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Tsochatzis EA, Valenti L, Thiele M, Péloquin S, Lazure P, Masson MH, Allen AM, Lazarus JV, Noureddin M, Rinella M, Tacke F, Murray S. Use of non-invasive diagnostic tools for metabolic dysfunction-associated steatohepatitis: A qualitative exploration of challenges and barriers. Liver Int 2024. [PMID: 38634796 DOI: 10.1111/liv.15941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 03/04/2024] [Accepted: 04/07/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND AIMS Non-invasive tests (NITs) are underutilized for diagnosis and risk stratification in metabolic dysfunction-associated steatotic liver disease (MASLD), despite good accuracy. This study aimed to identify challenges and barriers to the use of NITs in clinical practice. METHODS We conducted a qualitative exploratory study in Germany, Italy, United Kingdom and United States. Phase 1 participants (primary care physicians, hepatologists, diabetologists, researchers, healthcare administrators, payers and patient advocates; n = 29) were interviewed. Phase 2 participants (experts in MASLD; n = 8) took part in a group discussion to validate and expand on Phase 1 findings. Finally, we triangulated perspectives in a hybrid deductive/inductive thematic analysis. RESULTS Four themes hindering the use of NITs emerged: (1) limited knowledge and awareness; (2) unclear referral pathways for patients affected by liver conditions; (3) uncertainty over the value of NITs in monitoring and managing liver diseases; and (4) challenges justifying system-level reimbursement. Through these themes, participants perceived a stigma associated with liver diseases, and primary care physicians generally lacked awareness, adequate knowledge and skills to use recommended NITs. We identified uncertainties over the results of NITs, specifically to guide lifestyle intervention or to identify patients that should be referred to a specialist. Participants indicated an ongoing need for research and development to improve the prognostic value of NITs and communicating their cost-effectiveness to payers. CONCLUSIONS This qualitative study suggests that use of NITs for MASLD is limited due to several individual and system-level barriers. Multi-level interventions are likely required to address these barriers.
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Affiliation(s)
- Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Precision Medicine, Biological Resource Center Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maja Thiele
- Center for Liver Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | | | | | | | - Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
| | - Mazen Noureddin
- Houston Research Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Mary Rinella
- Prizker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Younossi ZM, Alqahtani SA, Alswat K, Yilmaz Y, Keklikkiran C, Funuyet-Salas J, Romero-Gómez M, Fan JG, Zheng MH, El-Kassas M, Castera L, Liu CJ, Wai-Sun Wong V, Zelber-Sagi S, Allen AM, Lam B, Treeprasertsuk S, Hameed S, Takahashi H, Kawaguchi T, Schattenberg JM, Duseja A, Newsome PN, Francque S, Spearman CW, Castellanos Fernández MI, Burra P, Roberts SK, Chan WK, Arrese M, Silva M, Rinella M, Singal AK, Gordon S, Fuchs M, Alkhouri N, Cusi K, Loomba R, Ranagan J, Eskridge W, Kautz A, Ong JP, Kugelmas M, Eguchi Y, Diago M, Yu ML, Gerber L, Fornaresio L, Nader F, Henry L, Racila A, Golabi P, Stepanova M, Carrieri P, Lazarus JV. Global survey of stigma among physicians and patients with nonalcoholic fatty liver disease. J Hepatol 2024; 80:419-430. [PMID: 37984709 DOI: 10.1016/j.jhep.2023.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND & AIMS Patients with fatty liver disease may experience stigma from the disease or comorbidities. In this cross-sectional study, we aimed to understand stigma among patients with nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH) and healthcare providers. METHODS Members of the Global NASH Council created two surveys about experiences/attitudes toward NAFLD and related diagnostic terms: a 68-item patient and a 41-item provider survey. RESULTS Surveys were completed by 1,976 patients with NAFLD across 23 countries (51% Middle East/North Africa [MENA], 19% Europe, 17% USA, 8% Southeast Asia, 5% South Asia) and 825 healthcare providers (67% gastroenterologists/hepatologists) across 25 countries (39% MENA, 28% Southeast Asia, 22% USA, 6% South Asia, 3% Europe). Of all patients, 48% ever disclosed having NAFLD/NASH to family/friends; the most commonly used term was "fatty liver" (88% at least sometimes); "metabolic disease" or "MAFLD" were rarely used (never by >84%). Regarding various perceptions of diagnostic terms by patients, there were no substantial differences between "NAFLD", "fatty liver disease (FLD)", "NASH", or "MAFLD". The most popular response was being neither comfortable nor uncomfortable with either term (56%-71%), with slightly greater discomfort with "FLD" among the US and South Asian patients (47-52% uncomfortable). Although 26% of patients reported stigma related to overweight/obesity, only 8% reported a history of stigmatization or discrimination due to NAFLD. Among providers, 38% believed that the term "fatty" was stigmatizing, while 34% believed that "nonalcoholic" was stigmatizing, more commonly in MENA (43%); 42% providers (gastroenterologists/hepatologists 45% vs. 37% other specialties, p = 0.03) believed that the name change to metabolic dysfunction-associated steatotic liver disease (or MASLD) might reduce stigma. Regarding the new nomenclature, the percentage of providers reporting "steatotic liver disease" as stigmatizing was low (14%). CONCLUSIONS The perception of NAFLD stigma varies among patients, providers, geographic locations and sub-specialties. IMPACT AND IMPLICATIONS Over the past decades, efforts have been made to change the nomenclature of nonalcoholic fatty liver disease (NAFLD) to better align with its underlying pathogenetic pathways and remove any potential stigma associated with the name. Given the paucity of data related to stigma in NAFLD, we undertook this global comprehensive survey to assess stigma in NAFLD among patients and providers from around the world. We found there is a disconnect between physicians and patients related to stigma and related nomenclature. With this knowledge, educational programs can be developed to better target stigma in NAFLD among all stakeholders and to provide a better opportunity for the new nomenclature to address the issues of stigma.
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Affiliation(s)
- Zobair M Younossi
- Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, VA, USA; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA; The Global NASH Council, Washington, DC, USA.
| | - Saleh A Alqahtani
- The Global NASH Council, Washington, DC, USA; Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA; Alfaisal University, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Khalid Alswat
- The Global NASH Council, Washington, DC, USA; Liver Disease Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yusuf Yilmaz
- The Global NASH Council, Washington, DC, USA; Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Caglayan Keklikkiran
- The Global NASH Council, Washington, DC, USA; Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Jesús Funuyet-Salas
- The Global NASH Council, Washington, DC, USA; Department of Personality, Assessment, and Psychological Treatment, Faculty of Psychology, University of Seville, Seville, Spain
| | - Manuel Romero-Gómez
- The Global NASH Council, Washington, DC, USA; UCM Digestive Diseases and ciberehd, Virgen del Rocío University Hospital; Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), Department of Medicine, University of Seville, Seville, Spain
| | - Jian-Gao Fan
- The Global NASH Council, Washington, DC, USA; Department of Gastroenterology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ming-Hua Zheng
- The Global NASH Council, Washington, DC, USA; MAFLD Research Center, Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, China
| | - Mohamed El-Kassas
- The Global NASH Council, Washington, DC, USA; Infectious Diseases and Hepatology Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Laurent Castera
- The Global NASH Council, Washington, DC, USA; Department of Hepatology, Beaujon Hospital; AP-HP, Université Paris Cité, Inserm UMR1149, Clichy, France
| | - Chun-Jen Liu
- The Global NASH Council, Washington, DC, USA; Hepatitis Research Center, Department of Internal Medicine and Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Vincent Wai-Sun Wong
- The Global NASH Council, Washington, DC, USA; Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Shira Zelber-Sagi
- The Global NASH Council, Washington, DC, USA; School of Public Health, University of Haifa, Haifa, Israel
| | - Alina M Allen
- The Global NASH Council, Washington, DC, USA; Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Brian Lam
- Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, VA, USA; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA; The Global NASH Council, Washington, DC, USA
| | - Sombat Treeprasertsuk
- The Global NASH Council, Washington, DC, USA; Division of Gastroenterology, Chulalongkorn University, Bangkok, Thailand
| | - Saeed Hameed
- The Global NASH Council, Washington, DC, USA; Department of Medicine, Clinical Trials Unit, Aga Khan University, Karachi, Pakistan
| | - Hirokazu Takahashi
- The Global NASH Council, Washington, DC, USA; Liver Center, Saga University Hospital, Saga, Japan
| | - Takumi Kawaguchi
- The Global NASH Council, Washington, DC, USA; Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Jörn M Schattenberg
- The Global NASH Council, Washington, DC, USA; Metabolic Liver Research Program, Department of Medicine, University Medical Center Mainz, Mainz, Germany
| | - Ajay Duseja
- The Global NASH Council, Washington, DC, USA; Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Phil N Newsome
- The Global NASH Council, Washington, DC, USA; University of Birmingham, Birmingham, UK
| | - Sven Francque
- The Global NASH Council, Washington, DC, USA; Department of Gastroenterology and Hepatology, Antwerp University Hospital; InflaMed Centre of Excellence, Translational Sciences in Inflammation and Immunology, Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - C Wendy Spearman
- The Global NASH Council, Washington, DC, USA; Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Marlen I Castellanos Fernández
- The Global NASH Council, Washington, DC, USA; Institute of Gastroenterology, University of Medical Sciences of Havana, Havana, Cuba
| | - Patrizia Burra
- The Global NASH Council, Washington, DC, USA; Department of Gastroenterology, Universita Degli Studi Di Padova, Padova, Italy
| | - Stuart K Roberts
- The Global NASH Council, Washington, DC, USA; The Alfred, Melbourne, VIC, Australia
| | - Wah-Kheong Chan
- The Global NASH Council, Washington, DC, USA; University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Marco Arrese
- The Global NASH Council, Washington, DC, USA; Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marcelo Silva
- The Global NASH Council, Washington, DC, USA; Hepatology and Liver Transplant Unit, Austral University Hospital, Buenos Aires, Argentina
| | - Mary Rinella
- The Global NASH Council, Washington, DC, USA; Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ashwani K Singal
- The Global NASH Council, Washington, DC, USA; Division of Gastroenterology and Hepatology, University of Louisville School of Medicine; Trager Transplant Center and Jewish Hospital, Louisville, KY, USA
| | - Stuart Gordon
- The Global NASH Council, Washington, DC, USA; William Beaumont Hospital, Royal Oak, MI, USA
| | - Michael Fuchs
- The Global NASH Council, Washington, DC, USA; Central Virginia VA Health Care System (CVHCS); Virginia Commonwealth University (VCU), Richmond, VA, USA
| | - Naim Alkhouri
- The Global NASH Council, Washington, DC, USA; Arizona Liver Health, Phoenix, AZ, USA
| | - Kenneth Cusi
- The Global NASH Council, Washington, DC, USA; Division of Endocrinology, Diabetes and Metabolism, The University of Florida, Gainesville, FL, USA
| | - Rohit Loomba
- The Global NASH Council, Washington, DC, USA; University of California, San Diego, San Diego, CA, USA
| | - Jane Ranagan
- The Global NASH Council, Washington, DC, USA; Focus Medical Communications, East Hanover, NJ, USA
| | - Wayne Eskridge
- The Global NASH Council, Washington, DC, USA; Fatty Liver Foundation, Boise, ID, USA
| | - Achim Kautz
- The Global NASH Council, Washington, DC, USA; Kautz5 gUG, Köln, Germany
| | - Janus P Ong
- The Global NASH Council, Washington, DC, USA; College of Medicine, University of the Philippines, Manila, Philippines
| | - Marcelo Kugelmas
- The Global NASH Council, Washington, DC, USA; Department of Hepatology and Research, South Denver Gastroenterology, PC, Englewood, CO, USA
| | - Yuichiro Eguchi
- The Global NASH Council, Washington, DC, USA; Loco Medical General Institute; Saga University Faculty of Medicine, Saga, Japan
| | - Moises Diago
- The Global NASH Council, Washington, DC, USA; Department of Medicine, University of Valencia; Hospital General Universitario Valencia, Valencia, Spain
| | - Ming-Lung Yu
- The Global NASH Council, Washington, DC, USA; School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-Sen University; Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Lynn Gerber
- Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, VA, USA; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA; The Global NASH Council, Washington, DC, USA
| | - Lisa Fornaresio
- Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fatema Nader
- The Global NASH Council, Washington, DC, USA; Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Linda Henry
- Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, VA, USA; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA; The Global NASH Council, Washington, DC, USA; Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Andrei Racila
- Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, VA, USA; Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India; Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Pegah Golabi
- Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, VA, USA; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA; Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Maria Stepanova
- Beatty Liver and Obesity Research Program, Inova Health System, Falls Church, VA, USA; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA; The Global NASH Council, Washington, DC, USA; Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Patrizia Carrieri
- The Global NASH Council, Washington, DC, USA; Aix Marseille Univ, Inserm, IRD, Sesstim, Sciences Economiques & Sociales De La Santé Et Traitement De L'information Médicale, Marseille, France
| | - Jeffrey V Lazarus
- The Global NASH Council, Washington, DC, USA; Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
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Siddiqui MS, Muthiah M, Satapathy SK, Patidar KR, Bhat M, Brandman D, Watt KD, Rinella M. Defining an approach for therapeutic strategies in metabolic dysfunction-associated steatotic liver disease after liver transplantation. Hepatology 2023:01515467-990000000-00683. [PMID: 38088872 DOI: 10.1097/hep.0000000000000720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/24/2023] [Indexed: 03/13/2024]
Abstract
Occurrence of metabolic dysfunction-associated steatotic liver disease (MASLD) is common following liver transplantation (LT). MASLD can be classified as a recurrent disease when it occurs in patients receiving LT for metabolic dysfunction-associated steatohepatitis (MASH) or as de novo when it occurs in patients undergoing transplantation for non-metabolic dysfunction-associated steatohepatitis etiologies of liver disease. Fibrosis progression in patients with MASLD is accelerated, with progression to cirrhosis occurring more rapidly compared with the general (ie, non-LT) population. Moreover, the metabolic burden in LT recipients with MASLD is high and synergizes with liver disease to negatively affect the clinical course. Despite the oversized clinical burden of MASLD among LT recipients, there is currently a lack of regulatory approach and pathway for therapeutics development in this patient population. The present document, thus, provides guidance for therapeutics development that incorporates nuances of transplant care in patients with post-LT MASLD to facilitate drug development.
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Affiliation(s)
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Nadolsky K, Cryer DR, Articolo A, Fisher T, Schneider J, Rinella M. Nonalcoholic steatohepatitis diagnosis and treatment from the perspective of patients and primary care physicians: a cross-sectional survey. Ann Med 2023; 55:2211349. [PMID: 37171239 PMCID: PMC10184582 DOI: 10.1080/07853890.2023.2211349] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND The global prevalence of nonalcoholic steatohepatitis (NASH) is rising. Despite this, NASH is underdiagnosed and does not yet have approved pharmacological treatments. We sought to understand the path to diagnosis, patient interactions with healthcare professionals, treatment regimens, and disease management for patients with NASH. METHODS Cross-sectional online surveys of patients with a self-reported diagnosis of NASH and healthcare professionals treating patients with NASH were conducted from 10th November 2020, to 1st January 2021. This manuscript focuses on responses from 152 patients with NASH and 101 primary care physicians (PCPs). RESULTS Patients (n = 152, mean age = 40, SD = 11) and healthcare professionals (n = 226) were located throughout the US. In the most common patient journey, 72% of patients had initial discussions about symptoms with a PCP but only 30% report receiving their NASH diagnosis from a PCP. Almost half of PCPs (47%) were not aware of any clinical practice guidelines for diagnosis and management of NASH. For ongoing management of NASH, PCPs most frequently prescribed lifestyle changes such as exercise (89%), lifestyle changes focused on diet (79%), and/or metformin (57%). Other healthcare professionals rarely referred patients to PCPs for treatment, but when they did, the primary reasons were patients struggling with lifestyle modifications (58%), needing to lose weight (46%), and needing treatment of comorbidities (42%). CONCLUSIONS PCPs may benefit from greater awareness of NASH and guidelines for its diagnosis and treatment. Given the absence of pharmacological treatments approved for NASH, PCPs can offer support in obesity management, comorbidity management, and risk stratification for liver disease progression.
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Affiliation(s)
- Karl Nadolsky
- MI State University College of Human Medicine, Holland Hospital Endocrinology, Obesity & Diabetes, Holland, MI, USA
| | | | | | | | | | - Mary Rinella
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
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Anstee QM, Lucas KJ, Francque S, Abdelmalek MF, Sanyal AJ, Ratziu V, Gadano AC, Rinella M, Charlton M, Loomba R, Mena E, Schattenberg JM, Noureddin M, Lazas D, Goh GB, Sarin SK, Yilmaz Y, Martic M, Stringer R, Kochuparampil J, Chen L, Rodriguez-Araujo G, Chng E, Naoumov NV, Brass C, Pedrosa MC. Tropifexor plus cenicriviroc combination versus monotherapy in nonalcoholic steatohepatitis: Results from the phase 2b TANDEM study. Hepatology 2023; 78:1223-1239. [PMID: 37162151 PMCID: PMC10521801 DOI: 10.1097/hep.0000000000000439] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND AND AIMS With distinct mechanisms of action, the combination of tropifexor (TXR) and cenicriviroc (CVC) may provide an effective treatment for NASH. This randomized, multicenter, double-blind, phase 2b study assessed the safety and efficacy of TXR and CVC combination, compared with respective monotherapies. APPROACH AND RESULTS Patients (N = 193) were randomized 1:1:1:1 to once-daily TXR 140 μg (TXR 140 ), CVC 150 mg (CVC), TXR 140 μg + CVC 150 mg (TXR 140 + CVC), or TXR 90 μg + CVC 150 mg (TXR 90 + CVC) for 48 weeks. The primary and secondary end points were safety and histological improvement, respectively. Rates of adverse events (AEs) were similar across treatment groups. Pruritus was the most frequently experienced AE, with highest incidence in the TXR 140 group (40.0%). In TXR and combination groups, alanine aminotransferase (ALT) decreased from baseline to 48 weeks (geometric mean change: -21%, TXR 140 ; -16%, TXR 140 + CVC; -13%, TXR 90 + CVC; and +17%, CVC). Reductions in body weight observed at week 24 (mean changes from baseline: TXR 140 , -2.5 kg; TXR 140 + CVC, -1.7 kg; TXR 90 + CVC, -1.0 kg; and CVC, -0.1 kg) were sustained to week 48. At least 1-point improvement in fibrosis stage/steatohepatitis resolution without worsening of fibrosis was observed in 32.3%/25.8%, 31.6%/15.8%, 29.7%/13.5%, and 32.5%/22.5% of patients in the TXR 140 , CVC, TXR 140 + CVC, and TXR 90 + CVC groups, respectively. CONCLUSIONS The safety profile of TXR + CVC combination was similar to respective monotherapies, with no new signals. TXR monotherapy showed sustained ALT and body weight decreases. No substantial incremental efficacy was observed with TXR + CVC combination on ALT, body weight, or in histological end points compared with monotherapy.
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Affiliation(s)
- Quentin M. Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Kathryn J. Lucas
- Diabetes and Endocrinology Consultants, Morehead City, North Carolina, USA
| | - Sven Francque
- Department of Gastroenterology Hepatology, Antwerp University Hospital, Antwerp, Belgium
- InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | | | - Arun J. Sanyal
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Vlad Ratziu
- Sorbonne Université, Hôpital Pitié Salpêtrière, ICAN Paris, France
| | | | - Mary Rinella
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | | | - Rohit Loomba
- University of California at San Diego, La Jolla, California, USA
| | - Edward Mena
- California Liver Research Institute, Pasadena, California, USA
| | - Jörn M. Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Center Mainz, Germany
| | | | - Donald Lazas
- Digestive Health Research and ObjectiveHealth, Nashville, Tennessee, USA
| | - George B.B. Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Shiv K. Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Yusuf Yilmaz
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | | | | | | | - Li Chen
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | | | | | - Clifford Brass
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
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Geier A, Heinz S, Balp MM, Brass C, Pedrosa M, Cai J, Hoad R, Sayadian AC, Rinella M, Ratziu V. The Cost of Diagnosing and Managing Non-alcoholic Steatohepatitis in Europe and the United States. J Gastrointestin Liver Dis 2022; 31:317-322. [PMID: 36004416 DOI: 10.15403/jgld-4275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND AIMS Non-alcoholic steatohepatitis (NASH) is acknowledged as a severe disease that is associated with a significant burden on patients, payers, and society. However, limited evidence exists on the cost associated with NASH across different countries. This analysis aims to describe the cost associated with the routine care of patients with NASH in France, Germany, and the United States. METHODS Data was sourced from the Gesellschaft für Konsumforschung (now Ipsos) Disease Atlas Real- World Evidence program collected from July through November 2017 in France, Germany, and the United States. Country-level unit cost was estimated from national databases for diagnostic tests and procedures, prescription drugs, hospital stays, and outpatient visits in respective local currency based on 2017 values. These were combined to provide an estimate of the cost of management of confirmed NASH in this specific patient population and are presented as mean cost per patient per year for each country in local currency and as USD adjusted for purchasing power parity for comparison. RESULTS Annual mean ± standard deviation cost of non-alcoholic steatohepatitis ranged from purchasing power parity USD 1,049±2,461 in Germany to USD 1,723±2,988 in the United States. In all markets, the predominant contributor to cost is healthcare resource use represented by hospitalisation and outpatient visits. CONCLUSIONS This study reveals that costs associated with NASH treatment and management vary across the three countries studied, in part due to differences in healthcare systems but also due to different approaches in managing this disease. Our analysis represents the costs for a specific cohort of patients and further studies are warranted to better understand the progressive impact of NASH on healthcare systems and society.
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Affiliation(s)
- Andreas Geier
- University Hospital Würzburg, Division of Hepatology, Würzburg, Germany.
| | | | | | - Clifford Brass
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
| | | | - Jennifer Cai
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
| | | | | | - Mary Rinella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Vlad Ratziu
- Hospital Pitié-Salpêtrière, Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, Paris, France.
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Younossi ZM, Stepanova M, Nader F, Loomba R, Anstee QM, Ratziu V, Harrison S, Sanyal AJ, Schattenberg JM, Barritt AS, Noureddin M, Bonacci M, Cawkwell G, Wong B, Rinella M. Obeticholic Acid Impact on Quality of Life in Patients With Nonalcoholic Steatohepatitis: REGENERATE 18-Month Interim Analysis. Clin Gastroenterol Hepatol 2022; 20:2050-2058.e12. [PMID: 34274514 DOI: 10.1016/j.cgh.2021.07.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Nonalcoholic steatohepatitis (NASH) affects patients' health-related quality of life (HRQoL). Patient-reported outcomes (PROs) evaluating HRQoL were assessed in the RandomizEd Global Phase 3 Study to Evaluate the Impact on NASH with FibRosis of Obeticholic Acid TreatmEnt (REGENERATE) study, which showed that obeticholic acid (OCA) significantly improved fibrosis in patients with NASH. METHODS Noncirrhotic NASH patients in a phase 3, double-blind, randomized, placebo-controlled, multicenter, international study of OCA were enrolled. The Chronic Liver Disease Questionnaire-NASH and EuroQol EQ-5D-5L were administered at baseline, 6, 12, and 18 months. RESULTS There were 1218 patients (age, 54.1 ± 11.5 y; 57% women; 43% stage F3) in the expanded intent-to-treat population (stages, F1-F3) assigned randomly to 10 mg (N = 407) or 25 mg (N = 404) OCA or placebo (N = 407). Baseline measurements were balanced across treatment groups for EuroQol EQ-5D-5L and Chronic Liver Disease Questionnaire-NASH, including Itch score: 5.75 ± 1.53 (scale 1-7, with 7 representing no itching). Nineteen (1.6%) patients discontinued therapy (protocol mandated) because of grade 3 pruritus. Patients receiving 25 mg OCA experienced mild worsening of itch scores primarily in the first months of treatment: mean ± SE change from baseline -0.66 ± 0.12, -0.44 ± 0.12, and -0.42 ± 0.13 at 6, 12, and 18 months, respectively (all P < .01). No other PRO worsening was associated with 25 mg OCA. Patients experiencing fibrosis improvement, Nonalcoholic Fatty Liver Disease Activity Score decrease (by ≥2 points), or NASH resolution had greater PRO improvements in some domains. CONCLUSIONS NASH patients evaluated in REGENERATE had impaired quality of life and underlying pruritus at baseline. Improvement of NASH corresponded with improvement in several HRQoL domains. Generally mild pruritus occurs early after OCA therapy initiation and does not worsen over time. CLINICALTRIALS gov: NCT02548351.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia; Center for Liver Diseases, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia.
| | - Maria Stepanova
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
| | - Fatema Nader
- Center for Outcomes Research in Liver Disease, Washington, District of Columbia
| | - Rohit Loomba
- University of California, San Diego, San Diego, California
| | - Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle National Institute for Health Research Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Vlad Ratziu
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Hôpital Pitié-Salpêtrière, INSERM UMRS 1138 CRC, Paris, France
| | | | - Arun J Sanyal
- Virginia Commonwealth University, Richmond, Virginia
| | | | - A Sidney Barritt
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | | | - Bruce Wong
- Intercept Pharmaceuticals, New York, New York
| | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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8
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Rinella M, Cryer DR, Articolo A, Fisher T, Schneider J, Nadolsky K. Nonalcoholic steatohepatitis medical patient journey from the perspective of hepatologists, gastroenterologists and patients: a cross-sectional survey. BMC Gastroenterol 2022; 22:335. [PMID: 35811319 PMCID: PMC9272554 DOI: 10.1186/s12876-022-02410-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Nonalcoholic steatohepatitis (NASH), the inflammatory subtype of nonalcoholic fatty liver disease, is underdiagnosed and expected to become the leading indication for liver transplant in the United States. We aimed to understand the medical journey of patients with NASH and role of hepatologists/gastroenterologists in diagnosing and treating patients with NASH.
Methods
A United States population-based cross-sectional online survey was completed by 226 healthcare professionals (HCPs) who treat patients with NASH and 152 patients with NASH; this study focuses on the patient and 75 hepatologist/gastroenterologist HCP respondents. Tests of differences (chi square, t-tests) between respondent types were performed using SPSS.
Results
Most patients reported receiving their diagnosis of NASH from a hepatologist (37%) or gastroenterologist (26%). Hepatologists/gastroenterologists were more likely than other HCPs to use FibroScan (transient elastography) to diagnose NASH and were more likely to distinguish between NASH with or without fibrosis. Hepatologists/gastroenterologists (68%) and patients (52%) agree that hepatologists/gastroenterologists are the primary coordinators of NASH care. The majority of hepatologists/gastroenterologists (85%) are aware of American Association for the Study of Liver Diseases (AASLD) clinical practice guidance, and 86% of those aware consider them when diagnosing patients with NASH. Hepatologists/gastroenterologists most frequently recommended exercise (86%), diet (70%), and supplements (58%) for ongoing management of NASH. Pharmaceutical medications for comorbidities were prescribed by a minority of hepatologists/gastroenterologists for their patients with NASH. Hepatologists/gastroenterologists cite difficulty (67%) or unwillingness (64%) to adhere to lifestyle changes as primary reasons patients with NASH discontinue NASH treatment.
Conclusions
Hepatologists/gastroenterologists are considered the coordinators of NASH care. While recognizing that patient adherence to lifestyle changes is the basis for successful treatment, important barriers limit successful implementation.
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9
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Brunt EM, Clouston AD, Goodman Z, Guy C, Kleiner DE, Lackner C, Tiniakos DG, Wee A, Yeh M, Leow WQ, Chng E, Ren Y, Boon Bee GG, Powell EE, Rinella M, Sanyal AJ, Neuschwander-Tetri B, Younossi Z, Charlton M, Ratziu V, Harrison SA, Tai D, Anstee QM. Complexity of ballooned hepatocyte feature recognition: Defining a training atlas for artificial intelligence-based imaging in NAFLD. J Hepatol 2022; 76:1030-1041. [PMID: 35090960 PMCID: PMC10544770 DOI: 10.1016/j.jhep.2022.01.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/21/2021] [Accepted: 01/07/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Histologically assessed hepatocyte ballooning is a key feature discriminating non-alcoholic steatohepatitis (NASH) from steatosis (NAFL). Reliable identification underpins patient inclusion in clinical trials and serves as a key regulatory-approved surrogate endpoint for drug efficacy. High inter/intra-observer variation in ballooning measured using the NASH CRN semi-quantitative score has been reported yet no actionable solutions have been proposed. METHODS A focused evaluation of hepatocyte ballooning recognition was conducted. Digitized slides were evaluated by 9 internationally recognized expert liver pathologists on 2 separate occasions: each pathologist independently marked every ballooned hepatocyte and later provided an overall non-NASH NAFL/NASH assessment. Interobserver variation was assessed and a 'concordance atlas' of ballooned hepatocytes generated to train second harmonic generation/two-photon excitation fluorescence imaging-based artificial intelligence (AI). RESULTS The Fleiss kappa statistic for overall interobserver agreement for presence/absence of ballooning was 0.197 (95% CI 0.094-0.300), rising to 0.362 (0.258-0.465) with a ≥5-cell threshold. However, the intraclass correlation coefficient for consistency was higher (0.718 [0.511-0.900]), indicating 'moderate' agreement on ballooning burden. 133 ballooned cells were identified using a ≥5/9 majority to train AI ballooning detection (AI-pathologist pairwise concordance 19-42%, comparable to inter-pathologist pairwise concordance of between 8-75%). AI quantified change in ballooned cell burden in response to therapy in a separate slide set. CONCLUSIONS The substantial divergence in hepatocyte ballooning identified amongst expert hepatopathologists suggests that ballooning is a spectrum, too subjective for its presence or complete absence to be unequivocally determined as a trial endpoint. A concordance atlas may be used to train AI assistive technologies to reproducibly quantify ballooned hepatocytes that standardize assessment of therapeutic efficacy. This atlas serves as a reference standard for ongoing work to refine how ballooning is classified by both pathologists and AI. LAY SUMMARY For the first time, we show that, even amongst expert hepatopathologists, there is poor agreement regarding the number of ballooned hepatocytes seen on the same digitized histology images. This has important implications as the presence of ballooning is needed to establish the diagnosis of non-alcoholic steatohepatitis (NASH), and its unequivocal absence is one of the key requirements to show 'NASH resolution' to support drug efficacy in clinical trials. Artificial intelligence-based approaches may provide a more reliable way to assess the range of injury recorded as "hepatocyte ballooning".
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Affiliation(s)
- Elizabeth M Brunt
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, Missouri, USA.
| | - Andrew D Clouston
- Molecular and Cellular Pathology, University of Queensland and Envoi Specialist Pathologists, Brisbane, Australia
| | - Zachary Goodman
- Pathology Department, and Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Cynthia Guy
- Division of Pathology, Duke University Medical Center, Durham, NC, USA
| | - David E Kleiner
- Laboratory of Pathology; Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Carolin Lackner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Dina G Tiniakos
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Dept of Pathology, Aretaieion Hospital, National and Kapodistrian University of Athens, Greece
| | - Aileen Wee
- Department of Pathology, Yong Loo Lin School of Medicine, National University of Singapore, National University Hospital, Singapore
| | - Matthew Yeh
- Department of Pathology, University of Washington, Seattle, Washington, USA
| | - Wei Qiang Leow
- Department of Anatomical Pathology, Singapore General Hospital, Singapore & Duke-NUS Medical School, Singapore
| | | | | | - George Goh Boon Bee
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Elizabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Mary Rinella
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Arun J Sanyal
- Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Zobair Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA
| | - Michael Charlton
- Center for Liver Diseases, and Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Vlad Ratziu
- Department of Hepatology, Sorbonne University and Pitié-Salpêtrière Hospital, Paris, France
| | - Stephen A Harrison
- Pinnacle Clinical Research, San Antonio, USA; Hepatology, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Dean Tai
- Department of Anatomical Pathology, Singapore General Hospital, Singapore & Duke-NUS Medical School, Singapore.
| | - Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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10
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Ramji A, Rinella M, Dufour J, Anstee QM, Younossi Z, Loomba R, Sanyal AJ, Capozza T, Trylesinki A, Ratziu V. A219 AMINOTRANSFERASE IMPROVEMENTS IN PATIENTS WITH NON-ALCOHOLIC STEATOHEPATITIS ARE ASSOCIATED WITH FIBROSIS REGRESSION IN THE REGENERATE STUDY. J Can Assoc Gastroenterol 2022. [DOI: 10.1093/jcag/gwab049.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The interim analysis of the REGENERATE study showed obeticholic acid (OCA) 25 mg treatment significantly improved liver histology in patients with nonalcoholic steatohepatitis (NASH) and fibrosis. Elevations in aminotransferases are associated with adverse liver-related outcomes in NASH.
Aims
Here, we evaluate the utility of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) as markers of treatment response to OCA in patients with NASH.
Methods
Changes in ALT (upper limit of normal [ULN] = 55 U/L) and AST (ULN = 34 U/L) were assessed systematically at 1, 3, 6, 12, and 18 months in 931 NASH patients with stage 2 or 3 fibrosis randomized 1:1:1 to placebo (PBO), OCA 10 mg, or OCA 25 mg in REGENERATE (intent-to-treat population). Least-square mean (LSM) and 95% confidence intervals (CIs) of percentage change from baseline in ALT and AST were analyzed using a mixed-effect repeated-measures model.
Results
Baseline characteristics were well-balanced across treatment arms: ALT 79±53 U/L; AST 58±36 U/L; 44% F2, 56% F3. Aminotransferase values were > ULN for ALT in 60% (7% > 3xULN), and for AST in 74% (9% > 3xULN) of patients. Rapid, progressive, and dose-dependent improvement in ALT and AST was seen across PBO, OCA 10 mg, and OCA 25 mg arms, which at Month 18 was: ALT LSM change (95% CI), respectively, -4.9% (-10.7–0.9), -23.2% (-28.9– -17.4) and -31.9% (-37.7– -26.1) and in AST, -8.7% (-12.1– -5.2), -13.4% (-16.8– -9.9), and -19.4 (-22.8– -15.9). ALT and AST LSM reductions in OCA arms vs PBO were seen regardless of patient ULN status at baseline. In all patients, ALT/AST reduction was associated with probability of fibrosis regression at Month 18, ranging from approximately 20%, 95% CI (14–27) to 45% (37–54) with any reduction in ALT (> 0%–100%) and between approximately 20%, 95% CI (25–38) to 43% (35–57) with any reduction in AST (> 0%–100%). Interestingly, even with increases of ≤ 40% in AST or ALT there was still a small probability of fibrosis regression (< 20%). Analysis of changes in ALT and AST in individual patients showed that more patients had improvements on OCA than PBO at Month 18 (FIG 1).
Conclusions
OCA resulted in consistent dose-dependent improvement of ALT and AST. Patients with reductions in ALT or AST were up to twice as likely to have fibrosis improvement than those whose ALT or AST increased. The REGENERATE study is ongoing and will continue through clinical outcomes for verification and description of clinical benefits of OCA in treatment of NASH.
Funding Agencies
None
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Affiliation(s)
- A Ramji
- Gastrointestinal Research Institute, Vancouver, BC, Canada
| | - M Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - J Dufour
- University Clinic for Visceral Surgery and Medicine, Inselspital, Bern, Switzerland & University of Bern, Bern, Switzerland
| | - Q M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Z Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, IL
| | - R Loomba
- University of California San Diego, La Jolla, CA
| | - A J Sanyal
- Virginia Commonwealth University, Richmond, VA
| | - T Capozza
- Intercept Pharmaceuticals Inc, New York, NY
| | - A Trylesinki
- Intercept Pharmaceuticals, London, United Kingdom
| | - V Ratziu
- Sorbonne Universite, Paris, Île-de-France, France
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11
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Lee BP, Im GY, Rice JP, Lazar A, Weinberg E, Han H, Maddur H, Ghobrial RM, Therapondos G, Hsu C, Fix OK, Eswaran S, Shetty K, Chhatwal J, Dalgic OO, Jakhete N, Mobley C, Victor DW, Mehta N, Dinges L, Rinella M, Schiano TD, Lucey MR, Terrault N. Patterns of Alcohol Use After Early Liver Transplantation for Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2022; 20:409-418.e5. [PMID: 33279780 DOI: 10.1016/j.cgh.2020.11.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/06/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Early liver transplantation (LT) for alcoholic hepatitis (AH) is lifesaving but concerns regarding return to harmful alcohol use remain. We sought to identify distinct patterns of alcohol use post-LT to inform pre-LT candidate selection and post-LT addiction care. METHODS Detailed post-LT alcohol use data was gathered retrospectively from consecutive patients with severe AH at 11 ACCELERATE-AH sites from 2006-2018. Latent class analysis identified longitudinal patterns of alcohol use post-LT. Logistic and Cox regression evaluated associations between patterns of alcohol use with pre-LT variables and post-LT survival. A microsimulation model estimated the effect of selection criteria on overall outcomes. RESULTS Of 153 LT recipients, 1-, 3-, and 5-year survival were 95%, 88% and 82%. Of 146 LT recipients surviving to home discharge, 4 distinct longitudinal patterns of post-LT alcohol use were identified: Pattern 1 [abstinent](n = 103; 71%), pattern 2 [late/non-heavy](n = 9; 6.2%), pattern 3 [early/non-heavy](n = 22; 15%), pattern 4 [early/heavy](n = 12; 8.2%). One-year survival was similar among the 4 patterns (100%), but patients with early post-LT alcohol use had lower 5-year survival (62% and 53%) compared to abstinent and late/non-heavy patterns (95% and 100%). Early alcohol use patterns were associated with younger age, multiple prior rehabilitation attempts, and overt encephalopathy. In simulation models, the pattern of post-LT alcohol use changed the average life-expectancy after early LT for AH. CONCLUSIONS A significant majority of LT recipients for AH maintain longer-term abstinence, but there are distinct patterns of alcohol use associated with higher risk of 3- and 5-year mortality. Pre-LT characteristics are associated with post-LT alcohol use patterns and may inform candidate selection and post-LT addiction care.
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Affiliation(s)
- Brian P Lee
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Gene Y Im
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - John P Rice
- Department of Medicine, University of Wisconsin, Madison, Wisconsin.
| | - Ann Lazar
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ethan Weinberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hyosun Han
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Haripriya Maddur
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - R Mark Ghobrial
- Weil Cornell College of Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas
| | - George Therapondos
- Ochsner Clinical School of Medicine, Ochsner Clinic, New Orleans, Louisiana
| | - Christine Hsu
- Georgetown University School of Medicine, Washington, DC
| | - Oren K Fix
- Swedish Organ Transplant and Liver Center, Swedish Medical Center, Seattle, Washington
| | - Sheila Eswaran
- Department of Medicine, Rush Medical Center, Chicago, Illinois
| | - Kirti Shetty
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jag Chhatwal
- Institute of Technology Assessment, Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Ozden O Dalgic
- Institute of Technology Assessment, Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Neha Jakhete
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Constance Mobley
- Weil Cornell College of Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas
| | - David W Victor
- Weil Cornell College of Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas
| | - Neil Mehta
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Lisanne Dinges
- Swedish Organ Transplant and Liver Center, Swedish Medical Center, Seattle, Washington
| | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Michael R Lucey
- Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Norah Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, California.
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12
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Lazarus JV, Mark HE, Anstee QM, Arab JP, Batterham RL, Castera L, Cortez-Pinto H, Crespo J, Cusi K, Dirac MA, Francque S, George J, Hagström H, Huang TTK, Ismail MH, Kautz A, Sarin SK, Loomba R, Miller V, Newsome PN, Ninburg M, Ocama P, Ratziu V, Rinella M, Romero D, Romero-Gómez M, Schattenberg JM, Tsochatzis EA, Valenti L, Wong VWS, Yilmaz Y, Younossi ZM, Zelber-Sagi S. Advancing the global public health agenda for NAFLD: a consensus statement. Nat Rev Gastroenterol Hepatol 2022; 19:60-78. [PMID: 34707258 DOI: 10.1038/s41575-021-00523-4] [Citation(s) in RCA: 283] [Impact Index Per Article: 141.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 12/11/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a potentially serious liver disease that affects approximately one-quarter of the global adult population, causing a substantial burden of ill health with wide-ranging social and economic implications. It is a multisystem disease and is considered the hepatic component of metabolic syndrome. Unlike other highly prevalent conditions, NAFLD has received little attention from the global public health community. Health system and public health responses to NAFLD have been weak and fragmented, and, despite its pervasiveness, NAFLD is largely unknown outside hepatology and gastroenterology. There is only a nascent global public health movement addressing NAFLD, and the disease is absent from nearly all national and international strategies and policies for non-communicable diseases, including obesity. In this global Delphi study, a multidisciplinary group of experts developed consensus statements and recommendations, which a larger group of collaborators reviewed over three rounds until consensus was achieved. The resulting consensus statements and recommendations address a broad range of topics - from epidemiology, awareness, care and treatment to public health policies and leadership - that have general relevance for policy-makers, health-care practitioners, civil society groups, research institutions and affected populations. These recommendations should provide a strong foundation for a comprehensive public health response to NAFLD.
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Affiliation(s)
- Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain. .,EASL International Liver Foundation, Geneva, Switzerland.
| | - Henry E Mark
- EASL International Liver Foundation, Geneva, Switzerland
| | - Quentin M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Juan Pablo Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rachel L Batterham
- Centre for Obesity Research, University College London and National Institute of Health Research, UCLH Biomedical Research Centre, London, UK
| | - Laurent Castera
- Department of Hepatology, Hôpital Beaujon, Université de Paris, Paris, France
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Laboratório de Nutrição, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Javier Crespo
- Gastroenterology and Heptology Unit, Hospital Universitario Marqués de Valdecilla, Santander, IDIVAL, Santander, Spain
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Veterans Health Administration and University of Florida, Gainesville, FL, USA
| | - M Ashworth Dirac
- Department of Health Metrics Sciences, Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Sven Francque
- Department of Gastroenterology Hepatology, University Hospital Antwerp, Antwerp, Belgium.,Translational Sciences in Inflammation and Immunology TWI2N, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Hannes Hagström
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Terry T-K Huang
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Mona H Ismail
- Division of Gastroenterology, Department of Internal Medicine, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rohit Loomba
- Department of Medicine, NAFLD Research Center, La Jolla, CA, USA.,Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Veronica Miller
- University of California Berkeley, School of Public Health, Forum for Collaborative Research, Washington, DC, USA
| | - Philip N Newsome
- National Institute for Health Research Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK
| | | | - Ponsiano Ocama
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Vlad Ratziu
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitie-Salpetriere, University of Paris, Paris, France
| | - Mary Rinella
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Diana Romero
- Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Manuel Romero-Gómez
- UCM Digestive Diseases, CIBEREHD and IBIS, Virgen del Rocío University Hospital, University of Seville, Seville, Spain
| | - Jörn M Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
| | - Emmanuel A Tsochatzis
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, UK.,Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Precision Medicine, Department of Transfusion Medicine and Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yusuf Yilmaz
- Department of Gastroenterology, Marmara University School of Medicine, Istanbul, Turkey.,Liver Research Unit, Institute of Gastroenterology, Marmara University, Istanbul, Turkey
| | | | - Shira Zelber-Sagi
- University of Haifa, Faculty of Social Welfare and Health Sciences, School of Public Health, Mount Carmel, Haifa, Israel.,Department of Gastroenterology, Tel-Aviv Medical Centre, Tel-Aviv, Israel
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Mowry CJ, Alonso C, Iruarrizaga-Lejarreta M, Ortiz P, Levitsky J, Rinella M. Utility of Metabolomic Biomarkers to Identify Nonalcoholic Fatty Liver Disease in Liver Transplant Recipients. Transplant Direct 2021; 7:e784. [PMID: 34778544 PMCID: PMC8580200 DOI: 10.1097/txd.0000000000001227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 11/25/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a rising indication for liver transplantation (LT). Identification of NAFLD recurrence and those at risk for more progressive disease after LT remains elusive as the diagnosis requires biopsy, which is invasive and impractical for serial monitoring. We therefore aimed to identify metabolites in the blood associated with recurrent NAFLD that could potentially be used for detection and monitoring.
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Affiliation(s)
| | | | | | - Pablo Ortiz
- OWL Metabolomics, Bizkaia Technology Park, Derio, Spain
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University the Feinberg School of Medicine, Chicago, IL
| | - Mary Rinella
- Division of Gastroenterology and Hepatology, Northwestern University the Feinberg School of Medicine, Chicago, IL
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14
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Loomba R, Mohseni R, Lucas KJ, Gutierrez JA, Perry RG, Trotter JF, Rahimi RS, Harrison SA, Ajmera V, Wayne JD, O'Farrell M, McCulloch W, Grimmer K, Rinella M, Wai-Sun Wong V, Ratziu V, Gores GJ, Neuschwander-Tetri BA, Kemble G. TVB-2640 (FASN Inhibitor) for the Treatment of Nonalcoholic Steatohepatitis: FASCINATE-1, a Randomized, Placebo-Controlled Phase 2a Trial. Gastroenterology 2021; 161:1475-1486. [PMID: 34310978 DOI: 10.1053/j.gastro.2021.07.025] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/17/2021] [Accepted: 07/13/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Increased de novo lipogenesis creates excess intrahepatic fat and lipotoxins, propagating liver damage in nonalcoholic steatohepatitis. TVB-2640, a fatty acid synthase inhibitor, was designed to reduce excess liver fat and directly inhibit inflammatory and fibrogenic pathways. We assessed the safety and efficacy of TVB-2640 in patients with nonalcoholic steatohepatitis in the United States. METHODS 3V2640-CLIN-005 (FASCINATE-1) was a randomized, placebo-controlled, single-blind study at 10 US sites. Adults with ≥8% liver fat, assessed by magnetic resonance imaging proton density fat fraction, and evidence of liver fibrosis by magnetic resonance elastography ≥2.5 kPa or liver biopsy were eligible. Ninety-nine patients were randomized to receive placebo or 25 mg or 50 mg of TVB-2640 (orally, once-daily for 12 weeks). The primary end points of this study were safety and relative change in liver fat after treatment. RESULTS Liver fat increased in the placebo cohort by 4.5% relative to baseline; in contrast TVB-2640 reduced liver fat by 9.6% in the 25-mg cohort (n = 30; least squares mean: -15.5%; 95% confidence interval, -31.3 to -0.23; P = .053), and 28.1% in the 50-mg cohort (n = 28; least squares mean: -28.0%; 95% confidence interval, -44.5 to -11.6; P = .001). Eleven percent of patients in the placebo group achieved a ≥30% relative reduction of liver fat compared to 23% in the 25-mg group, and 61% in the 50-mg group (P < .001). Secondary analyses showed improvements of metabolic, pro-inflammatory and fibrotic markers. TVB-2640 was well tolerated; adverse events were mostly mild and balanced among the groups. CONCLUSIONS TVB-2640 significantly reduced liver fat and improved biochemical, inflammatory, and fibrotic biomarkers after 12 weeks, in a dose-dependent manner in patients with nonalcoholic steatohepatitis. ClinicalTrials.gov, Number NCT03938246.
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Affiliation(s)
- Rohit Loomba
- Nonalcoholic Fatty Liver Disease Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, California.
| | | | | | | | | | - James F Trotter
- Baylor University Medical Center, Texas Digestive Disease Consultants, Dallas, Texas
| | - Robert S Rahimi
- Baylor University Medical Center, Texas Digestive Disease Consultants, Dallas, Texas
| | | | - Veeral Ajmera
- Nonalcoholic Fatty Liver Disease Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, California
| | | | | | | | | | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Vlad Ratziu
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtriére, Institute for Cardiometabolism and Nutrition, Paris, France
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brent A Neuschwander-Tetri
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St Louis, Missouri
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15
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Abstract
Non-alcoholic fatty liver disease (NAFLD) has a global prevalence of 25% and is a leading cause of cirrhosis and hepatocellular carcinoma. NAFLD encompasses a disease continuum from steatosis with or without mild inflammation (non-alcoholic fatty liver), to non-alcoholic steatohepatitis (NASH), which is characterised by necroinflammation and faster fibrosis progression than non-alcoholic fatty liver. NAFLD has a bidirectional association with components of the metabolic syndrome, and type 2 diabetes increases the risk of cirrhosis and related complications. Although the leading causes of death in people with NAFLD are cardiovascular disease and extrahepatic malignancy, advanced liver fibrosis is a key prognostic marker for liver-related outcomes and overall mortality, and can be assessed with combinations of non-invasive tests. Patients with cirrhosis should be screened for hepatocellular carcinoma and oesophageal varices. There is currently no approved therapy for NAFLD, although several drugs are in advanced stages of development. Because of the complex pathophysiology and substantial heterogeneity of disease phenotypes, combination treatment is likely to be required for many patients with NAFLD. Healthy lifestyle and weight reduction remain crucial to the prevention and treatment of NAFLD.
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Affiliation(s)
- Elizabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, University of Queensland, Translational Research Institute, Brisbane, QLD, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Mary Rinella
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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16
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Brunt EM, Kleiner DE, Carpenter DH, Rinella M, Harrison SA, Loomba R, Younossi Z, Neuschwander-Tetri BA, Sanyal AJ. NAFLD: Reporting Histologic Findings in Clinical Practice. Hepatology 2021; 73:2028-2038. [PMID: 33111374 DOI: 10.1002/hep.31599] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/18/2020] [Accepted: 09/25/2020] [Indexed: 12/17/2022]
Abstract
The role of liver biopsy in NASH has evolved along with the increased recognition of the significance of this disease, and the unmet medical need it presents. Drug development and clinical trials are rapidly growing, as are noninvasive tests for markers of steatosis, inflammation, injury, and fibrosis. Liver biopsy evaluation remains necessary for both drug development and clinical trials as the most specific means of diagnosis and patient identification for appropriate intervention. This White Paper, sponsored by the American Association for the Study of Liver Disease NASH Task Force, is a focused review of liver biopsy evaluation in fatty liver disease in subjects with presumed NAFLD for practicing clinical hepatologists and pathologists. The goal is to provide succinct and specific means for reporting the histopathologic elements of NASH, distinguishing NASH from nonalcoholic fatty liver without steatohepatitis, and from alcohol-associated steatohepatitis when possible. The discussion includes the special situations of NASH in advanced fibrosis or cirrhosis, and in the pediatric population. Finally, there is discussion of semiquantitative methods of evaluation of lesions of "disease activity" and fibrosis. Tables are presented for scoring and a suggested model for final reporting. Figures are presented to highlight the histopathologic elements of NASH.
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Affiliation(s)
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Mary Rinella
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, University of California at San Diego, La Jolla, CA
| | - Zobair Younossi
- Inova Medicine Services, Inova Health System, Falls Church, VA
| | | | - Arun J Sanyal
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
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17
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Montano-Loza AJ, Boursier J, Sanyal AJ, Ratziu V, Rinella M, Loomba R, Dufour J, Mozaffari E, Shringarpure R, MacConell L, Granston T, Zhou H, Trylesinski A, Harrison SA, Bedossa P, Goodman Z, Younossi Z, Noureddin M, Bugianesi E, Anstee QM. A217 NONINVASIVE ASSESSMENTS TO IDENTIFY PATIENTS WITH ADVANCED FIBROSIS DUE TO NASH: SCREENED POPULATION FROM THE REGENERATE TRIAL. J Can Assoc Gastroenterol 2021. [DOI: 10.1093/jcag/gwab002.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
We explored the ability of noninvasive tests (NITs) to identify patients (pts) with advanced fibrosis due to NASH.
Methods
All screened pts from the ongoing phase 3 REGENERATE with available histology data were included. Five NITs were evaluated using established literature cutoffs to identify or exclude advanced fibrosis (values between upper and lower thresholds were considered indeterminate): Aspartate Transaminase-to-Platelet Ratio Index (APRI; ≥0.57, ≤0.84), Enhanced Liver Fibrosis (ELF; ≥7.7, <9.8), Fibrosis-4 (FIB-4; ≥1.30, <2.67), NAFLD fibrosis score (NFS; ≥−1.455, <0.676), and Transient Elastography (TE; ≥7.9 kPa, <9.6 kPa). Three testing methods applied were single NIT, 2 simultaneous NITs weighted equally (NFS+ELF, FIB-4+ELF, NFS+TE, FIB-4+TE), and 2 sequential NITs with the second test performed only if the first test was indeterminate (NFS→ELF, FIB-4→ELF, NFS→TE, FIB-4→TE).
Results
4133 pts in the REGENERATE screened population had an available biopsy (baseline liver biopsy: F0, 15.5%; F1, 27.2%; F2, 21.2%; F3, 29.6%; F4, 6.5%). Of these, 96% had FIB-4, NFS, and APRI, 41% had TE, and 28% had ELF. Single NITs with upper thresholds demonstrating strong specificity for identification of advanced fibrosis were FIB-4 (97%), NFS (94%), and APRI (86%); NITs with lower thresholds demonstrating good sensitivity for identification of early fibrosis were ELF (100%) and TE (88%). Evaluation of 2 simultaneous NITs resulted in a greater percentage of pts in the indeterminate zone. Application of 2 sequential tests improved the accuracy of identification and reduced misclassification vs 2 simultaneous tests.
Conclusions
Sequential NIT strategies may decrease liver biopsy rates while maintaining the accuracy of noninvasive diagnosis in pts with advanced fibrosis due to NASH.
Funding Agencies
Intercept Pharmaceuticals
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Affiliation(s)
- A J Montano-Loza
- Division of Gastroenterology & Liver Unit, University of Alberta, Edmonton, AB, Canada
| | | | - A J Sanyal
- Virginia Commonwealth University, Richmond, VA
| | - V Ratziu
- Sorbonne Universite, Paris, Île-de-France, France
| | - M Rinella
- Northwestern University, Chicago, IL
| | - R Loomba
- University of California San Diego, La Jolla, CA
| | - J Dufour
- University of Bern, Bern, Switzerland
| | | | | | | | - T Granston
- Intercept Pharmaceuticals Inc, New York, NY
| | - H Zhou
- Intercept Pharmaceuticals Inc, New York, NY
| | | | - S A Harrison
- Pinnacle Clinical Research Center, San Antonio, TX
| | | | | | | | - M Noureddin
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Q M Anstee
- Newcastle University, Newcastle upon Tyne, Tyne and Wear, United Kingdom
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Ratziu V, Rinella M, Beuers U, Loomba R, Anstee QM, Harrison S, Francque S, Sanyal A, Newsome PN, Younossi Z. The times they are a-changin' (for NAFLD as well). J Hepatol 2020; 73:1307-1309. [PMID: 32890593 DOI: 10.1016/j.jhep.2020.08.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Vlad Ratziu
- Sorbonne Université, Hôpital Pitié-Salpêtrière, Institute for Cardiometabolism and Nutrition (ICAN) and INSERM UMRS 1138 CRC, Paris, France
| | - Mary Rinella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Rohit Loomba
- NAFLD Research Center, University of California at San Diego, La Jolla, CA, USA
| | - Quentin M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Sven Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Arun Sanyal
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, VA, USA
| | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, UK.
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19
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Younossi ZM, Corey KE, Alkhouri N, Noureddin M, Jacobson I, Lam B, Clement S, Basu R, Gordon SC, Ravendhra N, Puri P, Rinella M, Scudera P, Singal AK, Henry L. Clinical assessment for high-risk patients with non-alcoholic fatty liver disease in primary care and diabetology practices. Aliment Pharmacol Ther 2020; 52:513-526. [PMID: 32598051 DOI: 10.1111/apt.15830] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/21/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary care practitioners (PCPs) and diabetologists are at the frontline of potentially encountering patients with NASH. Identification of those at high risk for adverse outcomes is important. AIM To provide practical guidance to providers on how to identify these patients and link them to specialty care. METHODS US members of the Global Council on NASH evaluated the evidence about NASH and non-invasive tests and developed a simple algorithm to identify high-risk NASH patients for diabetologists and primary care providers. These tools can assist frontline providers in decision-making and referral to gastroenterology/hepatology practices for additional assessments. RESULTS The presence of NASH-related advanced fibrosis is an independent predictor of adverse outcomes. These patients with NASH are considered high risk and referral to specialists is warranted. Given that staging of fibrosis requires a liver biopsy, non-invasive tests for fibrosis would be preferred. Consensus recommendation from the group is to risk-stratify patients based on metabolic risk factors using the FIB-4 as the initial non-invasive test due to its simplicity and ease of use. A FIB-4 score ≥1.3 can be used for further assessment and linkage to specialty care where additional technology to assess liver stiffness or serum fibrosis test will be available. CONCLUSION Due to the growing burden of NAFLD and NASH, PCPs and diabetologists are faced with increased patient encounters in their clinical practices necessitating referral decisions. To assist in identifying high-risk NASH patients requiring specialty care, we provide a simple and easy to use algorithm.
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20
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Patel K, Harrison SA, Elkhashab M, Trotter JF, Herring R, Rojter SE, Kayali Z, Wong VWS, Greenbloom S, Jayakumar S, Shiffman ML, Freilich B, Lawitz EJ, Gane EJ, Harting E, Xu J, Billin AN, Chung C, Djedjos CS, Subramanian GM, Myers RP, Middleton MS, Rinella M, Noureddin M. Cilofexor, a Nonsteroidal FXR Agonist, in Patients With Noncirrhotic NASH: A Phase 2 Randomized Controlled Trial. Hepatology 2020; 72:58-71. [PMID: 32115759 DOI: 10.1002/hep.31205] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/06/2020] [Accepted: 02/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS We evaluated the safety and efficacy of cilofexor (formerly GS-9674), a small-molecule nonsteroidal agonist of farnesoid X receptor, in patients with nonalcoholic steatohepatitis (NASH). APPROACH AND RESULTS In this double-blind, placebo-controlled, phase 2 trial, 140 patients with noncirrhotic NASH, diagnosed by magnetic resonance imaging-proton density fat fraction (MRI-PDFF) ≥8% and liver stiffness ≥2.5 kPa by magnetic resonance elastography (MRE) or historical liver biopsy, were randomized to receive cilofexor 100 mg (n = 56), 30 mg (n = 56), or placebo (n = 28) orally once daily for 24 weeks. MRI-PDFF, liver stiffness by MRE and transient elastography, and serum markers of fibrosis were measured at baseline and week 24. At baseline, median MRI-PDFF was 16.3% and MRE-stiffness was 3.27 kPa. At week 24, patients receiving cilofexor 100 mg had a median relative decrease in MRI-PDFF of -22.7%, compared with an increase of 1.9% in those receiving placebo (P = 0.003); the 30-mg group had a relative decrease of -1.8% (P = 0.17 vs. placebo). Declines in MRI-PDFF of ≥30% were experienced by 39% of patients receiving cilofexor 100 mg (P = 0.011 vs. placebo), 14% of those receiving cilofexor 30 mg (P = 0.87 vs. placebo), and 13% of those receiving placebo. Serum gamma-glutamyltransferase, C4, and primary bile acids decreased significantly at week 24 in both cilofexor treatment groups, whereas significant changes in Enhanced Liver Fibrosis scores and liver stiffness were not observed. Cilofexor was generally well-tolerated. Moderate to severe pruritus was more common in patients receiving cilofexor 100 mg (14%) than in those receiving cilofexor 30 mg (4%) and placebo (4%). CONCLUSIONS Cilofexor for 24 weeks was well-tolerated and provided significant reductions in hepatic steatosis, liver biochemistry, and serum bile acids in patients with NASH. ClinicalTrials.gov No. NCT02854605.
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Affiliation(s)
| | | | | | | | | | | | | | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | | | | | | | - Eric J Lawitz
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, TX
| | - Edward J Gane
- Liver Unit, Auckland City Hospital, Auckland, New Zealand
| | | | - Jun Xu
- Gilead Sciences, Inc., Foster City, CA
| | | | | | | | | | | | | | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, IL
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21
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Eslam M, Sanyal AJ, George J, Neuschwander-Tetri B, Tiribelli C, Kleiner DE, Brunt E, Bugianesi E, Yki-Järvinen H, Grønbæk H, Cortez-Pinto H, George J, Fan J, Valenti L, Abdelmalek M, Romero-Gomez M, Rinella M, Arrese M, Eslam M, Bedossa P, Newsome PN, Anstee QM, Jalan R, Bataller R, Loomba R, Sookoian S, Sarin SK, Harrison S, Kawaguchi T, Wong VWS, Ratziu V, Yilmaz Y, Younossi Z. MAFLD: A Consensus-Driven Proposed Nomenclature for Metabolic Associated Fatty Liver Disease. Gastroenterology 2020; 158:1999-2014.e1. [PMID: 32044314 DOI: 10.1053/j.gastro.2019.11.312] [Citation(s) in RCA: 1586] [Impact Index Per Article: 396.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/27/2019] [Accepted: 11/05/2019] [Indexed: 12/02/2022]
Abstract
Fatty liver associated with metabolic dysfunction is common, affects a quarter of the population, and has no approved drug therapy. Although pharmacotherapies are in development, response rates appear modest. The heterogeneous pathogenesis of metabolic fatty liver diseases and inaccuracies in terminology and definitions necessitate a reappraisal of nomenclature to inform clinical trial design and drug development. A group of experts sought to integrate current understanding of patient heterogeneity captured under the acronym nonalcoholic fatty liver disease (NAFLD) and provide suggestions on terminology that more accurately reflects pathogenesis and can help in patient stratification for management. Experts reached consensus that NAFLD does not reflect current knowledge, and metabolic (dysfunction) associated fatty liver disease "MAFLD" was suggested as a more appropriate overarching term. This opens the door for efforts from the research community to update the nomenclature and subphenotype the disease to accelerate the translational path to new treatments.
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Affiliation(s)
- Mohammed Eslam
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, NSW, Australia.
| | - Arun J Sanyal
- Virginia Commonwealth University School of Medicine, Richmond, Virginia.
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, NSW, Australia.
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22
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Cotter TG, Rinella M. Nonalcoholic Fatty Liver Disease 2020: The State of the Disease. Gastroenterology 2020; 158:1851-1864. [PMID: 32061595 DOI: 10.1053/j.gastro.2020.01.052] [Citation(s) in RCA: 620] [Impact Index Per Article: 155.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/09/2020] [Accepted: 01/11/2020] [Indexed: 02/07/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease, with a worldwide prevalence of 25%. In the United States, NAFLD and its subtype, nonalcoholic steatohepatitis, affect 30% and 5% of the population, respectively. Considering the ongoing obesity epidemic beginning in childhood, the rise in diabetes, and other factors, the prevalence of NAFLD along with the proportion of those with advanced liver disease is projected to continue to increase. This will have an important impact on public health reflected in health care costs, including impact on the need for liver transplantation, for which nonalcoholic steatohepatitis is already close to becoming the most common indication. NAFLD patients with evidence of nonalcoholic steatohepatitis and advanced fibrosis are at markedly increased risk of adverse outcomes, including overall mortality, and liver-specific morbidity and mortality, respectively. Identification of this cohort of NAFLD patients is paramount, given the associated poorer outcomes, in order to target resources to those who need it most. Various noninvasive tools have been developed in this regard. This review provides an update on the epidemiology, clinical and prognostic features, and diagnostic approach to patients with NAFLD.
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Affiliation(s)
- Thomas G Cotter
- Division of Gastroenterology and Hepatology, The University of Chicago Medicine, Chicago, Illinois
| | - Mary Rinella
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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23
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Chalasani N, Abdelmalek MF, Garcia-Tsao G, Vuppalanchi R, Alkhouri N, Rinella M, Noureddin M, Pyko M, Shiffman M, Sanyal A, Allgood A, Shlevin H, Horton R, Zomer E, Irish W, Goodman Z, Harrison SA, Traber PG, Balart L, Borg B, Chalasani N, Charlton M, Conjeevaram H, Fuchs M, Ghalib R, Gholam P, Halegoua-De Marzio D, Harrison S, Jue C, Kemmer N, Kowdley K, Lai M, Lawitz E, Loomba R, Noureddin M, Paredes A, Rinella M, Rockey D, Rodriguez M, Rubin R, Ryan M, Sanyal A, Scanga A, Sepe T, Shiffman M, Shiffman M, Tetri B, Thuluvath P, Torres D, Vierling J, Wattacheril J, Weiland A, Zogg D. Effects of Belapectin, an Inhibitor of Galectin-3, in Patients With Nonalcoholic Steatohepatitis With Cirrhosis and Portal Hypertension. Gastroenterology 2020; 158:1334-1345.e5. [PMID: 31812510 DOI: 10.1053/j.gastro.2019.11.296] [Citation(s) in RCA: 183] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Increased levels of galectin 3 have been associated with nonalcoholic steatohepatitis (NASH) and contribute to toxin-induced liver fibrosis in mice. GR-MD-02 (belapectin) is an inhibitor of galectin 3 that reduces liver fibrosis and portal hypertension in rats and was safe and well tolerated in phase 1 studies. We performed a phase 2b, randomized trial of the safety and efficacy of GR-MD-02 in patients with NASH, cirrhosis, and portal hypertension. METHODS Patients with NASH, cirrhosis, and portal hypertension (hepatic venous pressure gradient [HVPG] ≥ 6 mm Hg) from 36 centers were randomly assigned, in a double-blind manner, to groups that received biweekly infusions of belapectin 2 mg/kg (n = 54), 8 mg/kg (n = 54), or placebo (n = 54) for 52 weeks. The primary endpoint was change in HVPG (Δ HVPG) at the end of the 52-week period compared with baseline. Secondary endpoints included changes in liver histology and development of liver-related outcomes. RESULTS We found no significant difference in ΔHVPG between the 2 mg/kg belapectin group and placebo group (-0.28 mm HG vs 0.10 mm HG, P = 1.0) or between the 8 mg/kg belapectin and placebo group (-0.25 mm HG vs 0.10 mm HG, P = 1.0). Belapectin had no significant effect on fibrosis or nonalcoholic fatty liver disease activity score, and liver-related outcomes did not differ significantly among groups. In an analysis of a subgroup of patients without esophageal varices at baseline (n = 81), 2 mg/kg belapectin was associated with a reduction in HVPG at 52 weeks compared with baseline (P = .02) and reduced development of new varices (P = .03). Belapectin (2 mg/kg) was well tolerated and produced no safety signals. CONCLUSIONS In a phase 2b study of 162 patients with NASH, cirrhosis, and portal hypertension, 1 year of biweekly infusion of belapectin was safe but not associated with significant reduction in HVPG or fibrosis compared with placebo. However, in a subgroup analysis of patients without esophageal varices, 2 mg/kg belapectin did reduce HVPG and development of varices. ClinicalTrials.gov number: NCT02462967.
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Affiliation(s)
- Naga Chalasani
- Indiana University School of Medicine, Indianapolis, Indiana.
| | | | | | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | | | - Maxmillan Pyko
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Arun Sanyal
- Virginia Commonwealth University, Richmond, Virginia
| | | | | | - Rex Horton
- Galectin Therapeutics Alpharetta, Georgia
| | | | - William Irish
- East Carolina University, Greenville, South Carolina
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Pedrosa M, Seyedkazemi S, Francque S, Sanyal A, Rinella M, Charlton M, Loomba R, Ratziu V, Kochuparampil J, Fischer L, Vaidyanathan S, Anstee QM. A randomized, double-blind, multicenter, phase 2b study to evaluate the safety and efficacy of a combination of tropifexor and cenicriviroc in patients with nonalcoholic steatohepatitis and liver fibrosis: Study design of the TANDEM trial. Contemp Clin Trials 2020; 88:105889. [DOI: 10.1016/j.cct.2019.105889] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/08/2019] [Accepted: 11/09/2019] [Indexed: 12/12/2022]
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Younossi ZM, Ratziu V, Loomba R, Rinella M, Anstee QM, Goodman Z, Bedossa P, Geier A, Beckebaum S, Newsome PN, Sheridan D, Sheikh MY, Trotter J, Knapple W, Lawitz E, Abdelmalek MF, Kowdley KV, Montano-Loza AJ, Boursier J, Mathurin P, Bugianesi E, Mazzella G, Olveira A, Cortez-Pinto H, Graupera I, Orr D, Gluud LL, Dufour JF, Shapiro D, Campagna J, Zaru L, MacConell L, Shringarpure R, Harrison S, Sanyal AJ. Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial. Lancet 2019. [PMID: 31813633 DOI: 10.3410/f.725273573.793504763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is a common type of chronic liver disease that can lead to cirrhosis. Obeticholic acid, a farnesoid X receptor agonist, has been shown to improve the histological features of NASH. Here we report results from a planned interim analysis of an ongoing, phase 3 study of obeticholic acid for NASH. METHODS In this multicentre, randomised, double-blind, placebo-controlled study, adult patients with definite NASH, non-alcoholic fatty liver disease (NAFLD) activity score of at least 4, and fibrosis stages F2-F3, or F1 with at least one accompanying comorbidity, were randomly assigned using an interactive web response system in a 1:1:1 ratio to receive oral placebo, obeticholic acid 10 mg, or obeticholic acid 25 mg daily. Patients were excluded if cirrhosis, other chronic liver disease, elevated alcohol consumption, or confounding conditions were present. The primary endpoints for the month-18 interim analysis were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of fibrosis, with the study considered successful if either primary endpoint was met. Primary analyses were done by intention to treat, in patients with fibrosis stage F2-F3 who received at least one dose of treatment and reached, or would have reached, the month 18 visit by the prespecified interim analysis cutoff date. The study also evaluated other histological and biochemical markers of NASH and fibrosis, and safety. This study is ongoing, and registered with ClinicalTrials.gov, NCT02548351, and EudraCT, 20150-025601-6. FINDINGS Between Dec 9, 2015, and Oct 26, 2018, 1968 patients with stage F1-F3 fibrosis were enrolled and received at least one dose of study treatment; 931 patients with stage F2-F3 fibrosis were included in the primary analysis (311 in the placebo group, 312 in the obeticholic acid 10 mg group, and 308 in the obeticholic acid 25 mg group). The fibrosis improvement endpoint was achieved by 37 (12%) patients in the placebo group, 55 (18%) in the obeticholic acid 10 mg group (p=0·045), and 71 (23%) in the obeticholic acid 25 mg group (p=0·0002). The NASH resolution endpoint was not met (25 [8%] patients in the placebo group, 35 [11%] in the obeticholic acid 10 mg group [p=0·18], and 36 [12%] in the obeticholic acid 25 mg group [p=0·13]). In the safety population (1968 patients with fibrosis stages F1-F3), the most common adverse event was pruritus (123 [19%] in the placebo group, 183 [28%] in the obeticholic acid 10 mg group, and 336 [51%] in the obeticholic acid 25 mg group); incidence was generally mild to moderate in severity. The overall safety profile was similar to that in previous studies, and incidence of serious adverse events was similar across treatment groups (75 [11%] patients in the placebo group, 72 [11%] in the obeticholic acid 10 mg group, and 93 [14%] in the obeticholic acid 25 mg group). INTERPRETATION Obeticholic acid 25 mg significantly improved fibrosis and key components of NASH disease activity among patients with NASH. The results from this planned interim analysis show clinically significant histological improvement that is reasonably likely to predict clinical benefit. This study is ongoing to assess clinical outcomes. FUNDING Intercept Pharmaceuticals.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Vlad Ratziu
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Institute for Cardiometabolism and Nutrition, Paris, France
| | - Rohit Loomba
- NAFLD Rsearch Center, University of California San Diego, San Diego, CA, USA
| | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Quentin M Anstee
- The Newcastle Liver Research Group, Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Zachary Goodman
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Pierre Bedossa
- Service d'Anatomie Pathologique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Andreas Geier
- Department of Hepatology, University of Wuerzburg, Wuerzburg, Germany
| | | | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Sheridan
- Institute of Translational & Stratified Medicine, University of Plymouth and University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - James Trotter
- Baylor Health, Liver Consultants of Texas, Dallas, TX, USA
| | | | - Eric Lawitz
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University Medical Center, Durham, NC, USA
| | | | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Jerome Boursier
- HIFIH Laboratory, UPRES EA3859, SFR 4208, Angers University, Angers, France; Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | | | | | - Giuseppe Mazzella
- Dipartimento di Scienze Mediche e Chirurgiche, University of Bologna, Bologna, Italy
| | - Antonio Olveira
- Department of Gastroenterology, Hospital Universitario La Paz, Madrid, Spain
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Isabel Graupera
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain; Institut D'investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - David Orr
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Lise Lotte Gluud
- The Gastrounit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jean-Francois Dufour
- University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Luna Zaru
- Intercept Pharmaceuticals, San Diego, CA, USA
| | | | | | | | - Arun J Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA.
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Younossi ZM, Ratziu V, Loomba R, Rinella M, Anstee QM, Goodman Z, Bedossa P, Geier A, Beckebaum S, Newsome PN, Sheridan D, Sheikh MY, Trotter J, Knapple W, Lawitz E, Abdelmalek MF, Kowdley KV, Montano-Loza AJ, Boursier J, Mathurin P, Bugianesi E, Mazzella G, Olveira A, Cortez-Pinto H, Graupera I, Orr D, Gluud LL, Dufour JF, Shapiro D, Campagna J, Zaru L, MacConell L, Shringarpure R, Harrison S, Sanyal AJ. Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial. Lancet 2019; 394:2184-2196. [PMID: 31813633 DOI: 10.1016/s0140-6736(19)33041-7] [Citation(s) in RCA: 716] [Impact Index Per Article: 143.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is a common type of chronic liver disease that can lead to cirrhosis. Obeticholic acid, a farnesoid X receptor agonist, has been shown to improve the histological features of NASH. Here we report results from a planned interim analysis of an ongoing, phase 3 study of obeticholic acid for NASH. METHODS In this multicentre, randomised, double-blind, placebo-controlled study, adult patients with definite NASH, non-alcoholic fatty liver disease (NAFLD) activity score of at least 4, and fibrosis stages F2-F3, or F1 with at least one accompanying comorbidity, were randomly assigned using an interactive web response system in a 1:1:1 ratio to receive oral placebo, obeticholic acid 10 mg, or obeticholic acid 25 mg daily. Patients were excluded if cirrhosis, other chronic liver disease, elevated alcohol consumption, or confounding conditions were present. The primary endpoints for the month-18 interim analysis were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of fibrosis, with the study considered successful if either primary endpoint was met. Primary analyses were done by intention to treat, in patients with fibrosis stage F2-F3 who received at least one dose of treatment and reached, or would have reached, the month 18 visit by the prespecified interim analysis cutoff date. The study also evaluated other histological and biochemical markers of NASH and fibrosis, and safety. This study is ongoing, and registered with ClinicalTrials.gov, NCT02548351, and EudraCT, 20150-025601-6. FINDINGS Between Dec 9, 2015, and Oct 26, 2018, 1968 patients with stage F1-F3 fibrosis were enrolled and received at least one dose of study treatment; 931 patients with stage F2-F3 fibrosis were included in the primary analysis (311 in the placebo group, 312 in the obeticholic acid 10 mg group, and 308 in the obeticholic acid 25 mg group). The fibrosis improvement endpoint was achieved by 37 (12%) patients in the placebo group, 55 (18%) in the obeticholic acid 10 mg group (p=0·045), and 71 (23%) in the obeticholic acid 25 mg group (p=0·0002). The NASH resolution endpoint was not met (25 [8%] patients in the placebo group, 35 [11%] in the obeticholic acid 10 mg group [p=0·18], and 36 [12%] in the obeticholic acid 25 mg group [p=0·13]). In the safety population (1968 patients with fibrosis stages F1-F3), the most common adverse event was pruritus (123 [19%] in the placebo group, 183 [28%] in the obeticholic acid 10 mg group, and 336 [51%] in the obeticholic acid 25 mg group); incidence was generally mild to moderate in severity. The overall safety profile was similar to that in previous studies, and incidence of serious adverse events was similar across treatment groups (75 [11%] patients in the placebo group, 72 [11%] in the obeticholic acid 10 mg group, and 93 [14%] in the obeticholic acid 25 mg group). INTERPRETATION Obeticholic acid 25 mg significantly improved fibrosis and key components of NASH disease activity among patients with NASH. The results from this planned interim analysis show clinically significant histological improvement that is reasonably likely to predict clinical benefit. This study is ongoing to assess clinical outcomes. FUNDING Intercept Pharmaceuticals.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Vlad Ratziu
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Institute for Cardiometabolism and Nutrition, Paris, France
| | - Rohit Loomba
- NAFLD Rsearch Center, University of California San Diego, San Diego, CA, USA
| | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Quentin M Anstee
- The Newcastle Liver Research Group, Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Zachary Goodman
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Pierre Bedossa
- Service d'Anatomie Pathologique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Andreas Geier
- Department of Hepatology, University of Wuerzburg, Wuerzburg, Germany
| | | | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Sheridan
- Institute of Translational & Stratified Medicine, University of Plymouth and University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - James Trotter
- Baylor Health, Liver Consultants of Texas, Dallas, TX, USA
| | | | - Eric Lawitz
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University Medical Center, Durham, NC, USA
| | | | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Jerome Boursier
- HIFIH Laboratory, UPRES EA3859, SFR 4208, Angers University, Angers, France; Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | | | | | - Giuseppe Mazzella
- Dipartimento di Scienze Mediche e Chirurgiche, University of Bologna, Bologna, Italy
| | - Antonio Olveira
- Department of Gastroenterology, Hospital Universitario La Paz, Madrid, Spain
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Isabel Graupera
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain; Institut D'investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - David Orr
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Lise Lotte Gluud
- The Gastrounit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jean-Francois Dufour
- University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Luna Zaru
- Intercept Pharmaceuticals, San Diego, CA, USA
| | | | | | | | - Arun J Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA.
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Samji NS, Verma R, Keri KC, Singal AK, Ahmed A, Rinella M, Bernstein D, Abdelmalek MF, Satapathy SK. Liver Transplantation for Nonalcoholic Steatohepatitis: Pathophysiology of Recurrence and Clinical Challenges. Dig Dis Sci 2019; 64:3413-3430. [PMID: 31312990 DOI: 10.1007/s10620-019-05716-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 07/02/2019] [Indexed: 02/08/2023]
Abstract
Nonalcoholic steatohepatitis is the fastest-growing indication for the liver transplant and a leading cause of hepatocellular carcinoma among patients listed for liver transplantation in the USA. Post-transplant nonalcoholic hepatic steatosis and steatohepatitis are frequent complications of liver transplantation. Nonalcoholic steatohepatitis poses a significant challenge in both pre- and post-transplant period due to its association with metabolic syndrome, coronary artery disease, chronic kidney disease, and obstructive sleep apnea. While optimal therapy is not yet available in the post-liver transplant setting, lifestyle interventions continue to remain as the mainstay of therapy for post-transplant nonalcoholic steatohepatitis. Early recognition with protocol biopsies and noninvasive modalities, along with modification of known risk factors, are the most effective methods to curtail the progression of nonalcoholic steatohepatitis in the absence of FDA-approved pharmacologic therapy.
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Affiliation(s)
- Naga Swetha Samji
- Tennova Cleveland Hospital, 2305 Chambliss Ave NW, Cleveland, TN, 37311, USA
| | - Rajanshu Verma
- Division of Transplant Surgery, Department of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | | | - Ashwani K Singal
- University of South Dakota Sanford School of Medicine, Avera Transplant Institute, S. Cliff Ave, Sioux Falls, SD, 57105, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Mary Rinella
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - David Bernstein
- Division of Hepatology and Sandra Atlas Bass Center for Liver Diseases, Northwell Health, Manhasset, NY, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology/Hepatology, Duke University, 40 Duke Medicine Cir, Durham, NC, USA
| | - Sanjaya K Satapathy
- Division of Hepatology at Sandra Atlas Bass Center for Liver Diseases and Transplantation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 400 Community Drive, Manhasset, NY, 11030, USA.
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Cheung A, Neuschwander-Tetri BA, Kleiner DE, Schabel E, Rinella M, Harrison S, Ratziu V, Sanyal AJ, Loomba R, Jeannin Megnien S, Torstenson R, Miller V. Defining Improvement in Nonalcoholic Steatohepatitis for Treatment Trial Endpoints: Recommendations From the Liver Forum. Hepatology 2019; 70:1841-1855. [PMID: 31034092 DOI: 10.1002/hep.30672] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 04/16/2019] [Indexed: 12/20/2022]
Abstract
Identifying effective therapies for nonalcoholic steatohepatitis (NASH) with fibrosis is a pressing challenge, with 1%-2% of the population in developed nations at risk of developing NASH cirrhosis and its complications. The design of NASH clinical therapeutic trials is hampered by the long period of minimally symptomatic disease that typically precedes the development of decompensated cirrhosis and the accompanying uncertainties regarding the best precirrhotic trial endpoints that reliably reflect a subsequent reduction in liver-related morbidity and mortality. The Liver Forum is a multistakeholder organization comprised of academic, industry, and regulatory experts working from a regulatory science perspective to identify barriers, prioritize research, and identify solutions to accelerate therapeutic development for NASH. Past work of The Liver Forum has focused on recommendations for disease definitions and baseline parameters to be implemented in clinical trials that are designed to assess disease status and prevent progression to cirrhosis, liver transplantation, hepatocellular carcinoma, and death. The purpose of this summary is to review currently available clinical data to identify parameters that change in parallel with liver histology and are likely to reflect clinically meaningful reductions in the risk of developing cirrhosis and its complications. We review available data on exploratory histological, blood-based, and imaging pharmacodynamic biomarkers that may reflect meaningful treatment responses and provide recommendations regarding measurements to be considered in phase 2 and 3 trials as well as during postmarketing monitoring trials.
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Affiliation(s)
- Amanda Cheung
- Stanford Hospital and Clinics, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | | | | | - Elmer Schabel
- Gastroenterology & Hepatology Unit, Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Germany/European Medicines Agency, London, United Kingdom
| | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Vlad Ratziu
- Department of Hepatology and Gastroenterology, Hôpital Pitié Salpêtrière et Université Pierre et Marie Curie, Paris, France
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA
| | - Rohit Loomba
- Division of Gastroenterology, University of California San Diego School of Medicine, San Diego, CA
| | | | | | - Veronica Miller
- Forum for Collaborative Research, University of California School of Public Health, Berkeley, CA
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Ratziu V, Sanyal AJ, Loomba R, Rinella M, Harrison S, Anstee QM, Goodman Z, Bedossa P, MacConell L, Shringarpure R, Shah A, Younossi Z. REGENERATE: Design of a pivotal, randomised, phase 3 study evaluating the safety and efficacy of obeticholic acid in patients with fibrosis due to nonalcoholic steatohepatitis. Contemp Clin Trials 2019; 84:105803. [PMID: 31260793 DOI: 10.1016/j.cct.2019.06.017] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/18/2019] [Accepted: 06/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nonalcoholic steatohepatitis (NASH) is a chronic, progressive, and severe form of nonalcoholic fatty liver disease. In FLINT, obeticholic acid (OCA) treatment improved multiple histological NASH features. The design and endpoints of REGENERATE, an ongoing phase 3 study, further evaluate OCA treatment in patients with fibrosis due to NASH. AIMS The Month 18 interim analysis assesses the effect of OCA on liver histology, defined as improvement of fibrosis by ≥1 stage with no worsening of NASH or resolution of NASH with no worsening of fibrosis. The end-of-study analyses evaluate the effect of OCA on mortality, liver-related clinical outcomes, and long-term safety. METHODS REGENERATE is a pivotal, long-term study of ~2400 patients with NASH, including ~2100 patients with stage 2 or 3 liver fibrosis. Additionally, ~300 patients with stage 1 fibrosis and ≥1 accompanying comorbidity are included to gather information on the safety of OCA and liver disease progression. Patients are randomised 1:1:1 to receive placebo or OCA (10 or 25 mg). A liver biopsy evaluation occurs at screening, Months 18 and 48, and end of study. The duration of the study is dependent upon accrual of a predetermined number of clinical outcome events. CONCLUSIONS REGENERATE is designed in conjunction with regulatory authorities to support regulatory approvals in NASH. This robust phase 3 study assesses the effect of OCA on liver histology as a surrogate for transplant-free survival and liver-related outcomes, including progression to cirrhosis and mortality, and will ultimately assess clinical benefit through specific evaluation of these outcomes. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov with the identifier NCT02548351.
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Affiliation(s)
- Vlad Ratziu
- Sorbonne Université, Hôpital Pitié - Salpêtrière, 91-105 Boulevard de l'Hôpital, 75013 Paris, France.
| | - Arun J Sanyal
- Department of Internal Medicine, Virginia Commonwealth University, 1101 E Marshall St, Richmond, VA, USA
| | - Rohit Loomba
- University of California, San Diego, 9500 Gilman Dr, La Jolla, CA, USA
| | - Mary Rinella
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, 676 N Saint Clair St, Chicago, IL, USA
| | - Stephen Harrison
- Pinnacle Clinical Research Center, 5109 Medical Dr. Ste 200, San Antonio, TX 78229, United States
| | - Quentin M Anstee
- Liver Research Group, Institute of Cellular Medicine, The Medical School, Newcastle University, Framlington Place, Newcastle-upon-Tyne, NE2 4HH, UK
| | - Zachary Goodman
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Claude Moore Health Education and Research Building, 3300 Gallows Rd, Falls Church, VA, USA
| | - Pierre Bedossa
- Service d'Anatomie Pathologique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1149-CRI, Université Denis Diderot Paris-7, 46 rue Henri Huchard, 75018 Clichy, France
| | - Leigh MacConell
- Intercept Pharmaceuticals, 4760 Eastgate Mall, San Diego, CA, USA
| | | | - Amrik Shah
- Intercept Pharmaceuticals, 4760 Eastgate Mall, San Diego, CA, USA
| | - Zobair Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Claude Moore Health Education and Research Building, 3300 Gallows Rd, Falls Church, VA, USA
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Whitsett M, Wilcox J, Yang A, Zhao L, Rinella M, VanWagner LB. Atrial fibrillation is highly prevalent yet undertreated in patients with biopsy-proven nonalcoholic steatohepatitis. Liver Int 2019; 39:933-940. [PMID: 30536602 PMCID: PMC6483865 DOI: 10.1111/liv.14018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/21/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Nonalcoholic steatohepatitis (NASH) is associated with increased cardiovascular disease. Atrial fibrillation is a prominent risk marker for underlying cardiovascular disease with a prevalence of 2% in patients <65 years old. Atrial fibrillation prevalence in NASH is unknown. We sought to assess the prevalence and impact of atrial fibrillation on healthcare utilization in NASH. METHODS Patients were identified from a tertiary care centre Electronic Database from 2002 to 2015. International Classification of Diseases 9 (ICD9) codes identified comorbidities and atrial fibrillation. Descriptive statistics were used to compare characteristics between patients with NASH with and without atrial fibrillation. RESULTS Of 9108 patients with ICD9 diagnosis of NASH, 215 (2.3%, mean age 57 years, 32% male) had biopsy-proven NASH. Atrial fibrillation prevalence was 4.6%. Patients with NASH and atrial fibrillation had a higher prevalence of heart failure (54.5% vs 8.8%, P < 0.001) and cerebrovascular (27.3% vs 2.0%, P < 0.001) or vascular disease (54.5% vs 13.2%, P = 0.002), compared to NASH without atrial fibrillation. All patients with NASH and atrial fibrillation had a CHA2DS2VASc score ≥2 indicating high stroke risk and need for anticoagulation. Eight of 10 patients were eligible for anticoagulation and 5 of 8 (62.5%) received appropriate therapy. CONCLUSION Atrial fibrillation prevalence is two-fold higher in patients with NASH compared to the general population. Patients with NASH have a high risk of stroke; however, many do not receive appropriate guideline-directed therapy. Future studies are needed to identify whether guideline-based management of atrial fibrillation in NASH reduces cardiovascular morbidity and mortality.
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Affiliation(s)
| | - Jane Wilcox
- Divison of Cardiology, Northwestern University Feinberg School of Medicine
| | - Amy Yang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Lihui Zhao
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine
| | - Mary Rinella
- Divison of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
| | - Lisa B. VanWagner
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine,Divison of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine
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Sarkar M, VanWagner LB, Terry JG, Carr JJ, Rinella M, Schreiner PJ, Lewis CE, Terrault N. Sex Hormone-Binding Globulin Levels in Young Men Are Associated With Nonalcoholic Fatty Liver Disease in Midlife. Am J Gastroenterol 2019; 114:758-763. [PMID: 30730350 PMCID: PMC6599461 DOI: 10.14309/ajg.0000000000000138] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cross-sectional data note lower levels of testosterone and sex hormone-binding globulin (SHBG) levels in men with nonalcoholic fatty liver disease (NAFLD). Whether sex hormone levels in young men are predictive of later risk of NAFLD is not known. METHODS Among men in the prospective population-based multicenter Coronary Artery Risk Development in Young Adults study (mean age 50; n = 837), we assessed whether testosterone and SHBG levels measured at study year 10 (median age 35 years) were associated with prevalent NAFLD at study year 25. NAFLD was defined using noncontrast abdominal computed tomography (CT) scan after excluding other causes of hepatic steatosis. The association of testosterone and SHBG with prevalent NAFLD was assessed by logistic regression. RESULTS Total testosterone levels in young men were inversely associated with subsequent prevalent NAFLD on unadjusted analysis (odds ratio [OR] 0.64, 95% confidence interval 0.53-0.7, P < 0.001), although no longer significant after adjustment for year 10 metabolic covariates as well as change in metabolic covariates from years 10 to 25 (OR 0.99, 95% confidence interval 0.76-1.27). In contrast, there was a significant inverse association of SHBG with prevalent NAFLD, independent of testosterone and metabolic covariates (OR 0.68, OR 0.51-0.92, P = 0.013). On formal mediation testing, visceral adiposity was found to explain ∼41.0% (95% confidence interval 27%-73%) of the association of lower SHBG with prevalent NAFLD. CONCLUSIONS Lower levels of SHBG in young men are associated with increase in prevalent NAFLD in middle age, independent of comprehensive metabolic risk factors. SHBG may provide a novel marker of NAFLD risk in young men.
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Affiliation(s)
- Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Lisa B. VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - James G. Terry
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J. Jeffrey Carr
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mary Rinella
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Pamela J. Schreiner
- Divisionof Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cora E. Lewis
- Division of Preventive Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Norah Terrault
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
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Affiliation(s)
- N Mazumder
- Division of Hepatology, Department of Medicine Feinberg
School of Medicine, Northwestern University, Chicago, Illinois
| | - M Rinella
- Division of Hepatology, Department of Medicine Feinberg
School of Medicine, Northwestern University, Chicago, Illinois
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Zemel MB, Kolterman O, Rinella M, Vuppalanchi R, Flores O, Barritt AS, Siddiqui M, Chalasani N. Randomized Controlled Trial of a Leucine-Metformin-Sildenafil Combination (NS-0200) on Weight and Metabolic Parameters. Obesity (Silver Spring) 2019; 27:59-67. [PMID: 30569637 DOI: 10.1002/oby.22346] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/20/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Leucine was previously demonstrated to allosterically activate mammalian sirtuin 1 and synergize with other sirtuin 1/AMP-activated protein kinase/nitric oxide pathway activators to modulate energy metabolism. The objective of this study was to evaluate the effects of a triple combination of leucine, metformin, and sildenafil (NS-0200) on body weight and obesity comorbidities in a phase 2 randomized trial. METHODS A total of 91 subjects with obesity were randomized to placebo, low dose (1.1 g leucine/0.5 g metformin/0.5 mg sildenafil), or high dose (1.1 g leucine/0.5 g metformin/1.0 mg sildenafil) twice daily for 16 weeks. Seventy subjects completed the trial and met all a priori compliance criteria. Hypertensive (n = 35) and hypertriglyceridemic (n = 22) subcohorts were also analyzed. RESULTS NS-0200 dose-responsively reduced weight; high dose reduced weight by 2.4 and 5.0 kg in the full and high-triglyceride cohorts, respectively (P < 0.0001). High-dose NS-0200 treatment also decreased blood pressure (-5.5 mm Hg diastolic pressure; P = 0.011), with greater effects among hypertensive subjects. NS-0200 also significantly reduced triglycerides and hemoglobin A1c. Significant improvement in ≥ 2 comorbidities was exhibited by 54% of subjects in the high-dose arm versus 5% of placebo subjects (P = 0.0009). Treatment-emergent adverse events did not significantly differ among groups. CONCLUSIONS These data support further study of NS-0200 as a therapy for obesity and associated comorbidities.
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Affiliation(s)
| | | | - Mary Rinella
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Illinois, USA
| | | | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Mohammad Siddiqui
- Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Illinois, USA
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Chalasani N, Vuppalanchi R, Rinella M, Middleton MS, Siddiqui MS, Barritt AS, Kolterman O, Flores O, Alonso C, Iruarrizaga‐Lejarreta M, Gil‐Redondo R, Sirlin CB, Zemel MB. Randomised clinical trial: a leucine-metformin-sildenafil combination (NS-0200) vs placebo in patients with non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2018; 47:1639-1651. [PMID: 29696666 PMCID: PMC6001629 DOI: 10.1111/apt.14674] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 02/24/2018] [Accepted: 03/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sirtuin 1 (Sirt1) is suppressed in non-alcoholic fatty liver disease (NAFLD), while its' stimulation or overexpression results in reduced disease severity in pre-clinical NAFLD models. Leucine allosterically activates Sirt1 and synergise with other Sirt/AMPK/NO pathway activators. We developed a triple combination of leucine, metformin and sildenafil (NS-0200), which was effective in a mouse model of non-alcoholic steatohepatitis (NASH). AIM To report the results from a Phase 2, randomised clinical trial of of NS-0200 in 91 subjects with NAFLD (liver fat ≥15% by magnetic resonance imaging-proton-density fat fraction (MRI-PDFF)). METHODS Subjects were randomised to placebo, low-dose (1.1 g leucine/0.5 g metformin/0.5 mg sildenafil) or high-dose NS-0200 (1.1 g leucine/0.5 g metformin/1.0 mg sildenafil) b.d. for 16 weeks; change in hepatic fat was assessed via MRI-PDFF, and lipid metabolism was assessed via changes in the lipidomic signature. Seventy subjects completed the trial and met a priori compliance criteria. Analyses were conducted on the full cohort and on those with alanine aminotransferase (ALT) values above median (50 U/L; n = 35). RESULTS In the full cohort, active treatments did not separate from placebo. High dose NS-0200 reduced hepatic fat by 15.7% (relative change from baseline) in the high ALT group (P < 0.005) while low dose NS-0200 and placebo did not significantly change hepatic fat. Lipidomic analysis showed dose-responsive treatment effects in both overall and high ALT cohorts, with significant decreases in metabolically active lipids and up-regulation of fatty acid oxidation. CONCLUSION These data support further evaluation of high-dose NS-0200 for treating NASH, especially in those with elevated ALT (NCT 02546609).
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Affiliation(s)
- N. Chalasani
- Indiana University School of MedicineIndianapolisINUSA
| | | | | | | | | | | | | | | | | | | | | | - C. B. Sirlin
- University of California at San DiegoSan DiegoCAUSA
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Pavone C, Abbadessa D, Tarantino M, Oxenius I, Laganà A, Lupo A, Rinella M. Associating Serenoa Repens, Urtica Dioica and Pinus Pinaster. Safety and Efficacy in the Treatment of Lower Urinary Tract Symptoms. Prospective Study on 320 Patients. Urologia 2018. [DOI: 10.1177/039156031007700108] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Serenoa repens (saw palmetto) has been employed for the treatment of lower urinary tract symptoms (LUTS) for several years. Its mechanism of action is believed to be due to antiandrogenic, antiproliferative and antinflammatory properties. An association of Serenoa with the nettle “Urtica dioica” showing antiproliferative activity and the pine “Pinus pinaster” derivative, showing antinflammatory action, has been proposed in recent years. Such an action is hoped to act not only by reducing LUTS but also by preventing the development of prostate cancer. Material and Methods During the years 2007 and 2008, 320 patients suffering from LUTS were treated with an association of Serenoa repens 320 mg, Urtica dioica 120 mg and Pinus pinaster 5 mg, named IPBTRE. This treatment was administered to all patients for a minimal duration of 30 days to a maximum of a year, either alone or in association with antibiotics or alpha-blockers, if needed. Outcome analysis was based on evaluation of symptoms, prostate volume and maximum flow rate (Qmax). Results From a careful analysis of the data collected in our database, the following observations can be made: ages varied between 19 and 78 years. The patients were affected by BPH in 46% of cases, chronic prostatitis syndrome in 43%, chronic genital-pelvic pain in 7% and other conditions in 4%, the absolute numbers being 147, 138, 22 and 7 patients, respectively. No untoward side effect was reported in any case. Variations in symptom score could be fully evaluated only in 80 of 320 patients (25%), of whom 68 (85%) reported a significant benefit, with special reference to an improvement of pain, urgency, strangury and nocturia. Data on variations in prostate volume, as measured by digital rectal examination, were available in 84 (26.5%) patients. No significant change was observed. Qmax after treatment was measured in 83 (26%) patients. It did not show significant changes from the initial values. Discussion The association tested in our study appeared to be safe and well tolerated. No changes in flow rate and prostate volume were observed, but a marked reduction of LUTS was observed in 85% of evaluable cases, especially with regard to pain and irritative symptoms. Whether or not such an association may display a prevention of prostate cancer, may be investigated in additional studies.
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Affiliation(s)
| | | | - M.L. Tarantino
- Dip. Di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche Università degli Studi di Palermo
| | | | - A. Laganà
- Dip. Di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche Università degli Studi di Palermo
| | - A. Lupo
- Dip. Di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche Università degli Studi di Palermo
| | - M. Rinella
- Dip. Di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche Università degli Studi di Palermo
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Chalasani N, Younossi Z, Lavine JE, Charlton M, Cusi K, Rinella M, Harrison SA, Brunt EM, Sanyal AJ. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2018; 67:328-357. [PMID: 28714183 DOI: 10.1002/hep.29367] [Citation(s) in RCA: 4068] [Impact Index Per Article: 678.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 06/29/2017] [Indexed: 02/06/2023]
Affiliation(s)
| | - Zobair Younossi
- Center for Liver Disease and Department of Medicine, Inova Fairfax Hospital, Falls Church, VA
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37
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Ryou M, McQuaid KR, Thompson CC, Edmundowicz S, Mergener K, Abu Dayyeh B, Apovian C, Burke C, Chand B, Chandraker A, Deas T, Dietz W, Dunkin B, Ernest O, Faigel D, Garber S, Hamdy O, Kaplan L, Kumar N, Kushner R, Larsen MC, Lerner H, Littenberg G, Mantzoros C, Mattar S, Moore R, Rinella M, Rothstein R, Schillinger D, Spring B, Sullivan S, Tice J, Vargo J, Wilson E, Woods K, Zundel N. ASGE EndoVators Summit: Defining the role and value of endoscopic therapies in obesity management. Gastrointest Endosc 2017; 86:757-767. [PMID: 29031371 DOI: 10.1016/j.gie.2017.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 02/08/2023]
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38
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Ryou M, McQuaid KR, Thompson CC, Edmundowicz S, Mergener K, Dayyeh BA, Apovian C, Burke C, Chand B, Chandraker A, Deas T, Dietz W, Dunkin B, Ernest O, Faigel D, Garber S, Hamdy O, Kaplan L, Kumar N, Kushner R, Larsen MC, Lerner H, Littenberg G, Mantzoros C, Mattar S, Moore R, Rinella M, Rothstein R, Schillinger D, Spring B, Sullivan S, Tice J, Vargo J, Wilson E, Woods K, Zundel N. ASGE EndoVators Summit: Defining the role and value of endoscopic therapies in obesity management. Surg Obes Relat Dis 2017; 13:1805-1816. [PMID: 29030161 DOI: 10.1016/j.soard.2017.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/30/2017] [Indexed: 02/05/2023]
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39
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Sarkar M, Wellons M, Cedars MI, VanWagner L, Gunderson EP, Ajmera V, Torchen L, Siscovick D, Carr JJ, Terry JG, Rinella M, Lewis CE, Terrault N. Testosterone Levels in Pre-Menopausal Women are Associated With Nonalcoholic Fatty Liver Disease in Midlife. Am J Gastroenterol 2017; 112:755-762. [PMID: 28291240 PMCID: PMC5664187 DOI: 10.1038/ajg.2017.44] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/01/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Young women with hyperandrogenism have high risk of metabolic co-morbidities, including increased risk of nonalcoholic fatty liver disease (NAFLD). Whether testosterone (the predominant androgen) is associated with NAFLD independent of metabolic co-factors is unclear. Additionally, whether testosterone confers increased risk of NAFLD in women without hyperandrogenism is unknown. METHODS Among women in the prospective population-based multicenter Coronary Artery Risk Development in Young Adults (CARDIA) study, we assessed whether free testosterone levels measured at Year 2 (1987-1988) were associated with prevalent NAFLD at Year 25 (2010-2011) (n=1052). NAFLD was defined using noncontrast abdominal CT scan with liver attenuation≤40 Hounsfield units after excluding other causes of hepatic fat. The association of free testosterone with prevalent NAFLD was assessed by logistic regression. RESULTS Increasing quintiles of free testosterone were associated with prevalent NAFLD at Year 25 (adjusted odds ratio (AOR) 1.25, 95% confidence interval (CI) 1.04-1.50, P=0.015), independent of insulin resistance, body mass index, waist circumference, and serum lipids. Importantly, the association persisted among n=955 women without androgen excess (AOR 1.27, 95% CI 1.05-1.53, P=0.016). Visceral adipose tissue (VAT) volume partially mediated the association of free testosterone with NAFLD (mediating effect 41.0%, 95% CI 22-119%). CONCLUSIONS Increasing free testosterone is associated with prevalent NAFLD in middle age, even in women without androgen excess. Visceral adiposity appears to play an important role in the relationship between testosterone and NAFLD in women. Testosterone may provide a potential novel target for NAFLD therapeutics, and future studies in pre-menopausal women should consider the importance of testosterone as a risk factor for NAFLD.
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Affiliation(s)
- Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Melissa Wellons
- Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcelle I. Cedars
- Department of Obstetrics and Gynecology, University of California, San Francisco, California, USA
| | - Lisa VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | | | - Veeral Ajmera
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Laura Torchen
- Division of Pediatric Endocrinology, Northwestern University, Chicago, Illinois, USA
| | | | - J. Jeffrey Carr
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James G. Terry
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mary Rinella
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Cora E. Lewis
- Division of Preventive Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Norah Terrault
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
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40
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Rinella M, Charlton M. The globalization of nonalcoholic fatty liver disease: Prevalence and impact on world health. Hepatology 2016; 64:19-22. [PMID: 26926530 DOI: 10.1002/hep.28524] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 02/26/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Mary Rinella
- Northwestern University Medical Center, Chicago, IL
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41
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Pavone C, Abbadessa D, Tarantino ML, Oxenius I, Laganà A, Lupo A, Rinella M. [Associating Serenoa repens, Urtica dioica and Pinus pinaster. Safety and efficacy in the treatment of lower urinary tract symptoms. Prospective study on 320 patients]. Urologia 2010; 77:43-51. [PMID: 20890858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2009] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Serenoa repens (saw palmetto) has been employed for the treatment of lower urinary tract symptoms (LUTS) for several years. Its mechanism of action is believed to be due to antiandrogenic, antiproliferative and antinflammatory properties. An association of Serenoa with the nettle "Urtica dioica" showing antiproliferative activity and the pine "Pinus pinaster" derivative, showing antinflammatory action, has been proposed in recent years. Such an action is hoped to act not only by reducing LUTS but also by preventing the development of prostate cancer. MATERIAL AND METHODS During the years 2007 and 2008, 320 patients suffering from LUTS were treated with an association of Serenoa repens 320 mg, Urtica dioica 120 mg and Pinus pinaster 5 mg, named IPBTRE. This treatment was administered to all patients for a minimal duration of 30 days to a maximum of a year, either alone or in association with antibiotics or alpha-blockers, if needed. Outcome analysis was based on evaluation of symptoms, prostate volume and maximum flow rate (Qmax). RESULTS From a careful analysis of the data collected in our database, the following observations can be made: ages varied between 19 and 78 years. The patients were affected by BPH in 46% of cases, chronic prostatitis syndrome in 43%, chronic genital-pelvic pain in 7% and other conditions in 4%, the absolute numbers being 147, 138, 22 and 7 patients, respectively. No untoward side effect was reported in any case. Variations in symptom score could be fully evaluated only in 80 of 320 patients (25%), of whom 68 (85%) reported a significant benefit, with special reference to an improvement of pain, urgency, strangury and nocturia. Data on variations in prostate volume, as measured by digital rectal examination, were available in 84 (26.5%) patients. No significant change was observed. Qmax after treatment was measured in 83 (26%) patients. It did not show significant changes from the initial values. DISCUSSION The association tested in our study appeared to be safe and well tolerated. No changes in flow rate and prostate volume were observed, but a marked reduction of LUTS was observed in 85% of evaluable cases, especially with regard to pain and irritative symptoms. Whether or not such an association may display a prevention of prostate cancer, may be investigated in additional studies.
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Affiliation(s)
- C Pavone
- UOS di Chirurgia Andrologica, Università degli Studi di Palermo, Italy
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42
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Nie W, Sweetser S, Rinella M, Green RM. Transcriptional regulation of murine Slc22a1 (Oct1) by peroxisome proliferator agonist receptor-alpha and -gamma. Am J Physiol Gastrointest Liver Physiol 2005; 288:G207-12. [PMID: 15458920 DOI: 10.1152/ajpgi.00057.2004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The transport and metabolism of organic cationic endobiotics, nutrients, and drugs are essential hepatic functions. Slc22A1 is the basolateral liver transporter mediating the uptake of organic cations; however, little is known about the regulation of this transport protein. Peroxisome proliferator agonist receptor (PPAR)-alpha and -gamma agonists are commonly used agents that regulate many hepatocellular transport functions. Thus the purpose of this study was to examine the effects of PPAR agonists on the hepatic regulation and function of Slc22a1. Mice and H35 cells were administered PPAR-alpha and -gamma agonists, and the effect on Slc22a1 gene expression was measured. We subsequently cloned the Slc22a1 promoter and employed chimeric constructs to assay Slc22a1 gene transcription. The effects of PPAR-agonist treatment on organic cation uptake was also assayed. Slc22a1 expression was increased by PPAR-alpha and -gamma agonist treatment in both murine livers and H35 cells. Gene expression in H35 cells was further increased following transfection with expression vectors of PPAR transcription factors and PPAR agonist treatment. We cloned the promoter region of Slc22a1 and identified a PPAR-response element, and transfections with chimeric Slc22a1; promoter-reporter gene constructs demonstrate that the increased gene expression was transcriptionally regulated. Functional assays confirmed that cells treated with PPAR agonists displayed significant increases in organic cation uptake. PPAR-alpha and -gamma agonists transcriptionally increase Slc22a1 gene expression, and the increased Slc22a1 expression results in enhanced cellular organic cation uptake. These studies may have implication for the uptake of organic cationic drugs and for lipid metabolism.
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Affiliation(s)
- Wenxian Nie
- Department of Medicine, Division of Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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43
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Allegro R, Serretta V, Aragona F, Motta M, Orestano L, Cammarata C, Melloni D, Magno C, Aragona C, Pirritano D, Paola Q, Cosentino V, Capizzi G, Saita A, Spampinato A, Nicolosi D, Raciti G, Salvia G, Rinella M, Macaluso MP, Orestano F, Vacirca F, Caramia M, Cozzupoli P, De Grande G, Lapira G, Ventrici F, Falvo F, Galfano G, Armenio A, Gange E, Rizzo I, Massarelli M, Saita A, Bartolotta S, Pepe P, Pavone C, Ingargiola G, Taschetti S, Vaccarella G, Contino G, De Leo F. Osservational Study on Early Diagnosis of Prostate Carcinoma in Sicily and Calabria. Urologia 2004. [DOI: 10.1177/039156030407100311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The diagnosis of prostate carcinoma has been monitored in Sicily and Calabria for one year. Material e Methods Twenty-seven urological centres of Sicily and Calabria joined the study. Detailed informations about age, familiarity, PSA, Gleason score and TNM stage at diagnosis were centralized between november 2001 and november 2002. Results 721 patients have been recruited. The median age was 73 years. More than 80% of the patients were older than 65 years. Median PSA was 14 ng/ml. The clinical stage at diagnosis was T1c in 33% of patients and 67% had an organ confined prostate cancer (T1-T2). Familiarity was detected in 8% of cases. Age and PSA at diagnosis in these patients were similar to those of the remaining population. However, only 18% of them had a T1 tumor, emphasizing the delay in diagnosis in these patients. Although only 10% of the patients shows at diagnosis a metastatic tumor, 29% only are fit for radical prostatectomy in according to age, PSA and stage.
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Affiliation(s)
- R. Allegro
- Ist. Urologia, Università di Palermo, Palermo
| | - V. Serretta
- Ist. Urologia, Università di Palermo, Palermo
| | - F. Aragona
- Div. Urologia, Ospedale Cannizzaro, Catania
| | - M. Motta
- Ist. Urologia, Università di Catania, Catania
| | - L. Orestano
- Div. Urologia, Casa di Cura Orestano, Palermo
| | | | - D. Melloni
- Ist. Urologia, Università di Messina, Messina
| | - C. Magno
- Ist. Urologia, Università di Messina, Messina
| | | | | | - Q. Paola
- Div. Urologia, Ospedale Civile, Sciacca (Agrigento)
| | - V. Cosentino
- Div. Urologia, Ospedale Civile, Gela (Caltanissetta)
| | - G. Capizzi
- Div. Urologia, Ospedale Civile, Comiso (Ragusa)
| | - A. Saita
- Ist. Urologia, Università di Catania, Catania
| | | | | | - G. Raciti
- Div. Urologia, Ospedale Oncologico San Luigi, Catania
| | - G. Salvia
- Div. Urologia, Ospedale Civile, Bronte (Catania)
| | - M. Rinella
- Ist. Urologia, Università di Palermo, Palermo
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - C. Pavone
- (Palermo) Dibenedetto (San Cataldo, Caltanissetra)
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