Empagliflozin and its impact on hepatic and metabolic outcomes in patients with type 2 diabetes and NAFLD: a systematic review and meta-analysis

BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly nonalcoholic fatty liver disease (NAFLD), often coexists with type 2 diabetes mellitus (T2DM) due to shared metabolic pathways such as insulin resistance. Empagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, may provide hepatic and metabolic benefits. This study evaluated its effects on liver fat, enzymes, fibrosis, metabolic parameters, and inflammation in T2DM with MASLD. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed according to PRISMA guidelines. Primary outcomes included liver fat content, enzymes, and fibrosis markers. Secondary outcomes were metabolic and inflammatory parameters. RESULTS: Eleven RCTs (n = 3077) were included. Empagliflozin significantly reduced liver fat (MD = -3.11%; 95% CI: -4.12 to -2.11; p < 0.00001) and liver stiffness (MD = -0.43 kPa; p = 0.003), but had no significant effect on AST (-0.27 IU/L; p = 0.89) or GGT (-9.25 IU/L; p = 0.14). It significantly lowered HbA1c (-0.54%; p < 0.0001), fasting glucose (-20.89 mg/dL; p < 0.0001), weight (-2.04 kg; p < 0.0001), and waist circumference (-3.47 cm; p < 0.0001), with a nonsignificant reduction in BMI (-0.77 kg/m²; p = 0.09).Uric acid decreased (-0.41 mg/dL; p < 0.00001), but IL-6 and fibrosis scores (FIB-4, NFS) remained unchanged. CONCLUSION: Empagliflozin improves liver fat, stiffness, glycemic control, body weight, and uric acid in T2DM with MASLD, but its effects on fibrosis and inflammation remain uncertain. Larger, long-term histologic trials are needed to confirm these outcomes.