Bring a large pot of generously salted water to a rolling boil. Add your fettuccine and cook according to the package directions until al dente. Before draining, scoop out about a cup of the starchy pasta water and set it aside it's a great tool for loosening the sauce later if needed.
While the pasta cooks, melt the butter in a large skillet over medium heat. Add the minced garlic and sage leaves, if using, and cook for about a minute until fragrant. Keep an eye on the garlic so it doesn't brown too quickly and turn bitter.
Pour in the heavy cream and whisk it together with the butter and garlic. Let it come to a gentle simmer for a minute or two so the flavors start to meld. This step sets the creamy foundation that the pumpkin will fold into next.
Add the pumpkin puree and whisk until it's fully incorporated and smooth. The sauce should turn a warm, inviting orange color. Let it simmer gently for another 2-3 minutes so it thickens slightly and loses any raw pumpkin taste.
Lower the heat and stir in the freshly grated Parmesan a little at a time, whisking constantly so it melts evenly. Season with nutmeg, black pepper, and salt to taste. If the sauce feels too thick, splash in a bit of the reserved pasta water.
Add your drained pasta directly into the skillet and toss until every strand is coated in that creamy pumpkin sauce. Serve immediately while it's hot, topped with extra Parmesan and a few cracked pepper flakes for a finishing touch.