Combination Therapy Potential of HTD1801 (Berbe-rine Ursodeoxycholate) in MASLD/MASH and Cardiovascular-Kidney-Metabolic Disease

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) and steatohepatitis (MASH) are central to the cardiovascular-kidney-metabolic (CKM) continuum, where metabolic injury, hepatocellular stress, and systemic inflammation converge. These features represent key markers across the MASLD and CKM continuum. In this context, HTD1801, an ionic complex of berberine and ursodeoxycholic acid (UDCA), has shown improvements in glycemic control, LDL cholesterol, hepatic fat, and liver enzymes in clinical trials. The evidence base remains limited, with trials conducted in China and the United States and no biopsy-confirmed histologic outcomes yet reported. Main body: This review summarizes the mechanistic profile of HTD1801 and examines potential intersections with therapies commonly used in MASLD/MASH and CKM disease. Metformin is currently the only partner supported by Phase 3 randomized data demonstrating efficacy of HTD1801 as add-on therapy. For GLP-1 receptor agonists, statins, and SGLT2 inhibitors, combination rationale is biologically plausible but rests on mechanistic, preclinical, or comparative evidence rather than randomized human combination trials. Combinations with PPAR agonists or resmetirom remain hypothetical pending direct combination data and published biopsy-based efficacy results for HTD1801. Conclusions: HTD1801 occupies an intermediate position between metabolic and liver-directed therapy. Its role is promising but not yet fully defined. Publication of biopsy-based results from the completed CENTRICITY Phase 2b trial, and dedicated combination trials will be the primary requirement to determine whether HTD1801 can bridge metabolic and hepatic treatment strategies within the CKM spectrum, with geographic validation serving as a secondary consideration.