Combination Therapy Potential of HTD1801 (Berberine Ursodeoxycholate) in MASLD/MASH and Cardiovascular–Kidney–Metabolic Disease: A Narrative Review

Abstract

Background/Objectives: The cardiovascular–kidney–metabolic (CKM) continuum is characterized by the close interrelatedness of metabolic, hepatic, cardiovascular, and renal disease, making multidomain therapies particularly relevant to MASLD/MASH. HTD1801, an investigational ionic therapeutic, combines berberine’s metabolic effects with the hepatoprotective effects of ursodeoxycholic acid (UDCA), making it a potential multidomain therapy within this setting. This review had two related goals: first, to synthesize the mechanistic and clinical evidence for HTD1801 itself; and second, to evaluate the rationale and available evidence for extending this complementary-action approach through combination with other therapies relevant to MASLD/MASH and CKM disease. Methods: PubMed/MEDLINE, ClinicalTrials.gov, conference abstracts, and selected regulatory or sponsor sources were reviewed through 9 August 2026. Six CKM-relevant therapeutic classes were selected for their human evidence of multidomain benefit: metformin, GLP-1 receptor agonists, statins, SGLT2 inhibitors, PPAR agonists, and resmetirom. Studies of both HTD1801 and its individual components, berberine and UDCA, were included. A systematic review or meta-analysis was not feasible due to the limited and heterogeneous evidence base, instead necessitatinganarrative review. Results: Across seven completed HTD1801 clinical studies with publicly reported results, treatment showed multidomain metabolic and hepatic benefits across the CKM spectrum, including improvements in HbA1c, LDL-C, MRI-PDFF hepatic fat, ALT, AST, and GGT. Direct human evidence: HTD1801 + metformin, supported by a Phase 3 randomized add-on trial. Indirect human evidence: HTD1801 + SGLT2 inhibitors. Preclinical evidence: HTD1801 + GLP-1 receptor agonists; berberine + statins. Theoretical mechanistic rationale only: HTD1801 + PPAR agonists; HTD1801 + resmetirom. Overall, mechanistic and preclinical rationale has advanced further than direct human validation, and evidence remains centered largely on surrogate rather than definitive clinical outcomes. Conclusions: HTD1801 has demonstrated multidomain metabolic and hepatic activity, but direct human evidence supporting its use with other CKM therapies remains limited and is currently established only for metformin. The principal next step is to test HTD1801 in dedicated combination RCTs for clinically meaningful benefit. Further studies should characterize combination-specific safety and tolerability and compare HTD1801 with separate berberine and UDCA administration.