In this study, 3-year SGLT2i treatment did not improve HSI and APRI in insulin-treated patients; however, SGLT2is significantly reduced both HSI and APRI in insulin-naïve patients, suggesting that exogeneous insulin as well as endogenous hyperinsulinemia may adversely affect MASDL and may attenuate the beneficial effects of SGLT2is for MASLD. Here, INS is linked to Hyperinsulinemia.