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Challenges and opportunities in drug development for nonalcoholic steatohepatitis
Journal Pre-proof Challenges and opportunities in drug development for nonalcoholic steatohepatitis Matthias Ocker PII:
S0014-2999(20)30005-4
DOI:
https://doi.org/10.1016/j.ejphar.2020.172913
Reference:
EJP 172913
To appear in:
European Journal of Pharmacology
Received Date: 30 October 2019 Revised Date:
4 December 2019
Accepted Date: 7 January 2020
Please cite this article as: Ocker, M., Challenges and opportunities in drug development for nonalcoholic steatohepatitis, European Journal of Pharmacology (2020), doi: https://doi.org/10.1016/ j.ejphar.2020.172913. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier B.V.
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Challenges and opportunities in drug development for nonalcoholic steatohepatitis
Matthias Ockera
a
Charité University Medicine Berlin, Berlin, Germany. [email protected]
Declaration of interest The author declares no conflict of interest related to this publication.
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Abstract Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are considered major global medical burdens with high prevalence and steeply rising incidence. Despite the characterization of numerous pathophysiologic pathways leading to metabolic disorder, lipid accumulation, inflammation, fibrosis, and ultimately end-stage liver disease or liver cancer formation, so far no causal pharmacological therapy is available. Drug development for NAFLD and NASH is limited by long disease duration and slow progression and the need for sequential biopsies to monitor the disease stage. Additional non-invasive biomarkers could therefore improve design and feasibility of such. Here, the current concepts on preclinical models, biomarkers and clinical endpoints and trial designs are briefly reviewed.
Abstract word count: 108
Keywords nonalcoholic fatty liver disease (NAFLD); nonalcoholic steatohepatitis (NASH); biomarker; clinical trials; drug development; drug discovery
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1. Introduction The liver is the central metabolic organ and affected by different acute and chronic injuries and chronic liver disease (CLD) remains a major medical burden worldwide. While in the past viral hepatitis was seen as the major cause of chronic liver disease, the incidence and prevalence of hepatitis B (HBV) and C (HCV) infections significantly decreased in recent years due to vaccination strategies and novel treatment options, nonalcoholic fatty liver disease (NAFLD) and subsequent nonalcoholic steatohepatitis (NASH) have now become the major cause of CLD. Although alcohol and HCV still remain significant, it is estimated that approx. 60% of CLD cases are now due to NAFLD and NASH (Younossi, 2019; Younossi et al., 2019). In the past 30 years, the prevalence of NAFLD in the general population of the US increased from 20% to 31.9% and was paralleled by an increase in obesity (from 22.2% to 38.9%), type 2 diabetes (from 7.2 to 13.5%), insulin resistance and hypertension (Younossi et al., 2019). In this study, NAFLD was identified as the only liver disease with increasing prevalence and diabetes and obesity have been shown to be independent predictors for NAFLD development. Considering the globally increasing rate of obesity and diabetes in children and young adults, it is estimated that the overall prevalence of NAFLD and NASH will increase by 21.3% and 63% until 2030, respectively, and NAFLD will then affect more than 100 million people (Estes et al., 2018). Due to the chronic nature, progression of NAFLD to NASH is commonly associated with the development of fibrosis and, over time, leading to cirrhosis and end-stage liver disease with an increased risk of development of hepatocellular carcinoma (HCC). It is thus expected that the prevalence of decompensated cirrhosis and HCC will increase steeply by 168% and 137%, respectively, until 2030 (Estes et al., 2018). Overall, CLD and its complications are estimated to cause annual health care costs of approx. 30 billion US$ (Moon et al., 2019). These numbers underline the need for improved diagnostic and surveillance approaches for NAFLD and NASH. Unfortunately, despite the high medical need, no causative treatment option is available yet. Clinical practice guidelines usually recommend weight reduction, lifestyle interventions and
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symptomatic treatment although epidemiologic data indicate that NAFLD patients tend to an unhealthy lifestyle and overconsumption of high-calorie soft drinks and food (Ratziu et al., 2015). While there is a strong pathophysiologic rationale (see below) to improve insulin resistance via exercise and to reduce calorie intake, only limited prospective clinical data is available to support this hypothesis. Available studies are usually observational studies and focus on weight loss over a small period of time only, as long-term adherence to exercise or dietary restrictions are difficult to achieve and most studies show low compliance even during a shorter time frame (Neuschwander-Tetri, 2009). Recent studies demonstrate a beneficial effect on steatosis and insulin resistance even by short-term exercise interventions even if no weight loss is achieved and exercise programs are now recommended to NAFLD and NASH patients (Rodriguez et al., 2012). Weak recommendations are currently given for the use of anti-oxidants like vitamin E, and for metabolic drugs like statins or glitazones (Blond et al., 2017; Chalasani et al., 2018). The complex biology and interplay between inflammation, metabolism and extracellular matrix deposition have so far limited drug development activities, also due to slow disease progression and uncertainty about appropriate endpoints for clinical trials. In this article, the current landscape for NASH drug development, its challenges and opportunities, and the underlying pathophysiology of the disease will be reviewed.
2. Pathophysiology of NAFLD and NASH Understanding the pathophysiology of NAFLD and how it progresses to NASH is crucial for identification of novel drug targets and the selection of appropriate preclinical models as well as clinical endpoints. Here, only basic principles will be reviewed and the reader is referred to other recent reviews focusing on more pathophysiologic details (Bessone et al., 2019; Manne et al., 2018; Pierantonelli and Svegliati-Baroni, 2019). Several pathophysiologic models of NAFLD and NASH have been proposed over the past decades, e.g. the “two-hit hypothesis” (Day and James, 1998), the “parallel multiple-hit theory” (Tilg and
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Moschen, 2010), and most recently the “distinct-hit theory” (Yilmaz, 2012). Common to those hypotheses are insulin resistance and hepatocytic lipid accumulation while the causal relationship of those phenomena is seen differently. Additional inflammatory hits, which can themselves lead to increased lipid accumulation, then trigger progression into NASH. In brief, metabolic disturbances lead to increased release of free fatty acids from adipocytes and increased glucose levels due to impaired uptake into adipocytes. This triggers further fatty acid synthesis in the liver which leads to toxic fatty acid metabolites, impaired lipophagy and release of VLDL and induction of oxidative stress via mitochondrial β-oxidation. These mechanisms maintain a pro-inflammatory environment which is associated with progression to NASH. Oxidative stress can cause hepatocyte apoptosis and activates hepatic stellate cells and Kupffer cells, both being key players for fibrogenesis and cirrhosis formation. Chronic oxidative stress and toxic lipid metabolites can also lead to DNA damage and activation of respective repair mechanisms like ATM (by reactive oxygen species or DNA doublestrand breaks) (Guo et al., 2010) or the rather error-prone non-homologous end-joining (NHEJ) via DNA-dependent protein kinase (DNAPK) also in NAFLD and NASH (Gao et al., 2004; Schults et al., 2012; Wong et al., 2009). While accumulating toxic metabolites are normally cleared by autophagy as a scavenger mechanism, this pathway is inhibited in NAFLD by excess triglycerides and free fatty acids which interfere with the PI3K/AKT/mTOR pathway, inhibit activation of the autophagy-sensing kinase ULK1 and trigger further intracellular stress by activating the endoplasmatic reticulum (ER) stress response (Lebeaupin et al., 2018; Ueno and Komatsu, 2017; Weiskirchen and Tacke, 2019). This maintains the vicious circle of further DNA damage, hepatocyte cell death, chronic inflammation and regeneration. Peripheral insulin resistance also contributes to sterile hepatic inflammation by release of proinflammatory cytokines like TNF-α, IL-1β, IL-6 or IL-8 from adipocytes which further attracts inflammatory cells to the liver (Bessone et al., 2019; El Husseny et al., 2017; Polyzos et al., 2011).
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3. Target discovery and drug development 3.1. Basic considerations The development of a new drug represents requires significant financial commitment over a period of more than 10 years. Since the early 2000s, costs for one newly approved drug exceed 1 billion US$ and mitigating the risk for failure is therefore of high priority for the pharmaceutical industry (Dugger et al., 2018). Considering the high global prevalence and increasing incidence, NAFLD and NASH clearly present an attractive commercial space for drug development and the disease itself has a high unmet medical need, both are considered basic pillars for the assessment of potential new drug targets (Gashaw et al., 2011). An overview on current and emerging anti-fibrotic therapies in other chronic liver diseaseshas recently been published elsewhere (Lemoinne and Friedman, 2019).
3.2. Animal models While the pathophysiology of NAFLD and NASH is well characterized, a plethora of potential drug targets is available, e.g. metabolic targets, immune modulation targets or antifibrotic and antiproliferative targets, although the individual contribution to the disease progression may still remain elusive. To fully characterize those potential targets, the availability of predictive preclinical models with high translatability to the human disease setting is of utmost importance (Gashaw et al., 2011). Mouse models for NASH are usually dietary models with our without additional genetic or toxic stimuli (Table 1) (Anstee et al., 2019; Ibrahim et al., 2016; Kucera and Cervinkova, 2014). Commonly used models are the methionine-choline-deficient (MCD) model, the high-fat diet (HFD) model or the Western diet (WD) model consisting of a high-fat, high-fructose and high-cholesterol (FFC) diet (Stephenson et al., 2018). Variants of these models include e.g. the concomitant application of carbon tetrachloride (CCl4) (Tsuchida et al., 2018) or are used in e.g. myc-transgenic mice (Ma et al., 2016)., FFC (Charlton et al., 2011), WD or the CD-HFD mimic human pathophysiology but results obtained from rodents should be validated in other species as energy metabolism and immune regulation are different in higher mammals. Humanized mice that reflect the human immune system more closely have been developed recently and were used for preclinical NASH
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models (Hui et al., 2018). Several dietary models have been applied to minipigs, e.g. the high-fat, high-sucrose diet in bama minipigs (Xia et al., 2014) or WD in Lee-Sung minipigs (Li et al., 2016). Yet, some of these larger animal models show high variability and need further optimization before routine use in preclinical drug development (Schumacher-Petersen et al., 2019). Although nonhuman primates have been successfully used for experimental NASH models and treatments (Esquejo et al., 2018; Goedeke et al., 2019; Wang et al., 2017), their general use is limited due to ethical reasons and slow disease progression similar to humans.
3.3. Biomarkers Biomarkers can be used for diagnosis, patient stratification and selection, disease monitoring and monitoring of treatment response (Califf, 2018; Group, 2016). They play a major role in increasing the probability of success in drug development and applying biomarkers for patient stratification can double the overall success rate for FDA approval from 5.5 to 10.3% with steepest effects in early phases of clinical development (Wong et al., 2019). While biopsies are still considered gold standard for diagnosis and monitoring of liver diseases, their availability is limited due to invasiveness and the susceptibility to sampling error. Noninvasive biomarkers and biomarker scores as well imaging techniques have been established as diagnostic biomarker tools for NAFLD, NASH and fibrosis and have recently been discussed elsewhere (Castera et al., 2019; Drescher et al., 2019; Zhou et al., 2019). Due to the long and slow disease progression, these noninvasive biomarkers are important to monitor the course of the disease and response to treatment (Wieckowska and Feldstein, 2008), although histological improvement (of fibrosis) should be confirmed according to FDA guidelines (Sanyal et al., 2011). Ideally, noninvasive biomarkers would detect changes in steatosis e.g. via magnetic resonance imaging proton density fat fraction (MRIPDFF) measurements (Jayakumar et al., 2019; Middleton et al., 2017), changes in liver function e.g. via measurement of transaminases, and changes in fibrosis e.g. via elastography techniques or validated serum scores like the aspartate aminotransferase to platelet ratio index (APRI) or the fibrosis-4 (FIB-4) score (Vilar-Gomez et al., 2017; Zhou et al., 2019).
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These panels are therefore considered adequate surrogate endpoints for clinical trials since the primary endpoint of reducing liver-related mortality might not be feasible to achieve due to the long course of the disease (Sanyal et al., 2011). Pharmacodynamic, or on-target biomarkers, are of high value during the early phases of clinical drug development. These biomarkers show if and to what extent a drug target is modulated (inhibited/activated) by a certain therapy and if the observed effects relate to the anticipated mode of action and to the expected clinical outcome. Pharmacodynamic biomarkers, together with safety data and pharmacokinetic data, are therefore important for finding the adequate dose and dosing schedule and for early de-risking of a drug candidate (O'Connell et al., 2020). Depending on the drug target, various potential biomarkers related to steatosis, metabolism (e.g. fatty acids, insulin resistance, glucose levels, adipokines, cholesterol levels etc.) (Hodson et al., 2017; Maciejewska et al., 2018; Razavi Zade et al., 2016), fibrogenesis (e.g. pro-collagen type III N-terminal peptide (PIIINP), hyaluronic acid, TIMP1) (Javed et al., 2019; Tanwar et al., 2013) or inflammation (e.g. cytokines, chemokines) (Farsi et al., 2016; Sepideh et al., 2016) were proposed besides the above mentioned scores or liver stiffness evaluations (Drescher et al., 2019).
3.4. Current drug targets Based on these considerations, several anti-NASH drug targets have been identified and are currently undergoing clinical investigation (Table 3). The majority of these drugs targets metabolic pathways (e.g. PPAR α/δ, FXR), but inflammatory (e.g. CCR2/5) or other cellular pathways (e.g. THR-β) related to NASH progression are also explored. Peroxisome proliferator-activated receptors (PPARs) are nuclear protein receptors that regulate genes for cellular differentiation, development and various pathways involved in lipid and glucose metabolism (Liss and Finck, 2017; Pawlak et al., 2015). PPAR α is predominantly expressed in the liver and plays a role in fatty acid and triglyceride metabolism, beta oxidation, ketogenesis and may also have anti-inflammatory roles. PPAR δ is expressed in skeletal muscle, adipocytes, hepatocytes and
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Kupffer cells and regulates mitochondrial metabolism, fatty acid metabolism and inflammation (Liss and Finck, 2017; Pawlak et al., 2015). Farnesoid X receptor (FXR) is another nuclear receptor involved in regulation of lipid, glucose and bile acid metabolism. Under physiologic conditions, FXR is a sensor for enterohepatic bile acid circulation (Tanaka et al., 2017). Stimulation of FXR has been shown to improve diabetes and steatosis via FGF15 signaling (Fang et al., 2015) and to reduce inflammation via inhibition of NF-κB and reduced production of proinflammatory cytokines (Inagaki et al., 2006). The sodium glucose co-transporter 2 (SGLT2) is expressed in the kidney and regulates urinary glucose reabsorption. SGLT2 inhibition was shown to reduce blood glucose levels and body weight in diabetic patients (Khan et al., 2019). Stearyl-CoA desaturase-1 (SCD-1) is the rate limiting enzyme in fatty acid synthesis and metabolism (Paton and Ntambi, 2009). SCD-1 is overexpressed in the liver under high carbohydrate diet and correlated with obesity, diabetes and metabolic syndrome (Flowers and Ntambi, 2009). Mice deficient in SCD-1 show reduced obesity and insulin resistance. Thyroid hormones can stimulate energy metabolism in the liver. Therefore, agonist at thyroid hormone receptors (THR-β agonists) can positively affect cholesterol and triglyceride levels and have been shown to improve steatosis in various mouse models (Dibba et al., 2018; Kowalik et al., 2018). Glucagon-like peptide 1 (GLP-1) is a cleavage product or proglucagon and stimulates secretion of insulin. GLP-1 agonist have been shown to lower blood glucose levels and improve metabolic function and steatosis in the liver (Knudsen and Lau, 2019). The mitochondrial pyruvate carrier (MPC) is a central regulator of oxidative and non-oxidative metabolic pathways. It was identified as a new binding site for antidiabetic thiazolidindiones and is upregulated under high-fat conditions (Colca et al., 2013). Knockdown or inhibition of MPC was shown to protect hepatocytes from lipotoxicity and to improve steatosis (Colca et al., 2018). In contrast to these metabolic drug targets, inhibition of the C-C chemokine receptors 2 and 5 (CCR2/5) aims at suppressing the infiltration of inflammatory cells, esp. Kupffer cells, macrophages
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and monocytes via CCR2 and T and NK cells via CCR5, during fibrosis and NASH progression (Tacke, 2018).
4. Clinical Development, endpoints and study design Successful clinical drug development and authority approval is closely linked to selecting the right endpoints and finding the best patient population. The ultimate primary endpoint for a successful NASH therapy would be the reduction in liver-related mortality. Yet, due to the long course of the disease, this endpoint is not considered feasible as study duration would easily exceed 10 years or more. In the accelerated approval process, US FDA can grant drug approval based on surrogate endpoints that are “reasonably likely to predict clinical benefit, or on a clinical endpoint that occurs earlier but may not be as robust as the standard endpoint used for approval. This approval pathway is especially useful when the drug is meant to treat a disease whose course is long, and an extended period of time is needed to measure its effect.” (FDA, 2019a). This pathway also mandates postapproval clinical trials to verify the observed effects of the drug. A similar approach is supported by the European Medicines Agency granting conditional approval based on surrogate endpoints. Secondary endpoints in NAFLD and NASH could relate to improvement of steatosis, inflammation, fibrosis or metabolic conditions. Unfortunately, these parameters might still require sequential tissue biopsies which are invasive and prone to sampling error so that the above outlined non-invasive biomarkers should be considered, although FDA so far accepted only histopathologic findings (resolution of NASH without worsening of fibrosis or improvement in fibrosis without worsening of NASH or combined resolution of fibrosis and improvement in fibrosis) as surrogate endpoints for precirrhotic patients with NASH (Cheung et al., 2019). Yet, the clinical significance of these and other surrogate endpoints like decompensation of cirrhosis, HCC incidence or decrease in portal vein pressure gradient, is still elusive and needs long-term follow-up (Rinella et al., 2019). An overview on these surrogate endpoints is provided in Table 2 and recently finished pivotal phase 2 studies actually applied some of these endpoints in conjunction with biopsies (Rinella et al., 2019; Roeb and Geier, 2019; Thiagarajan and Aithal, 2019). It is also recommended to adhere to FDA’s guidance documents
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on drug development for treatment of NASH fibrosis or compensated cirrhosis where adequate endpoints for Phase 2 and 3 studies are defined (FDA, 2018; 2019b). Therefore, currently (November 2019) ongoing Phase 3 studies in NASH still rely on histological endpoints like resolution of NASH and improvement in fibrosis (Table 3). Interestingly, these studies differ in their respective endpoints and in the patient populations enrolled and it is noteworthy, that fibrosis resolution or improvement in NAFLD activity score (NAS) by 2 points (which is an FDA accepted endpoint for efficacy) is observed in 12 to 25% of the placebo controls, too. For further details on ongoing Phase 3 studies, please see other recent reviews (Alukal and Thuluvath, 2019; Roeb and Geier, 2019; Sumida et al., 2019). Yet, the clinical significance of these surrogate endpoints is still elusive and long-term follow-up is needed. To further accelerate NASH drug development, adaptive (seamless) trial designs have proposed. Although some operational and regulatory aspects may be more complex in such a study, it provides an opportunity for patients to continue in different phases of the development and thus limit the need for enrolling new patients and it may reduce the required number of serial biopsies (Filozof et al., 2017).
5. Conclusion NAFLD and NASH are globally steeply increasing in incidence and prevalence. So far, no causative pharmacological therapy is available. NASH can progress to end-stage liver disease with need for transplantation and to HCC, so that effective treatment strategies are urgently needed. The complex pathophysiology of metabolic disturbance, insulin resistance, lipid accumulation, inflammation and fibrotic deployment lead to the identification of numerous potential targets for drug development. In this process, the selection of appropriate preclinical animal models that closely reflect human pathophysiology is important to validate the drug target and to confirm the mode of action of a drug candidate. The successful translation of these finding is dependent on adequate biomarkers to monitor treatment response. While tissue biopsies still represent the goldstandard here, novel noninvasive biomarkers as well as imaging techniques have become available. Although those biomarkers are not yet accepted as an adequate primary endpoint by regulatory authorities, they are
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and have to be an essential part of Phase 2 and Phase 3 clinical studies to address their correlation with outcome and to then foster drug development for NASH. Currently, several interesting Phase 3 studies are ongoing and can support the basis for those surrogate endpoints as tissue based parameters will also be available for comparison.
Acknowledgements This publication did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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References Alukal, J.J., Thuluvath, P.J., 2019. Reversal of NASH fibrosis with pharmacotherapy. Hepatol Int 13, 534-545.
Anstee, Q.M., Reeves, H.L., Kotsiliti, E., Govaere, O., Heikenwalder, M., 2019. From NASH to HCC: current concepts and future challenges. Nat Rev Gastroenterol Hepatol 16, 411-428.
Bessone, F., Razori, M.V., Roma, M.G., 2019. Molecular pathways of nonalcoholic fatty liver disease development and progression. Cell Mol Life Sci 76, 99-128.
Blond, E., Disse, E., Cuerq, C., Drai, J., Valette, P.J., Laville, M., Thivolet, C., Simon, C., Caussy, C., 2017. EASL-EASD-EASO clinical practice guidelines for the management of non-alcoholic fatty liver disease in severely obese people: do they lead to over-referral? Diabetologia 60, 1218-1222.
Califf, R.M., 2018. Biomarker definitions and their applications. Exp Biol Med (Maywood) 243, 213221.
Castera, L., Friedrich-Rust, M., Loomba, R., 2019. Noninvasive Assessment of Liver Disease in Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology 156, 1264-1281 e1264.
Chalasani, N., Younossi, Z., Lavine, J.E., Charlton, M., Cusi, K., Rinella, M., Harrison, S.A., Brunt, E.M., Sanyal, A.J., 2018. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology 67, 328-357.
Charlton, M., Krishnan, A., Viker, K., Sanderson, S., Cazanave, S., McConico, A., Masuoko, H., Gores, G., 2011. Fast food diet mouse: novel small animal model of NASH with ballooning, progressive fibrosis, and high physiological fidelity to the human condition. Am J Physiol Gastrointest Liver Physiol 301, G825-834.
Ocker: NASH drug development
14
Cheung, A., Neuschwander-Tetri, B.A., Kleiner, D.E., Schabel, E., Rinella, M., Harrison, S., Ratziu, V., Sanyal, A.J., Loomba, R., Jeannin Megnien, S., Torstenson, R., Miller, V., 2019. Defining Improvement in Nonalcoholic Steatohepatitis for Treatment Trial Endpoints: Recommendations From the Liver Forum. Hepatology 70, 1841-1855.
Colca, J.R., McDonald, W.G., Adams, W.J., 2018. MSDC-0602K, a metabolic modulator directed at the core pathology of non-alcoholic steatohepatitis. Expert Opin Investig Drugs 27, 631-636.
Colca, J.R., McDonald, W.G., Cavey, G.S., Cole, S.L., Holewa, D.D., Brightwell-Conrad, A.S., Wolfe, C.L., Wheeler, J.S., Coulter, K.R., Kilkuskie, P.M., Gracheva, E., Korshunova, Y., Trusgnich, M., Karr, R., Wiley, S.E., Divakaruni, A.S., Murphy, A.N., Vigueira, P.A., Finck, B.N., Kletzien, R.F., 2013. Identification of a mitochondrial target of thiazolidinedione insulin sensitizers (mTOT)--relationship to newly identified mitochondrial pyruvate carrier proteins. PLoS One 8, e61551.
Day, C.P., James, O.F., 1998. Steatohepatitis: a tale of two "hits"? Gastroenterology 114, 842-845.
Dibba, P., Li, A.A., Perumpail, B.J., John, N., Sallam, S., Shah, N.D., Kwong, W., Cholankeril, G., Kim, D., Ahmed, A., 2018. Emerging Therapeutic Targets and Experimental Drugs for the Treatment of NAFLD. Diseases 6.
Drescher, H.K., Weiskirchen, S., Weiskirchen, R., 2019. Current Status in Testing for Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH). Cells 8.
Dugger, S.A., Platt, A., Goldstein, D.B., 2018. Drug development in the era of precision medicine. Nat Rev Drug Discov 17, 182-196.
El Husseny, M.W., Mamdouh, M., Shaban, S., Ibrahim Abushouk, A., Zaki, M.M., Ahmed, O.M., AbdelDaim, M.M., 2017. Adipokines: Potential Therapeutic Targets for Vascular Dysfunction in Type II Diabetes Mellitus and Obesity. J Diabetes Res 2017, 8095926.
Ocker: NASH drug development
15
Esquejo, R.M., Salatto, C.T., Delmore, J., Albuquerque, B., Reyes, A., Shi, Y., Moccia, R., Cokorinos, E., Peloquin, M., Monetti, M., Barricklow, J., Bollinger, E., Smith, B.K., Day, E.A., Nguyen, C., Geoghegan, K.F., Kreeger, J.M., Opsahl, A., Ward, J., Kalgutkar, A.S., Tess, D., Butler, L., Shirai, N., Osborne, T.F., Steinberg, G.R., Birnbaum, M.J., Cameron, K.O., Miller, R.A., 2018. Activation of Liver AMPK with PF06409577 Corrects NAFLD and Lowers Cholesterol in Rodent and Primate Preclinical Models. EBioMedicine 31, 122-132.
Estes, C., Razavi, H., Loomba, R., Younossi, Z., Sanyal, A.J., 2018. Modeling the epidemic of nonalcoholic fatty liver disease demonstrates an exponential increase in burden of disease. Hepatology 67, 123-133.
Fang, S., Suh, J.M., Reilly, S.M., Yu, E., Osborn, O., Lackey, D., Yoshihara, E., Perino, A., Jacinto, S., Lukasheva, Y., Atkins, A.R., Khvat, A., Schnabl, B., Yu, R.T., Brenner, D.A., Coulter, S., Liddle, C., Schoonjans, K., Olefsky, J.M., Saltiel, A.R., Downes, M., Evans, R.M., 2015. Intestinal FXR agonism promotes adipose tissue browning and reduces obesity and insulin resistance. Nat Med 21, 159-165.
Farsi, F., Mohammadshahi, M., Alavinejad, P., Rezazadeh, A., Zarei, M., Engali, K.A., 2016. Functions of Coenzyme Q10 Supplementation on Liver Enzymes, Markers of Systemic Inflammation, and Adipokines in Patients Affected by Nonalcoholic Fatty Liver Disease: A Double-Blind, PlaceboControlled, Randomized Clinical Trial. J Am Coll Nutr 35, 346-353.
FDA, U., 2018. Noncirrhotic nonalcoholic steatohepatitis with liver fibrosis: developing drugs for treatment. Guidance for industry. https://www.fda.gov/media/119044/download (accessed 30.10.2019)
FDA, U., 2019a. Development & Approval Process | Drugs. https://www.fda.gov/drugs/developmentapproval-process-drugs (accessed 28.10.2019)
Ocker: NASH drug development
16
FDA, U., 2019b. Nonalcoholic steatohepatitis with compensated cirrhosis: developing drugs for treatment. Guidance for industry. https://www.fda.gov/media/127738/download (accessed 30.10.2019)
Filozof, C., Chow, S.C., Dimick-Santos, L., Chen, Y.F., Williams, R.N., Goldstein, B.J., Sanyal, A., 2017. Clinical endpoints and adaptive clinical trials in precirrhotic nonalcoholic steatohepatitis: Facilitating development approaches for an emerging epidemic. Hepatol Commun 1, 577-585.
Flowers, M.T., Ntambi, J.M., 2009. Stearoyl-CoA desaturase and its relation to high-carbohydrate diets and obesity. Biochim Biophys Acta 1791, 85-91.
Gao, D., Wei, C., Chen, L., Huang, J., Yang, S., Diehl, A.M., 2004. Oxidative DNA damage and DNA repair enzyme expression are inversely related in murine models of fatty liver disease. Am J Physiol Gastrointest Liver Physiol 287, G1070-1077.
Gashaw, I., Ellinghaus, P., Sommer, A., Asadullah, K., 2011. What makes a good drug target? Drug Discov Today 16, 1037-1043.
Goedeke, L., Peng, L., Montalvo-Romeral, V., Butrico, G.M., Dufour, S., Zhang, X.M., Perry, R.J., Cline, G.W., Kievit, P., Chng, K., Petersen, K.F., Shulman, G.I., 2019. Controlled-release mitochondrial protonophore (CRMP) reverses dyslipidemia and hepatic steatosis in dysmetabolic nonhuman primates. Sci Transl Med 11.
Group, F.-N.B.W., 2016. BEST (Biomarkers, EndpointS, and other Tools) Resource [Internet]. http://www.ncbi.nlm.nih.gov/pubmed/27010052 (accessed 28.10.2019)
Guo, Z., Kozlov, S., Lavin, M.F., Person, M.D., Paull, T.T., 2010. ATM activation by oxidative stress. Science 330, 517-521.
Hodson, L., Bhatia, L., Scorletti, E., Smith, D.E., Jackson, N.C., Shojaee-Moradie, F., Umpleby, M., Calder, P.C., Byrne, C.D., 2017. Docosahexaenoic acid enrichment in NAFLD is associated with
Ocker: NASH drug development
17
improvements in hepatic metabolism and hepatic insulin sensitivity: a pilot study. Eur J Clin Nutr 71, 973-979.
Hui, S.T., Kurt, Z., Tuominen, I., Norheim, F., R, C.D., Pan, C., Dirks, D.L., Magyar, C.E., French, S.W., Chella Krishnan, K., Sabir, S., Campos-Perez, F., Mendez-Sanchez, N., Macias-Kauffer, L., Leon-Mimila, P., Canizales-Quinteros, S., Yang, X., Beaven, S.W., Huertas-Vazquez, A., Lusis, A.J., 2018. The Genetic Architecture of Diet-Induced Hepatic Fibrosis in Mice. Hepatology 68, 2182-2196.
Ibrahim, S.H., Hirsova, P., Malhi, H., Gores, G.J., 2016. Animal Models of Nonalcoholic Steatohepatitis: Eat, Delete, and Inflame. Dig Dis Sci 61, 1325-1336.
Inagaki, T., Moschetta, A., Lee, Y.K., Peng, L., Zhao, G., Downes, M., Yu, R.T., Shelton, J.M., Richardson, J.A., Repa, J.J., Mangelsdorf, D.J., Kliewer, S.A., 2006. Regulation of antibacterial defense in the small intestine by the nuclear bile acid receptor. Proc Natl Acad Sci U S A 103, 3920-3925.
Javed, Z., Papageorgiou, M., Deshmukh, H., Kilpatrick, E.S., Mann, V., Corless, L., Abouda, G., Rigby, A.S., Atkin, S.L., Sathyapalan, T., 2019. A Randomized, Controlled Trial of Vitamin D Supplementation on Cardiovascular Risk Factors, Hormones, and Liver Markers in Women with Polycystic Ovary Syndrome. Nutrients 11.
Jayakumar, S., Middleton, M.S., Lawitz, E.J., Mantry, P.S., Caldwell, S.H., Arnold, H., Mae Diehl, A., Ghalib, R., Elkhashab, M., Abdelmalek, M.F., Kowdley, K.V., Stephen Djedjos, C., Xu, R., Han, L., Mani Subramanian, G., Myers, R.P., Goodman, Z.D., Afdhal, N.H., Charlton, M.R., Sirlin, C.B., Loomba, R., 2019. Longitudinal correlations between MRE, MRI-PDFF, and liver histology in patients with nonalcoholic steatohepatitis: Analysis of data from a phase II trial of selonsertib. J Hepatol 70, 133-141.
Khan, R.S., Bril, F., Cusi, K., Newsome, P.N., 2019. Modulation of Insulin Resistance in Nonalcoholic Fatty Liver Disease. Hepatology 70, 711-724.
Ocker: NASH drug development
18
Knudsen, L.B., Lau, J., 2019. The Discovery and Development of Liraglutide and Semaglutide. Front Endocrinol (Lausanne) 10, 155.
Kowalik, M.A., Columbano, A., Perra, A., 2018. Thyroid Hormones, Thyromimetics and Their Metabolites in the Treatment of Liver Disease. Front Endocrinol (Lausanne) 9, 382.
Kucera, O., Cervinkova, Z., 2014. Experimental models of non-alcoholic fatty liver disease in rats. World J Gastroenterol 20, 8364-8376.
Lebeaupin, C., Vallee, D., Hazari, Y., Hetz, C., Chevet, E., Bailly-Maitre, B., 2018. Endoplasmic reticulum stress signalling and the pathogenesis of non-alcoholic fatty liver disease. J Hepatol 69, 927-947.
Lemoinne, S., Friedman, S.L., 2019. New and emerging anti-fibrotic therapeutics entering or already in clinical trials in chronic liver diseases. Curr Opin Pharmacol 49, 60-70.
Li, S.J., Ding, S.T., Mersmann, H.J., Chu, C.H., Hsu, C.D., Chen, C.Y., 2016. A nutritional nonalcoholic steatohepatitis minipig model. J Nutr Biochem 28, 51-60.
Liss, K.H., Finck, B.N., 2017. PPARs and nonalcoholic fatty liver disease. Biochimie 136, 65-74.
Ma, C., Kesarwala, A.H., Eggert, T., Medina-Echeverz, J., Kleiner, D.E., Jin, P., Stroncek, D.F., Terabe, M., Kapoor, V., ElGindi, M., Han, M., Thornton, A.M., Zhang, H., Egger, M., Luo, J., Felsher, D.W., McVicar, D.W., Weber, A., Heikenwalder, M., Greten, T.F., 2016. NAFLD causes selective CD4(+) T lymphocyte loss and promotes hepatocarcinogenesis. Nature 531, 253-257.
Maciejewska, D., Marlicz, W., Ryterska, K., Banaszczak, M., Jamiol-Milc, D., Stachowska, E., 2018. Changes of the Fatty Acid Profile in Erythrocyte Membranes of Patients following 6-Month Dietary Intervention Aimed at the Regression of Nonalcoholic Fatty Liver Disease (NAFLD). Can J Gastroenterol Hepatol 2018, 5856201.
Ocker: NASH drug development
19
Manne, V., Handa, P., Kowdley, K.V., 2018. Pathophysiology of Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis. Clin Liver Dis 22, 23-37.
Middleton, M.S., Heba, E.R., Hooker, C.A., Bashir, M.R., Fowler, K.J., Sandrasegaran, K., Brunt, E.M., Kleiner, D.E., Doo, E., Van Natta, M.L., Lavine, J.E., Neuschwander-Tetri, B.A., Sanyal, A., Loomba, R., Sirlin, C.B., 2017. Agreement Between Magnetic Resonance Imaging Proton Density Fat Fraction Measurements and Pathologist-Assigned Steatosis Grades of Liver Biopsies From Adults With Nonalcoholic Steatohepatitis. Gastroenterology 153, 753-761.
Moon, A.M., Singal, A.G., Tapper, E.B., 2019. Contemporary Epidemiology of Chronic Liver Disease and Cirrhosis. Clin Gastroenterol Hepatol.
Neuschwander-Tetri, B.A., 2009. Lifestyle modification as the primary treatment of NASH. Clin Liver Dis 13, 649-665.
O'Connell, D., Shaikhibrahim, Z., Kramer, F., Ocker, M., 2020. Biomarkers from Bench to Bedside and Back - Back-Translation of Clinical Studies to Preclinical Models. In: Rahbari, R., Van Niewaal, J., Bleavins, M.R. (Eds.), Biomarkers in Drug Discovery and Development: A Handbook of Practice, Application, and Strategy. Wiley-Blackwell, Hoboken, pp. 309-331.
Paton, C.M., Ntambi, J.M., 2009. Biochemical and physiological function of stearoyl-CoA desaturase. Am J Physiol Endocrinol Metab 297, E28-37.
Pawlak, M., Lefebvre, P., Staels, B., 2015. Molecular mechanism of PPARalpha action and its impact on lipid metabolism, inflammation and fibrosis in non-alcoholic fatty liver disease. J Hepatol 62, 720733.
Pierantonelli, I., Svegliati-Baroni, G., 2019. Nonalcoholic Fatty Liver Disease: Basic Pathogenetic Mechanisms in the Progression From NAFLD to NASH. Transplantation 103, e1-e13.
Ocker: NASH drug development
20
Polyzos, S.A., Toulis, K.A., Goulis, D.G., Zavos, C., Kountouras, J., 2011. Serum total adiponectin in nonalcoholic fatty liver disease: a systematic review and meta-analysis. Metabolism 60, 313-326.
Ratziu, V., Goodman, Z., Sanyal, A., 2015. Current efforts and trends in the treatment of NASH. J Hepatol 62, S65-75.
Razavi Zade, M., Telkabadi, M.H., Bahmani, F., Salehi, B., Farshbaf, S., Asemi, Z., 2016. The effects of DASH diet on weight loss and metabolic status in adults with non-alcoholic fatty liver disease: a randomized clinical trial. Liver Int 36, 563-571.
Rinella, M.E., Tacke, F., Sanyal, A.J., Anstee, Q.M., 2019. Report on the AASLD/EASL joint workshop on clinical trial endpoints in NAFLD. J Hepatol 71, 823-833.
Rodriguez, B., Torres, D.M., Harrison, S.A., 2012. Physical activity: an essential component of lifestyle modification in NAFLD. Nat Rev Gastroenterol Hepatol 9, 726-731.
Roeb, E., Geier, A., 2019. Nonalcoholic steatohepatitis (NASH) - current treatment recommendations and future developments. Z Gastroenterol 57, 508-517.
Sanyal, A.J., Brunt, E.M., Kleiner, D.E., Kowdley, K.V., Chalasani, N., Lavine, J.E., Ratziu, V., McCullough, A., 2011. Endpoints and clinical trial design for nonalcoholic steatohepatitis. Hepatology 54, 344-353.
Schults, M.A., Nagle, P.W., Rensen, S.S., Godschalk, R.W., Munnia, A., Peluso, M., Claessen, S.M., Greve, J.W., Driessen, A., Verdam, F.J., Buurman, W.A., van Schooten, F.J., Chiu, R.K., 2012. Decreased nucleotide excision repair in steatotic livers associates with myeloperoxidaseimmunoreactivity. Mutat Res 736, 75-81.
Schumacher-Petersen, C., Christoffersen, B.O., Kirk, R.K., Ludvigsen, T.P., Zois, N.E., Pedersen, H.D., Vyberg, M., Olsen, L.H., 2019. Experimental non-alcoholic steatohepatitis in Gottingen Minipigs: consequences of high fat-fructose-cholesterol diet and diabetes. J Transl Med 17, 110.
Ocker: NASH drug development
21
Sepideh, A., Karim, P., Hossein, A., Leila, R., Hamdollah, M., Mohammad, E.G., Mojtaba, S., Mohammad, S., Ghader, G., Seyed Moayed, A., 2016. Effects of Multistrain Probiotic Supplementation on Glycemic and Inflammatory Indices in Patients with Nonalcoholic Fatty Liver Disease: A Double-Blind Randomized Clinical Trial. J Am Coll Nutr 35, 500-505.
Stephenson, K., Kennedy, L., Hargrove, L., Demieville, J., Thomson, J., Alpini, G., Francis, H., 2018. Updates on Dietary Models of Nonalcoholic Fatty Liver Disease: Current Studies and Insights. Gene Expr 18, 5-17.
Sumida, Y., Okanoue, T., Nakajima, A., 2019. Phase 3 drug pipelines in the treatment of non-alcoholic steatohepatitis. Hepatol Res.
Tacke, F., 2018. Cenicriviroc for the treatment of non-alcoholic steatohepatitis and liver fibrosis. Expert Opin Investig Drugs 27, 301-311.
Tanaka, N., Aoyama, T., Kimura, S., Gonzalez, F.J., 2017. Targeting nuclear receptors for the treatment of fatty liver disease. Pharmacol Ther 179, 142-157.
Tanwar, S., Trembling, P.M., Guha, I.N., Parkes, J., Kaye, P., Burt, A.D., Ryder, S.D., Aithal, G.P., Day, C.P., Rosenberg, W.M., 2013. Validation of terminal peptide of procollagen III for the detection and assessment of nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease. Hepatology 57, 103-111.
Thiagarajan, P., Aithal, G.P., 2019. Drug Development for Nonalcoholic Fatty Liver Disease: Landscape and Challenges. J Clin Exp Hepatol 9, 515-521.
Tilg, H., Moschen, A.R., 2010. Evolution of inflammation in nonalcoholic fatty liver disease: the multiple parallel hits hypothesis. Hepatology 52, 1836-1846.
Ocker: NASH drug development
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Tsuchida, T., Lee, Y.A., Fujiwara, N., Ybanez, M., Allen, B., Martins, S., Fiel, M.I., Goossens, N., Chou, H.I., Hoshida, Y., Friedman, S.L., 2018. A simple diet- and chemical-induced murine NASH model with rapid progression of steatohepatitis, fibrosis and liver cancer. J Hepatol 69, 385-395.
Ueno, T., Komatsu, M., 2017. Autophagy in the liver: functions in health and disease. Nat Rev Gastroenterol Hepatol 14, 170-184.
Vilar-Gomez, E., Calzadilla-Bertot, L., Friedman, S.L., Gra-Oramas, B., Gonzalez-Fabian, L., Lazo-Del Vallin, S., Diago, M., Adams, L.A., 2017. Serum biomarkers can predict a change in liver fibrosis 1 year after lifestyle intervention for biopsy-proven NASH. Liver Int 37, 1887-1896.
Wang, P.X., Ji, Y.X., Zhang, X.J., Zhao, L.P., Yan, Z.Z., Zhang, P., Shen, L.J., Yang, X., Fang, J., Tian, S., Zhu, X.Y., Gong, J., Zhang, X., Wei, Q.F., Wang, Y., Li, J., Wan, L., Xie, Q., She, Z.G., Wang, Z., Huang, Z., Li, H., 2017. Targeting CASP8 and FADD-like apoptosis regulator ameliorates nonalcoholic steatohepatitis in mice and nonhuman primates. Nat Med 23, 439-449.
Weiskirchen, R., Tacke, F., 2019. Relevance of Autophagy in Parenchymal and Non-Parenchymal Liver Cells for Health and Disease. Cells 8.
Wieckowska, A., Feldstein, A.E., 2008. Diagnosis of nonalcoholic fatty liver disease: invasive versus noninvasive. Semin Liver Dis 28, 386-395.
Wong, C.H., Siah, K.W., Lo, A.W., 2019. Estimation of clinical trial success rates and related parameters. Biostatistics 20, 273-286.
Wong, R.H., Chang, I., Hudak, C.S., Hyun, S., Kwan, H.Y., Sul, H.S., 2009. A role of DNA-PK for the metabolic gene regulation in response to insulin. Cell 136, 1056-1072.
Xia, J., Yuan, J., Xin, L., Zhang, Y., Kong, S., Chen, Y., Yang, S., Li, K., 2014. Transcriptome analysis on the inflammatory cell infiltration of nonalcoholic steatohepatitis in bama minipigs induced by a longterm high-fat, high-sucrose diet. PLoS One 9, e113724.
Ocker: NASH drug development
23
Yilmaz, Y., 2012. Review article: is non-alcoholic fatty liver disease a spectrum, or are steatosis and non-alcoholic steatohepatitis distinct conditions? Aliment Pharmacol Ther 36, 815-823.
Younossi, Z.M., 2019. Non-alcoholic fatty liver disease - A global public health perspective. J Hepatol 70, 531-544.
Younossi, Z.M., Stepanova, M., Younossi, Y., Golabi, P., Mishra, A., Rafiq, N., Henry, L., 2019. Epidemiology of chronic liver diseases in the USA in the past three decades. Gut.
Zhou, J.H., Cai, J.J., She, Z.G., Li, H.L., 2019. Noninvasive evaluation of nonalcoholic fatty liver disease: Current evidence and practice. World J Gastroenterol 25, 1307-1326.
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Table 1. Overview on dietary models for NAFLD and NASH. Model
NAFLD
NASH
Metabolic Syndrome
Obesity
Fibrosis
HCC
Comments
CDAA
+
+
-
-
+
< 5%
Sex differences; cachexia
CDAHFD
+
+
-
-
+
(+)
CD-HFD
+
+
+
+
+
25%
FFC
+
+
+
+
+
HFD
+
-
+
+
-
-
HFD + DEN
+
+
+
+
+
100%
MCD
+
+
-
-
+
-
WD
+
+
+
+
+
89%
WD + CCl4
+
+
+
+
+
> 50%
db/db + MCD
+
+
+
+
+
ob/ob + MCD
+
+
+
+
-
myc + MCD
+
+
-
-
+
Zucker rats + HFD
+
+
+
+
+
Low HCC incidence after 12 to 15 months HCC formation after 12 months
HCC formation after 9 months Cachexia and weight loss HCC formation after ~ 10 months Rapid HCC formation after 6 months
+
CCl4: Carbon tetracholide; CDAA: choline-deficient; L-amino-acid-defined diet; CDAHFD: choline-deficient, L-amino-acid-defined, high-fat diet; CD-HFD: cholinedeficient, high-fat diet; db/db: diabetic mouse model with mutation in leptin receptor; DEN: diethylnitrosamine; FFC: high-fat, fructose, cholesterol diet; HFD:
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high-fat diet; MCD: methionine-choline-deficient diet; myc: myc-transgenic; ob/ob: obesity mouse model with mutation in leptin; WD: western diet (high-fat, high-cholesterol, high-fructose)
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Table 2. Surrogate endpoints for clinical trials in NAFLD and NASH (Thiagarajan and Aithal, 2019). Endpoint
Tissue based
Noninvasive
Metabolic parameters
Steatosis
Imaging techniques(e.g. MRI-PDFF, ultrasound, elastography) Insuline resistance (e.g. HbA1c, oral glucose tolerance test, fasting glucose levels) Lipid profile BMI
Inflammation
Steatohepatitis
Imaging techniques (e.g. MRI, spectroscopy) Blood-based biomarkers (e.g. cytokines, ALT) NAS
Fibrosis
Fibrosis stage/scores
Fibrosis scores (e.g. Fib-4) Imaging techniques (e.g. elastography, spectroscopy) Blood-based scores (e.g. ELF score, PIIINP)
MRI-PDFF: magnetic resonance imaging proton density fat fraction; BMI: body mass index; NAS: NAFLD activity score; PIIINP: pro-collagen type III N-terminal peptide
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Table 3. Currently ongoing Phase 3 studies for NASH registered at clinicaltrials.gov NCT#
Drug
MoA
Patients
Time points
Primary outcome
Secondary outcome
NCT02704403
Elafibranor
PPARα/δ agonist
N = 2000,
72 wks -> 4 yrs
Resolution of NASH without Improvement in fibrosis (72 wks)
NAS > 4,
worsening of fibrosis (72 wks)
fibrosis > 1 and < 4
All-cause
mortality,
Improvement
in
histological
cirrhosis, NASH scores
liver-related clinical outcomes (4 Improvement in cardiometabolic yrs)
and liver markers Liver-related death
NCT03439254
Obeticholic
FXR agonist
acid
NCT03723252
Dapagliflozin SGLT2 inhibitor
N = 900,
72 wks
Improvement in fibrosis by 1 Improvement in fibrosis by 2
NASH and fibrosis
stage with no worsening of stages (72 wks)
score 4
NASH (72 wks)
Resolution of NASH
Improvement in liver histology
Resolution of NASH
N = 100,
52 wks
NASH (liver biopsy)
Various
metabolic
inflammatory
endpoints,
and e.g.
HbA1c, body weight, lipids, … NCT03028740
Cenicriviroc
CCR2/5
N = 2000,
52 wks -> 5 yrs
Improvement in fibrosis by 1 Improvement in fibrosis by 1
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28
NASH fibrosis stage
stage (52 wks)
2 or 3
Composite
stage (5 yrs) endpoint
on
cirrhosis, liver-related clinical outcome, all-cause mortality (5 yrs) NCT04104321
Aramchol
SCD-1 modulator
N = 2000,
52 wks
Resolution
of
NASH
or All-cause
mortality,
(arachidyl
NASH, NAS > 4,
improvement in fibrosis by 1 transplantation,
amido
fibrosis stage 2 or 3
stage and no worsening of NASH
cholanoic
liver
histological
progression, MELD score > 15 hospitalization
acid NCT03900429
Resmetirom
THR-β agonist
(MGL-3196)
N = 2000, NASH,
24 to 53 wks fibrosis
NASH resolution on histology (2 Change in LDL-cholesterol at 24 point reduction in NAS)
stage 2 or 3
wks
Composite endpoint on all-cause Improvement in fibrosis mortality, cirrhosis, liver-related clinical outcomes
NCT02654665
Liraglutide
GLP-1 agonist
N = 36,
52 wks
Improvement
in
NASH
Ocker: NASH drug development and bariatric
Obesity, NASH
29 (transaminases, steatosis)
surgery NCT03970031
MSDC0602K
MPC modulator
N = 3600,
24 to 124 wks
Change in HbA1c (24 wks)
Death or major hepatic or
NASH with fibrosis,
Histological resolution of NASH cardiac adverse event
type 2 diabetes
(52 wks)
PPARα/δ: peroxisome proliferator activated receptor α/δ; NAS: NAFLD activity score; wks: weeks; yrs: years; FXR: farnesoid X receptor; SGLT2: sodium glucose co-transporter 2; CCR2/5: chemokine receptor 2/5; SCD-1: stearyl-CoA desaturase-1; THR-β: thyroid hormone receptor β; GLP-1: glucagon-like peptide 1; MPC: mitochondrial pyruvate carrier
S0014-2999(20)30005-4
DOI:
https://doi.org/10.1016/j.ejphar.2020.172913
Reference:
EJP 172913
To appear in:
European Journal of Pharmacology
Received Date: 30 October 2019 Revised Date:
4 December 2019
Accepted Date: 7 January 2020
Please cite this article as: Ocker, M., Challenges and opportunities in drug development for nonalcoholic steatohepatitis, European Journal of Pharmacology (2020), doi: https://doi.org/10.1016/ j.ejphar.2020.172913. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier B.V.
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Challenges and opportunities in drug development for nonalcoholic steatohepatitis
Matthias Ockera
a
Charité University Medicine Berlin, Berlin, Germany. [email protected]
Declaration of interest The author declares no conflict of interest related to this publication.
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Abstract Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are considered major global medical burdens with high prevalence and steeply rising incidence. Despite the characterization of numerous pathophysiologic pathways leading to metabolic disorder, lipid accumulation, inflammation, fibrosis, and ultimately end-stage liver disease or liver cancer formation, so far no causal pharmacological therapy is available. Drug development for NAFLD and NASH is limited by long disease duration and slow progression and the need for sequential biopsies to monitor the disease stage. Additional non-invasive biomarkers could therefore improve design and feasibility of such. Here, the current concepts on preclinical models, biomarkers and clinical endpoints and trial designs are briefly reviewed.
Abstract word count: 108
Keywords nonalcoholic fatty liver disease (NAFLD); nonalcoholic steatohepatitis (NASH); biomarker; clinical trials; drug development; drug discovery
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1. Introduction The liver is the central metabolic organ and affected by different acute and chronic injuries and chronic liver disease (CLD) remains a major medical burden worldwide. While in the past viral hepatitis was seen as the major cause of chronic liver disease, the incidence and prevalence of hepatitis B (HBV) and C (HCV) infections significantly decreased in recent years due to vaccination strategies and novel treatment options, nonalcoholic fatty liver disease (NAFLD) and subsequent nonalcoholic steatohepatitis (NASH) have now become the major cause of CLD. Although alcohol and HCV still remain significant, it is estimated that approx. 60% of CLD cases are now due to NAFLD and NASH (Younossi, 2019; Younossi et al., 2019). In the past 30 years, the prevalence of NAFLD in the general population of the US increased from 20% to 31.9% and was paralleled by an increase in obesity (from 22.2% to 38.9%), type 2 diabetes (from 7.2 to 13.5%), insulin resistance and hypertension (Younossi et al., 2019). In this study, NAFLD was identified as the only liver disease with increasing prevalence and diabetes and obesity have been shown to be independent predictors for NAFLD development. Considering the globally increasing rate of obesity and diabetes in children and young adults, it is estimated that the overall prevalence of NAFLD and NASH will increase by 21.3% and 63% until 2030, respectively, and NAFLD will then affect more than 100 million people (Estes et al., 2018). Due to the chronic nature, progression of NAFLD to NASH is commonly associated with the development of fibrosis and, over time, leading to cirrhosis and end-stage liver disease with an increased risk of development of hepatocellular carcinoma (HCC). It is thus expected that the prevalence of decompensated cirrhosis and HCC will increase steeply by 168% and 137%, respectively, until 2030 (Estes et al., 2018). Overall, CLD and its complications are estimated to cause annual health care costs of approx. 30 billion US$ (Moon et al., 2019). These numbers underline the need for improved diagnostic and surveillance approaches for NAFLD and NASH. Unfortunately, despite the high medical need, no causative treatment option is available yet. Clinical practice guidelines usually recommend weight reduction, lifestyle interventions and
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symptomatic treatment although epidemiologic data indicate that NAFLD patients tend to an unhealthy lifestyle and overconsumption of high-calorie soft drinks and food (Ratziu et al., 2015). While there is a strong pathophysiologic rationale (see below) to improve insulin resistance via exercise and to reduce calorie intake, only limited prospective clinical data is available to support this hypothesis. Available studies are usually observational studies and focus on weight loss over a small period of time only, as long-term adherence to exercise or dietary restrictions are difficult to achieve and most studies show low compliance even during a shorter time frame (Neuschwander-Tetri, 2009). Recent studies demonstrate a beneficial effect on steatosis and insulin resistance even by short-term exercise interventions even if no weight loss is achieved and exercise programs are now recommended to NAFLD and NASH patients (Rodriguez et al., 2012). Weak recommendations are currently given for the use of anti-oxidants like vitamin E, and for metabolic drugs like statins or glitazones (Blond et al., 2017; Chalasani et al., 2018). The complex biology and interplay between inflammation, metabolism and extracellular matrix deposition have so far limited drug development activities, also due to slow disease progression and uncertainty about appropriate endpoints for clinical trials. In this article, the current landscape for NASH drug development, its challenges and opportunities, and the underlying pathophysiology of the disease will be reviewed.
2. Pathophysiology of NAFLD and NASH Understanding the pathophysiology of NAFLD and how it progresses to NASH is crucial for identification of novel drug targets and the selection of appropriate preclinical models as well as clinical endpoints. Here, only basic principles will be reviewed and the reader is referred to other recent reviews focusing on more pathophysiologic details (Bessone et al., 2019; Manne et al., 2018; Pierantonelli and Svegliati-Baroni, 2019). Several pathophysiologic models of NAFLD and NASH have been proposed over the past decades, e.g. the “two-hit hypothesis” (Day and James, 1998), the “parallel multiple-hit theory” (Tilg and
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Moschen, 2010), and most recently the “distinct-hit theory” (Yilmaz, 2012). Common to those hypotheses are insulin resistance and hepatocytic lipid accumulation while the causal relationship of those phenomena is seen differently. Additional inflammatory hits, which can themselves lead to increased lipid accumulation, then trigger progression into NASH. In brief, metabolic disturbances lead to increased release of free fatty acids from adipocytes and increased glucose levels due to impaired uptake into adipocytes. This triggers further fatty acid synthesis in the liver which leads to toxic fatty acid metabolites, impaired lipophagy and release of VLDL and induction of oxidative stress via mitochondrial β-oxidation. These mechanisms maintain a pro-inflammatory environment which is associated with progression to NASH. Oxidative stress can cause hepatocyte apoptosis and activates hepatic stellate cells and Kupffer cells, both being key players for fibrogenesis and cirrhosis formation. Chronic oxidative stress and toxic lipid metabolites can also lead to DNA damage and activation of respective repair mechanisms like ATM (by reactive oxygen species or DNA doublestrand breaks) (Guo et al., 2010) or the rather error-prone non-homologous end-joining (NHEJ) via DNA-dependent protein kinase (DNAPK) also in NAFLD and NASH (Gao et al., 2004; Schults et al., 2012; Wong et al., 2009). While accumulating toxic metabolites are normally cleared by autophagy as a scavenger mechanism, this pathway is inhibited in NAFLD by excess triglycerides and free fatty acids which interfere with the PI3K/AKT/mTOR pathway, inhibit activation of the autophagy-sensing kinase ULK1 and trigger further intracellular stress by activating the endoplasmatic reticulum (ER) stress response (Lebeaupin et al., 2018; Ueno and Komatsu, 2017; Weiskirchen and Tacke, 2019). This maintains the vicious circle of further DNA damage, hepatocyte cell death, chronic inflammation and regeneration. Peripheral insulin resistance also contributes to sterile hepatic inflammation by release of proinflammatory cytokines like TNF-α, IL-1β, IL-6 or IL-8 from adipocytes which further attracts inflammatory cells to the liver (Bessone et al., 2019; El Husseny et al., 2017; Polyzos et al., 2011).
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3. Target discovery and drug development 3.1. Basic considerations The development of a new drug represents requires significant financial commitment over a period of more than 10 years. Since the early 2000s, costs for one newly approved drug exceed 1 billion US$ and mitigating the risk for failure is therefore of high priority for the pharmaceutical industry (Dugger et al., 2018). Considering the high global prevalence and increasing incidence, NAFLD and NASH clearly present an attractive commercial space for drug development and the disease itself has a high unmet medical need, both are considered basic pillars for the assessment of potential new drug targets (Gashaw et al., 2011). An overview on current and emerging anti-fibrotic therapies in other chronic liver diseaseshas recently been published elsewhere (Lemoinne and Friedman, 2019).
3.2. Animal models While the pathophysiology of NAFLD and NASH is well characterized, a plethora of potential drug targets is available, e.g. metabolic targets, immune modulation targets or antifibrotic and antiproliferative targets, although the individual contribution to the disease progression may still remain elusive. To fully characterize those potential targets, the availability of predictive preclinical models with high translatability to the human disease setting is of utmost importance (Gashaw et al., 2011). Mouse models for NASH are usually dietary models with our without additional genetic or toxic stimuli (Table 1) (Anstee et al., 2019; Ibrahim et al., 2016; Kucera and Cervinkova, 2014). Commonly used models are the methionine-choline-deficient (MCD) model, the high-fat diet (HFD) model or the Western diet (WD) model consisting of a high-fat, high-fructose and high-cholesterol (FFC) diet (Stephenson et al., 2018). Variants of these models include e.g. the concomitant application of carbon tetrachloride (CCl4) (Tsuchida et al., 2018) or are used in e.g. myc-transgenic mice (Ma et al., 2016)., FFC (Charlton et al., 2011), WD or the CD-HFD mimic human pathophysiology but results obtained from rodents should be validated in other species as energy metabolism and immune regulation are different in higher mammals. Humanized mice that reflect the human immune system more closely have been developed recently and were used for preclinical NASH
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models (Hui et al., 2018). Several dietary models have been applied to minipigs, e.g. the high-fat, high-sucrose diet in bama minipigs (Xia et al., 2014) or WD in Lee-Sung minipigs (Li et al., 2016). Yet, some of these larger animal models show high variability and need further optimization before routine use in preclinical drug development (Schumacher-Petersen et al., 2019). Although nonhuman primates have been successfully used for experimental NASH models and treatments (Esquejo et al., 2018; Goedeke et al., 2019; Wang et al., 2017), their general use is limited due to ethical reasons and slow disease progression similar to humans.
3.3. Biomarkers Biomarkers can be used for diagnosis, patient stratification and selection, disease monitoring and monitoring of treatment response (Califf, 2018; Group, 2016). They play a major role in increasing the probability of success in drug development and applying biomarkers for patient stratification can double the overall success rate for FDA approval from 5.5 to 10.3% with steepest effects in early phases of clinical development (Wong et al., 2019). While biopsies are still considered gold standard for diagnosis and monitoring of liver diseases, their availability is limited due to invasiveness and the susceptibility to sampling error. Noninvasive biomarkers and biomarker scores as well imaging techniques have been established as diagnostic biomarker tools for NAFLD, NASH and fibrosis and have recently been discussed elsewhere (Castera et al., 2019; Drescher et al., 2019; Zhou et al., 2019). Due to the long and slow disease progression, these noninvasive biomarkers are important to monitor the course of the disease and response to treatment (Wieckowska and Feldstein, 2008), although histological improvement (of fibrosis) should be confirmed according to FDA guidelines (Sanyal et al., 2011). Ideally, noninvasive biomarkers would detect changes in steatosis e.g. via magnetic resonance imaging proton density fat fraction (MRIPDFF) measurements (Jayakumar et al., 2019; Middleton et al., 2017), changes in liver function e.g. via measurement of transaminases, and changes in fibrosis e.g. via elastography techniques or validated serum scores like the aspartate aminotransferase to platelet ratio index (APRI) or the fibrosis-4 (FIB-4) score (Vilar-Gomez et al., 2017; Zhou et al., 2019).
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These panels are therefore considered adequate surrogate endpoints for clinical trials since the primary endpoint of reducing liver-related mortality might not be feasible to achieve due to the long course of the disease (Sanyal et al., 2011). Pharmacodynamic, or on-target biomarkers, are of high value during the early phases of clinical drug development. These biomarkers show if and to what extent a drug target is modulated (inhibited/activated) by a certain therapy and if the observed effects relate to the anticipated mode of action and to the expected clinical outcome. Pharmacodynamic biomarkers, together with safety data and pharmacokinetic data, are therefore important for finding the adequate dose and dosing schedule and for early de-risking of a drug candidate (O'Connell et al., 2020). Depending on the drug target, various potential biomarkers related to steatosis, metabolism (e.g. fatty acids, insulin resistance, glucose levels, adipokines, cholesterol levels etc.) (Hodson et al., 2017; Maciejewska et al., 2018; Razavi Zade et al., 2016), fibrogenesis (e.g. pro-collagen type III N-terminal peptide (PIIINP), hyaluronic acid, TIMP1) (Javed et al., 2019; Tanwar et al., 2013) or inflammation (e.g. cytokines, chemokines) (Farsi et al., 2016; Sepideh et al., 2016) were proposed besides the above mentioned scores or liver stiffness evaluations (Drescher et al., 2019).
3.4. Current drug targets Based on these considerations, several anti-NASH drug targets have been identified and are currently undergoing clinical investigation (Table 3). The majority of these drugs targets metabolic pathways (e.g. PPAR α/δ, FXR), but inflammatory (e.g. CCR2/5) or other cellular pathways (e.g. THR-β) related to NASH progression are also explored. Peroxisome proliferator-activated receptors (PPARs) are nuclear protein receptors that regulate genes for cellular differentiation, development and various pathways involved in lipid and glucose metabolism (Liss and Finck, 2017; Pawlak et al., 2015). PPAR α is predominantly expressed in the liver and plays a role in fatty acid and triglyceride metabolism, beta oxidation, ketogenesis and may also have anti-inflammatory roles. PPAR δ is expressed in skeletal muscle, adipocytes, hepatocytes and
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Kupffer cells and regulates mitochondrial metabolism, fatty acid metabolism and inflammation (Liss and Finck, 2017; Pawlak et al., 2015). Farnesoid X receptor (FXR) is another nuclear receptor involved in regulation of lipid, glucose and bile acid metabolism. Under physiologic conditions, FXR is a sensor for enterohepatic bile acid circulation (Tanaka et al., 2017). Stimulation of FXR has been shown to improve diabetes and steatosis via FGF15 signaling (Fang et al., 2015) and to reduce inflammation via inhibition of NF-κB and reduced production of proinflammatory cytokines (Inagaki et al., 2006). The sodium glucose co-transporter 2 (SGLT2) is expressed in the kidney and regulates urinary glucose reabsorption. SGLT2 inhibition was shown to reduce blood glucose levels and body weight in diabetic patients (Khan et al., 2019). Stearyl-CoA desaturase-1 (SCD-1) is the rate limiting enzyme in fatty acid synthesis and metabolism (Paton and Ntambi, 2009). SCD-1 is overexpressed in the liver under high carbohydrate diet and correlated with obesity, diabetes and metabolic syndrome (Flowers and Ntambi, 2009). Mice deficient in SCD-1 show reduced obesity and insulin resistance. Thyroid hormones can stimulate energy metabolism in the liver. Therefore, agonist at thyroid hormone receptors (THR-β agonists) can positively affect cholesterol and triglyceride levels and have been shown to improve steatosis in various mouse models (Dibba et al., 2018; Kowalik et al., 2018). Glucagon-like peptide 1 (GLP-1) is a cleavage product or proglucagon and stimulates secretion of insulin. GLP-1 agonist have been shown to lower blood glucose levels and improve metabolic function and steatosis in the liver (Knudsen and Lau, 2019). The mitochondrial pyruvate carrier (MPC) is a central regulator of oxidative and non-oxidative metabolic pathways. It was identified as a new binding site for antidiabetic thiazolidindiones and is upregulated under high-fat conditions (Colca et al., 2013). Knockdown or inhibition of MPC was shown to protect hepatocytes from lipotoxicity and to improve steatosis (Colca et al., 2018). In contrast to these metabolic drug targets, inhibition of the C-C chemokine receptors 2 and 5 (CCR2/5) aims at suppressing the infiltration of inflammatory cells, esp. Kupffer cells, macrophages
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and monocytes via CCR2 and T and NK cells via CCR5, during fibrosis and NASH progression (Tacke, 2018).
4. Clinical Development, endpoints and study design Successful clinical drug development and authority approval is closely linked to selecting the right endpoints and finding the best patient population. The ultimate primary endpoint for a successful NASH therapy would be the reduction in liver-related mortality. Yet, due to the long course of the disease, this endpoint is not considered feasible as study duration would easily exceed 10 years or more. In the accelerated approval process, US FDA can grant drug approval based on surrogate endpoints that are “reasonably likely to predict clinical benefit, or on a clinical endpoint that occurs earlier but may not be as robust as the standard endpoint used for approval. This approval pathway is especially useful when the drug is meant to treat a disease whose course is long, and an extended period of time is needed to measure its effect.” (FDA, 2019a). This pathway also mandates postapproval clinical trials to verify the observed effects of the drug. A similar approach is supported by the European Medicines Agency granting conditional approval based on surrogate endpoints. Secondary endpoints in NAFLD and NASH could relate to improvement of steatosis, inflammation, fibrosis or metabolic conditions. Unfortunately, these parameters might still require sequential tissue biopsies which are invasive and prone to sampling error so that the above outlined non-invasive biomarkers should be considered, although FDA so far accepted only histopathologic findings (resolution of NASH without worsening of fibrosis or improvement in fibrosis without worsening of NASH or combined resolution of fibrosis and improvement in fibrosis) as surrogate endpoints for precirrhotic patients with NASH (Cheung et al., 2019). Yet, the clinical significance of these and other surrogate endpoints like decompensation of cirrhosis, HCC incidence or decrease in portal vein pressure gradient, is still elusive and needs long-term follow-up (Rinella et al., 2019). An overview on these surrogate endpoints is provided in Table 2 and recently finished pivotal phase 2 studies actually applied some of these endpoints in conjunction with biopsies (Rinella et al., 2019; Roeb and Geier, 2019; Thiagarajan and Aithal, 2019). It is also recommended to adhere to FDA’s guidance documents
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on drug development for treatment of NASH fibrosis or compensated cirrhosis where adequate endpoints for Phase 2 and 3 studies are defined (FDA, 2018; 2019b). Therefore, currently (November 2019) ongoing Phase 3 studies in NASH still rely on histological endpoints like resolution of NASH and improvement in fibrosis (Table 3). Interestingly, these studies differ in their respective endpoints and in the patient populations enrolled and it is noteworthy, that fibrosis resolution or improvement in NAFLD activity score (NAS) by 2 points (which is an FDA accepted endpoint for efficacy) is observed in 12 to 25% of the placebo controls, too. For further details on ongoing Phase 3 studies, please see other recent reviews (Alukal and Thuluvath, 2019; Roeb and Geier, 2019; Sumida et al., 2019). Yet, the clinical significance of these surrogate endpoints is still elusive and long-term follow-up is needed. To further accelerate NASH drug development, adaptive (seamless) trial designs have proposed. Although some operational and regulatory aspects may be more complex in such a study, it provides an opportunity for patients to continue in different phases of the development and thus limit the need for enrolling new patients and it may reduce the required number of serial biopsies (Filozof et al., 2017).
5. Conclusion NAFLD and NASH are globally steeply increasing in incidence and prevalence. So far, no causative pharmacological therapy is available. NASH can progress to end-stage liver disease with need for transplantation and to HCC, so that effective treatment strategies are urgently needed. The complex pathophysiology of metabolic disturbance, insulin resistance, lipid accumulation, inflammation and fibrotic deployment lead to the identification of numerous potential targets for drug development. In this process, the selection of appropriate preclinical animal models that closely reflect human pathophysiology is important to validate the drug target and to confirm the mode of action of a drug candidate. The successful translation of these finding is dependent on adequate biomarkers to monitor treatment response. While tissue biopsies still represent the goldstandard here, novel noninvasive biomarkers as well as imaging techniques have become available. Although those biomarkers are not yet accepted as an adequate primary endpoint by regulatory authorities, they are
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and have to be an essential part of Phase 2 and Phase 3 clinical studies to address their correlation with outcome and to then foster drug development for NASH. Currently, several interesting Phase 3 studies are ongoing and can support the basis for those surrogate endpoints as tissue based parameters will also be available for comparison.
Acknowledgements This publication did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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References Alukal, J.J., Thuluvath, P.J., 2019. Reversal of NASH fibrosis with pharmacotherapy. Hepatol Int 13, 534-545.
Anstee, Q.M., Reeves, H.L., Kotsiliti, E., Govaere, O., Heikenwalder, M., 2019. From NASH to HCC: current concepts and future challenges. Nat Rev Gastroenterol Hepatol 16, 411-428.
Bessone, F., Razori, M.V., Roma, M.G., 2019. Molecular pathways of nonalcoholic fatty liver disease development and progression. Cell Mol Life Sci 76, 99-128.
Blond, E., Disse, E., Cuerq, C., Drai, J., Valette, P.J., Laville, M., Thivolet, C., Simon, C., Caussy, C., 2017. EASL-EASD-EASO clinical practice guidelines for the management of non-alcoholic fatty liver disease in severely obese people: do they lead to over-referral? Diabetologia 60, 1218-1222.
Califf, R.M., 2018. Biomarker definitions and their applications. Exp Biol Med (Maywood) 243, 213221.
Castera, L., Friedrich-Rust, M., Loomba, R., 2019. Noninvasive Assessment of Liver Disease in Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology 156, 1264-1281 e1264.
Chalasani, N., Younossi, Z., Lavine, J.E., Charlton, M., Cusi, K., Rinella, M., Harrison, S.A., Brunt, E.M., Sanyal, A.J., 2018. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology 67, 328-357.
Charlton, M., Krishnan, A., Viker, K., Sanderson, S., Cazanave, S., McConico, A., Masuoko, H., Gores, G., 2011. Fast food diet mouse: novel small animal model of NASH with ballooning, progressive fibrosis, and high physiological fidelity to the human condition. Am J Physiol Gastrointest Liver Physiol 301, G825-834.
Ocker: NASH drug development
14
Cheung, A., Neuschwander-Tetri, B.A., Kleiner, D.E., Schabel, E., Rinella, M., Harrison, S., Ratziu, V., Sanyal, A.J., Loomba, R., Jeannin Megnien, S., Torstenson, R., Miller, V., 2019. Defining Improvement in Nonalcoholic Steatohepatitis for Treatment Trial Endpoints: Recommendations From the Liver Forum. Hepatology 70, 1841-1855.
Colca, J.R., McDonald, W.G., Adams, W.J., 2018. MSDC-0602K, a metabolic modulator directed at the core pathology of non-alcoholic steatohepatitis. Expert Opin Investig Drugs 27, 631-636.
Colca, J.R., McDonald, W.G., Cavey, G.S., Cole, S.L., Holewa, D.D., Brightwell-Conrad, A.S., Wolfe, C.L., Wheeler, J.S., Coulter, K.R., Kilkuskie, P.M., Gracheva, E., Korshunova, Y., Trusgnich, M., Karr, R., Wiley, S.E., Divakaruni, A.S., Murphy, A.N., Vigueira, P.A., Finck, B.N., Kletzien, R.F., 2013. Identification of a mitochondrial target of thiazolidinedione insulin sensitizers (mTOT)--relationship to newly identified mitochondrial pyruvate carrier proteins. PLoS One 8, e61551.
Day, C.P., James, O.F., 1998. Steatohepatitis: a tale of two "hits"? Gastroenterology 114, 842-845.
Dibba, P., Li, A.A., Perumpail, B.J., John, N., Sallam, S., Shah, N.D., Kwong, W., Cholankeril, G., Kim, D., Ahmed, A., 2018. Emerging Therapeutic Targets and Experimental Drugs for the Treatment of NAFLD. Diseases 6.
Drescher, H.K., Weiskirchen, S., Weiskirchen, R., 2019. Current Status in Testing for Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH). Cells 8.
Dugger, S.A., Platt, A., Goldstein, D.B., 2018. Drug development in the era of precision medicine. Nat Rev Drug Discov 17, 182-196.
El Husseny, M.W., Mamdouh, M., Shaban, S., Ibrahim Abushouk, A., Zaki, M.M., Ahmed, O.M., AbdelDaim, M.M., 2017. Adipokines: Potential Therapeutic Targets for Vascular Dysfunction in Type II Diabetes Mellitus and Obesity. J Diabetes Res 2017, 8095926.
Ocker: NASH drug development
15
Esquejo, R.M., Salatto, C.T., Delmore, J., Albuquerque, B., Reyes, A., Shi, Y., Moccia, R., Cokorinos, E., Peloquin, M., Monetti, M., Barricklow, J., Bollinger, E., Smith, B.K., Day, E.A., Nguyen, C., Geoghegan, K.F., Kreeger, J.M., Opsahl, A., Ward, J., Kalgutkar, A.S., Tess, D., Butler, L., Shirai, N., Osborne, T.F., Steinberg, G.R., Birnbaum, M.J., Cameron, K.O., Miller, R.A., 2018. Activation of Liver AMPK with PF06409577 Corrects NAFLD and Lowers Cholesterol in Rodent and Primate Preclinical Models. EBioMedicine 31, 122-132.
Estes, C., Razavi, H., Loomba, R., Younossi, Z., Sanyal, A.J., 2018. Modeling the epidemic of nonalcoholic fatty liver disease demonstrates an exponential increase in burden of disease. Hepatology 67, 123-133.
Fang, S., Suh, J.M., Reilly, S.M., Yu, E., Osborn, O., Lackey, D., Yoshihara, E., Perino, A., Jacinto, S., Lukasheva, Y., Atkins, A.R., Khvat, A., Schnabl, B., Yu, R.T., Brenner, D.A., Coulter, S., Liddle, C., Schoonjans, K., Olefsky, J.M., Saltiel, A.R., Downes, M., Evans, R.M., 2015. Intestinal FXR agonism promotes adipose tissue browning and reduces obesity and insulin resistance. Nat Med 21, 159-165.
Farsi, F., Mohammadshahi, M., Alavinejad, P., Rezazadeh, A., Zarei, M., Engali, K.A., 2016. Functions of Coenzyme Q10 Supplementation on Liver Enzymes, Markers of Systemic Inflammation, and Adipokines in Patients Affected by Nonalcoholic Fatty Liver Disease: A Double-Blind, PlaceboControlled, Randomized Clinical Trial. J Am Coll Nutr 35, 346-353.
FDA, U., 2018. Noncirrhotic nonalcoholic steatohepatitis with liver fibrosis: developing drugs for treatment. Guidance for industry. https://www.fda.gov/media/119044/download (accessed 30.10.2019)
FDA, U., 2019a. Development & Approval Process | Drugs. https://www.fda.gov/drugs/developmentapproval-process-drugs (accessed 28.10.2019)
Ocker: NASH drug development
16
FDA, U., 2019b. Nonalcoholic steatohepatitis with compensated cirrhosis: developing drugs for treatment. Guidance for industry. https://www.fda.gov/media/127738/download (accessed 30.10.2019)
Filozof, C., Chow, S.C., Dimick-Santos, L., Chen, Y.F., Williams, R.N., Goldstein, B.J., Sanyal, A., 2017. Clinical endpoints and adaptive clinical trials in precirrhotic nonalcoholic steatohepatitis: Facilitating development approaches for an emerging epidemic. Hepatol Commun 1, 577-585.
Flowers, M.T., Ntambi, J.M., 2009. Stearoyl-CoA desaturase and its relation to high-carbohydrate diets and obesity. Biochim Biophys Acta 1791, 85-91.
Gao, D., Wei, C., Chen, L., Huang, J., Yang, S., Diehl, A.M., 2004. Oxidative DNA damage and DNA repair enzyme expression are inversely related in murine models of fatty liver disease. Am J Physiol Gastrointest Liver Physiol 287, G1070-1077.
Gashaw, I., Ellinghaus, P., Sommer, A., Asadullah, K., 2011. What makes a good drug target? Drug Discov Today 16, 1037-1043.
Goedeke, L., Peng, L., Montalvo-Romeral, V., Butrico, G.M., Dufour, S., Zhang, X.M., Perry, R.J., Cline, G.W., Kievit, P., Chng, K., Petersen, K.F., Shulman, G.I., 2019. Controlled-release mitochondrial protonophore (CRMP) reverses dyslipidemia and hepatic steatosis in dysmetabolic nonhuman primates. Sci Transl Med 11.
Group, F.-N.B.W., 2016. BEST (Biomarkers, EndpointS, and other Tools) Resource [Internet]. http://www.ncbi.nlm.nih.gov/pubmed/27010052 (accessed 28.10.2019)
Guo, Z., Kozlov, S., Lavin, M.F., Person, M.D., Paull, T.T., 2010. ATM activation by oxidative stress. Science 330, 517-521.
Hodson, L., Bhatia, L., Scorletti, E., Smith, D.E., Jackson, N.C., Shojaee-Moradie, F., Umpleby, M., Calder, P.C., Byrne, C.D., 2017. Docosahexaenoic acid enrichment in NAFLD is associated with
Ocker: NASH drug development
17
improvements in hepatic metabolism and hepatic insulin sensitivity: a pilot study. Eur J Clin Nutr 71, 973-979.
Hui, S.T., Kurt, Z., Tuominen, I., Norheim, F., R, C.D., Pan, C., Dirks, D.L., Magyar, C.E., French, S.W., Chella Krishnan, K., Sabir, S., Campos-Perez, F., Mendez-Sanchez, N., Macias-Kauffer, L., Leon-Mimila, P., Canizales-Quinteros, S., Yang, X., Beaven, S.W., Huertas-Vazquez, A., Lusis, A.J., 2018. The Genetic Architecture of Diet-Induced Hepatic Fibrosis in Mice. Hepatology 68, 2182-2196.
Ibrahim, S.H., Hirsova, P., Malhi, H., Gores, G.J., 2016. Animal Models of Nonalcoholic Steatohepatitis: Eat, Delete, and Inflame. Dig Dis Sci 61, 1325-1336.
Inagaki, T., Moschetta, A., Lee, Y.K., Peng, L., Zhao, G., Downes, M., Yu, R.T., Shelton, J.M., Richardson, J.A., Repa, J.J., Mangelsdorf, D.J., Kliewer, S.A., 2006. Regulation of antibacterial defense in the small intestine by the nuclear bile acid receptor. Proc Natl Acad Sci U S A 103, 3920-3925.
Javed, Z., Papageorgiou, M., Deshmukh, H., Kilpatrick, E.S., Mann, V., Corless, L., Abouda, G., Rigby, A.S., Atkin, S.L., Sathyapalan, T., 2019. A Randomized, Controlled Trial of Vitamin D Supplementation on Cardiovascular Risk Factors, Hormones, and Liver Markers in Women with Polycystic Ovary Syndrome. Nutrients 11.
Jayakumar, S., Middleton, M.S., Lawitz, E.J., Mantry, P.S., Caldwell, S.H., Arnold, H., Mae Diehl, A., Ghalib, R., Elkhashab, M., Abdelmalek, M.F., Kowdley, K.V., Stephen Djedjos, C., Xu, R., Han, L., Mani Subramanian, G., Myers, R.P., Goodman, Z.D., Afdhal, N.H., Charlton, M.R., Sirlin, C.B., Loomba, R., 2019. Longitudinal correlations between MRE, MRI-PDFF, and liver histology in patients with nonalcoholic steatohepatitis: Analysis of data from a phase II trial of selonsertib. J Hepatol 70, 133-141.
Khan, R.S., Bril, F., Cusi, K., Newsome, P.N., 2019. Modulation of Insulin Resistance in Nonalcoholic Fatty Liver Disease. Hepatology 70, 711-724.
Ocker: NASH drug development
18
Knudsen, L.B., Lau, J., 2019. The Discovery and Development of Liraglutide and Semaglutide. Front Endocrinol (Lausanne) 10, 155.
Kowalik, M.A., Columbano, A., Perra, A., 2018. Thyroid Hormones, Thyromimetics and Their Metabolites in the Treatment of Liver Disease. Front Endocrinol (Lausanne) 9, 382.
Kucera, O., Cervinkova, Z., 2014. Experimental models of non-alcoholic fatty liver disease in rats. World J Gastroenterol 20, 8364-8376.
Lebeaupin, C., Vallee, D., Hazari, Y., Hetz, C., Chevet, E., Bailly-Maitre, B., 2018. Endoplasmic reticulum stress signalling and the pathogenesis of non-alcoholic fatty liver disease. J Hepatol 69, 927-947.
Lemoinne, S., Friedman, S.L., 2019. New and emerging anti-fibrotic therapeutics entering or already in clinical trials in chronic liver diseases. Curr Opin Pharmacol 49, 60-70.
Li, S.J., Ding, S.T., Mersmann, H.J., Chu, C.H., Hsu, C.D., Chen, C.Y., 2016. A nutritional nonalcoholic steatohepatitis minipig model. J Nutr Biochem 28, 51-60.
Liss, K.H., Finck, B.N., 2017. PPARs and nonalcoholic fatty liver disease. Biochimie 136, 65-74.
Ma, C., Kesarwala, A.H., Eggert, T., Medina-Echeverz, J., Kleiner, D.E., Jin, P., Stroncek, D.F., Terabe, M., Kapoor, V., ElGindi, M., Han, M., Thornton, A.M., Zhang, H., Egger, M., Luo, J., Felsher, D.W., McVicar, D.W., Weber, A., Heikenwalder, M., Greten, T.F., 2016. NAFLD causes selective CD4(+) T lymphocyte loss and promotes hepatocarcinogenesis. Nature 531, 253-257.
Maciejewska, D., Marlicz, W., Ryterska, K., Banaszczak, M., Jamiol-Milc, D., Stachowska, E., 2018. Changes of the Fatty Acid Profile in Erythrocyte Membranes of Patients following 6-Month Dietary Intervention Aimed at the Regression of Nonalcoholic Fatty Liver Disease (NAFLD). Can J Gastroenterol Hepatol 2018, 5856201.
Ocker: NASH drug development
19
Manne, V., Handa, P., Kowdley, K.V., 2018. Pathophysiology of Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis. Clin Liver Dis 22, 23-37.
Middleton, M.S., Heba, E.R., Hooker, C.A., Bashir, M.R., Fowler, K.J., Sandrasegaran, K., Brunt, E.M., Kleiner, D.E., Doo, E., Van Natta, M.L., Lavine, J.E., Neuschwander-Tetri, B.A., Sanyal, A., Loomba, R., Sirlin, C.B., 2017. Agreement Between Magnetic Resonance Imaging Proton Density Fat Fraction Measurements and Pathologist-Assigned Steatosis Grades of Liver Biopsies From Adults With Nonalcoholic Steatohepatitis. Gastroenterology 153, 753-761.
Moon, A.M., Singal, A.G., Tapper, E.B., 2019. Contemporary Epidemiology of Chronic Liver Disease and Cirrhosis. Clin Gastroenterol Hepatol.
Neuschwander-Tetri, B.A., 2009. Lifestyle modification as the primary treatment of NASH. Clin Liver Dis 13, 649-665.
O'Connell, D., Shaikhibrahim, Z., Kramer, F., Ocker, M., 2020. Biomarkers from Bench to Bedside and Back - Back-Translation of Clinical Studies to Preclinical Models. In: Rahbari, R., Van Niewaal, J., Bleavins, M.R. (Eds.), Biomarkers in Drug Discovery and Development: A Handbook of Practice, Application, and Strategy. Wiley-Blackwell, Hoboken, pp. 309-331.
Paton, C.M., Ntambi, J.M., 2009. Biochemical and physiological function of stearoyl-CoA desaturase. Am J Physiol Endocrinol Metab 297, E28-37.
Pawlak, M., Lefebvre, P., Staels, B., 2015. Molecular mechanism of PPARalpha action and its impact on lipid metabolism, inflammation and fibrosis in non-alcoholic fatty liver disease. J Hepatol 62, 720733.
Pierantonelli, I., Svegliati-Baroni, G., 2019. Nonalcoholic Fatty Liver Disease: Basic Pathogenetic Mechanisms in the Progression From NAFLD to NASH. Transplantation 103, e1-e13.
Ocker: NASH drug development
20
Polyzos, S.A., Toulis, K.A., Goulis, D.G., Zavos, C., Kountouras, J., 2011. Serum total adiponectin in nonalcoholic fatty liver disease: a systematic review and meta-analysis. Metabolism 60, 313-326.
Ratziu, V., Goodman, Z., Sanyal, A., 2015. Current efforts and trends in the treatment of NASH. J Hepatol 62, S65-75.
Razavi Zade, M., Telkabadi, M.H., Bahmani, F., Salehi, B., Farshbaf, S., Asemi, Z., 2016. The effects of DASH diet on weight loss and metabolic status in adults with non-alcoholic fatty liver disease: a randomized clinical trial. Liver Int 36, 563-571.
Rinella, M.E., Tacke, F., Sanyal, A.J., Anstee, Q.M., 2019. Report on the AASLD/EASL joint workshop on clinical trial endpoints in NAFLD. J Hepatol 71, 823-833.
Rodriguez, B., Torres, D.M., Harrison, S.A., 2012. Physical activity: an essential component of lifestyle modification in NAFLD. Nat Rev Gastroenterol Hepatol 9, 726-731.
Roeb, E., Geier, A., 2019. Nonalcoholic steatohepatitis (NASH) - current treatment recommendations and future developments. Z Gastroenterol 57, 508-517.
Sanyal, A.J., Brunt, E.M., Kleiner, D.E., Kowdley, K.V., Chalasani, N., Lavine, J.E., Ratziu, V., McCullough, A., 2011. Endpoints and clinical trial design for nonalcoholic steatohepatitis. Hepatology 54, 344-353.
Schults, M.A., Nagle, P.W., Rensen, S.S., Godschalk, R.W., Munnia, A., Peluso, M., Claessen, S.M., Greve, J.W., Driessen, A., Verdam, F.J., Buurman, W.A., van Schooten, F.J., Chiu, R.K., 2012. Decreased nucleotide excision repair in steatotic livers associates with myeloperoxidaseimmunoreactivity. Mutat Res 736, 75-81.
Schumacher-Petersen, C., Christoffersen, B.O., Kirk, R.K., Ludvigsen, T.P., Zois, N.E., Pedersen, H.D., Vyberg, M., Olsen, L.H., 2019. Experimental non-alcoholic steatohepatitis in Gottingen Minipigs: consequences of high fat-fructose-cholesterol diet and diabetes. J Transl Med 17, 110.
Ocker: NASH drug development
21
Sepideh, A., Karim, P., Hossein, A., Leila, R., Hamdollah, M., Mohammad, E.G., Mojtaba, S., Mohammad, S., Ghader, G., Seyed Moayed, A., 2016. Effects of Multistrain Probiotic Supplementation on Glycemic and Inflammatory Indices in Patients with Nonalcoholic Fatty Liver Disease: A Double-Blind Randomized Clinical Trial. J Am Coll Nutr 35, 500-505.
Stephenson, K., Kennedy, L., Hargrove, L., Demieville, J., Thomson, J., Alpini, G., Francis, H., 2018. Updates on Dietary Models of Nonalcoholic Fatty Liver Disease: Current Studies and Insights. Gene Expr 18, 5-17.
Sumida, Y., Okanoue, T., Nakajima, A., 2019. Phase 3 drug pipelines in the treatment of non-alcoholic steatohepatitis. Hepatol Res.
Tacke, F., 2018. Cenicriviroc for the treatment of non-alcoholic steatohepatitis and liver fibrosis. Expert Opin Investig Drugs 27, 301-311.
Tanaka, N., Aoyama, T., Kimura, S., Gonzalez, F.J., 2017. Targeting nuclear receptors for the treatment of fatty liver disease. Pharmacol Ther 179, 142-157.
Tanwar, S., Trembling, P.M., Guha, I.N., Parkes, J., Kaye, P., Burt, A.D., Ryder, S.D., Aithal, G.P., Day, C.P., Rosenberg, W.M., 2013. Validation of terminal peptide of procollagen III for the detection and assessment of nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease. Hepatology 57, 103-111.
Thiagarajan, P., Aithal, G.P., 2019. Drug Development for Nonalcoholic Fatty Liver Disease: Landscape and Challenges. J Clin Exp Hepatol 9, 515-521.
Tilg, H., Moschen, A.R., 2010. Evolution of inflammation in nonalcoholic fatty liver disease: the multiple parallel hits hypothesis. Hepatology 52, 1836-1846.
Ocker: NASH drug development
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Tsuchida, T., Lee, Y.A., Fujiwara, N., Ybanez, M., Allen, B., Martins, S., Fiel, M.I., Goossens, N., Chou, H.I., Hoshida, Y., Friedman, S.L., 2018. A simple diet- and chemical-induced murine NASH model with rapid progression of steatohepatitis, fibrosis and liver cancer. J Hepatol 69, 385-395.
Ueno, T., Komatsu, M., 2017. Autophagy in the liver: functions in health and disease. Nat Rev Gastroenterol Hepatol 14, 170-184.
Vilar-Gomez, E., Calzadilla-Bertot, L., Friedman, S.L., Gra-Oramas, B., Gonzalez-Fabian, L., Lazo-Del Vallin, S., Diago, M., Adams, L.A., 2017. Serum biomarkers can predict a change in liver fibrosis 1 year after lifestyle intervention for biopsy-proven NASH. Liver Int 37, 1887-1896.
Wang, P.X., Ji, Y.X., Zhang, X.J., Zhao, L.P., Yan, Z.Z., Zhang, P., Shen, L.J., Yang, X., Fang, J., Tian, S., Zhu, X.Y., Gong, J., Zhang, X., Wei, Q.F., Wang, Y., Li, J., Wan, L., Xie, Q., She, Z.G., Wang, Z., Huang, Z., Li, H., 2017. Targeting CASP8 and FADD-like apoptosis regulator ameliorates nonalcoholic steatohepatitis in mice and nonhuman primates. Nat Med 23, 439-449.
Weiskirchen, R., Tacke, F., 2019. Relevance of Autophagy in Parenchymal and Non-Parenchymal Liver Cells for Health and Disease. Cells 8.
Wieckowska, A., Feldstein, A.E., 2008. Diagnosis of nonalcoholic fatty liver disease: invasive versus noninvasive. Semin Liver Dis 28, 386-395.
Wong, C.H., Siah, K.W., Lo, A.W., 2019. Estimation of clinical trial success rates and related parameters. Biostatistics 20, 273-286.
Wong, R.H., Chang, I., Hudak, C.S., Hyun, S., Kwan, H.Y., Sul, H.S., 2009. A role of DNA-PK for the metabolic gene regulation in response to insulin. Cell 136, 1056-1072.
Xia, J., Yuan, J., Xin, L., Zhang, Y., Kong, S., Chen, Y., Yang, S., Li, K., 2014. Transcriptome analysis on the inflammatory cell infiltration of nonalcoholic steatohepatitis in bama minipigs induced by a longterm high-fat, high-sucrose diet. PLoS One 9, e113724.
Ocker: NASH drug development
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Yilmaz, Y., 2012. Review article: is non-alcoholic fatty liver disease a spectrum, or are steatosis and non-alcoholic steatohepatitis distinct conditions? Aliment Pharmacol Ther 36, 815-823.
Younossi, Z.M., 2019. Non-alcoholic fatty liver disease - A global public health perspective. J Hepatol 70, 531-544.
Younossi, Z.M., Stepanova, M., Younossi, Y., Golabi, P., Mishra, A., Rafiq, N., Henry, L., 2019. Epidemiology of chronic liver diseases in the USA in the past three decades. Gut.
Zhou, J.H., Cai, J.J., She, Z.G., Li, H.L., 2019. Noninvasive evaluation of nonalcoholic fatty liver disease: Current evidence and practice. World J Gastroenterol 25, 1307-1326.
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Table 1. Overview on dietary models for NAFLD and NASH. Model
NAFLD
NASH
Metabolic Syndrome
Obesity
Fibrosis
HCC
Comments
CDAA
+
+
-
-
+
< 5%
Sex differences; cachexia
CDAHFD
+
+
-
-
+
(+)
CD-HFD
+
+
+
+
+
25%
FFC
+
+
+
+
+
HFD
+
-
+
+
-
-
HFD + DEN
+
+
+
+
+
100%
MCD
+
+
-
-
+
-
WD
+
+
+
+
+
89%
WD + CCl4
+
+
+
+
+
> 50%
db/db + MCD
+
+
+
+
+
ob/ob + MCD
+
+
+
+
-
myc + MCD
+
+
-
-
+
Zucker rats + HFD
+
+
+
+
+
Low HCC incidence after 12 to 15 months HCC formation after 12 months
HCC formation after 9 months Cachexia and weight loss HCC formation after ~ 10 months Rapid HCC formation after 6 months
+
CCl4: Carbon tetracholide; CDAA: choline-deficient; L-amino-acid-defined diet; CDAHFD: choline-deficient, L-amino-acid-defined, high-fat diet; CD-HFD: cholinedeficient, high-fat diet; db/db: diabetic mouse model with mutation in leptin receptor; DEN: diethylnitrosamine; FFC: high-fat, fructose, cholesterol diet; HFD:
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high-fat diet; MCD: methionine-choline-deficient diet; myc: myc-transgenic; ob/ob: obesity mouse model with mutation in leptin; WD: western diet (high-fat, high-cholesterol, high-fructose)
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Table 2. Surrogate endpoints for clinical trials in NAFLD and NASH (Thiagarajan and Aithal, 2019). Endpoint
Tissue based
Noninvasive
Metabolic parameters
Steatosis
Imaging techniques(e.g. MRI-PDFF, ultrasound, elastography) Insuline resistance (e.g. HbA1c, oral glucose tolerance test, fasting glucose levels) Lipid profile BMI
Inflammation
Steatohepatitis
Imaging techniques (e.g. MRI, spectroscopy) Blood-based biomarkers (e.g. cytokines, ALT) NAS
Fibrosis
Fibrosis stage/scores
Fibrosis scores (e.g. Fib-4) Imaging techniques (e.g. elastography, spectroscopy) Blood-based scores (e.g. ELF score, PIIINP)
MRI-PDFF: magnetic resonance imaging proton density fat fraction; BMI: body mass index; NAS: NAFLD activity score; PIIINP: pro-collagen type III N-terminal peptide
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Table 3. Currently ongoing Phase 3 studies for NASH registered at clinicaltrials.gov NCT#
Drug
MoA
Patients
Time points
Primary outcome
Secondary outcome
NCT02704403
Elafibranor
PPARα/δ agonist
N = 2000,
72 wks -> 4 yrs
Resolution of NASH without Improvement in fibrosis (72 wks)
NAS > 4,
worsening of fibrosis (72 wks)
fibrosis > 1 and < 4
All-cause
mortality,
Improvement
in
histological
cirrhosis, NASH scores
liver-related clinical outcomes (4 Improvement in cardiometabolic yrs)
and liver markers Liver-related death
NCT03439254
Obeticholic
FXR agonist
acid
NCT03723252
Dapagliflozin SGLT2 inhibitor
N = 900,
72 wks
Improvement in fibrosis by 1 Improvement in fibrosis by 2
NASH and fibrosis
stage with no worsening of stages (72 wks)
score 4
NASH (72 wks)
Resolution of NASH
Improvement in liver histology
Resolution of NASH
N = 100,
52 wks
NASH (liver biopsy)
Various
metabolic
inflammatory
endpoints,
and e.g.
HbA1c, body weight, lipids, … NCT03028740
Cenicriviroc
CCR2/5
N = 2000,
52 wks -> 5 yrs
Improvement in fibrosis by 1 Improvement in fibrosis by 1
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NASH fibrosis stage
stage (52 wks)
2 or 3
Composite
stage (5 yrs) endpoint
on
cirrhosis, liver-related clinical outcome, all-cause mortality (5 yrs) NCT04104321
Aramchol
SCD-1 modulator
N = 2000,
52 wks
Resolution
of
NASH
or All-cause
mortality,
(arachidyl
NASH, NAS > 4,
improvement in fibrosis by 1 transplantation,
amido
fibrosis stage 2 or 3
stage and no worsening of NASH
cholanoic
liver
histological
progression, MELD score > 15 hospitalization
acid NCT03900429
Resmetirom
THR-β agonist
(MGL-3196)
N = 2000, NASH,
24 to 53 wks fibrosis
NASH resolution on histology (2 Change in LDL-cholesterol at 24 point reduction in NAS)
stage 2 or 3
wks
Composite endpoint on all-cause Improvement in fibrosis mortality, cirrhosis, liver-related clinical outcomes
NCT02654665
Liraglutide
GLP-1 agonist
N = 36,
52 wks
Improvement
in
NASH
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Obesity, NASH
29 (transaminases, steatosis)
surgery NCT03970031
MSDC0602K
MPC modulator
N = 3600,
24 to 124 wks
Change in HbA1c (24 wks)
Death or major hepatic or
NASH with fibrosis,
Histological resolution of NASH cardiac adverse event
type 2 diabetes
(52 wks)
PPARα/δ: peroxisome proliferator activated receptor α/δ; NAS: NAFLD activity score; wks: weeks; yrs: years; FXR: farnesoid X receptor; SGLT2: sodium glucose co-transporter 2; CCR2/5: chemokine receptor 2/5; SCD-1: stearyl-CoA desaturase-1; THR-β: thyroid hormone receptor β; GLP-1: glucagon-like peptide 1; MPC: mitochondrial pyruvate carrier