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Boulos M, Mousa RS, Jeries N, Simaan E, Alam K, Bulus B, Assy N. Hidden in the Fat: Unpacking the Metabolic Tango Between Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Syndrome. Int J Mol Sci 2025; 26:3448. [PMID: 40244398 PMCID: PMC11989262 DOI: 10.3390/ijms26073448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2025] [Revised: 03/25/2025] [Accepted: 03/30/2025] [Indexed: 04/18/2025] Open
Abstract
Metabolic syndrome (MetS) and metabolic dysfunction-associated steatotic liver disease (MASLD) are closely related, with rapidly increasing prevalence globally, driving significant public health concerns. Both conditions share common pathophysiological mechanisms such as insulin resistance (IR), adipose tissue dysfunction, oxidative stress, and gut microbiota dysbiosis, which contribute to their co-occurrence and progression. While the clinical implications of this overlap, including increased cardiovascular, renal, and hepatic risk, are well recognized, current diagnostic and therapeutic approaches remain insufficient due to the clinical and individuals' heterogeneity and complexity of these diseases. This review aims to provide an in-depth exploration of the molecular mechanisms linking MetS and MASLD, identify critical gaps in our understanding, and highlight existing challenges in early detection and treatment. Despite advancements in biomarkers and therapeutic interventions, the need for a comprehensive, integrated approach remains. The review also discusses emerging therapies targeting specific pathways, the potential of precision medicine, and the growing role of artificial intelligence in enhancing research and clinical management. Future research is urgently needed to combine multi-omics data, precision medicine, and novel biomarkers to better understand the complex interactions between MetS and MASLD. Collaborative, multidisciplinary efforts are essential to develop more effective diagnostic tools and therapies to address these diseases on a global scale.
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Affiliation(s)
- Mariana Boulos
- Internal Medicine Department, Galilee Medical Centre, Nahariya 221001, Israel; (R.S.M.); (N.J.); (E.S.); (K.A.); (B.B.); (N.A.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Rabia S. Mousa
- Internal Medicine Department, Galilee Medical Centre, Nahariya 221001, Israel; (R.S.M.); (N.J.); (E.S.); (K.A.); (B.B.); (N.A.)
| | - Nizar Jeries
- Internal Medicine Department, Galilee Medical Centre, Nahariya 221001, Israel; (R.S.M.); (N.J.); (E.S.); (K.A.); (B.B.); (N.A.)
| | - Elias Simaan
- Internal Medicine Department, Galilee Medical Centre, Nahariya 221001, Israel; (R.S.M.); (N.J.); (E.S.); (K.A.); (B.B.); (N.A.)
| | - Klode Alam
- Internal Medicine Department, Galilee Medical Centre, Nahariya 221001, Israel; (R.S.M.); (N.J.); (E.S.); (K.A.); (B.B.); (N.A.)
| | - Bulus Bulus
- Internal Medicine Department, Galilee Medical Centre, Nahariya 221001, Israel; (R.S.M.); (N.J.); (E.S.); (K.A.); (B.B.); (N.A.)
| | - Nimer Assy
- Internal Medicine Department, Galilee Medical Centre, Nahariya 221001, Israel; (R.S.M.); (N.J.); (E.S.); (K.A.); (B.B.); (N.A.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
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Xu R, Liu B, Zhou X. Comparison of Glucagon-Like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter Protein-2 Inhibitors on Treating Metabolic Dysfunction-Associated Steatotic Liver Disease or Metabolic Dysfunction-Associated Steatohepatitis: Systematic Review and Network Meta-Analysis of Randomised Controlled Trials. Endocr Pract 2025; 31:521-535. [PMID: 39701283 DOI: 10.1016/j.eprac.2024.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Revised: 11/11/2024] [Accepted: 11/24/2024] [Indexed: 12/21/2024]
Abstract
OBJECTIVE To assess glucagon-like peptide-1 receptor agonists (GLP-1 receptor agonists) and sodium-glucose cotransporter protein-2 inhibitors (SGLT-2 inhibitors) in patients with metabolic dysfunction-associated steatotic liver disease or metabolic dysfunction-associated steatohepatitis (previously known as nonalcoholic fatty liver disease [NAFLD] and nonalcoholic steatohepatitis [NASH]), we performed a systematic review and network meta-analysis of randomized controlled trials. METHODS The study searched Pubmed, Embase, the Cochrane Library, and Web of Science databases up to November 26, 2023. Two reviewers independently selected the studies, extracted the data, and assessed the risk of bias. RESULTS Thirty-seven studies were included in the analysis. GLP-1 receptor agonists were found to be more effective than placebo in resolving NASH (relative risk: 2.48, 95% CI:1.86 to 3.30). Both drugs were superior to placebo in reducing liver fat content, as well as decreasing levels of liver enzyme. Network meta-analysis indicated that SGLT-2 inhibitors were more effective than GLP-1 receptor agonists in reducing alanine aminotransferase and aspartate aminotransferase levels. According to the surface under the cumulative probability ranking curve values, GLP-1 receptor agonists and SGLT-2 inhibitors consistently ranked among the top 2 in terms of reducing anthropometric data compared to other included drugs. CONCLUSIONS GLP-1 receptor agonists and SGLT-2 inhibitors have significant effects on reducing liver fat content and liver enzymes in NAFLD or NASH patients compared to placebo. GLP-1 receptor agonists were found to be superior to placebo in resolving NASH. SGLT-2 inhibitors were more effective than GLP-1 receptor agonists in reducing alanine aminotransferase and aspartate aminotransferase levels.
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Affiliation(s)
- Ruhan Xu
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Bo Liu
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xianghai Zhou
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China.
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Stratina E, Stanciu C, Nastasa R, Zenovia S, Stafie R, Rotaru A, Cuciureanu T, Muzica C, Sfarti C, Girleanu I, Minea H, Petrea O, Huiban L, Chiriac S, Singeap AM, Vlad O, Cojocariu C, Trifan A. New Insights on Using Oral Semaglutide versus Dapagliflozin in Patients with Type 2 Diabetes and Metabolic Dysfunction-Associated Steatotic Liver Disease. Diagnostics (Basel) 2024; 14:1475. [PMID: 39061612 PMCID: PMC11275343 DOI: 10.3390/diagnostics14141475] [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: 06/11/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND AND AIMS Increases in both the prevalence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity are closely related. Type 2 diabetes (T2DM) has been associated with metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis and hepatocellular carcinoma. Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist approved for the treatment of T2DM and has an important role in weight loss. Also, it may represent a new therapeutic option for the treatment of MASH in obese diabetic patients. The main outcomes were changes from baseline in liver steatosis and fibrosis at week 24. MATERIAL AND METHODS A total of one hundred eighty-seven patients with T2DM were eligible for this prospective study; ninety-five subjects were treated with oral semaglutide, and ninety-two patients were treated with dapagliflozin as an add-on to metformin. All the subjects were evaluated using Vibration Controlled Transient Elastography (VCTE) from June to December 2022. RESULTS From our cohort, 54% of the patients were females, with a mean age of 59.92 ± 11.89 years and a mean body mass index (BMI) of 29.53 ± 5.33 kg/m2. Following a six-month medication period, we observed a substantial reduction in anthropometric measurements, including the BMI, waist circumference (WC), and waist-to-hip ratio (WtHr), in both groups. Regarding HbA1c, a notable decrease was observed in the semaglutide group (p < 0.001) when compared to the dapagliflozin group (p = 0.011). In addition, the liver stiffness measurement (LSM) according to VCTE improved significantly in the semaglutide group participants from 8.07 ± 2.90 kPa at baseline to 6.51 ± 3.09 kPa after medication (p < 0.001). CONCLUSION The superior metabolic effects of semaglutide, correlated to dapagliflozin, may contribute to a more efficient decrease in hepatic stress and injury, leading to a substantial enhancement of liver function in T2DM patients. Further investigations conducted over an ideal timeframe are necessary to confirm the evidence presented in this study.
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Affiliation(s)
- Ermina Stratina
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Carol Stanciu
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Robert Nastasa
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Sebastian Zenovia
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Remus Stafie
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Adrian Rotaru
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Tudor Cuciureanu
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Cristina Muzica
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Catalin Sfarti
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Irina Girleanu
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Horia Minea
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Oana Petrea
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Laura Huiban
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Stefan Chiriac
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Ana-Maria Singeap
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Oana Vlad
- Unit of Diabetes, Nutrition and Metabolic Diseases, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Camelia Cojocariu
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (E.S.); (C.S.); (S.Z.); (R.S.); (A.R.); (T.C.); (C.M.); (C.S.); (I.G.); (H.M.); (O.P.); (L.H.); (S.C.); (A.-M.S.); (C.C.); (A.T.)
- “St. Spiridon” Emergency Hospital, Institute of Gastroenterology and Hepatology, 700111 Iasi, Romania
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Barana L, Nelva A, Scivetti P, Costanzo M, Fanelli CG. Diagnosis of hepatic steatosis and steatohepatitis in people with new-onset type 2 diabetes: a multidisciplinary approach. Endocrine 2024; 84:412-419. [PMID: 38347338 DOI: 10.1007/s12020-024-03715-5] [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: 10/04/2023] [Accepted: 01/23/2024] [Indexed: 05/08/2024]
Abstract
AIMS Non-Alcoholic-Fatty-Liver-Disease (NAFLD) is the most common cause of chronic liver disease in Western countries; closely linked to obesity and type 2 diabetes (T2DM), it is an additional cardiovascular risk factor. The aim of this study is to investigate the prevalence of NAFLD at T2DM onset. METHODS 122 newly diagnosed T2DM patients were enroled; NAFLD was diagnosed using ultrasound and fibrosis risk calculated with an FIB4-score. Intermediate and high-risk patients were referred to a hepatologist and underwent transient elastography (TE). RESULTS At T2DM diagnosis, 25% of patients were overweight, 47% were obese; ultrasound steatosis was present in 79% of patients; the average FIB-4 score was 1.4 (0.7). The NAFLD population was characterised by higher presence of obesity (60%, p 0.06); hypertension (56%, p 0.00); AST (26.3 (23.6) UI/L; p 0.00); ALT (49.3(41.0) UI/L p 0.00); FIB-4 score (1.6 (0.8); p 0.00). Among patients referred to a hepatologist, at TE, 65% had severe steatosis, 22% significant fibrosis and 25% advanced fibrosis. CONCLUSION This is the first proposal of a NAFLD screening model at T2DM diagnosis. The high prevalence of fibrosis found at the early stage T2DM confirms the compelling need for early management of NAFLD through cost-effective screening and long-term monitoring algorithms.
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Affiliation(s)
- L Barana
- Diabetology and Endocrinology, Nuovo Ospdale degli Infermi di Biella, Ponderano, Biella, 13875, Italy.
- Section of Endocrinology and Metabolism, Department of Medicine, University of Perugia, Piazzale Gambuli 1, Perugia, 06129, Italy.
| | - A Nelva
- Diabetology and Endocrinology, Nuovo Ospdale degli Infermi di Biella, Ponderano, Biella, 13875, Italy
| | - P Scivetti
- Internal Medicine, Nuovo Ospdale degli Infermi di Biella, Ponderano, Biella, 13875, Italy
| | - M Costanzo
- Internal Medicine, Nuovo Ospdale degli Infermi di Biella, Ponderano, Biella, 13875, Italy
| | - C G Fanelli
- Section of Endocrinology and Metabolism, Department of Medicine, University of Perugia, Piazzale Gambuli 1, Perugia, 06129, Italy
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Weinberg Sibony R, Segev O, Dor S, Raz I. Drug Therapies for Diabetes. Int J Mol Sci 2023; 24:17147. [PMID: 38138975 PMCID: PMC10742594 DOI: 10.3390/ijms242417147] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/21/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
The treatment of type 2 diabetes (T2D) necessitates a multifaceted approach that combines behavioral and pharmacological interventions to mitigate complications and sustain a high quality of life. Treatment encompasses the management of glucose levels, weight, cardiovascular risk factors, comorbidities, and associated complications through medication and lifestyle adjustments. Metformin, a standard in diabetes management, continues to serve as the primary, first-line oral treatment across all age groups due to its efficacy, versatility in combination therapy, and cost-effectiveness. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) offer notable benefits for HbA1c and weight reduction, with significant cardiovascular benefits. Sodium-glucose cotransporter inhibitors (SGLT-2i) lower glucose levels independently of insulin while conferring notable benefits for cardiovascular, renal, and heart-failure outcomes. Combined therapies emphasizing early and sustained glycemic control are promising options for diabetes management. As insulin therapy remains pivotal, metformin and non-insulin agents such as GLP-1 RA and SGLT-2i offer compelling options. Notably, exciting novel treatments like the dual GLP-1/ glucose-dependent insulinotropic polypeptide (GIP) agonist show promise for substantially reducing glycated hemoglobin and body weight. This comprehensive review highlights the evolving landscape of pharmacotherapy in diabetes, the drugs currently available for treating diabetes, their effectiveness and efficacy, the impact on target organs, and side effects. This work also provides insights that can support the customization of treatment strategies.
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Affiliation(s)
- Roni Weinberg Sibony
- Faculty of Medicine, Ben-Gurion University, Beer Sheva 8443944, Israel; (R.W.S.); (S.D.)
| | - Omri Segev
- Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel;
| | - Saar Dor
- Faculty of Medicine, Ben-Gurion University, Beer Sheva 8443944, Israel; (R.W.S.); (S.D.)
| | - Itamar Raz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem 91240, Israel
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Guo N, Shi H, Zhang H, Wang H. Comparison of the efficacy and safety of hypoglycemic treatments in patients with non-alcoholic fatty liver disease and type-2 diabetes: a systematic review and Bayesian network analysis. Eur J Clin Pharmacol 2023; 79:1465-1474. [PMID: 37682287 DOI: 10.1007/s00228-023-03561-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE The association between non-alcoholic fatty liver disease (NAFLD) and metabolic disorders, especially type-2 diabetes (T2DM), has been proven to be bidirectional. Hypoglycemic agents may be promising treatments for those disorders. However, there is currently no approved hypoglycemic therapy for NAFLD. In this review, we aimed to compare the efficacy and safety of twelve different hypoglycemic treatments in patients with NAFLD and T2DM. METHODS We systematically screened randomized controlled trials (RCTs) published from March 2013 to March 2023 by searching PubMed, Embase, Medline, and Web of Science without any language restriction. We registered this project on the PROSPERO website: https://www.crd.york.ac.uk/PROSPERO/ (ID: CRD42023429701). All subsequent analyses were performed under the registered protocol. The mean difference (MD) and 95% confidence interval (95% CI) were adapted to evaluate the effect size of the treatment. The surface under the cumulative sorting curve (SUCRA) was used to rank the efficacy of the included treatments. RESULTS We included 19 trials involving 1212 patients in total. Insulin plus glucagon-like peptide-1 receptor agonist (GLP1RA) combination therapy was probably the most effective treatment for reducing weight and body mass index (BMI) (SUCRA: 0.93 and 1.00). Thiazolidinediones (TZD) were probably the most effective treatment for reducing glycosylated hemoglobin (HbA1c) and γ-glutamyltranspeptidase (γ-GGT) levels (SUCRA: 0.78 and 0.97). Sodium-glucose cotransporter 2 inhibitors (SGLT2i) had the highest probability of presenting good therapeutic efficacy in reducing triglyceride (TG) levels (SUCRA: 0.72). The most common adverse reactions were gastrointestinal disorders, mainly after the administration of GLP1RA, and mild hypoglycemia, which was closely related to the use of insulin. CONCLUSION GLP1RA plus insulin combination therapy, GLP1RA, SGLT2i, and TZD may be the most effective therapeutic methods for patients with NAFLD and T2DM.
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Affiliation(s)
- Nuojin Guo
- Department of Endocrinology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong District, Shanghai, 200120, China
| | - Hekai Shi
- Department of Bariatric and Metabolic Surgery, Fudan University Affiliated Huadong Hospital, Shanghai, 200040, China
| | - Hao Zhang
- Department of Endocrinology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong District, Shanghai, 200120, China
| | - Hua Wang
- Department of Endocrinology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong District, Shanghai, 200120, China.
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Park MJ, Kim H, Kim MG, Kim K. Comparison of glucagon-like peptide-1 receptor agonists and thiazolidinediones on treating nonalcoholic fatty liver disease: A network meta-analysis. Clin Mol Hepatol 2023; 29:693-704. [PMID: 36907574 PMCID: PMC10366812 DOI: 10.3350/cmh.2022.0330] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/25/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND/AIMS Previous studies have revealed that glucagon-like peptide-1 receptor agonist (GLP-1RA) and thiazolidinedione (TZD) can improve nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH). However, comprehensive research comparing the effects of GLP-1RA and TZD is limited. Thus, this study aimed to compare the effects of GLP-1RA and TZD on NAFLD or NASH through a network meta-analysis. METHODS The PubMed, Embase, Web of Science, and Scopus databases were searched for randomized controlled trials (RCTs) that explored the efficacy of GLP-1RAs or TZDs in adult patients with NAFLD or NASH. The outcomes were liver biopsy-based (NAFLD activity score [NAS], fibrosis stage, and NASH resolution), noninvasive technique-based (liver fat content on proton magnetic resonance spectroscopy [1H-MRS] and controlled attenuation parameter [CAP]), biological, and anthropometric indicators. A random effects model was used to calculate the mean difference (MD) and relative risk with 95% confidence interval (CI). RESULTS Twenty-five RCTs with 2,237 overweight or obese patients were included. GLP-1RA was significantly superior in reducing liver fat content evaluated using 1H-MRS (MD -2.42, 95% CI -3.84 to -1.00), body mass index (MD -1.60, 95% CI -2.41 to -0.80), and waist circumference (MD -4.89, 95% CI -8.17 to -1.61) than TZD. In liver biopsy-based evaluation and liver fat content assessment using CAP, GLP-1RA tended to surpass TZD, albeit not significantly. Sensitivity analysis showed consistent results with the main results. CONCLUSION Compared with TZD, GLP-1RA had better effects on liver fat content, body mass index, and waist circumference in overweight or obese patients with NAFLD or NASH.
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Affiliation(s)
- Min Jeong Park
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hayeon Kim
- College of Pharmacy, Korea University, Sejong, Korea
| | - Myeong Gyu Kim
- College of Pharmacy, Ewha Womans University, Seoul, Korea
| | - Kyungim Kim
- College of Pharmacy, Korea University, Sejong, Korea
- Institute of Pharmaceutical Science, Korea University, Sejong, Korea
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8
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Huang X, Chen H, Wen S, Dong M, Zhou L, Yuan X. Therapeutic Approaches for Nonalcoholic Fatty Liver Disease: Established Targets and Drugs. Diabetes Metab Syndr Obes 2023; 16:1809-1819. [PMID: 37366486 PMCID: PMC10290856 DOI: 10.2147/dmso.s411400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD), as a multisystemic disease, is the most prevalent chronic liver disease characterized by extremely complex pathogenic mechanisms and multifactorial etiology, which often develops as a consequence of obesity, metabolic syndrome. Pathophysiological mechanisms involved in the development of NAFLD include diet, obesity, insulin resistance (IR), genetic and epigenetic determinants, intestinal dysbiosis, oxidative/nitrosative stress, autophagy dysregulation, hepatic inflammation, gut-liver axis, gut microbes, impaired mitochondrial metabolism and regulation of hepatic lipid metabolism. Some of the new drugs for the treatment of NAFLD are introduced here. All of them achieve therapeutic objectives by interfering with certain pathophysiological pathways of NAFLD, including fibroblast growth factors (FGF) analogues, peroxisome proliferator-activated receptors (PPARs) agonists, glucagon-like peptide-1 (GLP-1) agonists, G protein-coupled receptors (GPCRs), sodium-glucose cotransporter-2 inhibitors (SGLT-2i), farnesoid X receptor (FXR), fatty acid synthase inhibitor (FASNi), antioxidants, etc. This review describes some pathophysiological mechanisms of NAFLD and established targets and drugs.
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Affiliation(s)
- Xiaojing Huang
- Graduate School of Fudan University, Shanghai, People’s Republic of China
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Huiling Chen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Meiyuan Dong
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Ligang Zhou
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Xinlu Yuan
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
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Gu Y, Sun L, Zhang W, Kong T, Zhou R, He Y, Deng C, Yang L, Kong J, Chen Y, Shi J, Hu Y. Comparative efficacy of 5 sodium-glucose cotransporter protein-2 (SGLT-2) inhibitor and 4 glucagon-like peptide-1 (GLP-1) receptor agonist drugs in non-alcoholic fatty liver disease: A GRADE-assessed systematic review and network meta-analysis of randomized controlled trials. Front Pharmacol 2023; 14:1102792. [PMID: 36992825 PMCID: PMC10040540 DOI: 10.3389/fphar.2023.1102792] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 02/28/2023] [Indexed: 03/14/2023] Open
Abstract
Background: The relative efficacy of 5 sodium-glucose cotransporter protein-2 (SGLT-2) inhibitors and 4 glucagon-like peptide-1 (GLP-1) receptor agonists for non-alcoholic fatty liver disease (NAFLD) therapy has not been sufficiently investigated. Methods: Randomized controlled trials (RCTs) in which patients with NAFLD were treated with SGLT-2 inhibitors or GLP-1 receptor agonists were included. Primary outcomes were improvements in liver enzymes and liver fat parameters, while secondary outcomes included anthropometric measures, blood lipids and glycemic parameters. The frequentist method was used to perform a network meta-analysis. Evidence certainty was assessed using the grading of recommendations assessment, development, and evaluation (GRADE). Results: The criteria were satisfied by 37 RCTs with 9 interventions (5 SGLT-2 inhibitors and 4 GLP-1 receptor agonists). Based on high certainty evidence, in patients with NAFLD (or comorbid with type 2 diabetes), semaglutide could lower alanine aminotransferase as well as aspartate aminotransferase, γ-glutamyl transferase, controlled attenuation parameter, liver stiffness measurement, body weight, systolic blood pressure, triglycerides, high-density lipoprotein-cholesterol, glycosylated hemoglobin. Liraglutide could lower alanine aminotransferase as well as subcutaneous adipose tissue, body mass index, fasting blood glucose, glycosylated hemoglobin, glucose and homeostasis model assessment, while dapagliflozin could lower alanine aminotransferase as well as body weight, fasting blood glucose, postprandial blood glucose, glycosylated hemoglobin, glucose and homeostasis model assessment. Conclusion: Semaglutide, liraglutide, and dapagliflozin all have a certain effect on NAFLD (or comorbid with type 2 diabetes) based on high confidence evidence from indirect comparisons, and semaglutide appears to have a therapeutic advantage over the other included medicines. Head-to-head studies are needed to provide more confidence in clinical decision-making.
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Affiliation(s)
- Yunpeng Gu
- School of Public Health, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Lei Sun
- Medical School, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Wei Zhang
- School of Public Health, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Tingting Kong
- School of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Run Zhou
- School of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Yining He
- Medical School, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Chaohua Deng
- Medical School, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Luping Yang
- Medical School, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jianing Kong
- Medical School, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Yutong Chen
- School of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Junping Shi
- The Department of Hepatology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Yanli Hu
- School of Nursing, Guangzhou Medical University, Guangzhou, Guangdong, China
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10
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Gu Y, Sun L, He Y, Yang L, Deng C, Zhou R, Kong T, Zhang W, Chen Y, Li J, Shi J. Comparative efficacy of glucagon-like peptide 1 (GLP-1) receptor agonists, pioglitazone and vitamin E for liver histology among patients with nonalcoholic fatty liver disease: systematic review and pilot network meta-analysis of randomized controlled trials. Expert Rev Gastroenterol Hepatol 2023; 17:273-282. [PMID: 36689199 DOI: 10.1080/17474124.2023.2172397] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION There is no conclusive evidence comparing the efficacy of glucagon-like peptide 1 (GLP-1) receptor agonists to the other guidelines recommended pharmacotherapy for nonalcoholic fatty liver disease (NAFLD). Therefore, we aim to compare the effects of GLP-1 receptor agonists, pioglitazone and vitamin E in patients with NAFLD. METHODS We searched PubMed, Embase, Web of Science and Cochrane Library up to 11 April 2022. Randomized clinical trials (RCTs) comparing GLP-1 receptor agonists, pioglitazone and vitamin E against placebo or other active controls in patients with NAFLD were included. RESULTS Nine RCTs including 1482 patients proved eligible. GLP-1 receptor agonists ranked first in steatosis, ballooning necrosis, γ-glutamyl transferase, body weight, body mass index, and triglycerides. Administration of GLP-1 receptor agonists, as compared with placebo, was associated with improvement in liver histology [steatosis (OR = 4.11, 95% CI: 2.83, 5.96), ballooning necrosis (OR = 3.07, 95% CI: 2.14, 4.41), lobular inflammation (OR = 1.86, 95% CI: 1.29, 2.68), fibrosis (OR = 1.52, 95% CI: 1.06, 2.20)]. CONCLUSIONS GLP-1 receptor agonists were as effective as pioglitazone and vitamin E for liver histology among patients with NAFLD. GLP-1 receptor agonists might be considered as an alternative or complementary treatment in the future clinical practice. [Figure: see text].
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Affiliation(s)
- Yunpeng Gu
- School of Public Health, Hangzhou Normal University, Zhejiang, Hangzhou, China
| | - Lei Sun
- Medical School, Hangzhou Normal University, Zhejiang, China
| | - Yining He
- Medical School, Hangzhou Normal University, Zhejiang, China
| | - Luping Yang
- Medical School, Zhejiang Chinese Medicine University, Zhejiang, Hangzhou, China
| | - Chaohua Deng
- Medical School, Hangzhou Normal University, Zhejiang, China
| | - Run Zhou
- School of Nursing, Hangzhou Normal University, Zhejiang, Hangzhou, China
| | - Tingting Kong
- School of Nursing, Hangzhou Normal University, Zhejiang, Hangzhou, China
| | - Wei Zhang
- School of Public Health, Hangzhou Normal University, Zhejiang, Hangzhou, China
| | - Yutong Chen
- School of Nursing, Hangzhou Normal University, Zhejiang, Hangzhou, China
| | - Jie Li
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.,Institute of Viruses and Infectious Diseases, Nanjing University, Nanjing, Jiangsu, China
| | - Junping Shi
- The Department of Hepatology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
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11
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Zou CY, Sun Y, Liang J. Comparative efficacy of diabetes medications on liver enzymes and fat fraction in patients with nonalcoholic fatty liver disease: A network meta-analysis ,. Clin Res Hepatol Gastroenterol 2023; 47:102053. [PMID: 36403941 DOI: 10.1016/j.clinre.2022.102053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/03/2022] [Accepted: 11/16/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This network meta-analysis (NMA) aimed to evaluate the relative rank-order of existing diabetes medications in patients with nonalcoholic fatty liver disease (NAFLD) with or without type 2 diabetes mellitus (T2DM). METHODS A systematic literature search was conducted using the Medline, Embase and Cochrane databases. Clinical trials comparing the efficacy of diabetes medications with other interventions, including lifestyle modification and placebo, in patients with NAFLD were included. The results from the NMA are presented as the weighted mean difference (WMD) of the continuous results and the corresponding 95% confidence intervals (95% CIs). RESULTS The articles presented the results of 49 trials involving 3,836 subjects published between 2013 and 2021. According to our results, thiazolidinedione (TZD) was ranked as the best diabetes medication in the reduction of alanine aminotransferase (ALT) (WMD = -10.10, 95% CI: -15.18, -5.01), followed by dipeptidyl peptidase-4 inhibitor (DPP4i) (WMD = -8.90, 95% CI: -14.41, -3.40). DPP4i also resulted in the greatest reduction in aspartate aminotransferase (AST) (WMD = -6.89, 95% CI: -11.72, -2.07). γ-Glutamyl transferase (γ-GT) reduction was highest in patients treated with glucagon-like peptide 1 receptor agonists (GLP1RAs) (WMD = -15.48, 95% CI: -30.93, -0.02). Ultimately, SGLT2is and GLP1RAs were superior to other diabetes medications or placebo in reducing liver fat fraction (LFF) (WMD = -6.09, 95% CI: -10.50, -1.68; WMD = -5.55, 95% CI: -10.40, -0.69, respectively). CONCLUSION Diabetes medications, including TZD, DPP4i and GLP1RAs, were found to be suitable alternatives for liver enzyme reduction in the treatment of NAFLD patients. SGLT2is are considered the most effective therapies for lipid modulation in these patients.
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Affiliation(s)
- Cai-Yan Zou
- Medical College, Soochow University, Suzhou, Jiangsu 215123, China; Department of Endocrinology, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, China
| | - Yan Sun
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, China
| | - Jun Liang
- Medical College, Soochow University, Suzhou, Jiangsu 215123, China; Department of Endocrinology, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, China.
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Patoulias D, Michailidis T. SGLT-2 Inhibitor and GLP-1 Receptor Agonist Treatment for Patients with Nonalcoholic Fatty Liver Disease and Type 2 Diabetes Mellitus: Is Their Combination the Optimal Treatment Option? J Clin Transl Hepatol 2022; 10:574-576. [PMID: 36062276 PMCID: PMC9396330 DOI: 10.14218/jcth.2022.00278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 06/16/2022] [Accepted: 06/22/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Dimitrios Patoulias
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, General Hospital “Hippokration,” Thessaloniki, Greece
- Correspondence to: Dimitrios Patoulias, Second Propedeutic Department of Internal Medicine, General Hospital “Hippokration,” Konstantinoupoleos 49, 54642, Thessaloniki, Greece. ORCID: https://orcid.org/0000-0002-6899-684X. Tel: +30-6946900777, Fax: +30-2310225083, E-mail:
| | - Theodoros Michailidis
- Second Department of Internal Medicine, Aristotle University of Thessaloniki, General Hospital “Hippokration,” Thessaloniki, Greece
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Mirarchi L, Amodeo S, Citarrella R, Licata A, Soresi M, Giannitrapani L. SGLT2 Inhibitors as the Most Promising Influencers on the Outcome of Non-Alcoholic Fatty Liver Disease. Int J Mol Sci 2022; 23:3668. [PMID: 35409028 PMCID: PMC8998221 DOI: 10.3390/ijms23073668] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 02/07/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD), the most frequent liver disease in the Western world, is a common hepatic manifestation of metabolic syndrome (MetS). A specific cure has not yet been identified, and its treatment is currently based on risk factor therapy. Given that the initial accumulation of triglycerides in the liver parenchyma, in the presence of inflammatory processes, mitochondrial dysfunction, lipotoxicity, glucotoxicity, and oxidative stress, can evolve into non-alcoholic steatohepatitis (NASH). The main goal is to identify the factors contributing to this evolution because, once established, untreated NASH can progress through fibrosis to cirrhosis and, ultimately, be complicated by hepatocellular carcinoma (HCC). Several drugs have been tested in clinical trials for use as specific therapy for NAFLD; most of them are molecules used to cure type 2 diabetes mellitus (T2DM), which is one of the main risk factors for NAFLD. Among the most studied is pioglitazone, either alone or in combination with vitamin E, glucagon-like peptide-1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors. Actually, the most promising category seems to be sodium-glucose cotransporter (SGLT2) inhibitors. Their action is carried out by inhibiting glucose reabsorption in the proximal renal tubule, leading to its increased excretion in urine and decreased levels in plasma. Experimental studies in animal models have suggested that SGLT2 inhibitors may have beneficial modulatory effects on NAFLD/NASH, and several trials in patients have proven their beneficial effects on liver enzymes, BMI, blood lipids, blood glucose, and insulin resistance in NAFLD patients, thus creating strong expectations for their possible use in preventing the evolution of liver damage in these patients. We will review the main pathogenetic mechanisms, diagnostic modalities, and recent therapies of NAFLD, with particular attention to the use of SGLT2 inhibitors.
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Affiliation(s)
- Luigi Mirarchi
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (L.M.); (S.A.); (R.C.); (A.L.); (M.S.)
| | - Simona Amodeo
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (L.M.); (S.A.); (R.C.); (A.L.); (M.S.)
| | - Roberto Citarrella
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (L.M.); (S.A.); (R.C.); (A.L.); (M.S.)
| | - Anna Licata
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (L.M.); (S.A.); (R.C.); (A.L.); (M.S.)
| | - Maurizio Soresi
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (L.M.); (S.A.); (R.C.); (A.L.); (M.S.)
| | - Lydia Giannitrapani
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy; (L.M.); (S.A.); (R.C.); (A.L.); (M.S.)
- Institute for Biomedical Research and Innovation (IRIB), National Research Council, 90146 Palermo, Italy
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