1. Pentoxifylline Improves Nonalcoholic Steatohepatitis : A Randomized Placebo - Controlled Trial Claudia O. Zein, Lisa M. Yerian, Prema Gogate, Rocio Lopez, John P. Kirwan, Ariel E. Feldstein, and Arthur J. McCullough HEPATOLOGY 2011;54:1610-1619 R 2 Chihyeok Oh

2. Introduction Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis(NASH) –Histologic spectrum : simple steatosis ~ Nonalcoholic steatohepatitis(NASH) hepatocellular injury, inflammation, and fibrosis  progress to cirrhosis –No therapy : definitely proven beneficial Vitamin E ? Need for additional and more effective therapies for patients with NASH –Multiple factors and pathways ↔ pathogenesis and progression of NAFLD and NASH Imbalances in inflammatory cytokines, oxidative stress, and insulin resistance TNF-α, proinflammatory cytokine, adiponectin, antiinflammatory cytokine : hepatocellular damage, inflammation, and fibrogenesis in NASH In mice - improved by inhibition of hepatic TNF-a production and by infusion of anti- TNF-a neutralizing antibody PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

3. Pentoxifylline (PTX) –a methylxanthine derivative –RBC flexibility ↑, blood viscosity ↓, PLT aggregation ↓ –Inhibition : a number of pro-inflammatory cytokines including TNF-a –hepatoprotective effects hepatic glutathione levels ↑ production of oxygen radicals ↓ –Potential antifibrogenic effects –So, number of mechanisms → therapeutic benefit to NASH patients The primary aim of this study –to compare the effectiveness of PTX over 1 yr with placebo in Pts. with NASH –defined as an improvement of 2 or more points in the NAFLD activity score (NAS) Other aims of this study –the effects of PTX on serum transaminases –the effect of PTX on insulin sensitivity –the effect of PTX on hepatocyte apoptosis –the effect of therapy with PTX on serum levels of TNF-a and adiponectin –compare the rate of adverse events

4. Methods - Selection of Patients Recruited at two medical centers in Cleveland Inclusion criteria –well-established diagnosis of NASH based on liver biopsy performed within 6 months of entry –daily alcohol intake of <30 g for males and <15 g for females –Appropriate exclusion of other liver diseases –age between 18 and 70 years –the ability to give informed consent –If patient with diabetes mellitus type 2 (DM) if their therapeutic regimen : limited to oral agents –sulfonylureas (e.g., glipizide and glyburide) and/or biguanides (e.g., metformin) stable (defined by no changes in oral agents or their dose for at least 6 months) adequate glucose control as defined by HbA1C <8% PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

5. Exclusion criteria –history of past excessive alcohol drinking (> 2 years in the past 10 years) –HBV or HCV –any other suspected cause of liver disease history, blood tests, or clinical findings –taking medications cause steatosis benefits in previous NASH pilot studies (vitamin E, Betaine, S-adenosylmethionine, thiazolidinediones, and alpha-glucosidase inhibitors) –cirrhosis defined by stage 4 fibrosis on liver biopsy –with a history of hypersensitivity to PTX or the methylxanthines (caffeine, theophylline, theobromine) –history of cerebral or retinal hemorrhage –Taking theophylline or coumadin

6. Methods - Study Design and Organization double-blinded, randomized, placebo-controlled trial approved by the Institutional Review Boards at all involved institutions Enrollment : December 2006 ~ February 2009 The trial completion : April of 2010 In the treatment arm –oral dose of 400 mg three times per day of PTX for 1 year In the placebo arm –white, oblong capsules with no markings, no discernible odor, and no difference to taste PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

7. Methods - Evaluation and Monitoring of Patients Clinical history and physical examination –At entry and at 1 year Follow-up liver biopsy –12 months of taking the study medication and prior to discontinuation Laboratory studies –at entry & at 12 months –Liver enzymes(3,6,9 months), basic metabolic panel, CBC, PT, HbA1 C, fasting insulin, C-peptide, lipid panel, TNF-a, and adiponectin Weight and height for BMI calculation and waist Individualized nutritional counseling –for adequate caloric intake lifestyle modifications Compliance and adverse effects –at 1, 3, 6, 9, and 12 months into the study PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

8. Methods Assessment of Liver Histology –The NAS grades NAFLD based on the individual scores for steatosis, inflammation, and ballooning –Fibrosis staged 0 to 4 (0: absent; 1: perisinusoidal or portal/periportal only; 2: perisinusoidal and periportal; 3: bridging fibrosis; 4: cirrhosis) The primary outcome (The primary endpoint of the study) –an improvement of ≥2 points in the NAS measure PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

9. Results - Study Patients(1) Fig. 1 Patient flow diagram illustrating the two study groups. PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

10. Results - Study Patients(2) PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

11. Results - Primary Outcome PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

12. Results - Primary Outcome PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

13. Results - Secondary Outcomes ( Histologic Features ) PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

14. Results - Secondary Outcomes Change in Aminotransferases –Normalization or improvement of 30% or more in ALT levels from baseline 57% in PTX Vs 23% in Placebo (P=0.016) –Regarding AST No significant differences between two groups Changes in Insulin Resistance, TNF-a, and Adiponectin, and Hepatocyte Apoptosis PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

15. Results - Secondary Outcomes (Safety and Adverse Events) No study drug-related severe adverse event No patients discontinued therapy as a result of adverse events PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial

16. Conclusion PTX improves NASH and may impact the progression of liver fibrosis in NASH PTX was overall well tolerated in patients with NASH But larger studies and underlying mechanisms will be needed PentoxifyllineImprovesNonalcoholicSteatohepatitis:ARandomizedPlacebo-ControlledTrial