stellate cell activation reduces collagen deposition, delaying fibrosis. Overall, processes lead to reduced hepatic steatosis and inflammation, lowering cirrhosis risk.</alt-text>
</graphic>
</fig>
</sec>
<sec id="sec2">
<label>2</label>
<title>MASLD&#x2019;s pathophysiology and current treatment</title>
<p>MASLD is characterized by an abnormal accumulation of lipids in hepatocytes, commonly occurring in the context of obesity, insulin resistance, and T2DM-key features of metabolic syndrome that substantially affect patient quality of life and long-term prognosis (<xref ref-type="bibr" rid="ref1">1</xref>). The pathophysiology of MASLD is complex and multifactorial, involving hepatic lipid accumulation driven by excess adiposity, systemic inflammation, insulin resistance, and activation of hepatic stellate cells (HSC)-factors that collectively contribute to liver injury and fibrogenesis. Traditionally, diagnosis has depended on invasive liver biopsy; meanwhile, noninvasive imaging modalities and serum biomarkers are now increasingly helpful for both diagnosis and disease monitoring (<xref ref-type="bibr" rid="ref1">1</xref>).</p>
<p>The complex pathophysiology of MASLD calls for integrated, multi-faceted therapeutic regimens and improved diagnostic tools to enhance clinical outcomes. Several agents have demonstrated histological and biochemical effects by targeting core pathophysiological pathways. Recently, Resmetirom, a thyroid receptor agonist was approved by the FDA as the first drug on the label for MASH with fibrosis 2 and 3. At the moment, some medications can collaborate in the treatment of MASLD, some of them approved for the treatment of comorbidities such as GLP-1 agonists indicated for the treatment of T2DM or obesity, but also with benefit in the MASH treatment (<xref ref-type="bibr" rid="ref9">9</xref>, <xref ref-type="bibr" rid="ref10">10</xref>). Also Phase three studies are underway for MASLD with these drugs. Pioglitazone and vitamin E can be considered with improvement in MASH and stabilization of fibrosis, as suggested by some studies (<xref ref-type="bibr" rid="ref10">10</xref>, <xref ref-type="bibr" rid="ref11">11</xref>).</p>
</sec>
<sec id="sec3">
<label>3</label>
<title>The mechanisms of GLP-1 with dual or triple receptor agonists in MASLD treatment</title>
<sec id="sec4">
<label>3.1</label>
<title>The mechanisms of GLP-1 receptor agonists in MASLD treatment</title>
<sec id="sec5">
<label>3.1.1</label>
<title>Regulation of hepatic lipid metabolism</title>
<p>GLP-1RAs exert multifaceted regulatory effects on hepatic lipid metabolism, which are pivotal to their therapeutic potential in MASLD. A common thread among new treatments is the activation of energy- sensing pathways, especially AMP- activated protein kinase (AMPK), which helps the liver break down fatty acids, stops lipogenesis and reduces inflammation and fibrosis. Experimental evidence clearly demonstrates that GLP-1RAs such as liraglutide and semaglutide enhance AMPK activity, leading to increased expression of genes involved in mitochondrial fatty acid oxidation and diminished lipogenesis (<xref ref-type="bibr" rid="ref12">12</xref>, <xref ref-type="bibr" rid="ref13">13</xref>). This metabolic alteration not only decreases intrahepatic triglyceride content but also alleviates lipotoxicity, a key driver of hepatocellular injury in MASLD.</p>
<p>Concomitantly, GLP-1RAs suppress the expression of lipogenic transcription factors and enzymes, including sterol regulatory element-binding protein 1c (SREBP-1c) and fatty acid synthase (FAS), resulting in reduced <italic>de novo</italic> lipogenesis. For instance, <italic>in vitro</italic> studies using HepG2 cells treated with palmitic acid revealed that the GLP-1RA exendin-4 downregulated the expression of SREBP-1c and FAS, thereby attenuating steatosis (<xref ref-type="bibr" rid="ref14">14</xref>, <xref ref-type="bibr" rid="ref15">15</xref>). This regulatory effect is partly mediated via the AMPK/sirtuin-1 (SIRT1) axis, as knockdown of SIRT1 abrogated the lipid-lowering and autophagy-inducing effects of GLP-1RAs, highlighting a crucial role of this pathway in regulating lipid metabolism by facilitating degradation of lipid droplets, thus preventing excessive lipid accumulation (<xref ref-type="bibr" rid="ref12">12</xref>). Moreover, GLP-1RAs enhance the export of lipids from hepatocytes, contributing to restoration of lipid homeostasis (<xref ref-type="bibr" rid="ref16">16</xref>). Clinical studies provide strong support for these mechanistic insights, showing that GLP-1RA treatment significantly reduces liver fat content (LFC) as measured by imaging modalities and improves biochemical markers of liver injury (<xref ref-type="bibr" rid="ref17">17</xref>, <xref ref-type="bibr" rid="ref18">18</xref>). Meta-analyses of randomized controlled trials (RCTs) reveal that GLP-1RAs decrease hepatic steatosis by approximately 4&#x2013;5% and improve histological features of steatohepatitis (<xref ref-type="bibr" rid="ref7">7</xref>, <xref ref-type="bibr" rid="ref19">19</xref>). The hepatic benefits of GLP-1RAs are partially independent of weight loss, as demonstrated in clinical trials in which matched weight loss achieved by lifestyle intervention did not replicate the full metabolic improvements seen with GLP-1RA therapy, including enhanced glucose handling and decreased <italic>de novo</italic> lipogenesis (<xref ref-type="bibr" rid="ref20">20</xref>).</p>
<p>In summary, GLP-1 receptor agonists regulate hepatic lipid metabolism in MASLD through activation of AMPK-mediated fatty acid <italic>&#x03B2;</italic>-oxidation, suppressing lipogenesis-related gene expression, and enhancing lipid export and autophagy. This indicates that GLP-1RAs are effective agents for the management of MASLD.</p>
</sec>
<sec id="sec6">
<label>3.1.2</label>
<title>Anti-inflammatory and immunomodulatory effects</title>
<p>Chronic hepatic inflammation, driven by activated Kupffer cells, infiltrating macrophages, and pro-inflammatory cytokines like tumor necrosis factor-alpha (TNF-<italic>&#x03B1;</italic>) and interleukin-6 (IL-6), is a crucial factor in MASLD progression to steatohepatitis and fibrosis. Beyond metabolic regulation, GLP-1RAs exhibit potent anti-inflammatory and immunomodulatory properties that contribute to their therapeutic efficacy in MASLD. Preclinical studies have clearly demonstrated that GLP-1RAs effectively reduce hepatic macrophage infiltration and suppress expression of TNF-<italic>&#x03B1;</italic>, IL-6, and other pro-inflammatory mediators in animal models of MASLD (<xref ref-type="bibr" rid="ref21">21</xref>, <xref ref-type="bibr" rid="ref22">22</xref>). This effect is, at least in part, mediated through the inhibition of the nuclear factor-kappa B (NF-&#x03BA;B) signaling pathway, which serves as a central regulator of inflammatory gene transcription. Treatment with GLP-1RA downregulates NF-&#x03BA;B activation in hepatic tissue, thereby leading to decreased transcription of cytokines and chemokines that sustain inflammation (<xref ref-type="bibr" rid="ref23">23</xref>, <xref ref-type="bibr" rid="ref24">24</xref>).</p>
<p>Furthermore, GLP-1RAs influence the phenotype and function of immune cells. They promote a shift from pro-inflammatory M1 macrophages to anti-inflammatory M2 macrophages, thereby creating a reparative hepatic environment (<xref ref-type="bibr" rid="ref25">25</xref>). Additionally, GLP-1RAs augment regulatory T cell (Treg) populations and elevate the levels of anti-inflammatory cytokines such as IL-10, contributing to immune tolerance and resolution of inflammation (<xref ref-type="bibr" rid="ref26">26</xref>). These immunomodulatory effects are not confined to the liver. Clinical studies have demonstrated that GLP-1RAs can reduce systemic inflammation markers, including C-reactive protein (CRP) and IL-18R&#x03B1; (<xref ref-type="bibr" rid="ref27">27</xref>, <xref ref-type="bibr" rid="ref28">28</xref>). Mechanistic insights also reveal that GLP-1RAs modulate inflammasome activity, specifically the NLRP3 inflammasome, thus reducing pyroptosis and inflammatory cell death in hepatic and immune cells (<xref ref-type="bibr" rid="ref29">29</xref>).</p>
<p>In conclusion, GLP-1 receptor agonists effectively alleviate hepatic inflammation in MASLD by suppressing pro-inflammatory cytokine release, inhibiting NF-&#x03BA;B signaling, modulating the phenotypes of immune cells, and reducing the activation of inflammasomes. These immunomodulatory effects complement their metabolic actions, contributing to improved liver outcomes and systemic benefits.</p>
</sec>
<sec id="sec7">
<label>3.1.3</label>
<title>Anti-fibrotic and hepatoprotective effects</title>
<p>Fibrosis serves as a crucial of prognosis in MASLD, with progressive extracellular matrix deposition leading to cirrhosis and liver failure. Activated HSCs are responsible for the production of collagen and other matrix components. Mechanistically, GLP-1RAs inhibit the activation of hepatic stellate cells (HSCs), which are the principal fibrogenic cell type in the liver. Transforming growth factor-<italic>&#x03B2;</italic> (TGF-&#x03B2;) plays a pivotal role in the fbrotic process and is considered a key driver of fibrosis. Treatment with GLP-1RAs reduces expression of <italic>&#x03B1;</italic>-smooth muscle actin (&#x03B1;-SMA) and collagen type I in HSCs, thereby attenuating fibrogenesis (<xref ref-type="bibr" rid="ref18">18</xref>, <xref ref-type="bibr" rid="ref30">30</xref>). This effect is mediated through modulation of signaling pathways TGF-<italic>&#x03B2;</italic>/Smad and peroxisome proliferator-activated receptor gamma (PPAR&#x03B3;), which regulate HSC activation and extracellular matrix (ECM) synthesis (<xref ref-type="bibr" rid="ref30">30</xref>, <xref ref-type="bibr" rid="ref31">31</xref>).</p>
<p><italic>In vivo</italic> studies conducted on animal models of MASLD/MASH have reveal that GLP-1RAs can reduce liver fibrosis scores and collagen deposition, accompanied by decreased inflammatory infiltration and oxidative stress (<xref ref-type="bibr" rid="ref24">24</xref>, <xref ref-type="bibr" rid="ref32">32</xref>). Clinical trials have reported improvements in noninvasive fibrosis markers, including liver stiffness measured by elastography and serum biomarkers such as procollagen III peptide, following GLP-1RA therapy (<xref ref-type="bibr" rid="ref18">18</xref>, <xref ref-type="bibr" rid="ref33">33</xref>). Although histological reversal of advanced fibrosis remains challenging, GLP-1RAs seem to prevent the progression of fibrosis and may promote the regression of early-stage fibrosis.</p>
<p>Beyond anti-fibrotic effects, GLP-1RAs promote hepatocyte regeneration and repair. They enhance autophagy and reduce lipotoxicity-induced hepatocyte apoptosis, thereby preserving the integrity of liver parenchyma (<xref ref-type="bibr" rid="ref12">12</xref>). GLP-1RAs also improve hepatic microcirculation and reduce oxidative stress, contributing to hepatoprotection (<xref ref-type="bibr" rid="ref29">29</xref>). Combination therapies that involve GLP-1RAs and other agents, such as fibroblast growth factor 21 (FGF21) analogs, THR-<italic>&#x03B2;</italic> action to enhance anti-fibrotic efficacy (<xref ref-type="bibr" rid="ref5">5</xref>, <xref ref-type="bibr" rid="ref34">34</xref>).</p>
<p>In summary, GLP-1 receptor agonists exert anti-fibrotic effects in MASLD through the inhibition of hepatic stellate cell activation, the modulation of profibrotic signaling pathways, and the promotion of hepatocyte regeneration. This clearly highlights GLP-1RAs as promising agents for the management of MASLD.</p>
</sec>
</sec>
<sec id="sec8">
<label>3.2</label>
<title>The mechanisms of GLP-1/GIP or GCG receptor dual agonists in MASLD</title>
<sec id="sec9">
<label>3.2.1</label>
<title>Metabolic regulatory effects</title>
<p>Dual agonists targeting GLP-1 and GIP receptors have emerged as promising agents for metabolic regulation in MASLD. The GIP receptor agonism complements GLP-1 receptor activation by enhancing glucose-dependent insulin secretion, thereby improving glycemic control and weight loss more effectively than GLP-1RAs alone. Tirzepatide&#x2019;s imbalanced receptor engagement, which favors GIP receptor activation, combined with biased signaling at the GLP-1 receptor, further enhances insulin secretion and metabolic benefits (<xref ref-type="bibr" rid="ref35">35</xref>, <xref ref-type="bibr" rid="ref36">36</xref>). These multifaceted metabolic effects position dual GLP-1/GIP receptor agonists as superior therapeutic candidates for MASLD, especially in patients with coexisting obesity and T2DM, where dysregulated glucose and lipid metabolism drive the progression of the disease.</p>
</sec>
<sec id="sec10">
<label>3.2.2</label>
<title>Regulation of hepatic lipid metabolism</title>
<p>Dual GLP-1 receptor agonists facilitate hepatic lipid metabolism through coordinated activation of intracellular signaling pathways that suppress lipogenesis and enhance fatty acid oxidation. The GLP-1 component activates hepatic AMPK/SIRT1 pathways, which inhibit SREBP-1c, a master regulator of <italic>de novo</italic> lipogenesis, thereby reducing hepatic triglyceride synthesis (<xref ref-type="bibr" rid="ref37">37</xref>, <xref ref-type="bibr" rid="ref38">38</xref>). Concurrently, the GCGR agonist component stimulates the hepatic cyclic AMP (cAMP)/protein kinase A (PKA) pathway, robustly enhancing mitochondrial <italic>&#x03B2;</italic>-oxidation of fatty acids and ketogenesis. This activation mobilizes stored triglycerides within hepatocytes for oxidation, effectively decreasing hepatic lipid content (<xref ref-type="bibr" rid="ref39">39</xref>, <xref ref-type="bibr" rid="ref40">40</xref>). The dual action synergistically suppresses hepatic <italic>de novo</italic> lipogenesis while promoting lipid catabolism, resulting in a net reduction of hepatic steatosis (<xref ref-type="bibr" rid="ref41">41</xref>, <xref ref-type="bibr" rid="ref42">42</xref>). Animal studies have demonstrated that combination therapies involving GLP-1 receptor agonists and agents targeting lipid metabolism pathways produce marked reductions in liver fat content, downregulate lipogenic enzymes, and upregulate proteins involved in lipid oxidation (<xref ref-type="bibr" rid="ref41">41</xref>).</p>
<p>In summary, this dual mechanism addresses the fundamental lipid dysregulation in MASLD by restoring the balance between lipid synthesis and degradation within the liver, thereby mitigating steatosis and its metabolic consequences (<xref ref-type="bibr" rid="ref40">40</xref>, <xref ref-type="bibr" rid="ref43">43</xref>).</p>
</sec>
<sec id="sec11">
<label>3.2.3</label>
<title>Anti-inflammatory and anti-fibrotic effects</title>
<p>Activation of GLP-1 receptors by dual agonists exerts potent anti-inflammatory effects within the liver microenvironment, which are crucial for preventing progression from steatosis to steatohepatitis and fibrosis. GLP-1 receptor activation inhibits the activation of hepatic Kupffer cells and infiltrating macrophages, leading to decreased production of pro-inflammatory cytokines such as TNF-<italic>&#x03B1;</italic> and IL-1&#x03B2;, thereby attenuating hepatic inflammation (<xref ref-type="bibr" rid="ref44">44</xref>).</p>
<p>Preclinical models have shown that GLP-1 analogs suppress hepatic stellate cell activation, the key drivers of fibrogenesis, resulting in reduced collagen deposition and fibrosis (<xref ref-type="bibr" rid="ref45">45</xref>, <xref ref-type="bibr" rid="ref46">46</xref>). Additionally, GCGR activation may indirectly influence fibrogenesis by modulating the hepatic metabolic milieu, reducing lipotoxicity and oxidative stress that serve as upstream triggers for fibrotic pathways (<xref ref-type="bibr" rid="ref39">39</xref>, <xref ref-type="bibr" rid="ref47">47</xref>). By alleviating lipotoxicity and inflammatory signaling, dual GLP-1 receptor agonists disrupt the feed-forward cycle driving hepatic fibrosis, thus offering a therapeutic avenue to prevent or reverse liver fibrosis in MASLD (<xref ref-type="bibr" rid="ref40">40</xref>, <xref ref-type="bibr" rid="ref48">48</xref>).</p>
<p>Clinical trials that investigate dual GLP-1/GIP receptor agonists have presented encouraging evidence for their efficacy and safety in treating MASLD. Phase 2 and 3 studies, such as randomized controlled trials, have shown that these agents significantly reduce liver fat content, improve liver enzyme profiles, and promote histological improvements in patients with MASLD and MASH (<xref ref-type="bibr" rid="ref6">6</xref>, <xref ref-type="bibr" rid="ref46">46</xref>). In a randomized, placebo-controlled study, pemvidutide, a dual GLP-1/GCG receptor agonist, significantly decreased liver fat content by up to 68.5% after 12&#x202F;weeks of treatment, accompanied by reductions in hepatic inflammation markers and body weight, highlighting the potential of dual receptor agonists to modify MASLD pathophysiology (<xref ref-type="bibr" rid="ref47">47</xref>). Meta-analyses have further confirmed that dual GLP-1/GIP receptor agonists are more effective than single GLP-1RAs in reversing liver fibrosis and reducing hepatic fat accumulation, suggesting a dose-dependent and receptor-combinatorial effect on liver outcomes (<xref ref-type="bibr" rid="ref48">48</xref>).</p>
<p>This integrated anti-inflammatory and anti-fibrotic action complements their metabolic benefits, positioning dual GLP-1 receptor agonists as promising agents in the comprehensive management of MASLD and its complications.</p>
</sec>
</sec>
<sec id="sec12">
<label>3.3</label>
<title>The mechanistic GLP-1/GIP/GCG receptors triple agonists in MASLD</title>
<sec id="sec13">
<label>3.3.1</label>
<title>Metabolic effects</title>
<p>The development of triple receptor agonists targeting GLP-1, GIP, and GCG receptors represents a promising advancement in the treatment of MASLD. Its triple-agonist mechanism achieves multi-pathway metabolic regulation by simultaneously activating GLP-1 receptors (enhancing insulin secretion and inhibiting gastric emptying), GIP receptors (promoting energy storage in adipose tissue), and GCG receptors (increasing energy expenditure). At present, seven triple receptor agonists, including Retatrutide (LY3437943), SAR441255 and xGLP/GCG/GIP-32, have entered the clinical research stage. Among them, retatrutide has shown significant clinical advantages in phase II clinical trials, reducing the weight of obese patients by up to 24.2% in 48&#x202F;weeks and lowering the HbA1c of type 2 diabetes patients by 2.2% in 36&#x202F;weeks (<xref ref-type="bibr" rid="ref49">49</xref>, <xref ref-type="bibr" rid="ref50">50</xref>). The combination of these three hormones results in a weight loss effect that surpasses that achieved by individual or dual agonists, making it a cornerstone in the therapeutic approach to MASLD (<xref ref-type="bibr" rid="ref6">6</xref>).</p>
</sec>
<sec id="sec14">
<label>3.3.2</label>
<title>Regulation of hepatic lipid metabolism</title>
<p>Triple receptor agonists exhibit promising synergistic effects on hepatic lipid metabolism, a central pathological feature in MASLD. These hormones exert direct effects on the liver; glucagon receptor activation stimulates <italic>&#x03B2;</italic>-oxidation of fatty acids, reducing hepatic lipid content, while GLP-1 enhances systemic insulin sensitivity and decreases lipolysis in adipose tissue, thereby indirectly reducing hepatic fat influx (<xref ref-type="bibr" rid="ref51">51</xref>). In a phase 2 trial in participants with obesity and MASLD, once-weekly treatment with the GIP/GLP-1/GCG triple agonist retatrutide resulted in substantial reductions in liver fat, body weight, abdominal visceral adipose tissue (VAT) and abdominal subcutaneous adipose tissue (ASAT), serum lipids. Hepatic steatosis resolved in more than 85% of participants in two highest dose groups (<xref ref-type="bibr" rid="ref52">52</xref>). These mechanisms suggest a coordinated regulation of key enzymes and signaling pathways involved in lipid synthesis and breakdown, such as AMPK and SREBP-1c, which are critical for maintaining hepatic lipid homeostasis (<xref ref-type="bibr" rid="ref6">6</xref>).</p>
</sec>
<sec id="sec15">
<label>3.3.3</label>
<title>Anti-inflammatory and anti-fibrotic effects</title>
<p>The anti-inflammatory and anti-fibrotic potential of GLP-1 receptor activation has garnered significant attention in the context of liver disease. Activation of GLP-1 receptors has been shown to exert direct anti-inflammatory effects, potentially by inhibiting the activation of hepatic stellate cells and reducing the production of pro-inflammatory cytokines (<xref ref-type="bibr" rid="ref6">6</xref>). This action may be particularly beneficial in the context of MASLD, where inflammation plays a pivotal role in disease progression. The combination of GLP-1, GIP, and glucagon receptor agonism may further enhance these effects by collectively reducing the hepatic fat burden and systemic inflammatory state, thereby indirectly inhibiting the progression of fibrosis (<xref ref-type="bibr" rid="ref47">47</xref>). In preclinical models with an acute diet-induced liver injury model due to a single high-dose fructose binge in mice, as well as a chronic mouse feeding model incorporating fructose intended to mirror early MASLD with features of steatohepatitis, Retatrutide reduced the expression of hepatic inflammation markers chemokine ligand-1 (Cxcl-1), serum amyloid A1 (Saa-1), and serum amyloid A2 (Saa-2) (<xref ref-type="bibr" rid="ref53">53</xref>). Retatrutide markedly suppressed the expression of pro-inflammatory cytokines (TNF-<italic>&#x03B1;</italic>, caspase-1, and NLRP3) and pro-fibrotic factors (fibronectin, &#x03B1;-SMA, and collagen I) in treating diabetic kidney disease (DKD) in db/db mice (<xref ref-type="bibr" rid="ref54">54</xref>). Furthermore, Retatrutide substantially enhanced liver function, reduced triglyceride levels, cholesterol levels. The potential for these triple receptor agonists to not only improve metabolic parameters but also to exert protective effects on liver inflammation and fibrosis positions them as promising candidates for future therapeutic strategies in managing metabolic liver diseases.</p>
<p>In summary, triple receptor agonists orchestrate a multidimensional regulation of liver inflammation and fibrosis by modulating cytokine profiles, inhibiting fibrogenic signaling, and improving metabolic derangements that contribute to hepatic injury. This comprehensive and targeted approach presents a novel therapeutic avenue that effectively addresses both the metabolic and histopathological facets of MASLD.</p>
</sec>
</sec>
</sec>
<sec id="sec16">
<label>4</label>
<title>Challenges and future directions</title>
<sec id="sec17">
<label>4.1</label>
<title>Safety considerations</title>
<p>The safety profile of dual or triple receptor agonists targeting GLP-1, GIP, and GCG receptors in the treatment of MASLD and related metabolic disorders warrants careful evaluation. The glucagon component, while contributing to enhanced metabolic benefits, poses a potential risk of hypoglycemia, necessitating precise dose titration to avoid adverse glycemic events. Clinical trials have reported gastrointestinal side effects as common adverse events with incretin-based therapies, including nausea and vomiting, which may affect patient adherence. Meanwhile, it is worth noting that although the current data do not show a significant increase in the risk of pancreatitis, long-term follow-up should still focus on the potential risks of pancreatitis and thyroid C-cell tumors, especially as GCGR activation may affect pancreatic exocrine function (<xref ref-type="bibr" rid="ref55">55</xref>). Moreover, individual metabolic characteristics, such as coexisting diabetes, obesity, or hepatic impairment, influence drug metabolism and response, underscoring the need for personalized treatment strategies.</p>
</sec>
<sec id="sec18">
<label>4.2</label>
<title>Combination therapy strategies</title>
<p>Combining triple receptor agonists with other pharmacological agents holds promise for synergistic metabolic benefits in MASLD management. Notably, co-administration with farnesoid X receptor (FXR) agonists or peroxisome proliferator-activated receptor (PPAR) agonists may enhance lipid metabolism regulation and anti-inflammatory effects, addressing multiple pathogenic pathways simultaneously. Preclinical and clinical data suggest that FXR and PPAR dual modulators can improve insulin sensitivity, reduce hepatic steatosis, and attenuate fibrosis, which may complement the actions of GLP-1/GIP/GCG receptors agonists. Additionally, sodium-glucose cotransporter 2 (SGLT2) inhibitors, known for their glycemic and cardiovascular benefits, when combined with incretin-based therapies, have demonstrated additive improvements in weight loss, glycemic control, and liver function markers. Optimizing dosing schedules and administration routes is critical to maximize therapeutic efficacy while minimizing adverse effects such as hypoglycemia and gastrointestinal intolerance. Nonetheless, rigorous clinical trials are needed to establish the safety, efficacy, and optimal protocols for these combination regimens in MASLD patients (<xref ref-type="bibr" rid="ref56 ref57 ref58">56&#x2013;58</xref>).</p>
</sec>
</sec>
<sec sec-type="conclusions" id="sec19">
<label>5</label>
<title>Conclusion</title>
<p>In conclusion, the evolving landscape of MASLD treatment underscores the significant therapeutic promise of GLP-1RAs and dual or triple receptor agonists. From an expert perspective, the development of GLP-1RAs has marked a pivotal advancement by targeting key pathophysiological mechanisms such as hepatic lipid metabolism, inflammation, and fibrosis. These agents have demonstrated robust efficacy in modulating metabolic dysfunctions central to MASLD progression, positioning them as a cornerstone in contemporary therapeutic strategies. Continued interdisciplinary research that integrates basic science, clinical investigation, and personalized medicine principles will be crucial for fully harnessing their therapeutic potential and improving outcomes for patients suffering from MASLD.</p>
</sec>
</body>
<back>
<sec sec-type="author-contributions" id="sec20">
<title>Author contributions</title>
<p>XL: Writing &#x2013; original draft, Writing &#x2013; review &#x0026; editing. LY: Conceptualization, Writing &#x2013; review &#x0026; editing, Writing &#x2013; original draft.</p>
</sec>
<sec sec-type="COI-statement" id="sec21">
<title>Conflict of interest</title>
<p>The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.</p>
</sec>
<sec sec-type="ai-statement" id="sec22">
<title>Generative AI statement</title>
<p>The author(s) declared that Generative AI was not used in the creation of this manuscript.</p>
<p>Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.</p>
</sec>
<sec sec-type="disclaimer" id="sec23">
<title>Publisher&#x2019;s note</title>
<p>All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.</p>
</sec>
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<fn-group>
<fn fn-type="custom" custom-type="edited-by" id="fn0001">
<p>Edited by: <ext-link ext-link-type="uri" xlink:href="https://loop.frontiersin.org/people/2774422/overview">Jianbin Zhang</ext-link>, Dalian Medical University, China</p>
</fn>
<fn fn-type="custom" custom-type="reviewed-by" id="fn0002">
<p>Reviewed by: <ext-link ext-link-type="uri" xlink:href="https://loop.frontiersin.org/people/1620796/overview">Theodoros Androutsakos</ext-link>, National and Kapodistrian University of Athens, Greece</p>
<p><ext-link ext-link-type="uri" xlink:href="https://loop.frontiersin.org/people/1434660/overview">Feng Zhang</ext-link>, Nanjing University of Chinese Medicine, China</p>
</fn>
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