Columbia Grand Rounds 2016 by Joel Lavine

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Evolving Diagnostics, Prognostics and Therapeutics for 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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

NASH in NYC

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Pediatric NAFLD What is it? 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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Histologic Natural History of Pediatric NAFLD N=122

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Baseline Predictors for NASH Progression

Lavine et al, unpublished

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Change Predictors for NASH Progression Risk ratio

Lavine et al, unpublished

P-value

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Pathogenesis of NASH

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Is Pediatric Histology the Same? N=100 Type 1

Type 2/BZ1

Schwimmer et al, Hepatology, 2005

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Sex Steroid Hormone Production

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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.

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Borderline zone 1/Not NASH

Definite NASH/Not NASH

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

•Sex hormone relation to fibrosis severity Sex hormone assayed (T= tertile)

Fibrosis, RR (95% CI)

Estrone T1 T2 T3 Ptrend

1 (reference) 0.71 (0.51-0.99) 0.64 (0.45-0.93) 0.01

Estradiol T1 T2 T3 Ptrend

1 (reference) 0.95 (0.65-1.39) 1.33 (0.95-1.87) 0.11

DHEA T1 T2 T3 Ptrend

1 (reference) 0.82 (0.59-1.14) 0.62 (0.42-0.92) 0.015

Androstenedione T1 T2 T3 Ptrend

1 (reference) 0.97 (0.69-1.37) 0.73 (0.47-1.14) 0.15

Multivariate model adjusted for age, sex, race/ethnicity, Tanner stage, and BMI z-score

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Proposed Influence of Estrogen on NASH

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Proteomic Biomarkers for NAFLD/NASH

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Assay of serum proteins predictive of histology

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

How Can We Treat It: Therapeutic Targets for NASH Decrease insulin resistance

Diminish oxidative stress – Lifestyle

– Lifestyle

– Weight loss

– Metformin

– Diet

– Thiazolidinediones

– Exercise

– Increase antioxidants – Diminish inflammation – Decrease sleep apnea – Antifibrotics

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

TONIC CONSORT

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Baseline Characteristics (N=173) Character (units) 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)

Vitamin E N= 58

Placebo N= 58

Metformin N= 57

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

ALT Decreased in All Groups

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Change in NAFLD Activity Score PIVENS vs. TONIC •Steatosis •Inflammatio n •p <0.001

•p = 0.008

•Cell Injury •p <0.001

•Steatosis •Inflammatio n •p = 0.24

•Cell Injury •p = 0.006

•p = 0.14

PIVENS (152 Adults)

TONIC (97 Children)

NEJM, 2010

JAMA, 2011

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Resolution of NASH Histologically •PIVENS (152 Adults)

•TONIC (82 Children) •p = 0.006

•p = 0.05

•Vitamin E

•Placebo

•Vitamin E

•Placebo

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

FLINT baseline characteristics Obeticholic acid (n = 141)

Placebo (n = 142)

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

Age (years)

•Neuschwander-Tetri et al, The Lancet, http://dx.doi.org/10.1016/S0140-6736(14)61933-4

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Changes in enzymes and body weight •ALT

•Alk Phos

•Off

•GGT

•Off

•Body weight

•Off

•Off •(EOT)

•(EOT)

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

Enteric-coated Cysteamine Pilot for Pediatric NASH

•Dohil et al, Alim Pharmacol Ther, 2011

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

CyNCh DR-Cysteamine for NAFLD in Children  Double-blind, placebo-controlled trial evaluating DRcysteamine 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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD

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

Evolution of Diagnostics and Therapeutics in Pediatric NAFLD