Columbia Grand Rounds 2016.ppt

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD
Joel Lavine, MD, PhD
Professor and Vice Chair for Research
Department of Pediatrics
Columbia University
Chief, Pediatric Gastroenterology,
Hepatology and Nutrition,
Columbia University Medical Center
Evolving Diagnostics, Prognostics
and Therapeutics for NAFLD

•I have the following disclosures; unrelated to presentation:
Consultant:
Merck
Janssen
Takeda
Allergan
Pfizer
Bristol Myers Squibb
Viking
Amarin
• Grants/Research contracts: NIDDK/NICHD

NASH in NYC

An alcohol-like disease of the liver that
develops in children who drink no or
little alcohol; most prevalent chronic
liver disease in US children
Pediatric
NAFLD
What is it?

Histologic Natural History of Pediatric NAFLD
N=122

Baseline Predictors for NASH Progression
Lavine et al, unpublished

Change Predictors for NASH Progression
Risk ratio P-value
Lavine et al, unpublished

Baseline Characteristics of Those
Developing Diabetes over 120 wks
Feature Diabetes
N=5
Not Diabetic
N=53
Significance
Gender (male) 60% 81% -
Age (13 and
over)
80% 49% -
Hispanic 80% 66% -
Race (white) 100% 75% -
Body fat % 40.8 42.5 -
BMI z-score 2.6 2.3 0.04
HbA1c 5.6 5.2 0.01
Ballooning 100% 54% 0.02
Fibrosis
(stage 0 or 1)
100% 85% -
•In children with NAFLD treated with SOC diet and exercise

Pathogenesis of NASH

Is Pediatric Histology the Same? N=100
Type 1 Type 2/BZ1
Schwimmer et al, Hepatology, 2005

•Kleiner et al, Hepatology (2006) 44: 259A

What role do sex hormones play in NAFLD?
• NAFLD development and progression is dependent on
gender, pubertal stage and reproductive state.
• Greatest prevalence in obese post-pubertal adolescent
boys.
• Also, anti-estrogenic drugs, aromatase deficiency cause
severe fatty liver
• Sex hormones alter lipid metabolism, inflammation, fibrosis,
apoptosis in cell culture, mouse models

Sex Steroid Hormone Production

Methods
• Multi-center, cross-sectional prospective study.
• 573 children (72% boys, <18 yo) with biopsy-proven NAFLD.
• Sex hormones were collected and assayed using ELISA.
• NAFLD histology scored by consensus of masked pathologists.
• Clinical data, sex hormone level and histology compared between
sexes using calculated p-value.
• Odds ratio and p-values calculated between each sex hormone and
histologic feature, adjusted for sex, race, Tanner stage.
• Independent predictors of NAFLD diagnosis determined with
multinomial logistic regression.

Relationship between Sex Hormones and NAFLD Patterns
Borderline zone
3/Not NASH
Borderline zone
1/Not NASH
Definite NASH/Not
NASH

Multivariate model adjusted for age, sex,
race/ethnicity, Tanner stage, and BMI z-score
Sex hormone assayed
(T= tertile)
Fibrosis,
RR (95% CI)
Estrone
T1 1 (reference)
T2 0.71 (0.51-0.99)
T3 0.64 (0.45-0.93)
Ptrend 0.01
Estradiol
T1 1 (reference)
T2 0.95 (0.65-1.39)
T3 1.33 (0.95-1.87)
Ptrend 0.11
DHEA
T1 1 (reference)
T2 0.82 (0.59-1.14)
T3 0.62 (0.42-0.92)
Ptrend 0.015
Androstenedione
T1 1 (reference)
T2 0.97 (0.69-1.37)
T3 0.73 (0.47-1.14)
Ptrend 0.15
•Sex hormone relation to fibrosis severity

Proposed Influence of Estrogen on NASH

Proteomic Biomarkers for NAFLD/NASH

Aptamer-based 1129-plex derives protein
sets predictive of fibrosis stage

18 proteins of 1129 relate commonly to grade
and stage for histology features of NASH

Assay of serum proteins predictive of histology

Lifestyle Factors Associated with NAFLD
 Modern diets
– Ingested calories>expended energy
– Diet and beverage composition
 Insufficient activity/play
– Decreased PE in schools
– Availability of transportation
– Sedentary activity/games/TV
– Concern about neighborhood safety
– Latchkey kids and latchkey pets
 Other
– Obstructive sleep apnea
– Altered gut microbiome

How Can We Treat It:
Therapeutic Targets for NASH
Decrease insulin
resistance
– Lifestyle
– Metformin
– Thiazolidinediones
Diminish oxidative stress
– Lifestyle
– Weight loss
– Diet
– Exercise
– Increase antioxidants
– Diminish inflammation
– Decrease sleep apnea
– Antifibrotics

Clinical Trial Design: TONIC
 Double-blind placebo-controlled randomized trial
of vitamin E or metformin for treatment of
children with nonalcoholic fatty liver
 173 subjects at 8 clinical centers
 Liver biopsy at beginning and end after 96
weeks of treatment
 Outcomes based on changes in blood and liver
•Lavine et al, JAMA 2011

TONIC CONSORT
229 Screened
57 Metformin
50 biopsied
at 96 weeks
173
Randomized
58 Placebo
47 biopsied
at 96 weeks
58 vitamin E
50 biopsied
at 96 weeks
56 Excluded:
51 Ineligible
3 Declined
2 Other

Baseline Characteristics (N=173)
Character (units)
Vitamin E
N= 58
Placebo
N= 58
Metformin
N= 57
Age (y)
Female (%)
Hispanic (%)
BMI (kg/m2)
Waist circumference (cm)
Trunk fat (%)
ALT (U/L)
AST (U/L)
AlkPhos (U/L)
Triglycerides (mg/dL)
IR (HOMA-IR)
13.4
19
62
34
109
45
121
70
220
154
8.6
12.9
21
67
33
106
44
126
74
229
153
11.0
13.1
18
54
34
108
45
121
69
237
151
7.9

ALT Decreased in All Groups

Vitamin E significantly improved
NAFLD activity score (NAS)
Vitamin E
(n=50)
Placebo
(n=47)
Metformin
(n=50)
Mean change -1.8 -1.1 -0.7
P-value 0.02 0.25

Vitamin E increased resolution of NASH
(from initial definite or borderline NASH)
Vitamin E
(n=43)
Placebo
(n=38)
Metformin
(n=39)
Resolved (%) 58% 28% 41%
P-value 0.006 --- 0.23

Change in NAFLD Activity Score
PIVENS vs. TONIC
•Steatosis •Inflammatio
n
•Cell Injury •Cell Injury
•Inflammatio
n
•Steatosis
PIVENS (152 Adults)
NEJM, 2010
TONIC (97 Children)
JAMA, 2011
•p <0.001 •p = 0.008 •p <0.001 •p = 0.24 •p = 0.14
•p = 0.006

Resolution of NASH Histologically
•Vitamin E
•TONIC (82 Children)
•p = 0.05
•p = 0.006
•Vitamin E •Placebo •Placebo
•PIVENS (152 Adults)

Practice Guidelines Recommend Vitamin E for
Biopsy-proven NASH in Adults and Children

•Partial funding for the trial,
obeticholic acid, and placebo were
provided by Intercept
Pharmaceuticals under a
Collaborative Research and
Development Agreement with the
NIDDK.

The FLINT Trial
 Obeticholic acid (OCA), 25 mg orally daily vs placebo
 Inclusion: adults with NASH on biopsy, NAS ≥ 4
 Exclusion: cirrhosis
 N = 283 patients randomized at 8 clinical centers
 72 weeks treatment
 Biopsy ≤ 3 mo. before treatment and after 72 weeks
 Primary endpoint
– Improvement in NAFLD activity score ≥ 2 pts with no
worsening of fibrosis
•Neuschwander-Tetri et al, The Lancet, http://dx.doi.org/10.1016/S0140-6736(14)61933-4

FLINT baseline characteristics
Obeticholic acid
(n = 141)
Placebo
(n = 142)
Age (years) 52 ± 11* 51 ± 12
% Female 69% 63%
% Hispanic 16% 15%
BMI (kg/m2) 35 ± 7 34 ± 6
Diabetes 53% 52%
Hypertension 62% 60%
Hyperlipidemia 62% 61%
Vitamin E use 21% 23%
ALT (U/L) 83 ± 49 82 ± 51
NAFLD activity
score
5.3 ± 1.3 5.1 ± 1.3
Fibrosis stage 1.9 ± 1.1 1.8 ± 1.0
•Neuschwander-Tetri et al, The Lancet, http://dx.doi.org/10.1016/S0140-6736(14)61933-4

•ALT •Alk Phos
•GGT •Body weight
Changes in enzymes and body weight
•(EOT) •(EOT)
•Off
•Off •Off
•Off

Enteric-coated Cysteamine Pilot
for Pediatric NASH
10
15
20
25
30
35
40
45
50
55
60
20
30
40
50
60
70
80
90
100
110
120
0 4 8 12 16 20 24 28 32 36 40 44 48
BMI
[kg/m
2
]
ALT
[IU/l]
Weeks
Mean ALT / AST / BMI development
ALT AST BMI
•Dohil et al, Alim Pharmacol Ther, 2011

CyNCh
DR-Cysteamine for NAFLD in Children
 Double-blind, placebo-controlled trial evaluating DR-
cysteamine over 52 w treatment
 SOC diet and exercise advice for all
 10 clinical centers, NIDDK-sponsored 6/12 through 8/15
 169 subjects (8-17 y) randomized; ITT design
 52 week treatment with weight-based dosing, 9-12 mg/kg
 Primary outcome improvement in histology, with NAS
improvement of 2 or more, no worsening in fibrosis
Schwimmer, Lavine et al, 2016

Inclusion/Exclusion Criteria
 Inclusion
– Ages 8-17 y, definite NAFLD on histology
– NAS score greater than or equal to 4
– Able to swallow capsules
– Informed consent/assent
 Exclusion
– Cirrhosis or uncompensated liver disease
– Poorly controlled T2DM
– Other causes of liver disease
– Pregnant, nursing or not using birth control if applicable

Histology Outcomes
 88 received DR-C, 81 placebo
 Mean age 13.7 y, 70% boys
 End of treatment biopsies in 81% on drug, 93% on
placebo (p=0.03)
 No significant difference in response rates for primary
outcome between drug and placebo groups with ITT (28%
v 22%, p=0.34)
 ITT analyses of 4 histologic features including fibrosis,
steatosis, ballooning and lobular inflammation not
significant with statistical correction

CyNCh Secondary Outcomes
 Those on drug had greater mean change in ALT and AST
(p=0.02 and p=0.008, respectively) compared to placebo
 Reductions occurred within first 4 weeks and sustained
through week 52 of treatment. Sustained after tx
discontinued.
 No change in serum lipids, cholesterol, insulin sensitivity
 No difference in adverse events or serious adverse events

Fatty Liver Disease Summary
 The most common cause of liver disease in children
 Can cause early cirrhosis in childhood
 A subset has a distinct histopathologic pattern
 Children who progress have predictive clinical markers
 Proteomic diagnostics are on the horizon to replace bx
 Vitamin E 800 IU natural form daily demonstrates
benefit for pediatric (and adult) NASH
 DR-cysteamine rapidly results in dramatic sustained
reduction in serum aminotransferases but did not
achieve primary histologic endpoint

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