Alcohol-aware risk stratification and subtype-specific care pathways across metabolic dysfunction-associated steatotic liver disease, metabolic dysfunction and alcohol-associated liver disease, and alcohol-associated liver disease.

Accurate classification and risk stratification across metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-associated liver disease (MetALD), and alcohol-associated liver disease (ALD) depend critically on the assessment of alcohol exposure. However, current clinical practice relies largely on self-reported alcohol intake, which may underestimate drinking quantity, pattern, and prior heavy exposure and consequently lead to subtype misclassification. This review focuses on an alcohol-aware approach to steatotic liver disease (SLD) phenotyping and clinical management. We discuss the complementary role of structured alcohol assessment and objective biomarkers, particularly phosphatidylethanol, while emphasizing biological, analytical, and host factors that limit interpretation of a single biomarker value. We further examine how active or recent alcohol exposure modifies the interpretation of commonly used risk-stratification tools, particularly FIB-4 and liver stiffness measurement, and when repeat assessment after alcohol reduction or abstinence may be appropriate. Finally, we propose practical subtype-specific care pathways integrating alcohol exposure, non-invasive fibrosis assessment, and longitudinal reassessment across MASLD, MetALD, and ALD. An alcohol-aware approach may reduce subtype misclassification and enable more appropriate referral, monitoring, and therapeutic decision-making across the SLD spectrum.