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Mai W, Chow SC. Analysis of innovative two-stage seamless adaptive design with different endpoints and population shift. J Biopharm Stat 2024:1-14. [PMID: 38515269 DOI: 10.1080/10543406.2024.2330204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/01/2024] [Indexed: 03/23/2024]
Abstract
In recent years, clinical trials utilizing a two-stage seamless adaptive trial design have become very popular in drug development. A typical example is a phase 2/3 adaptive trial design, which consists of two stages. As an example, stage 1 is for a phase 2 dose-finding study and stage 2 is for a phase 3 efficacy confirmation study. Depending upon whether or not the target patient population, study objectives, and study endpoints are the same at different stages, Chow (2020) classified two-stage seamless adaptive design into eight categories. In practice, standard statistical methods for group sequential design with one planned interim analysis are often wrongly directly applied for data analysis. In this article, following similar ideas proposed by Chow and Lin (2015) and Chow (2020), a statistical method for the analysis of a two-stage seamless adaptive trial design with different study endpoints and shifted target patient population is discussed under the fundamental assumption that study endpoints have a known relationship. The proposed analysis method should be useful in both clinical trials with protocol amendments and clinical trials with the existence of disease progression utilizing a two-stage seamless adaptive trial design.
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Affiliation(s)
- Weijia Mai
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shein-Chung Chow
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
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Nguyen M, Asgharpour A, Dixon DL, Sanyal AJ, Mehta A. Emerging therapies for MASLD and their impact on plasma lipids. Am J Prev Cardiol 2024; 17:100638. [PMID: 38375066 PMCID: PMC10875196 DOI: 10.1016/j.ajpc.2024.100638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/18/2024] [Accepted: 02/04/2024] [Indexed: 02/21/2024] Open
Abstract
Metabolic-dysfunction associated steatotic liver disease (MASLD) affects 1 out of every 3 individuals in the adult population and the disease prevalence is predicted to increase worldwide. Patients with MASLD are also burdened by cardiovascular disease, which is the leading cause of mortality in this population. Complex metabolic derangements such as insulin resistance and atherogenic dyslipidemia affect patients with MASLD. In patients with MASLD, treatment such as pharmacotherapy may be best directed towards improving the adverse concomitant metabolic disorders associated with MASLD, particularly the ones that may contribute to MASLD. Herein, we discuss conventional therapies that target cardiometabolic risk factors which have the potential to improve hepatic injury, and summarize emerging therapies that target hepatic receptors, fibrosis, and fatty acid oxidation in patients with MASLD. Given the relationship between hepatic injury which leads to MASLD, insulin resistance, and ultimately atherogenic dyslipidemia our review uniquely delves into the effects of conventional and emerging therapies for MASLD on plasma lipid parameters.
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Affiliation(s)
- Madison Nguyen
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
| | - Amon Asgharpour
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
- VCU Stravitz-Sanyal Institute of Liver Disease and Metabolic Health, Richmond, VA, United States
| | - Dave L. Dixon
- Department of Pharmacotherapy and Outcome Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States
- VCU Health Pauley Heart Center, Richmond, VA, United States
| | - Arun J. Sanyal
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
- VCU Stravitz-Sanyal Institute of Liver Disease and Metabolic Health, Richmond, VA, United States
| | - Anurag Mehta
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
- VCU Health Pauley Heart Center, Richmond, VA, United States
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Lonardo A, Ballestri S, Mantovani A, Targher G, Bril F. Endpoints in NASH Clinical Trials: Are We Blind in One Eye? Metabolites 2024; 14:40. [PMID: 38248843 PMCID: PMC10820221 DOI: 10.3390/metabo14010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
This narrative review aims to illustrate the notion that nonalcoholic steatohepatitis (NASH), recently renamed metabolic dysfunction-associated steatohepatitis (MASH), is a systemic metabolic disorder featuring both adverse hepatic and extrahepatic outcomes. In recent years, several NASH trials have failed to identify effective pharmacological treatments and, therefore, lifestyle changes are the cornerstone of therapy for NASH. with this context, we analyze the epidemiological burden of NASH and the possible pathogenetic factors involved. These include genetic factors, insulin resistance, lipotoxicity, immuno-thrombosis, oxidative stress, reprogramming of hepatic metabolism, and hypoxia, all of which eventually culminate in low-grade chronic inflammation and increased risk of fibrosis progression. The possible explanations underlying the failure of NASH trials are also accurately examined. We conclude that the high heterogeneity of NASH, resulting from variable genetic backgrounds, exposure, and responses to different metabolic stresses, susceptibility to hepatocyte lipotoxicity, and differences in repair-response, calls for personalized medicine approaches involving research on noninvasive biomarkers. Future NASH trials should aim at achieving a complete assessment of systemic determinants, modifiers, and correlates of NASH, thus adopting a more holistic and unbiased approach, notably including cardiovascular-kidney-metabolic outcomes, without restricting therapeutic perspectives to histological surrogates of liver-related outcomes alone.
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Affiliation(s)
- Amedeo Lonardo
- AOU—Modena—Ospedale Civile di Baggiovara, 41126 Modena, Italy;
| | | | - Alessandro Mantovani
- Section of Endocrinology and Diabetes, Department of Medicine, University of Verona, Piazzale Stefani, 37126 Verona, Italy
| | - Giovanni Targher
- Department of Medicine, University of Verona, 37126 Verona, Italy;
- Metabolic Diseases Research Unit, IRCCS Sacro Cuore—Don Calabria Hospital, 37024 Negrar di Valpolicella, Italy
| | - Fernando Bril
- Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL 35233, USA;
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Chen X, Shi J, Lai Y, Xue Y, Ung COL, Hu H. Systematic analysis of randomised controlled trials of Chinese herb medicine for non-alcoholic steatohepatitis (NASH): implications for future drug development and trial design. Chin Med 2023; 18:58. [PMID: 37208742 DOI: 10.1186/s13020-023-00761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/28/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is a liver disease currently lacking an approved therapy, resulting in significant clinical demand. Traditional Chinese medicines (TCMs) have been commonly used to manage NASH. This study aimed to systematically analyse the randomised controlled trials (RCTs) using TCMs for NASH management. METHODS A systematic literature review was performed by following PRISMA guidelines 2020 in six electronic databases: PubMed, Web of Science, Scopus, Embase, the Cochrane Library, and China National Knowledge Infrastructure, from inception until August 2022. RCTs using TCMs for NASH were included in the analysis, irrespective of language or blinding. RESULTS 112 RCTs were included in this review, with 10,573 NASH participants. 108 RCTs were conducted in China, and 4 RCTs were in other countries. Herbal medicine decoction was the major dosage form used for treating NASH (82/112). 11 TCMs products have been approved for NASH treatment (8 in China, 2 in Iran, and 1 in Japan). Classic prescriptions, such as "Huang Lian Jie Du decoction", "Yin Chen Hao decoction", and "Yi Guan Jian" were used in some studies. The TCMs treatment of NASH involved the use of 199 different plants, with the top 5 herbs being Salviae Miltiorrhizae Radix Et Rhizoma, Alismatis Rhizoma, Bupleuri Radix, Poria, and Curcumae Radix. "Salviae Miltiorrhizae Radix Et Rhizoma + Bupleuri Radix/Alismatis Rhizoma" were the mostly common drug-pair in the herbs network analysis. Nowadays, "Bupleuri Radix/Alismatis Rhizoma + Atractylodis Macrocephalae Rhizoma" are increasingly applied in herbal formulas for NASH. Based on the PICOS principles, the included studies varied in terms of the population, intervention, comparator, outcomes, and study design. However, some studies reported unstandardised results and failed to report diagnostic standards, inclusion or exclusion criteria, or sufficient patient information. CONCLUSION Adopting Chinese classic prescriptions or drug-pair may provide a basis for developing new drugs of NASH management. Further research is needed to refine the clinical trial design and obtain more convincing evidence for using TCMs to treat NASH.
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Affiliation(s)
- Xianwen Chen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao, China
| | - Junnan Shi
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao, China
| | - Yunfeng Lai
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan Xue
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao, China.
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Taipa, Macao, China.
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao, China.
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Taipa, Macao, China.
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Kaizer AM, Belli HM, Ma Z, Nicklawsky AG, Roberts SC, Wild J, Wogu AF, Xiao M, Sabo RT. Recent innovations in adaptive trial designs: A review of design opportunities in translational research. J Clin Transl Sci 2023; 7:e125. [PMID: 37313381 PMCID: PMC10260347 DOI: 10.1017/cts.2023.537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/29/2023] [Accepted: 04/17/2023] [Indexed: 06/15/2023] Open
Abstract
Clinical trials are constantly evolving in the context of increasingly complex research questions and potentially limited resources. In this review article, we discuss the emergence of "adaptive" clinical trials that allow for the preplanned modification of an ongoing clinical trial based on the accumulating evidence with application across translational research. These modifications may include terminating a trial before completion due to futility or efficacy, re-estimating the needed sample size to ensure adequate power, enriching the target population enrolled in the study, selecting across multiple treatment arms, revising allocation ratios used for randomization, or selecting the most appropriate endpoint. Emerging topics related to borrowing information from historic or supplemental data sources, sequential multiple assignment randomized trials (SMART), master protocol and seamless designs, and phase I dose-finding studies are also presented. Each design element includes a brief overview with an accompanying case study to illustrate the design method in practice. We close with brief discussions relating to the statistical considerations for these contemporary designs.
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Affiliation(s)
- Alexander M. Kaizer
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hayley M. Belli
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Zhongyang Ma
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Andrew G. Nicklawsky
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Samantha C. Roberts
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jessica Wild
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Adane F. Wogu
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mengli Xiao
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Roy T. Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
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Saxena AR, Lyle SA, Khavandi K, Qiu R, Whitlock M, Esler WP, Kim AM. A phase 2a, randomized, double-blind, placebo-controlled, three-arm, parallel-group study to assess the efficacy, safety, tolerability and pharmacodynamics of PF-06835919 in patients with non-alcoholic fatty liver disease and type 2 diabetes. Diabetes Obes Metab 2023; 25:992-1001. [PMID: 36515213 DOI: 10.1111/dom.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/29/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
AIM To assess the safety, tolerability and pharmacodynamics (PD) of the ketohexokinase inhibitor PF-06835919 in participants with non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2D). MATERIALS AND METHODS This double-blind, placebo-controlled, parallel-group study enrolled adults with NAFLD (≥ 8% whole liver fat [WLF] using MRI proton density fat fraction [MRI-PDFF]) and T2D on stable doses of metformin (≥ 500 mg/day). Participants received once-daily placebo, PF-06835919 150 or 300 mg for 16 weeks. Randomization (1:1:1) was via an interactive response technology system. Endpoints included percentage change from baseline (CFB) in WLF using MRI-PDFF (primary endpoint) and CFB in HbA1c (co-primary endpoint) at 16 weeks, PD, safety and tolerability. RESULTS Among 164 participants randomized and treated, 145 completed the treatment (placebo, n = 50; PF-06835919 150 mg, n = 46; PF-06835919 300 mg, n = 49). At week 16, least squares mean (90% confidence interval) percentage CFB in WLF was -5.26% (-12.86%, 2.99%), -17.05% (-24.01%, -9.46%) and -19.13% (-25.51%, -12.20%) in the placebo, PF-06835919 150-mg and 300-mg groups, respectively (PF-06835919 300-mg group vs. placebo, P = .0288). Modest numerical reductions in HbA1c were observed in all groups that did not reach statistical significance. Treatment-emergent adverse event incidence was similar across groups (40.7%, 45.5% and 32.7% in the placebo, PF-06835919 150-mg and 300-mg groups, respectively), with no apparent dose-related trend. CONCLUSIONS PF-06835919 administration over 16 weeks was generally safe and well tolerated and resulted in reductions in WLF in participants with NAFLD and T2D.
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Affiliation(s)
- Aditi R Saxena
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
| | - Stephanie-An Lyle
- Early Clinical Development, Pfizer Inc, Cambridge, Massachusetts, USA
| | - Kaivan Khavandi
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
| | - Ruolun Qiu
- Early Clinical Development, Pfizer Inc, Cambridge, Massachusetts, USA
| | - Mark Whitlock
- Early Clinical Development, Pfizer Inc, Cambridge, UK
| | - William P Esler
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
| | - Albert M Kim
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
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Ahmed NR, Kulkarni VV, Pokhrel S, Akram H, Abdelgadir A, Chatterjee A, Khan S. Comparing the Efficacy and Safety of Obeticholic Acid and Semaglutide in Patients With Non-Alcoholic Fatty Liver Disease: A Systematic Review. Cureus 2022; 14:e24829. [PMID: 35693370 PMCID: PMC9173657 DOI: 10.7759/cureus.24829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/08/2022] [Indexed: 11/05/2022] Open
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Amin NB, Darekar A, Anstee QM, Wong VWS, Tacke F, Vourvahis M, Lee DS, Charlton M, Alkhouri N, Nakajima A, Yunis C. Efficacy and safety of an orally administered DGAT2 inhibitor alone or coadministered with a liver-targeted ACC inhibitor in adults with non-alcoholic steatohepatitis (NASH): rationale and design of the phase II, dose-ranging, dose-finding, randomised, placebo-controlled MIRNA (Metabolic Interventions to Resolve NASH with fibrosis) study. BMJ Open 2022; 12:e056159. [PMID: 35354614 PMCID: PMC8968568 DOI: 10.1136/bmjopen-2021-056159] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Small molecule inhibitors of the terminal step in intrahepatic triglyceride synthesis (diacylglycerol acyltransferase 2 inhibitor (DGAT2i, PF-06865571, ervogastat)) and upstream blockade of de novo lipogenesis via acetyl-coenzyme A carboxylase inhibitor (ACCi, PF-05221304, clesacostat) showed promise in reducing hepatic steatosis in early clinical trials. This study assesses efficacy and safety of these metabolic interventions to resolve non-alcoholic steatohepatitis (NASH) with fibrosis. METHODS AND ANALYSIS This phase II, randomised, dose-ranging, dose-finding study evaluates DGAT2i 25-300 mg two times per day (BID) or 150-300 mg once a day, DGAT2i 150-300 mg BID+ACCi 5-10 mg BID coadministration or matching placebo in a planned 450 adults with biopsy-confirmed NASH and liver fibrosis stages 2-3 from approximately 220 sites in 11 countries across North America, Europe and Asia. A triage approach including double-confirmation via non-invasive markers is included prior to screening/baseline liver biopsy. On confirmation of histological diagnosis, participants enter a ≥6-week run-in period, then a 48-week double-blind, double-dummy dosing period. The primary endpoint is the proportion of participants achieving histological NASH resolution without worsening fibrosis, ≥1 stage improvement in fibrosis without worsening NASH, or both, assessed by central pathologists. Other endpoints include assessment of hepatic steatosis (imaging substudy), overall safety and tolerability, and evaluation of blood-based biomarkers and quantitative ultrasound parameters over time. ETHICS AND DISSEMINATION Metabolic Interventions to Resolve NASH with fibrosis (MIRNA) is conducted in accordance with the Declaration of Helsinki and Council for International Organisations of Medical Sciences (CIOMS) International Ethical Guidelines, International Council on Harmonisation Good Clinical Practice guidelines, applicable laws and regulations, including privacy laws. Local independent review board/ethics committees (IRB/ECs) review/approve the protocol, any amendments, informed consent and other forms. Participants provide written informed consent. Details of all IRB/ECs, as well as results, will be published in a peer-reviewed journal and publicly disclosed through ClinicalTrials.gov, EudraCT, and/or www.pfizer.com and other public registries as per applicable local laws/regulations. TRIAL REGISTRATION NUMBER NCT04321031.
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Affiliation(s)
- Neeta B Amin
- Pfizer Global Product Development, Cambridge, Massachusetts, USA
| | | | - Quentin M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Frank Tacke
- Charité-Universitätsmedizin Berlin, Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | | | - Douglas S Lee
- Pfizer Global Product Development, Groton, Connecticut, USA
| | - Michael Charlton
- Transplant Institute, Center for Liver Diseases, University of Chicago Biological Sciences, Chicago, Illinois, USA
| | | | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Carla Yunis
- Pfizer Global Product Development, New York, New York, USA
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Jiang B, Wang D, Hu Y, Li W, Liu F, Zhu X, Li X, Zhang H, Bai H, Yang Q, Yang X, Ben J, Chen Q. Serum Amyloid A1 Exacerbates Hepatic Steatosis via TLR4 Mediated NF-κB Signaling Pathway. Mol Metab 2022; 59:101462. [PMID: 35247611 PMCID: PMC8938331 DOI: 10.1016/j.molmet.2022.101462] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Chronic inflammatory response plays a prominent role in obesity-related nonalcoholic fatty liver disease (NAFLD). However, the intrahepatic triggering mechanism of inflammation remains obscure. This study aimed to elucidate the role of serum amyloid A1 (SAA1), an acute-phase response protein, in the obesity-induced hepatic inflammation and NAFLD. Methods Male mice were fed a high fat diet (HFD) for 16 weeks, and insulin resistance, hepatic steatosis, and inflammation in mice were monitored. Murine SAA1/2 was genetically manipulated to investigate the role of SAA1 in NAFLD. Results We found that SAA1 was increased in the NAFLD liver in both humans and mice. Knockout of SAA1/2 or knockdown of hepatic SAA1/2 promoted energy expenditure and alleviated HFD-induced metabolic disorder, hepatic steatosis, and inflammation. Endogenous overexpression of SAA1 in hepatocytes by adeno-associated virus 8 (AAV8) transfection aggravated overnutrition-associated gain of body weight, insulin resistance, hepatic lipid accumulation, and liver injury, which were markedly alleviated by knockout of murine toll-like receptor 4 (TLR4). Mechanistically, SAA1 directly bound with TLR4/myeloid differentiation 2 (MD2) to induce TLR4 internalization, leading to the activation of nuclear factor (NF)-κB signaling and production of both SAA1 and other inflammatory cytokines, including interleukin (IL)-6 and C–C chemokine ligand (CCL2) in hepatocytes. Administration of HFD mice with an AAV8-shRNA-SAA1/2 showed a therapeutic effect on hepatic inflammation and NAFLD progression. Conclusions These results demonstrate that SAA1 triggers hepatic steatosis and intrahepatic inflammatory response by forming a SAA1/TLR4/NF-κB/SAA1 feedforward regulatory circuit, which, in turn, leads to NAFLD progression. SAA1 may act as a potential target for the disease intervention. SAA1/2 deficiency alleviates HFD-induced hepatic steatosis and inflammation in mice. SAA1 aggravating overnutrition-associated hepatic steatosis and inflammation is dependent on TLR4. SAA1 directly binds to TLR4/MD2 to induce TLR4 internalization, leading to the activation of NF-κB signaling . SAA1/TLR4/NF-κB/SAA1 positive feedback in hepatocytes may be a potential target for obesity associated NAFLD.
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Affiliation(s)
- Bin Jiang
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Dongdong Wang
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Yunfu Hu
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Wenxuan Li
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Fengjiang Liu
- Innovative Center for Pathogen Research, Guangzhou Laboratory, Guangzhou, China
| | - Xudong Zhu
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Xiaoyu Li
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Hanwen Zhang
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Hui Bai
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Qing Yang
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China
| | - Xiuna Yang
- Institute for Advanced Immunochemical Studies, ShanghaiTech University, Shanghai, China.
| | - Jingjing Ben
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China.
| | - Qi Chen
- Department of Pathophysiology, Key Laboratory of Cardiovascular Disease and Molecular Intervention, Nanjing Medical University, Nanjing, China.
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Chow SC, Chow SS, Pong A. Review of current controversial issues in clinical trials. Gen Psychiatr 2021; 34:e100540. [PMID: 34790887 PMCID: PMC8552128 DOI: 10.1136/gpsych-2021-100540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/06/2021] [Indexed: 11/03/2022] Open
Abstract
In clinical development, adequate and well-controlled randomised clinical trials are usually conducted to evaluate the safety and efficacy of test treatment under investigation. The purpose is to ensure that there is an accurate and reliable assessment of test treatment under study. In practice, however, some controversial issues inevitably appear despite the compliance of good clinical practice. These debatable issues include, but are not limited to, (1) appropriateness of hypotheses for clinical investigation, (2) feasibility of power calculation for sample size requirement, (3) integrity of randomisation/blinding, (4) strategy for clinical endpoint selection, (5) demonstrating effectiveness or ineffectiveness, (6) impact of protocol amendments and (7) independence of independent data monitoring committee. In this article, these controversial issues are discussed. The impact of these issues in evaluating the safety and efficacy of the test treatment under investigation is also assessed. Recommendations regarding possible resolutions to these issues are provided whenever possible.
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Affiliation(s)
- Shein-Chung Chow
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan S Chow
- Kansas City University, College of Osteopathic Medicine, Kansas City, Missouri, USA
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Stine JG, Munaganuru N, Barnard A, Wang JL, Kaulback K, Argo CK, Singh S, Fowler KJ, Sirlin CB, Loomba R. Change in MRI-PDFF and Histologic Response in Patients With Nonalcoholic Steatohepatitis: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2021; 19:2274-2283.e5. [PMID: 32882428 PMCID: PMC7914285 DOI: 10.1016/j.cgh.2020.08.061] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Magnetic resonance imaging proton density fat fraction (MRI-PDFF) offers promise as a non-invasive biomarker of treatment response in early-phase nonalcoholic steatohepatitis (NASH) trials. We performed a systematic review to quantify the association between a ≥ 30% reduction in MRI-PDFF and histologic response in NASH. METHODS We searched the Cochrane Library, Embase, Medline and trial registries through May 2020 for early-phase clinical trials that incorporated MRI-PDFF and examined histologic response following intervention in adults with NASH. Subjects were classified as MRI-PDFF responders (relative decline in liver fat ≥30%) or non-responders (relative decline in liver fat <30%). MRI-PDFF responders versus non-responders were compared. Primary outcome was histologic response defined as a 2-point improvement in NAFLD Activity Score with at least 1-point improvement in lobular inflammation or ballooning. Secondary outcome was NASH resolution. Proportions and random effects odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated. RESULTS Seven studies met inclusion criteria, comprising 346 subjects (median age 51 years; 59% female; 46% with diabetes). MRI-PDFF responders were significantly more likely to have a histologic response (51% vs 14%, P < .001; OR 6.98, 95% CI 2.38-20.43, P < .001) and NASH resolution (41% vs 7%, P < .001; OR 5.45, 95% CI 1.53-19.46, P = .009) compared to non-responders. CONCLUSIONS This meta-analysis demonstrates that a ≥30% relative decline in MRI-PDFF is associated with higher odds of histologic response and NASH resolution. These results support the use of MRI-PDFF in non-invasive monitoring of treatment response in early-phase NASH clinical trials and provide helpful data for sample-size estimation for histology-based assessment.
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Affiliation(s)
- Jonathan G. Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA,Department of Public Health Sciences, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA,Liver Center, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA,Cancer Institute, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
| | | | - Abbey Barnard
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jennifer L. Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Curtis K. Argo
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Siddarth Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Kathryn J. Fowler
- Liver Imaging Group, Department of Radiology, University of California San Diego, La Jolla, CA, USA
| | - Claude B. Sirlin
- Liver Imaging Group, Department of Radiology, University of California San Diego, La Jolla, CA, USA
| | - Rohit Loomba
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego, La Jolla, California; Division of Epidemiology, Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, California; NAFLD Research Center, University of California, San Diego, La Jolla, California.
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12
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Hardesty JE, Wahlang B, Prough RA, Head KZ, Wilkey D, Merchant M, Shi H, Jin J, Cave MC. Effect of Epidermal Growth Factor Treatment and Polychlorinated Biphenyl Exposure in a Dietary-Exposure Mouse Model of Steatohepatitis. ENVIRONMENTAL HEALTH PERSPECTIVES 2021; 129:37010. [PMID: 33788613 PMCID: PMC8011667 DOI: 10.1289/ehp8222] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 02/26/2021] [Accepted: 03/03/2021] [Indexed: 05/12/2023]
Abstract
BACKGROUND Polychlorinated biphenyls (PCBs) are signaling disrupting chemicals that exacerbate nonalcoholic steatohepatitis (NASH) in mice. They are epidermal growth factor receptor (EGFR) inhibitors that enhance hepatic inflammation and fibrosis in mice. OBJECTIVES This study tested the hypothesis that epidermal growth factor (EGF) administration can attenuate PCB-related NASH by increasing hepatic EGFR signaling in a mouse model. METHODS C57BL/6 male mice were fed a 42% milk fat diet and exposed to Aroclor 1260 (20 mg / kg ) or vehicle for 12 wk. EGF (0.2 μ g / g ) or vehicle were administered daily for 10 d starting at study week 10. Liver and metabolic phenotyping were performed. The EGF dose was selected based on results of an acute dose-finding study (30 min treatment of EGF at 0.2, 0.02, 0.002 μ g / g of via intraperitoneal injection). Hepatic phosphoproteomic analysis was performed using liver tissue from this acute study to understand EGFR's role in liver physiology. RESULTS Markers of EGFR signaling were higher in EGF-treated mice. EGF + PCB -exposed mice had lower hepatic free fatty acids, inflammation, and fibrosis relative to PCB-only exposed mice. EGF-treated mice had higher plasma lipids, with no improvement in hepatic steatosis, and an association with higher LXR target gene expression and de novo lipogenesis. EGF-treated mice showed more severe hyperglycemia associated with lower adiponectin levels and insulin sensitivity. EGF-treated mice had higher hepatic HNF 4 α , NRF2, and AhR target gene expression but lower constitutive androstane receptor and farnesoid X receptor target gene expression. The hepatic EGF-sensitive phosphoproteome demonstrated a role for EGFR signaling in liver homeostasis. DISCUSSION These results validated EGFR inhibition as a causal mode of action for PCB-related hepatic inflammation and fibrosis in a mouse model of NASH. However, observed adverse effects may limit the clinical translation of EGF therapy. More data are required to better understand EGFR's underinvestigated roles in liver and environmental health. https://doi.org/10.1289/EHP8222.
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Affiliation(s)
- Josiah E. Hardesty
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Banrida Wahlang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- University of Louisville Superfund Research Center, University of Louisville, Louisville, Kentucky, USA
| | - Russell A. Prough
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Kim Z. Head
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- The Animal Model and Biorepository Core of the Hepatobiology and Toxicology Center, University of Louisville, Louisville, Kentucky, USA
| | - Daniel Wilkey
- University of Louisville Superfund Research Center, University of Louisville, Louisville, Kentucky, USA
- Division of Nephrology and Hypertension, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- The ’Omics Core of the Hepatobiology and Toxicology Center, University of Louisville, Louisville, Kentucky, USA
| | - Michael Merchant
- University of Louisville Superfund Research Center, University of Louisville, Louisville, Kentucky, USA
- Division of Nephrology and Hypertension, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- The ’Omics Core of the Hepatobiology and Toxicology Center, University of Louisville, Louisville, Kentucky, USA
| | - Hongxue Shi
- Department of Pharmacology & Toxicology, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jian Jin
- Department of Pharmacology & Toxicology, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Matthew C. Cave
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- University of Louisville Superfund Research Center, University of Louisville, Louisville, Kentucky, USA
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- The Animal Model and Biorepository Core of the Hepatobiology and Toxicology Center, University of Louisville, Louisville, Kentucky, USA
- Department of Pharmacology & Toxicology, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- The Robley Rex Veterans Affairs Medical Center, U.S. Department of Veterans Affairs, Louisville, Kentucky, USA
- The Liver Transplant Program, Jewish Hospital Trager Transplant Center, UofL Health, Louisville, Kentucky, USA
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13
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Corradini S, Niyazi M, Verellen D, Valentini V, Walsh S, Grosu AL, Lauber K, Giaccia A, Unger K, Debus J, Pieters BR, Guckenberger M, Senan S, Budach W, Rad R, Mayerle J, Belka C. X-change symposium: status and future of modern radiation oncology-from technology to biology. Radiat Oncol 2021; 16:27. [PMID: 33541387 PMCID: PMC7863262 DOI: 10.1186/s13014-021-01758-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
Future radiation oncology encompasses a broad spectrum of topics ranging from modern clinical trial design to treatment and imaging technology and biology. In more detail, the application of hybrid MRI devices in modern image-guided radiotherapy; the emerging field of radiomics; the role of molecular imaging using positron emission tomography and its integration into clinical routine; radiation biology with its future perspectives, the role of molecular signatures in prognostic modelling; as well as special treatment modalities such as brachytherapy or proton beam therapy are areas of rapid development. More clinically, radiation oncology will certainly find an important role in the management of oligometastasis. The treatment spectrum will also be widened by the rational integration of modern systemic targeted or immune therapies into multimodal treatment strategies. All these developments will require a concise rethinking of clinical trial design. This article reviews the current status and the potential developments in the field of radiation oncology as discussed by a panel of European and international experts sharing their vision during the "X-Change" symposium, held in July 2019 in Munich (Germany).
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Affiliation(s)
- Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Dirk Verellen
- Department of Radiotherapy, Iridium Network, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Vincenzo Valentini
- Department of Radiation Oncology and Hematology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica S. Cuore, Rome, Italy
| | | | - Anca-L Grosu
- Department of Radiation Oncology, Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Kirsten Lauber
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Amato Giaccia
- Division of Radiation and Cancer Biology, Department of Radiation Oncology, Stanford University, Stanford, USA
| | - Kristian Unger
- Integrative Biology Group, Helmholtz Zentrum Munich, Munich, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bradley R Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Roland Rad
- Center for Translational Cancer Research (TranslaTUM), TU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Internal Medicine II, University Hospital, LMU, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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14
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Albhaisi S, Noureddin M. Current and Potential Therapies Targeting Inflammation in NASH. Front Endocrinol (Lausanne) 2021; 12:767314. [PMID: 34925237 PMCID: PMC8678040 DOI: 10.3389/fendo.2021.767314] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022] Open
Abstract
Nonalcoholic steatohepatitis (NASH) is the advanced form of nonalcoholic fatty liver disease (NAFLD). It is characterized by hepatic steatosis, inflammation, hepatocellular injury, and fibrosis. Inflammation plays a key role in the progression of NASH and can be provoked by intrahepatic (e.g., lipotoxicity, immune responses, oxidative stress and cell death) and extrahepatic sources (adipose tissue or gut). The identification of triggers of inflammation is central to understanding the mechanisms in NASH development and progression and in designing targeted therapies that can halt or reverse the disease. In this review, we summarize the current and potential therapies targeting inflammation in NASH.
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Affiliation(s)
- Somaya Albhaisi
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
- *Correspondence: Somaya Albhaisi,
| | - Mazen Noureddin
- Karsh Division of Gastroenterology and Hepatology Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, CA, United States
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15
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Van Gaal LF, Mertens J, Francque S, De Block C. Therapeutic approaches for non-alcoholic steatohepatitis. Ther Adv Endocrinol Metab 2021; 12:20420188211034300. [PMID: 34497708 PMCID: PMC8419532 DOI: 10.1177/20420188211034300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 12/15/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) have been reported as a novel worldwide epidemic, very often associated with obesity, metabolic syndrome, and type 2 diabetes. Both conditions have also been shown to be associated with a number of endocrine pathologies. Despite the epidemic, the complex pathophysiology and major complications, ranging from metabolic disturbances (diabetes and more) to cardiovascular disease, people with NASH are left with very few management options. The best and most approved therapeutic option is lifestyle intervention. Although pharmacotherapies based on pathophysiological background are in development, response rates appear modest, mainly for fibrosis treatment, which is the reason for lack of approved drug therapy. Previous drugs analyzed, such as pioglitazone and vitamin E, show weak efficacy. From different phase II trials, antidiabetic (injectable) drugs seem to be promising, both in mono- or bitherapy. Also, derivatives of peroxisome proliferator-activated receptors may have an interesting future, as well. For that reason, more focus should be given on prevention of this novel disease entity. In view of this booming epidemic, with a background of obesity and type 2 diabetes, and the important medical consequences, early recognition, prevention and intervention of NAFLD/NASH seems appropriate. In this review, we will focus on the different current and future therapeutic intervention options, taking into consideration the complex pathophysiology of this disease.
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Affiliation(s)
| | | | - Sven Francque
- Department of Gastroenterology & Hepatology, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, Faculty of Medicine & Health Sciences, LEMP, Wilrijk, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology & Metabolism, Antwerp University Hospital, Edegem, Belgium
- University of Antwerp, Faculty of Medicine & Health Sciences, LEMP, Wilrijk, Belgium
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16
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Abstract
Nonalcoholic steatohepatitis (NASH) with liver fibrosis is an increasingly important cause of liver-related morbidity and mortality. A diagnosis of NASH can only be made using liver biopsy. Liver histology also forms the endpoint for the expedited licensing strategies that have been approved by regulators to allow patients with NASH access to treatment before the impact of these on clinical outcomes is known. Validation of these histological surrogate endpoints is critical for the ongoing development of new therapies for NASH. The use of liver biopsy to define both trial entry and endpoints raises questions about the use of treatments for NASH in practice when the effectiveness of treatment will likely depend, at least in part, on the use of histology for patient selection in the real world.
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Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, United Kingdom.,Leeds Institute for Data Analytics, University of Leeds, United Kingdom.,Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom
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17
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Do A, Ilagan-Ying YC, Mehal WZ, Lim JK. Drug development of nonalcoholic fatty liver disease: challenges in research, regulatory pathways, and study endpoints. Expert Opin Drug Discov 2020; 16:125-134. [PMID: 33086894 DOI: 10.1080/17460441.2020.1811674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The growing prevalence of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), and its association with obesity as a metabolic disease contributes to harmful outcomes and healthcare resource burden worldwide. For this reason, there is an urgent need to develop new therapies. Identification of treatment targets, research design, endpoints definitions and assessments, and supportive regulatory pathways for drug approval all play prominent roles in shaping efforts in drug discovery, investigation, and approval. AREAS COVERED In this perspective, the authors enumerate key challenges of NAFLD clinical research and offer a conceptual framework to address these issues which arise during clinical trials. EXPERT OPINION With the anticipated significant healthcare and costs burden that NAFLD will impose throughout the world, the diagnostics and drug development processes need to be accelerated. Important measures to improve clinical trial research include standardization of case definitions, comprehensive and granular covariate data collection, quality study development incorporating novel trial designs, and quality data reporting. The authors believe that these actions will accelerate understanding, development, and ultimately approval of efficacious treatments.
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Affiliation(s)
- Albert Do
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine , New Haven, CT, USA
| | | | - Wajahat Z Mehal
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine , New Haven, CT, USA
| | - Joseph K Lim
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine , New Haven, CT, USA
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18
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Thorp A, Stine JG. Exercise as Medicine: The Impact of Exercise Training on Nonalcoholic Fatty Liver Disease. ACTA ACUST UNITED AC 2020; 19:402-411. [PMID: 33767944 DOI: 10.1007/s11901-020-00543-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose of review Nonalcoholic fatty liver disease (NAFLD) is a leading cause of global liver disease. Because current pharmacologic treatments are ineffective, lifestyle change centered on exercise remains the most effective NAFLD treatment. The aim of this systematic review is to summarize and evaluate the current evidence supporting the use of exercise training as a medical treatment for adult patients with NAFLD. Recent findings At least 150 minutes each week of moderate intensity exercise of any type can improve NAFLD, both with and without modest weight loss. Exercise training reduces hepatic steatosis and liver inflammation, favorably changes body composition, improves vascular endothelial function, increases cardiorespiratory fitness and can lead to histologic response. To date, exercise-based NAFLD trials are limited by small sample size and significant heterogeneity. Summary While several key questions remain unanswered, exercise training will always be an important part of the medical management of patients with NAFLD.
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Affiliation(s)
- Audrey Thorp
- Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
| | - Jonathan G Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
- Department of Public Health Sciences, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
- Liver Center, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
- Cancer Institute, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
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19
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Ampuero J, Romero-Gomez M. Stratification of patients in NASH clinical trials: A pitfall for trial success. JHEP Rep 2020; 2:100148. [PMID: 32954243 PMCID: PMC7486452 DOI: 10.1016/j.jhepr.2020.100148] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 02/08/2023] Open
Abstract
Identifying the most effective therapeutic intervention in patients with NAFLD is challenging. Precise stratification in clinical trials is key to ensuring the inclusion of patients who will benefit (and not those who will be harmed) and/or in whom the natural history can be improved. Clinical trials in NAFLD can provide useful information about the individual components that underlie this complex metabolic disorder and the concomitant medications that could interfere with responses to an experimental intervention. However, to date, clinical trial reporting for NAFLD has been suboptimal, limiting our understanding. Frequently dysmetabolic comorbidities and/or daily habits are not reported or adequately accounted for. Herein, we suggest new strategies to integrate the spectra of comorbidities usually present in patients with NAFLD, accounting for the impact of lifestyle, to develop personalised therapeutic approaches. First, the mechanism of action of the drug being explored should be considered. Second, the same proportion of patients with relevant metabolic comorbidities should be maintained from phase II to III clinical trials, if such comorbidities are expected to impact on the treatment response. Third, innovative trial designs, such as the adaptative, umbrella or basket strategies, could be used to increase the efficiency of clinical trials, potentially benefiting patients while reducing costs and enhancing the likelihood of finding a real benefit of the therapy being studied. Finally, alcohol intake and daily exercise should be assessed objectively not only in the screening period but also during follow-up.
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Affiliation(s)
- Javier Ampuero
- Hospital Universitario Virgen del Rocío, Sevilla, Spain.,SeLiver Group, Instituto de Biomedicina de Sevilla, Sevilla, Spain.,CIBERehd, Spain
| | - Manuel Romero-Gomez
- Hospital Universitario Virgen del Rocío, Sevilla, Spain.,SeLiver Group, Instituto de Biomedicina de Sevilla, Sevilla, Spain.,CIBERehd, Spain
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20
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Liu F, Goh GBB, Tiniakos D, Wee A, Leow WQ, Zhao JM, Rao HY, Wang XX, Wang Q, Wan WK, Lim KH, Romero-Gomez M, Petta S, Bugianesi E, Tan CK, Harrison SA, Anstee QM, Chang PEJ, Wei L. qFIBS: An Automated Technique for Quantitative Evaluation of Fibrosis, Inflammation, Ballooning, and Steatosis in Patients With Nonalcoholic Steatohepatitis. Hepatology 2020; 71:1953-1966. [PMID: 31600834 DOI: 10.1002/hep.30986] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 09/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Nonalcoholic steatohepatitis (NASH) is a common cause of chronic liver disease. Clinical trials use the NASH Clinical Research Network (CRN) system for semiquantitative histological assessment of disease severity. Interobserver variability may hamper histological assessment, and diagnostic consensus is not always achieved. We evaluate a second harmonic generation/two-photon excitation fluorescence (SHG/TPEF) imaging-based tool to provide an automated quantitative assessment of histological features pertinent to NASH. APPROACH AND RESULTS Images were acquired by SHG/TPEF from 219 nonalcoholic fatty liver disease (NAFLD)/NASH liver biopsy samples from seven centers in Asia and Europe. These were used to develop and validate qFIBS, a computational algorithm that quantifies key histological features of NASH. qFIBS was developed based on in silico analysis of selected signature parameters for four cardinal histopathological features, that is, fibrosis (qFibrosis), inflammation (qInflammation), hepatocyte ballooning (qBallooning), and steatosis (qSteatosis), treating each as a continuous rather than categorical variable. Automated qFIBS analysis outputs showed strong correlation with each respective component of the NASH CRN scoring (P < 0.001; qFibrosis [r = 0.776], qInflammation [r = 0.557], qBallooning [r = 0.533], and qSteatosis [r = 0.802]) and high area under the receiver operating characteristic curve values (qFibrosis [0.870-0.951; 95% confidence interval {CI}, 0.787-1.000; P < 0.001], qInflammation [0.820-0.838; 95% CI, 0.726-0.933; P < 0.001), qBallooning [0.813-0.844; 95% CI, 0.708-0.957; P < 0.001], and qSteatosis [0.939-0.986; 95% CI, 0.867-1.000; P < 0.001]) and was able to distinguish differing grades/stages of histological disease. Performance of qFIBS was best when assessing degree of steatosis and fibrosis, but performed less well when distinguishing severe inflammation and higher ballooning grades. CONCLUSIONS qFIBS is an automated tool that accurately quantifies the critical components of NASH histological assessment. It offers a tool that could potentially aid reproducibility and standardization of liver biopsy assessments required for NASH therapeutic clinical trials.
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Affiliation(s)
- Feng Liu
- Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Peking University People's Hospital, Beijing, China
| | - George Boon-Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Dina Tiniakos
- Institute of Clinical and Translational Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Department of Pathology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aileen Wee
- Department of Pathology, Yong Loo Lin School of Medicine, National University of Singapore, National University Hospital, Singapore
| | - Wei-Qiang Leow
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Jing-Min Zhao
- Department of Pathology and Hepatology, The Fifth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hui-Ying Rao
- Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Peking University People's Hospital, Beijing, China
| | - Xiao-Xiao Wang
- Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Peking University People's Hospital, Beijing, China
| | - Qin Wang
- Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Peking University People's Hospital, Beijing, China
| | - Wei-Keat Wan
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Kiat-Hon Lim
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Manuel Romero-Gomez
- Unit for the Clinical Management of Digestive Diseases, Centro para la Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Institute of Biomedicine Seville (IBIS), Virgen del Rocio University Hospital, University of Seville, Seville, Spain
| | - Salvatore Petta
- Sezione di Gastroenterologia ed Epatologia, Dipartimento di Medicina Interna e Specialistica, DIBIMIS, Universita di Palermo, Palermo, Italy
| | - Elisabetta Bugianesi
- Division of Gastroenterology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Chee-Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Stephen A Harrison
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Quentin M Anstee
- Institute of Clinical and Translational Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Pik-Eu Jason Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Lai Wei
- Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Peking University People's Hospital, Beijing, China.,Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China.,Institute for Precision Medicine, Tsinghua University, Beijing, China
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21
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Challenges and opportunities in drug development for nonalcoholic steatohepatitis. Eur J Pharmacol 2020; 870:172913. [PMID: 31926994 DOI: 10.1016/j.ejphar.2020.172913] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/04/2019] [Accepted: 01/07/2020] [Indexed: 12/22/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are considered major global medical burdens with high prevalence and steeply rising incidence. Despite the characterization of numerous pathophysiologic pathways leading to metabolic disorder, lipid accumulation, inflammation, fibrosis, and ultimately end-stage liver disease or liver cancer formation, so far no causal pharmacological therapy is available. Drug development for NAFLD and NASH is limited by long disease duration and slow progression and the need for sequential biopsies to monitor the disease stage. Additional non-invasive biomarkers could therefore improve design and feasibility of such. Here, the current concepts on preclinical models, biomarkers and clinical endpoints and trial designs are briefly reviewed.
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22
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Alkhouri N, Kohli R, Feldstein AE. Designing Clinical Trials in Pediatric Nonalcoholic Steatohepatitis: Tips for Patient Selection and Appropriate Endpoints. Hepatol Commun 2019; 3:1563-1570. [PMID: 31832567 PMCID: PMC6887671 DOI: 10.1002/hep4.1449] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/20/2019] [Indexed: 12/17/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is common in children and may progress to nonalcoholic steatohepatitis (NASH), advanced fibrosis, and even cirrhosis in childhood or early adulthood, indicating the need for pharmacologic treatment in this age group. Multiple trials are evaluating different therapeutic targets for NASH with fibrosis in adults, and the U.S. Food and Drug Administration has recently provided clear guidance to the pharmaceutical industry on developing drugs for the treatment of noncirrhotic NASH with liver fibrosis. Pediatric NAFLD has several unique aspects that distinguish it from the adult disease in terms of histology, our understanding of the natural history, and the utility of noninvasive tests. These differences have the potential to impact the design of clinical trials to test different drugs in the pediatric population. The aim of this article is to provide a review of common misconceptions regarding pediatric NAFLD and key differences from adult NAFLD. We have provided our recommendations on the design of early proof-of-concept and late phase 2 trials based on lessons learned from previous clinical trials. We believe that clinical drug development for children with NAFLD should happen in parallel with ongoing adult trials.
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Affiliation(s)
- Naim Alkhouri
- Metabolic Health Center Texas Liver Institute University of Texas Health San Antonio San Antonio TX
| | - Rohit Kohli
- Division of Gastroenterology, Hepatology and Nutrition Children's Hospital Los Angeles Keck School of Medicine of University of Southern California Los Angeles CA
| | - Ariel E Feldstein
- Department of Pediatric Gastroenterology University of California San Diego La Jolla CA
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Pharmacological Therapy of Non-Alcoholic Fatty Liver Disease: What Drugs Are Available Now and Future Perspectives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224334. [PMID: 31703268 PMCID: PMC6888162 DOI: 10.3390/ijerph16224334] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/01/2019] [Accepted: 11/03/2019] [Indexed: 12/25/2022]
Abstract
The non-alcoholic fatty liver disease (NAFLD) is rapidly becoming the most common cause of chronic liver disease as well as the first cause of liver transplantation. NAFLD is commonly associated with metabolic syndrome (MetS), and this is the most important reason why it is extremely difficult to treat this disease bearing in mind the enormous amount of interrelationships between the liver and other systems in maintaining the metabolic health. The treatment of NAFLD is a key point to prevent NASH progression to advanced fibrosis, to prevent cirrhosis and to prevent the development of its hepatic complications (such as liver decompensation and HCC) and even extrahepatic one. A part of the well-known healthy effect of diet and physical exercise in this setting it is important to design the correct pharmaceutical strategy in order to antagonize the progression of the disease. In this regard, the current review has the scope to give a panoramic view on the possible pharmacological treatment strategy in NAFLD patients.
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Kelly N, Wattacheril J. Nonalcoholic Fatty Liver Disease: Evidence-Based Management and Early Recognition of Nonalcoholic Steatohepatitis. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2019.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Arrese M, Barrera F, Triantafilo N, Arab JP. Concurrent nonalcoholic fatty liver disease and type 2 diabetes: diagnostic and therapeutic considerations. Expert Rev Gastroenterol Hepatol 2019; 13:849-866. [PMID: 31353974 DOI: 10.1080/17474124.2019.1649981] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: The relationship between nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM) is complex and bidirectional. NAFLD increases the risk of incident diabetes and is very prevalent in T2DM patients and T2DM is an aggravating factor for NAFLD. Timely T2DM diagnosis and treatment in subjects with NAFLD and diagnosis, staging and treatment of NAFLD in those with T2DM are critical issues. Areas covered: PubMed/MEDLINE was searched for articles related to concomitant occurrence of NAFLD and T2DM between January 2013 and May 2019. Areas covered included epidemiological, diagnostic and therapeutic aspects. Expert opinion: there is a need for increased awareness on NAFLD adding liver disease as an end-organ complication of T2DM. Emphasis on use of simple non-invasive tools to triage patients with potentially severe liver disease should be made. Management of patients with NAFLD and T2DM relies on lifestyle optimization to achieve significant weight loss. Currently, there is no drug approved for treatment of NAFLD in patients with T2DM although Vitamin E and pioglitazone might be used in selected patients. Approved diabetic medications hold promise for NAFLD treatment and several liver-specific drugs are in evaluation clinical trials. A combination approach will likely represent the future of NAFLD therapeutics.
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Affiliation(s)
- Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile , Santiago , Chile.,Departamento de Biología Celular y Molecular, Facultad de Ciencias Biológicas Pontificia Universidad Católica de Chile, Centro de Envejecimiento y Regeneración (CARE) , Santiago , Chile
| | - Francisco Barrera
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile , Santiago , Chile
| | - Nicolas Triantafilo
- Departamento de Hematologia y oncología, Escuela de Medicina, Pontificia Universidad Católica de Chile , Santiago , Chile
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile , Santiago , Chile
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26
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Chow SC, Huang Z. Innovative Thinking on Endpoint Selection in Clinical Trials. J Biopharm Stat 2019; 29:941-951. [PMID: 31454270 DOI: 10.1080/10543406.2019.1657140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In clinical trials, selection of appropriate study endpoints is critical for an accurate and reliable evaluation of safety and effectiveness of a test treatment under investigation. In practice, however, there are usually multiple endpoints available for measurement of disease status and/or therapeutic effect of the test treatment under study. For example, in cancer clinical trials, overall survival, response rate, and/or time to disease progression are usually considered as primary clinical endpoints for evaluation of safety and effectiveness of the test treatment under investigation. Once the study endpoints have been selected, sample size required for achieving a desired power is then determined. It, however, should be noted that different study endpoints may result in different sample sizes. In practice, it is usually not clear which study endpoint can best inform the disease status and measure the treatment effect. Moreover, different study endpoints may not translate one another although they may be highly correlated one another. In this article, we intend to develop an innovative endpoint namely therapeutic index based on a utility function to combine and utilize information collected from all study endpoints. Statistical properties and performances of the proposed therapeutic index are evaluated theoretically. A numerical example concerning a cancer clinical trial is given to illustrate the use of the proposed therapeutic index.
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Affiliation(s)
- Shein-Chung Chow
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine , Durham , NC , USA
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Abstract
Non-alcoholic fatty liver disease (NAFLD) has become the most frequently encountered chronic liver disease. NAFLD is associated with increased liver-related morbidity and mortality, but also contributes to cardiovascular disease, diabetes and non-liver-related malignancy. Non-alcoholic steatohepatitis (NASH) is considered the more severe subtype of NAFLD that drives most of these adverse outcomes. Lifestyle modification and associated weight loss can improve NASH but are not always sufficient and sustained results are difficult to obtain. There is hence an urgent need for pharmacological treatment. In this review we discuss some of the concepts and challenges in the development of pharmacological treatment. We also briefly summarise what can be achieved with some of the drugs that are currently available for other indications but have demonstrated benefit in the treatment of NASH. Finally we present an overview of some of the main drugs or types of drugs, mainly based on their mode of action, that are now being developed specifically to treat NASH and that might soon result in the availability of drugs licensed for NASH.
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Affiliation(s)
- Sven Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium.
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium.
| | - Luisa Vonghia
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
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29
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Gege C, Hambruch E, Hambruch N, Kinzel O, Kremoser C. Nonsteroidal FXR Ligands: Current Status and Clinical Applications. Handb Exp Pharmacol 2019; 256:167-205. [PMID: 31197565 DOI: 10.1007/164_2019_232] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
FXR agonists have demonstrated very promising clinical results in the treatment of liver disorders such as primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and nonalcoholic steatohepatitis (NASH). NASH, in particular, is one of the last uncharted white territories in the pharma landscape, and there is a huge medical need and a large potential pharmaceutical market for a NASH pharmacotherapy. Clinical efficacy superior to most other treatment options was shown by FXR agonists such as obeticholic acid (OCA) as they improved various metabolic features including liver steatosis as well as liver inflammation and fibrosis. But OCA's clinical success comes with some major liabilities such as pruritus, high-density lipoprotein cholesterol (HDLc) lowering, low-density lipoprotein cholesterol (LDLc) increase, and a potential for drug-induced liver toxicity. Some of these effects can be attributed to on-target effects exerted by FXR, but with others it is not clear whether it is FXR- or OCA-related. Therefore a quest for novel, proprietary FXR agonists is ongoing with the aim to increase FXR potency and selectivity over other proteins and to overcome at least some of the OCA-associated clinical side effects through an improved pharmacology. In this chapter we will discuss the historical and ongoing efforts in the identification and development of nonsteroidal, which largely means non-bile acid-type, FXR agonists for clinical use.
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Affiliation(s)
- Christian Gege
- Phenex Pharmaceuticals AG, Drug Discovery Research, Heidelberg, Germany
| | - Eva Hambruch
- Phenex Pharmaceuticals AG, Drug Discovery Research, Heidelberg, Germany
| | - Nina Hambruch
- Phenex Pharmaceuticals AG, Drug Discovery Research, Heidelberg, Germany
| | - Olaf Kinzel
- Phenex Pharmaceuticals AG, Drug Discovery Research, Heidelberg, Germany
| | - Claus Kremoser
- Phenex Pharmaceuticals AG, Drug Discovery Research, Heidelberg, Germany.
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30
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Uteng M, Urban L, Brees D, Muller PY, Kullak-Ublick GA, Bouchard P, Tougas G, Chibout SD. Safety differentiation: emerging competitive edge in drug development. Drug Discov Today 2018; 24:285-292. [PMID: 30244081 DOI: 10.1016/j.drudis.2018.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/24/2018] [Accepted: 09/12/2018] [Indexed: 12/12/2022]
Abstract
With increasing expectations to provide evidence of drug efficacy, safety, and cost-effectiveness, best-in-class drugs are a major value driver for the pharmaceutical industry. Superior safety is a key differentiation criterion that could be achieved through better risk:benefit profiles, safety margins, fewer contraindications, and improved patient compliance. To accomplish this, comparative safety assessments using innovative and adaptive nonclinical and clinical outcome-based approaches should be undertaken, and continuous strategic adjustments must be made as the risk:benefit profiles evolve. Key success criteria include scientific expertise and integration between all disciplines during the full extent of the drug development process.
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Affiliation(s)
- Marianne Uteng
- Novartis Institutes for Biomedical Research, Translational Medicine, Pre-Clinical Safety, Basel, Switzerland.
| | - Laszlo Urban
- Novartis Institutes for Biomedical Research, Translational Medicine, Pre-Clinical Safety, Cambridge, MA, USA
| | - Dominique Brees
- Novartis Institutes for Biomedical Research, Translational Medicine, Pre-Clinical Safety, Basel, Switzerland
| | | | - Gerd A Kullak-Ublick
- Novartis Pharma AG, Global Drug Development, Chief Medical Office and Patient Safety, Basel, Switzerland; Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Page Bouchard
- Novartis Institutes for Biomedical Research, Translational Medicine, Pre-Clinical Safety, Cambridge, MA, USA
| | - Gervais Tougas
- Novartis Pharma AG, Global Drug Development, Chief Medical Office and Patient Safety, Basel, Switzerland
| | - Salah-Dine Chibout
- Novartis Institutes for Biomedical Research, Translational Medicine, Pre-Clinical Safety, Basel, Switzerland
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Affiliation(s)
- Rui E Castro
- Research Institute for Medicines (iMed.ULisboa), Universidade de Lisboa, Lisbon, Portugal; Department of Biochemistry and Human Biology, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal.
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Schuster S, Cabrera D, Arrese M, Feldstein AE. Triggering and resolution of inflammation in NASH. Nat Rev Gastroenterol Hepatol 2018; 15:349-364. [PMID: 29740166 DOI: 10.1038/s41575-018-0009-6] [Citation(s) in RCA: 520] [Impact Index Per Article: 86.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nonalcoholic steatohepatitis (NASH) is considered the progressive form of nonalcoholic fatty liver disease (NAFLD) and is characterized by liver steatosis, inflammation, hepatocellular injury and different degrees of fibrosis. A central issue in this field relates to the identification of those factors that trigger inflammation, thus fuelling the transition from nonalcoholic fatty liver to NASH. These triggers of liver inflammation might have their origins outside the liver (such as in adipose tissue or the gut) as well as inside the organ (for instance, lipotoxicity, innate immune responses, cell death pathways, mitochondrial dysfunction and endoplasmic reticulum stress), both of which contribute to NASH development. In this Review, we summarize the currently available information on the key upstream triggers of inflammation in NASH. We further delineate the mechanisms by which liver inflammation is resolved and the implications of a defective pro-resolution process. A better knowledge of these mechanisms should help to design targeted therapies able to halt or reverse disease progression.
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Affiliation(s)
- Susanne Schuster
- Department of Pediatrics, University of California, San Diego, CA, USA
| | - Daniel Cabrera
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Departamento de Ciencias Químicas y Biológicas, Facultad de Salud, Universidad Bernardo O Higgins, Santiago, Chile
| | - Marco Arrese
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Centre for Aging and Regeneration (CARE), Department of Cellular and Molecular Biology, Faculty of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ariel E Feldstein
- Department of Pediatrics, University of California, San Diego, CA, USA.
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Cai J, Zhang XJ, Li H. Progress and challenges in the prevention and control of nonalcoholic fatty liver disease. Med Res Rev 2018; 39:328-348. [PMID: 29846945 DOI: 10.1002/med.21515] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/02/2018] [Accepted: 05/12/2018] [Indexed: 12/17/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is rapidly becoming the most common liver disease worldwide. Individuals with NAFLD have a high frequency of developing progressive liver disease and metabolism-related comorbidities, which result from of a lack of awareness and poor surveillance of the disease and a paucity of approved and effective therapies. Managing the complications of NAFLD has already begun to place a tremendous burden on health-care systems. Although efforts to identify effective therapies are underway, the lack of validated preclinical NAFLD models that represent the biology and outcomes of human disease remains a major barrier. This review summarizes the characteristics and prevalence of the disease and the status of our understanding of its mechanisms and potential therapeutic targets.
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Affiliation(s)
- Jingjing Cai
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China.,Institute of Model Animal of Wuhan University, Wuhan, China
| | - Xiao-Jing Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Institute of Model Animal of Wuhan University, Wuhan, China
| | - Hongliang Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Institute of Model Animal of Wuhan University, Wuhan, China.,Basic Medical School, Wuhan University, Wuhan, China
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34
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Konerman MA, Jones JC, Harrison SA. Pharmacotherapy for NASH: Current and emerging. J Hepatol 2018; 68:362-375. [PMID: 29122694 DOI: 10.1016/j.jhep.2017.10.015] [Citation(s) in RCA: 208] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 12/13/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) has become one of the most prominent forms of chronic liver disease worldwide, reflecting the epidemic of global obesity. Those with the progressive variant of NAFLD, non-alcoholic steatohepatitis (NASH), are at significantly increased risk of multisystem morbidity and mortality. However, there are currently no approved pharmacologic therapies for NASH. Given the disease burden, there is an important unmet need for pharmacologic treatment options for this patient population. The underlying pathophysiologic mechanisms that contribute to the development and progression of NAFLD and NASH are complex and reflected by the myriad of therapies, with different targets, currently under investigation. In broad strokes, drug development has focused on modulation of metabolic pathways, inflammatory cascades, and/or mechanisms impacting fibrosis. Although much progress has been made in enhancing our understanding of NAFLD pathogenesis, development of pharmacologic treatments has been hindered by challenges in clinical trial enrollment and complexities in clinical trial design. The compounds in phase IIa have provided promising results in terms of potential benefits on various aspects of histopathology. Agents in later stages of development have shown fairly modest results in terms of reduction of hepatic steatosis, necroinflammation and fibrosis. If longer term safety and efficacy are established among heterogeneous cohorts, these medications may help mitigate potential morbidity and mortality for this burgeoning patient population.
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Affiliation(s)
- Monica A Konerman
- University of Michigan, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ann Arbor, MI, USA
| | | | - Stephen A Harrison
- University of Oxford, Radcliffe Department of Medicine, Oxford, United Kingdom.
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Accelerating the Drug Delivery Pipeline for Acute and Chronic Pancreatitis-Knowledge Gaps and Research Opportunities: Overview Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2018; 47:1180-1184. [PMID: 30325855 PMCID: PMC6201320 DOI: 10.1097/mpa.0000000000001176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A workshop was sponsored by the Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, on July 25, 2018, in Pittsburgh, Penn. The workshop was designed to bring together a multidisciplinary group of experts to accelerate the development of therapeutics for clinical application in inflammatory diseases of the exocrine pancreas. Three separate working groups (acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis) were formed to address the needs, gaps, and opportunities. The working groups included patients with pancreatic diseases, pharmaceutical company leaders, basic scientists, clinical researchers, and representatives from the US Food and Drug Administration to assist with regulatory considerations and to identify the unmet needs, research targets, and opportunities to provide direction for successful development of therapeutic agents in these diseases. This article represents the summary of the overview presentations at the National Institute of Diabetes and Digestive and Kidney Diseases workshop including an ongoing drug trial in acute pancreatitis; a successful drug development network developed by the Cystic Fibrosis Foundation; and considerations for subject selection in drug trials, incorporating Food and Drug Administration guidelines on clinical trial design and clinical outcome measures. The summaries of each working group follow separately in accompanying articles.
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