This long-term observational pilot study showed that one year of pemafibrate therapy significantly improved markers of hepatic inflammation (ALT), function (ALBI score), and fibrosis (M2BPGi) in patients with both T2DM and NAFLD who were refractory to long-term therapy using SGLT2 inhibitors. This evidence concerns the gene SLC5A2 and metabolic dysfunction-associated steatotic liver disease.