Individuals with steatotic liver disease who consume significant amounts of alcohol and meet at least one cardiometabolic criterion are classified as having metabolic and alcohol-associated liver disease (MetALD). The efficacy of saroglitazar and simvastatin in this population remains unclear. In this single-center retrospective cohort study, 102 patients with MetALD were included. The reduction in CAP score was greater in the saroglitazar group (-40 (-109 to 3) dB/m) compared to the simvastatin group (-33 (-100 to 36) dB/m), although this difference did not reach statistical significance (P = 0.08). However, a significant difference was observed in the change in liver stiffness measurement (LSM) scores, with the saroglitazar group showing a greater reduction (-1.9 (-19.5 to 26.3) kPa) than the simvastatin group (-0.8 (-12.2 to 9) kPa) (P = 0.01). Saroglitazar also demonstrated a more pronounced effect on glycosylated hemoglobin (HbA1c), with a median decrease of -0.61 ± 0.96 compared to -0.1 ± 0.4 in the simvastatin group (P = 0.02). Saroglitazar is more effective than simvastatin in reducing CAP, LSM, and HbA1c over six months. Further prospective, well-controlled randomized studies are warranted to validate these findings.