I try to keep an eye on the drug companies working in our disease space, not because I'm an investor (I'm not), but because what they do affects us directly. Madrigal Pharmaceuticals just reported their fourth quarter and full year 2025 earnings, and there's a lot to unpack. I want to walk through it with you as a patient, not as a Wall Street analyst.
Here's what caught my attention.
## The headline number
Rezdiffra — the first and only FDA-approved drug specifically for MASH with moderate to advanced fibrosis — brought in $958.4 million in its first full year of sales. That's nearly a billion dollars. For context, it was only approved in March 2024. Going from nothing to a billion dollars in less than two years is extraordinarily fast for any drug, let alone one for a disease that most doctors still don't screen for.
In my experience, what's more telling to me is the patient count. By the end of 2025, over 36,250 patients were on Rezdiffra. That number matters more than the dollars. It tells us that real people with our disease are actually getting treated, not just diagnosed and sent home with a pamphlet about diet and exercise.
## The diagnosis problem is getting better
One of the slides in their earnings presentation really jumped out at me.
Look at those numbers. The diagnosed MASH population with F2/F3 fibrosis — meaning moderate to bridging fibrosis, the stage where Rezdiffra is indicated — grew from about 315,000 to 460,000 people between 2023 and 2025. The target market grew by 46% in two years.
Now, I don't celebrate the fact that more people have MASH. They always had it. What's changing is that more of them are being found. And that's actually good news, because you can't treat a disease nobody's looked for. Increasing disease awareness, increasing diagnosis, and more patients getting to a specialist — those are the three drivers Madrigal highlighted, and as a patient advocate, those are exactly the things I've been pushing for since we started the foundation.
## What Rezdiffra actually does
For those who haven't followed it closely, let me explain what the drug does in plain terms.
Rezdiffra is a thyroid hormone receptor-beta (THR-β) agonist. If that sounds complicated, think of it this way — your liver has receptors that respond to thyroid hormones, and those hormones tell your liver to burn fat and reduce inflammation. Rezdiffra is designed to activate that specific receptor without affecting your heart or bones the way actual thyroid hormones would.
In the clinical trials, patients with F2 or F3 fibrosis who took 80mg of Rezdiffra had about a 26% rate of fibrosis improvement with no worsening of the inflammatory component (MASH resolution), compared to about 14% on placebo. For MASH resolution with no worsening of fibrosis, the numbers were even better — roughly 30% versus 10%. These aren't miracle numbers. But they're statistically real, and for a disease where we had literally nothing before, they're meaningful.
The drug is a daily pill, taken once a day. That matters a lot. We're not talking about injections or infusions. It's something you can just add to your morning routine.
## The F4 cirrhosis story — this is the part that hit me personally
I have cirrhosis. So when Madrigal showed data on patients with compensated cirrhosis (what they call F4c), I paid very close attention.
This slide tells a remarkable story if you understand what **CSPH** means. CSPH stands for clinically significant portal hypertension — it's the high blood pressure in the blood vessels around your liver that causes many of the worst complications of cirrhosis. Varices, ascites, the things that send people to the emergency room. Having CSPH is essentially the dividing line between "compensated" cirrhosis (manageable) and "decompensated" cirrhosis (life-threatening).
In this study extension, 100% of the F4c patients on Rezdiffra started with confirmed CSPH. After two years:
- 65% of those patients shifted into a lower CSPH risk category
- The percentage with no or low CSPH grew from 0% at baseline to 34% at year 1 and 42% at year 2
- Meanwhile, confirmed CSPH dropped from 100% to 41% at year 1 and just 35% at year 2
Let me put that another way. Patients who all started in the highest-risk category saw their portal hypertension improve to the point where, after two years, only about a third still had confirmed CSPH. For those of us living with cirrhosis, that's the kind of data that actually changes how we think about our future.
Now, it's important to be honest here — Rezdiffra isn't currently approved for F4 cirrhosis patients. This is open-label extension data, and the formal outcomes trial (MAESTRO-NASH OUTCOMES) won't report results until 2027. But the early signals are encouraging, and that matters when you're the one living with the disease.
## Looking ahead — it's not going to be one drug
One thing I want to make clear: the future of treating MASH isn't going to be a single pill. Madrigal seems to understand this.
They're building a pipeline with over 10 programs, including combination approaches that pair Rezdiffra with other mechanisms — things like an oral GLP-1 (similar to what Ozempic does, but in a pill you can combine with Rezdiffra), a DGAT-2 inhibitor (targets how belly fat makes triglycerides), and even siRNA therapies (a genetic approach that can shut down specific proteins the liver uses to make too much fat).
This is exactly the model we've seen work in other diseases. Think about HIV — it took years, but the key was combinations of drugs that attack the problem from multiple angles. MASH is a metabolic disease with multiple drivers, so it makes sense that the best treatment will eventually be a cocktail tailored to the individual patient.
Here's the thing — they also launched in Germany after EU approval. That matters for our international community.
## What this means for you
If you're a patient with MASH and fibrosis stage F2 or F3, Rezdiffra is available now. Talk to your hepatologist about whether it's appropriate for your situation. If your doctor isn't familiar with it, that's a red flag that you may need a specialist who's actually following this field.
If you're at F4 like me, we wait and watch. The data is encouraging, but we need the outcomes trial to confirm it. In the meantime, everything else we do — managing our metabolic health, staying active, monitoring our lab work — isn't optional. A drug can help, but it's not a substitute for the daily work of living with this disease.
The biggest takeaway from this report, from my perspective, isn't the billion dollars in sales. It's that 36,000 people are being treated for a disease that, five years ago, had zero approved therapies. That's progress. It's not fast enough, it's not cheap enough, and it's not available to everyone who needs it. But it's real.
If you want to stay informed about developments like this in our disease space, follow the foundation and consider joining our community. And if you haven't been screened for liver disease, or your doctor hasn't ordered a FibroScan — ask. The first step is always knowing where you stand.
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