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1
NAFLD – the new epidemic: New concepts
for therapy
Nicolas Goossens, MD, MSc, PD
Division of Gastroenterology & Hepatology
Geneva University Hospitals
Sanct Gallen 2019 Gastroenterology/Hepatology
December 5th 2019
Non-alcoholic fatty liver disease (NAFLD)
Normal liver
NAFLD
Exclusion:
HBV, HCV
Alcohol
Hemochromatosis
Auto-immune….
Factors linked to
progression
• Insulin resistance
• Overweight
• Metabolic syndrome
• Ethnicity
• Genetics
• Sex
• Food
• ….
Definition:
Steatosis in >5% of
hepatocytes
EASL, J Hepatology, 2016
2
Adapted from Drew, Nature 2017
Natural history of NAFLD
Simple
steatosis
Cirrhosis
NASH &
fibrosis
Adapted from Drew, Nature 2017
Simple
steatosis
Cirrhosis
NASH &
fibrosis
Natural history of NAFLD
3
Hepatocellular
carcinoma
(HCC)
Adapted from Drew, Nature 2017
Simple
steatosis
Cirrhosis
NASH &
fibrosis
Natural history of NAFLD
Dulai et al, Hepatology, 2017
NASH – the role of liver fibrosis
Systematic review of 1,495 NAFLD patients with 17,452 patient years of follow‐up.
No adjustment for confounders
0
10
20
30
40
50
F0 F1 F2 F3 F4
Mort
alit
y r
ate
(per
1,0
00 P
YF
)
Fibrosis stage
All-cause and liver-related mortality in NAFLD
All-cause
Liver-related
4
NASH is a reversible disease
Lassailly et al, Gastro 2015
1 year after bariatric surgery in 109 obese NASH subjects
33% 24%
Resolution
of NASH
Improvement of
fibrosis
Lifestyle interventions
Vilar-Gomez et al, Gastroenterology, 2015
Romero-Gomez et al, J Hep, 2017
N=293 patients with biopsy-proven NASH.
52 weeks of lifestyle interventions (low-fat hypocaloric diet, walk 200 mins/week,
behavioral sessions every week). 2nd liver biopsy at 52 weeks (n=261/293)
16% 18% 16% 45%
5
Lifestyle interventions
Vilar-Gomez et al, Gastroenterology, 2015
Romero-Gomez et al, J Hep, 2017
N=293 patients with biopsy-proven NASH.
52 weeks of lifestyle interventions (low-fat hypocaloric diet, walk 200 mins/week,
behavioral sessions every week). 2nd liver biopsy at 52 weeks (n=261/293)
16% 18% 16% 45%
No clear role for metformin
Musso, Hepatology, 2010
AST/ALT
Steatosis
Fibrosis resolution
6
247 patients
83 Placebo 84 Vitamine E
(800 IU)
80 Pioglitazone (30mg)
Pioglitazone and Vitamine E in non-diabetic patients with NASH (22 months)
19%
[VALUE]
34%
0%
10%
20%
30%
40%
50%
P=0.001 P=0.04
Histological Improvement
31%
[VALUE]
44%
0%
10%
20%
30%
40%
50%
P=0.24 P=0.12
Fibrosis Improvement
Placebo
Vitamin E
Pioglitazone
Sanyal, NEJM, 2010
101 patients
51 Placebo 50 Pioglitazone
(45mg)
Pioglitazone in patients with (pre-) diabetes and NASH (18 months)
17%
58%
0%
10%
20%
30%
40%
50%
60%
70%
P<0.001
Improvement NAS ≥ 2 with
no worsening fibrosis
25%
39%
0%
10%
20%
30%
40%
50%
P=0.13
Fibrosis ≥ 1 Improvement
Placebo
Pioglitazone
Cusi, Ann Int Med, 2016
Pioglitazone
101 patients
51 Placebo 50 Pioglitazone
(45mg)
7
Upcoming therapies in NAFLD
Drew, Nature, 2017
Intrahepatic drug targets in phase 2 and 3 clinical trials for NASH.
Friedman, Nat Med, 2018
8
Intrahepatic drug targets in phase 2 and 3 clinical trials for NASH.
MGL-3196
Elafibranor
Elafibranor
Selonsertib
Obeticholic acid
Cenicriviroc
Friedman, Nat Med, 2018
Obeticholic acid
Positive results from REGENERATE: A phase 3 international, randomized, placebo-controlled study of obeticholic acid (FXR
agonist) treatment for NASH
INTERCEPT press release Feb 19th 2019
Oral presentation EASL ILC 2019, April 2019
11.9%
8.0%
17.6%
11.2%
23.1%
11.7%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Fib improvement (no worseningNASH)
NASH resolution (no worseningfibrosis)
REGENERATE phase 3 study (OCA in stage 2-3 NASH – month 18 interim analysis)
Placebo, n=311
OCA 10mg, n=312
OCA 25mg, n=308
* *
* p < 0.05 compared to placebo
Pruritus - Placebo 19%, OCA 10mg 28%, OCA 25mg 51% (9% discont.)
Increase in LDL cholesterol peak at wk 4
9
Phase 3 trials of selonsertib (ASK-1 inhibitor) in NASH with advanced fibrosis (STELLAR-3 and -4) did not meet week 48 primary
endpoint
GILEAD press release Feb 11th 2019 and April 25th 2019
13.2% 12.8% 12.1% 12.5%
9.3%
14.4%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
STELLAR 3 (F3) STELLAR 4 (F4)
Selonsertib in NASH phase 3 studies (F3 or F4 fibrosis)
Placebo
SEL 6mg
SEL 18mg
Fibrosis improvement without worsening of NASH
Ratziu et al, Gastroenterology 2016
Phase 2 trial of elafibranor (PPAR α/δ agonist) – 1 year
Resolution of NASH
(modified definition)
Detailed fibrosis improvement not
reported
Reduced liver fibrosis in subjects
with NASH resolution
276 non-cirrhotic NASH ≈40% T2D, 23% F3
12%
[VALUE]
19%
0%
5%
10%
15%
20%
Placebo, n=92
Elafibranor 80mg, n=93
Elafibranor 120mg, n=91
Phase 3 clinical trial interim results of first 1,000 enrolled patients after 72
weeks of therapy due end 2019
*
Fibrosis ?
10
Friedman et al, Hepatology, 2018
Phase 2 trial of cenicriviroc (CCR2-CCR5 antagonist) – 1 y results