Traditional Chinese Medicines for Metabolic Dysfunction‐Associated Steatotic Liver Disease: A Mixed‐Method Systematic Review

OBJECTIVE: This mixed-method systematic review evaluated the efficacy and safety of Traditional Chinese Medicine (TCM) for metabolic dysfunction-associated steatotic liver disease (MASLD) and identified core TCM herbs/compatibility regimens. METHODS: Six databases were searched (inception to December 31, 2025) for randomized controlled trials (RCTs) of TCM combinations for adult MASLD, with placebo/treatment-as-usual (TAU) as controls. Two independent teams performed screening, data extraction and quality assessment. Quantitative synthesis included meta-analysis with subgroup/meta-regression analyses, publication bias assessment and sensitivity analysis; qualitative synthesis used TCM data mining to identify core herbs and compatibility patterns. RESULTS: A total of 56 RCTs were included. TCM significantly improved TCM Symptom Score, clinical effective rate, liver controlled attenuation parameter (CAP), liver function (ALT, AST, GGT), lipid metabolism (TC, TG, LDL-C) and reduced BMI, with no benefit for HDL-C. Male proportion had no moderating effect on outcomes. TCM-related adverse events (mainly diarrhea and gastrointestinal discomfort) were mild and rare; 63.2% of studies reported no adverse events. Included RCTs had suboptimal methodological quality (high unclear bias in allocation concealment and blinding). Qualitative analysis of 39 studies identified 78 TCM herbs, with Crataegus pinnatifida (Shan Zha) the most frequent. Six core herbs were identified, with Salvia miltiorrhiza (Dan Shen) and Crataegus pinnatifida (Shan Zha) as the core of the compatibility regimens. CONCLUSIONS: TCM formulations may provide symptomatic and metabolic benefits for MASLD with acceptable safety and identifiable core herbs; however, evidence certainty is very low due to pervasive poor methodological quality of included RCTs, which severely undermines confidence in findings. High-quality RCTs and mechanistic research are warranted.