Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver disease 
worldwide, and there is no approved pharmacotherapy. The efficacy of vitamin E 
and pioglitazone has been established in nonalcoholic steatohepatitis (NASH), a 
progressive form of NAFLD. GLP-1RA and SGLT2 inhibitors, which are currently 
approved for use in diabetes, have shown early efficacy in NASH, and also have 
beneficial cardiovascular or renal effects. Innovative NASH therapies include 
four main pathways. The first approach is targeting hepatic fat accumulation. 
Medications in this approach include modulation of peroxisome 
proliferator-activator receptors (e.g., pemafibrate, elafibranor), medications 
targeting farnesoid X receptor axis [obeticholic acid; OCA)], inhibitors of de 
novo lipogenesis (aramchol, ACC inhibitor), and fibroblast growth factor-21 
analogues. A second target is oxidative stress, inflammation, and apoptosis. 
This class of drug includes apoptosis signaling kinase 1 (ASK1) inhibitor and 
emricasan (an irreversible caspase inhibitor). A third target is intestinal 
microbiomes and metabolic endotoxemia. Several agents are in ongoing trials, 
including IMMe124, TLR4 antagonist, and solithromycin (macrolide antibiotics). 
The final target is hepatic fibrosis, which is strongly associated with 
all-cause or liver-related mortality in NASH. Antifibrotic agents are a 
cysteine-cysteine motif chemokine receptor-2/5 antagonist (cenicriviroc; CVC) 
and galectin 3 antagonist. Among a variety of medications in development, four 
agents such as OCA, elafibranor, ASK1 inhibitor, and CVC are currently being 
evaluated in an international phase 3 trial for the treatment of NASH. Within 
the next few years, the availability of therapeutic options for NASH will 
hopefully curb the rising trend of NASH-related diseases.