Pharmacological Approaches to Nonalcoholic Fatty Liver Disease: Current and Future Therapies

Nonalcoholic fatty liver disease (NAFLD) and its more severe form, nonalcoholic steatohepatitis (NASH), can promote the development of cirrhosis, hepatocellular carcinoma, cardiovascular disease, and type 2 diabetes. Similarly, type 2 diabetes confers the greatest risk for the development of NASH, especially when associated with obesity. Although lifestyle changes are critical to success, early implementation of pharmacological treatments for obesity and type 2 diabetes are essential to treat NASH and avoid disease progression. This article reviews current guidance regarding the use of pharmacological agents such as pioglitazone, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors in the setting of NAFLD and NASH. It also reviews the latest information on new drugs currently being investigated for the treatment of NASH.

Association between hepatic steatosis and lipoprotein(a) levels in non-alcoholic patients: A systematic review

BACKGROUND AND OBJECTIVES

It is well known that lipid abnormalities exist in the context of non-alcoholic fatty liver disease (NAFLD). The association between lipoprotein(a) [Lp(a)] levels and NAFLD is poorly understood. The main objective of the present study was to assess the association between Lp(a) levels and NAFLD.

METHODS

This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO CRD42023392526). A literature search was performed to detect studies that evaluated the association between Lp(a) levels, NAFLD and steatohepatitis (NASH).

RESULTS

Ten observational studies, including 40,045 patients, were identified and considered eligible for this systematic review. There were 9266 subjects in the NAFLD groups and 30,779 individuals in the respective control groups. Five studies evaluated patients with NAFLD (hepatic steatosis was associated with lower Lp(a) levels in four studies, while the remaining showed opposite results). Two studies evaluating NASH patients showed that Lp(a) levels were not different compared to controls. However, the increment of Lp(a) levels was correlated with liver fibrosis in one of them. In addition, one study analyzed simultaneously patients with NAFLD and NASH, showing a neutral result in NAFLD patients and a positive relationship in NASH patients. Two studies that included patients with the new definition of metabolic-associated fatty liver disease (MAFLD) also showed neutral results.

CONCLUSION

Although there could be an association between Lp(a) levels and hepatic steatosis, the results of the studies published to date are contradictory and not definitive.

NAFLD and type 2 diabetes: A practical guide for the joint management

Non-alcoholic fatty liver disease (NAFLD) is becoming a major cause of liver disease-related morbidity, as well as mortality. Importantly, NAFLD is considered a mediator of systemic diseases including cardiovascular disease. Its prevalence is expected to increase, mainly due to its close association with obesity and type 2 diabetes mellitus (T2D). In addition, T2D and NAFLD share common pathophysiological mechanisms, and one can lead to or worsen the other. Therefore, a close collaboration between primary care physician, endocrinologists and hepatologists is essential to optimize the management of patients with NAFLD and T2D. Here, we summarize relevant aspects about NAFLD and T2D that all clinician managing these patients should know as well as current therapeutic options for the treatment of T2D associated with NAFLD.

Circulating metabolomic and lipidomic changes in subjects with new-onset type 1 diabetes after optimization of glycemic control

AIMS

To uncover novel candidate metabolomic and lipidomic biomarkers in newly-diagnosed type 1 diabetes (T1DM) after achieving optimal glucose control.

METHODS

Comprehensive lipidomic and metabolomic analysis was performed in serum of 12 adults with T1DM at onset and after achieving optimal glycemic control (HbA1c < 7 %) (after 2-6 months).

RESULTS

After intensive therapy, subjects (mean age 25.2 years, 58.3 % men) showed decreases in blood glucose (p < 0.001), HbA1c [11.5 % (9.2-13.4) to 6.2 % (5.2 - 6.7); p < 0.001] and changes in 51 identified lipids. Among these changes, we found that triglycerides (TG) containing medium chain fatty acids (TG45:0, TG47:1), sphingomyelins (SM) (SM(d18:2/20:0), SM42:4)), and phosphatidylcholines (PC) (PC(O-26:2), PC(O-30:0), PC(O-32:0), PC(O-42:6), PC(O-44:5), PC(O-38:3), PC(O-33:0), PC(O-46:8), PC(O-44:6), PC(O-40:3), PC(O-42:4), PC(O-46:7), PC(O-46:6), PC(O-44:5), PC(O-42:3), PC(O-44:4)) decreased; whereas PC(35:1), PC(37:1) and TG containing longer chain fatty acids (TG(52:1), TG(55:7), TG(51:2), TG(53:3), TG52:2), TG(53:2), TG(57:3), TG(61:3), TG(61:2) increased. Further, dihydro O-acylceramide (18:1/18:0/16:0), diacylglycerophosphoethanolamine (PE(34:1)), diacylglycerophosphoinositol (PI(38:6), and dihydrosphingomyelins (dihydroSM(36:0), dihydroSM(40:0), dihydroSM(41:0), dihydroSM(42:0)) increased. Uric acid, mannitol, and mannitol-1-acetate levels also increased.

CONCLUSIONS

Our data uncovered potential favorable changes in the metabolism of glycerophospholipids, glycerolipids, and sphingolipids in new-onset T1DM after achieving optimal glycemic control. Further research on their potential role in developing diabetes-related complications is needed.

Obesity Surgery Improves Hypogonadism and Sexual Function in Men without Effects in Sperm Quality

(1) Background: Obesity is associated with hypogonadism, sexual dysfunction, and impaired fertility in men. However, its effects on semen parameters or sexual function remain debatable. (2) Methods: This paper involves a longitudinal study in men submitted for obesity surgery at a university tertiary hospital. Patients were studied at baseline and at 6, 12, and 18 months after obesity surgery. At each visit, anthropometry measures were collected and hormonal and semen parameters were studied. Sexual function was evaluated with the International Index of Erectile Function (IIEF). (3) Results: A total of 12 patients were included. The average body mass index of patients decreased from 42.37 ± 4.44 to 29.6 ± 3.77 kg/m2 at 18 months after surgery (p < 0.05). Hormonal parameters improved after obesity surgery. The proportion of sperm cells with normal morphology tended to decrease from baseline and became most significant at 18 months (5.83 ± 4.50 vs. 2.82 ± 2.08). No significant changes were found in the remaining semen parameters. Erectile function improved significantly at six months after surgery. (4) Conclusions: The authors believe that, in general, the effects of obesity surgery on fertility may be limited or even deleterious (at least in the short and midterm follow-up).

Evaluation of the usefulness of and satisfaction with the flash glucose monitoring system (FreeStyle Libre®) guide for use in patients with type 1 diabetes⋆

The Flash Guide (FG) for insulin dosing (A. Chico, C. González) was the first document intended for FreeStyle Libre® (FSL) user patients to help with decision-making depending on glucose level and trend. The objective of the study was to evaluate the usefulness of and the level of satisfaction with the recommendations given by the FG in a group of patients with type 1 diabetes (DM1) who were FSL users. It included 31 subjects (54% women; age 41 ± 15 years; DM duration 21 ± 14 years; 22 with FSL > 12 months) who were provided with the FG. They completed a questionnaire on decision-making depending on glucose trend in different situations (before and three months after using the FG), and a satisfaction questionnaire (ad hoc). Demographic, clinical and glycaemic control data were collected. The percentage of subjects who used glucose trend in decision-making after receiving the FG increased: for adjusting insulin (51 vs. 83; p = 0.016), action without insulin (51 vs. 90%; p = 0.001), and in special circumstances. The FG was evaluated as very useful (4.19/5). There were no significant changes in glycaemic control, although the percentage of data gathered increased significantly (89.07 vs. 94.46%; p = 0.042). In conclusion, the FG was evaluated well for managing glucose trends with FSL by the patients with DM1 analysed, increasing their use of trend in decision-making, with no changes in glycaemic control, but with more data gathered.

Obesity and related comorbidities in a large population-based cohort of subjects with type 1 diabetes in Catalonia

INTRODUCTION

Obesity, an increasing global health problem, can affect people with other disease conditions. The prevalence of obesity in people with type 1 diabetes (T1D) is not well known. The aim of this study was to describe extensively the characteristics and prevalence of different classes of obesity according to BMI (body mass index) categories in a large cohort of patients with T1D.

MATERIAL AND METHODS

This was a retrospective, cross-sectional study in Catalonia. We reviewed all patients with T1D diagnosis, ≥ 18 years old and with BMI data from the SIDIAP database. Sociodemographic and clinical data, cardiovascular risk factors, laboratory parameters and concomitant medications were collected.

RESULTS

A total of 6,068 patients with T1D were analyzed. The prevalence of obesity in the total sample was 18% (13.8% with class 1 obesity [BMI 30-34.9 kg/m2]). Patients with obesity had a higher prevalence of other cardiovascular risk factors (i.e. hypertension was 61.4% vs. 37.5%; dyslipidemia 63.6% vs 44%, and chronic kidney disease 38.4% vs. 24.4%; p<0.001 in all cases) and poorer control of them. The higher prevalence was regardless of sex, age and duration of diabetes. The increase in these comorbidities was noticeable from a BMI > 25 kg/m2. Patients with obesity did not have poorer glycemic control.

CONCLUSION

The presence of obesity in people with T1D is frequent and cardiovascular risk factors are more common and more poorly controlled in T1D patients with obesity.

Accuracy of Flash Glucose Monitoring in Patients with Diabetes Mellitus on Hemodialysis and Its Relationship with Hydration Status

BACKGROUND

The use of flash-glucose monitoring system FreeStyle Libre (FSL) has demonstrated benefits in metabolic control and quality of life in different populations with diabetes mellitus (DM), being funded in many countries. Due to this, DM subjects on hemodialysis (HD) are using FSL despite the accuracy in this population being unclear. The aims of the present study are to assess the accuracy of FSL in DM subjects on HD, its relationship to hydration status, and patient satisfaction.

MATERIAL AND METHODS

A prospective study in 16 patients with DM in a chronic HD program was conducted. Interstitial glucose values from FSL during a 14-day period were compared to capillary glucose measurements obtained at the same time. Hydration status was measured via bioimpedance spectroscopy. Satisfaction with FSL was obtained from an ad hoc satisfaction questionnaire.

RESULTS

A total of 766 paired interstitial and capillary glucose levels were analyzed. A correlation coefficient of 0.936 was determined and a mean absolute relative difference (MARD) value of 23%, increasing to 29% during HD. MARD was not related to hydration status. Interstitial glucose values were lower during HD (100.1 ± 17 mg/dL) than within the 12 hours after (125.1 ± 39 mg/dL; P = .012) and the days without HD (134.2 ± 32 mg/dL; P = .001). Subjects showed high satisfaction with FSL.

CONCLUSION

The accuracy of FSL in DM patients on HD is lower than in other populations, especially during HD sessions and is not related with the hydration status. Despite this, the degree of patient satisfaction with FSL is very high.

Immunotherapy-induced isolated ACTH deficiency in cancer therapy

Central adrenal insufficiency (AI) due to isolated adrenocorticotropic hormone (ACTH) deficiency (IAD) has been recently associated with immune checkpoint inhibitor (ICI) therapy. Our aim was to analyze the prevalence, clinical characteristics, and therapeutic outcomes in cancer patients with IAD induced by ICI therapy. A retrospective and multicenter study was performed. From a total of 4447 cancer patients treated with ICI antibodies, 37 (0.8%) (23 men (62.2%), mean age 64.7 ± 8.3 years (range 46-79 years)) were diagnosed with IAD. The tumor most frequently related to IAD was lung cancer (n = 20, 54.1%), followed by melanoma (n = 8, 21.6%). The most common ICI antibody inhibitors reported were nivolumab (n = 18, 48.6%), pembrolizumab (n = 16, 43.2%), and ipilimumab (n = 8, 21.6%). About half of the patients (n = 19, 51.4%) had other immune-related adverse events, mainly endocrine adverse effects (n = 10, 27.0%). IAD was diagnosed at a median time of 7.0 months (IQR, 5-12) after starting immunotherapy. The main reported symptom at presentation was fatigue (97.3%), followed by anorexia (81.8%) and general malaise (81.1%). Mean follow-up time since IAD diagnosis was 15.2 ± 12.5 months (range 0.3-55 months). At last visit, all patients continued with hormonal deficiency of ACTH. Median overall survival since IAD diagnosis was 6.0 months. In conclusion, IAD is a rare but a well-established complication associated with ICI therapy in cancer patients. It develops around 7 months after starting the treatment, mainly anti-PD1 antibodies. Recovery of the corticotropic axis function should not be expected.

Evaluation of the usefulness of and satisfaction with the flash glucose monitoring system (FreeStyle Libre®) guide for use in patients with type 1 diabetes

The Flash Guide (FG) for insulin dosing (A. Chico, C. González) was the first document intended for FreeStyle Libre® (FSL) user patients to help with decision-making depending on glucose level and trend. The objective of the study was to evaluate the usefulness of and the level of satisfaction with the recommendations given by the FG in a group of patients with type 1 diabetes (DM1) who were FSL users. It included 31 subjects (54% women; age 41±15 years; DM duration 21±14 years; 22 with FSL>12 months) who were provided with the FG. They completed a questionnaire on decision-making depending on glucose trend in different situations (before and three months after using the FG), and a satisfaction questionnaire (ad hoc). Demographic, clinical and glycaemic control data were collected. The percentage of subjects who used glucose trend in decision-making after receiving the FG increased: for adjusting insulin (51 vs. 83; P=.016), action without insulin (51 vs. 90%; P=.001), and in special circumstances. The FG was evaluated as very useful (4.19/5). There were no significant changes in glycaemic control, although the percentage of data gathered increased significantly (89.07 vs. 94.46%; P=.042). In conclusion, the FG was evaluated well for managing glucose trends with FSL by the patients with DM1 analysed, increasing their use of trend in decision-making, with no changes in glycaemic control, but with more data gathered.

Effects of Bariatric Surgery on HDL Cholesterol

BACKGROUND

Low levels of high-density lipoprotein cholesterol (HDLc) are independent predictive factors of coronary heart disease. Bariatric surgery increases HDLc concentration, but the chronology and predictors of this improvement in HDLc levels are not well-established. The aim of the present study was to analyse the changes over time in HDLc concentrations after bariatric surgery and to determine the predictors of their increase.

SUBJECTS AND METHODS

This was a retrospective, observational study. The medical records of patients who had undergone bariatric surgery at a tertiary care hospital between January 2007 and March 2015 were reviewed. Patients who underwent revisional surgery or were treated with fibrates were excluded from the analysis.

RESULTS

A total of 185 patients were included in the study. Follow-up rates were as follows: 87% (year 2) and 28% (year 5). At postoperative month 3, HDLc levels decreased significantly versus baseline (- 11.1%; p = 0.000), at which point they began to rise, reaching their maximum level 2 years after bariatric surgery (26.2% increase from baseline; p = 0.000). The increase in HDLc concentration 2 years after surgery correlated with the preoperative HDLc level (r = - 0.292, p = 0.001), and it was greater in patients who underwent sleeve gastrectomy versus gastric bypass (0.36 ± 0.4 vs. 0.18 ± 0.4 mmol/L, respectively; p = 0.018).

CONCLUSION

Bariatric surgery has a beneficial effect on HDLc levels. The maximum increase in postoperative HDLc concentrations is observed 2 years after surgery. Preoperative HDLc and the type of surgery are both significant predictors of the maximum increase in HDLc levels.

Effectiveness of Bariatric Surgery in Patients with the Metabolically Healthy Obese Phenotype

BACKGROUND

To evaluate the effectiveness and safety of bariatric surgery in metabolically healthy obese (MHO) patients.

METHODS

In this retrospective, observational study, we reviewed the medical records of patients who underwent bariatric surgery at a tertiary care hospital between January 2007 and March 2015. Patients who underwent revisional surgery and patients with type 1 diabetes were excluded from the analysis. MHO patients were defined as those without a previous diagnosis of diabetes or atherogenic dyslipidemia and absence of hypoglycemic treatment or treatment with fibrates.

RESULTS

A total of 188 patients were included (mean age 48.97 ± 10.32 years, 68.6% of women). Sleeve gastrectomy was performed in 121 patients (64%) and a gastric bypass in 67 patients (36%). Prior to surgery, 36 patients (19%) were MHO. In the second- and third-year post-surgery, MHO patients presented a higher percentage of total weight loss (%TWL) (35.16% vs. 30.34%; p = 0.02 and 33.97% vs. 27.78%; p = 0.013 respectively). Multiple regression analysis showed that MHO was associated with a higher weight loss irrespective of age, sex, baseline BMI, and type of surgery. We did not detect any differences in acute complications between patients with and without MHO after bariatric surgery.

CONCLUSIONS

Bariatric surgery in MHO patients in our study was associated with higher weight loss than that in MUHO patients. There were no differences between the two groups in respect to acute complications following surgery.

[Multiple sphincterotomies in the surgical treatment of cataracts in narrow pupils]

Deficient mydriasis of diverse etiology renders extracapsular cataract extraction and posterior chamber intraocular lens implantation technically difficult. Several techniques are available to improve surgical results when this problem is present. We have used multiple sphincterotomies in 6 patients with narrow pupils undergoing cataract extraction. We discuss the indications, intraoperative complications and postoperatory evolution of these cases.

New 5-hydroxy-2-indolecarbohydrazides as platelet aggregation inhibitors in ethylene glycol

The effect of ethylene glycol on blood platelet aggregation was examined using a previously described method. This method also was used to investigate several derivatives of 2-indolecarbohydrazide in vitro. All compounds inhibited platelet aggregation induced by collagen, epinephrine, or adenosine diphosphate at concentrations below 5 x 10(-4) M.