The Effect of GLP-1 Analogues on Liver Steatosis and Fibrosis in Diabetic and Obese Patients in a Clinical Setting
Conditions: Non-Alcoholic Fatty Liver Disease
Sponsor: Universitair Ziekenhuis Brussel

 
 
 
 
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Study Protocol 
 
Study title: The effect of GLP-1 analogues on liver steatosis and fibrosis in diabetic and obese patients in a clinical setting  
Study Acronym: GLP1_NAFLD 
Protocol Number: 23141_GLP1_NAFLD 
Protocol Version and Date: V 1.0 – 28/04/2023 
 
ClinicTrials.gov Registry Number:  
 
 
 
 
 
 
Investigational product: GLP-1 analogues  
 
 
 
 
 
Sponsor: UZ Brussel 
  
Coordinating/Principal Investigator: Hendrik Reynaert 
 
 
The information contained in this document is the property of the Sponsor/Coordinating Investigator and may not be 
reproduced, published or disclosed to others without written authorization of the Sponsor/Coordinating Investigator. 
PROTOCOL SIGNATURE PAGE 
Protocol Version and date: V 1.0 – 28/04/2023  
Protocol Title: The effect of GLP-1 analogues on NAFLD in diabetic and/or obese patients in a clinical setting  
Sponsor: UZ Brussel / Vrije universiteit Brussel  
 
 
Principal Investigator: Hendrik Reynaert 
 
I agree: 
- 
to assume responsibility for the proper conduct of this study 
- 
to conduct the study in compliance with this protocol and any future amendments  
- 
not to implement any deviations from or changes to the protocol without prior review and written approval 
from the Ethics Committee, except where necessary to eliminate an immediate hazard to the subjects, or for 
administrative aspects of the study (where permitted by all applicable regulatory requirements) 
- 
that I am thoroughly familiar with the appropriate use of the investigational drug, as described in this pro-
tocol 
- 
to ensure that all persons assisting me with the study are adequately informed about the investigational drug 
and their study-related duties and functions as described in the protocol 
- 
that I am aware of and will comply with the current good clinical practice (GCP) guidelines and ethical 
principles outlined in the Declaration of Helsinki 
- 
to conduct the study in accordance with all applicable laws and regulations 
 
 
 
 
 
Printed name                                                      Signature                                         Date 
        
    
                      Hendrik Reynaert  
 
 

 
 
 
 
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1. Table of Contents 
PROTOCOL SIGNATURE PAGE .................................................................................................................................... 1 
1. 
Table of Contents ...................................................................................................................................................... 2 
2. 
Synopsis .................................................................................................................................................................... 3 
3. 
Protocol Version History ........................................................................................................................................... 4 
4. 
Sponsor/Coordinating Investigator Information ........................................................................................................ 4 
5. 
List of Abbreviations ................................................................................................................................................. 4 
6. 
Introduction ............................................................................................................................................................... 5 
7. 
Study Objectives ....................................................................................................................................................... 6 
7.1 Primary Objective .................................................................................................................................................... 6 
7.2 Secondary Objectives ............................................................................................................................................... 6 
8. 
Methodology ............................................................................................................................................................. 7 
8.1 Study Overview ....................................................................................................................................................... 7 
8.2 Data Collection for Inclusion- and Exclusion Criteria ............................................................................................. 7 
8.3 Data Collection ........................................................................................................................................................ 7 
8.4 Data Protection and Management ............................................................................................................................ 8 
8.5 Data Processing ........................................................................................................................................................ 9 
9. 
Selection of Subjects ................................................................................................................................................. 9 
9.1 Selection of Study Population .................................................................................................................................. 9 
9.2 Inclusion Criteria ..................................................................................................................................................... 9 
9.3 Exclusion Criteria .................................................................................................................................................. 10 
10. Ethical Considerations ................................................................................................................................................ 10 
10.1 Ethical conduct of the study ................................................................................................................................. 10 
10.1.1 Declaration of Helsinki ................................................................................................................................ 10 
10.1.2 Ethics Committee ......................................................................................................................................... 10 
10.2 Informed Consent ................................................................................................................................................. 10 
10.3 Subject and Study Data Protection ....................................................................................................................... 10 
10.4 Conflict of Interest ............................................................................................................................................... 11 
12. Reporting and Dissemination ...................................................................................................................................... 11 
13. Conflict of interest statement ...................................................................................................................................... 11 
14. References .................................................................................................................................................................. 12 
 
 
 

 
 
 
 
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2. Synopsis 
Information 
ClinicalTrials.gov: 
pending 
Official Title: 
The effect of GLP-1 analogues on liver steatosis and fibrosis in diabetic and obese patients in a 
clinical setting 
Objectives: 
This study aims to measure the effect of GLP-1 analogues on NAFLD in a real-life clinical 
setting. 
Investigational Product: 
GLP-1 analogues 
Study population: 
Obese and/or diabetic patients with objectified NAFLD starting a GLP-1 analogue 
Number of patients: 
+- 100 
Overview of  
study design: 
Retrospective and prospective non-interventional study 
Sponsor: 
UZ Brussel 
Country of  recruitment: 
Belgium 
Inclusion Criteria: 
 
The patient is older than 18 years old. 
 
The patient has obesity, defined as a BMI of 30 or higher; and/or the patient suffers from 
T2DM, defined as a twice measured sfG of > 125 mg/dl or higher, or a sfG of 100 - 125 
mg/dl and a twice measured oral glucose tolerance test (OGTT) with a serum glucose (sG) 
of > 200 mg/dl, or higher after 2 hours, or a random sG of 200 mg/dl or higher in sympto-
matic patients. 
 
The patient suffers from NAFLD in any stage, except cirrhosis. This has to be objectively 
diagnosed by either a CAP fibroscan (cutoff: > 238 dB/m); or by the calculated Fatty Liver 
Index (cutoff: > 60), at least one of which has to be positive.  
 
The patient is starting a GLP-1 analogue as treatment for T2DM or obesity (standard of 
care); 
or the patient has started a GLP-1 analogue as treatment for T2DM or obesity (standard of 
care) 12 months prior to inclusion. 
 
If the patient is part of the retro-prospective branch data collected 12 months prior include 
at least a (CAP) fibroscan, a blood sample (measuring AST, ALT, GGT, sfG, sfI, HbA1c, 
HDL, LDL, total cholesterol and platelets) and a physical examination (measuring blood 
pressure, waist circumference, weight and length). 
Exclusion Criteria: 
 
The patient suffers from alcohol induced fatty liver disease. Macrocytic anemia; decreased 
vitamin B12 and folic acid; increased GGT, bilirubin, ferritin, TG and AST/ALT ratio can 
be used as serum markers of alcohol abuse. Interpretation of these results will be left to the 
patient’s clinician and their clinical expertise. Alternatively a weekly alcohol consumption 
of 21 units for men and 14 units for women can be used as a cutoff.  
 
The patient suffers from drug induced liver steatosis. Drugs warranting exclusion include: 
glucocorticoids, amiodarone, tamoxifen, methotrexate, valproate, tetracycline and chemo-
therapeutic agents.  
 
The patient suffers from any other chronic liver disease. This will be checked trough lab 
test results in the patients file.  
 
The patient has liver cirrhosis, defined as a fibroscan score of 14 kPa or more;  
or an elastography measurement of 10,5 kPa or more; 
or a FIB-4 index of > 2,67.  
 
The patient is pregnant at time of enrolment or at any time during the study. 
 
The patient refuses to agree to the informed consent. 
Date of first enrolment: 
Prospective inclusion: September 2023; Retrospective inclusion: September 2022 
Target sample size: 
+- 100 
 
 
 

 
 
 
 
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3. Protocol Version History 
Version No. 
Approval Date Lead EC 
Release Date 
V 1.0 
 
28/04/2023 
 
 
 
 
 
 
 
4. Sponsor/Coordinating Investigator Information 
Coordinating Investigator: Hendrik Reynaert 
Sponsor: UZ Brussel 
Principal Investigator: Hendrik Reynaert 
Co-investigators: Yannis Polspoel 
 
 
 
 
Additional co-researchers: NA 
 
Statistician: NA 
 
 
 
 
Laboratory: NA 
Pharmacy: NA 
 
 
 
  
Study Coordinator: Virgini Van Buggenhout 
 
Study sites and co-investigators: UZ Brussel 
5. List of Abbreviations 
Non-alcoholic fatty liver disease: NAFLD 
Insulin resistance: IR 
Advanced glycosylation end products: AGEs 
Liver steatosis: LS 
Alanine amino transferase: ALT 
Lower limit of normal: LLN 
Aspartate amino transferase: AST 
Metabolic syndrome: MetS 
Body mass index: BMI 
Non-alcoholic steatohepatitis: NASH 
De novo lipogenesis: DNL 
Oral glucose tolerance test: OGTT 
Free fatty acids: FFA 
Serum fasting glucose: sfG 
Gamma glutamyl transferase: GGT 
Serum fasting insulin: sfI 
Glucagon like peptide 1: GLP-1 
Serum glucose: sG 
Glucose dependent insulinotropic  
polypeptide: GIP 
Type 2 diabetes mellitus: T2DM 
Homeostatic model assessment of insulin  
resistance: HOMA-IR 
Upper limit of normal: ULN 
 
 
 

 
 
 
 
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6. Introduction 
Non-alcoholic fatty liver disease (NAFLD) has relatively recently become the leading cause of 
chronic liver disease in the West. (1) In Europe the prevalence is 23% which is predicted to grow 
further. Together with obesity and type 2 diabetes mellitus (T2DM), NAFLD is one of the major 
public health problems of the 21 century and therefore warrants further research. All three diseases 
are tightly associated with each other. (2, 3) Excess calorie intake leads to an increased triglyceride 
storage in adipocytes. Eventually this will cause insulin resistance (IR) predominantly through sys-
temic low-grade inflammation, lipotoxicity and a changed adipokine balance1. (4) IR and excess cal-
orie intake lead to abnormal lipid storage in hepatocytes which further increases local and systemic 
IR. Partially because of this fat deposits will form in pancreatic insulin-secreting beta cells leading to 
dysfunction. Other mechanisms of beta cell damage include glucotoxicity, lipotoxicity, inflammation 
(such as in obesity) and islet amyloid depositions. Impaired insulin secretion and IR eventually cause 
T2DM. All these mechanisms form self-reenforcing and interacting cycles2. Evidently there are com-
plex and interlinked pathways connecting obesity, T2DM and NAFLD which are not yet fully under-
stood. 
 
The pathophysiology of NAFLD is complex and multifactorial. Liver steatosis (LS) is the first step 
in this process. (5) Lipolysis in adipocytes, increased by IR and excess fat stores in obesity, causes 
free fatty acids (FFA) to be offered to hepatocytes. (3, 6) Excess caloric intake, especially fructose 
and other carbohydrates, will further generate FFA. Lastly de novo lipogenesis (DNL), again 
strengthened by IR, increases the FFA acid load in liver cells. Triglyceride (TG) are formed and 
accumulate in fat droplets which cause LS, which in turn further contributes to IR and the thus to the 
development of T2DM. Non-alcoholic steatohepatitis (NASH) is the next step in pathogenesis of 
NAFLD. Lipotoxicity3, inflammasome activation and an altered microbiome with increased epithelial 
permeability cause mitochondrial dysfunction, endoplasmic reticular stress and other hepatocytic in-
juries. (7) The resulting cellular dysfunction, inflammation, necrosis and apoptosis form NASH. Liver 
damage eventually starts fibrotic processes which can end in cirrhosis or hepatocellular carcinoma. 
Obesity and T2DM form aggravating factors for abovementioned disease processes trough an altered 
adipokine balance and formation of advanced glycosylation end products (AGEs) which activate fi-
brogenesis. Evidently LS, IR, T2DM and obesity have great influence on each other and have bidi-
rectional effects.  
 
GLP-1 analogues, such as semaglutide and liraglutide, are relatively novel drugs used for the treat-
ment of T2DM and obesity. They work through different mechanisms to decrease glycemia and IR, 
and improve weight loss. (8, 9) Glycemic control is increased through the so-called incretin effect. In 
physiological conditions glucagon like peptide 1 (GLP-1) and glucose dependent insulinotropic pol-
ypeptide (GIP) are post-prandially released from respectively intestinal L- and K cells. They then act 
on beta cells by stimulating the glucose-mediated release of insulin. Additionally GLP-1 inhibits the 
release of glucagon from pancreatic alpha cells, thus lowering glycemia. Weight loss is partially in-
duced by delayed gastric emptying and decreased accommodation which increase satiation4. (10) 
Central actions include stimulation of satiety5 and inhibition of food intake. IR mostly improves 
through weight loss, recent studies show however that GLP-1 can have direct effects on insulin sen-
sitivity. (11) 
 
                                                 
1 Increased resistine and TNF alpha, and decreased leptin and adiponectin lead to elevated IR. 
2 The exact pathophysiological processes and the order in which these take place are still partially unknown and have to 
be further explored. 
3 Lipotoxicity is mostly caused by oxidative stress mediated through FFA accumulation. 
4 Satiation refers to the feeling of fullness during and immediately after a meal acting as a mechanism to stop eating. 
5 Satiety refers to the feeling of fullness between meals acting as an inhibition to food intake. 

 
 
 
 
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Novel research shows that GLP-1 analogues can decrease LS and ameliorate liver histology. (12) 
Serum markers of glycemic control, IR, hepatic damage and inflammation all improved. (13) The 
exact mechanisms of action are not yet fully uncovered, but it is assumed that weight loss and im-
proved IR play pivotal roles. Some direct actions on liver physiology have also been discovered. (9) 
Although these results seem promising the amount of studies focusing specifically on the effect of 
GLP-1 analogues on NAFLD, especially in a clinical setting, are limited. Factors such as lifestyle, 
age, polymedication, polypathology, compliance and social demographics have often been disre-
garded. Real patient populations, especially in hyper-diverse cities such as Brussels, are heterogene-
ous in this regard. The effects of GLP-1 analogues are likely different in this context. The real clinical 
impact has thus yet to be documented, which is why we propose this prospective non-interventional 
study evaluating the effects of GLP-1 analogues given to patients with NAFLD and suffering from 
obesity and/or T2DM. The goal is to verify if previously measured outcomes can be replicated in a 
real-life clinical setting with all the difficulties and confounding factors that accompany this. This 
study does not however aim to document all these factors, only to measure their end result.  
7. Study Objectives 
7.1 Primary Objective 
This study aims to measure the effect of GLP-1 analogues on liver steatosis and fibrosis in diabetic 
and obese patients in a real-life clinical setting. Serum markers will be used to follow the evolution 
of liver damage and used to calculate the Fatty Liver Index and the FIB-4 index to evaluate steatosis 
and fibrosis respectively. Both pathogenic conditions will also be visualized and objectified using a 
(CAP) fibroscan.  
 
7.2 Secondary Objectives 
The effects of GLP-1 analogues on its primary indications, namely obesity and T2DM, will be inves-
tigated in a real-life clinical setting. Additionally the secondary effects on dyslipidemia will be eval-
uated. Parameters measured during a physical examination will be used to asses obesity. Serum mark-
ers will be used to follow the evolution of glycemic- and lipid control. 
 

 
 
 
 
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8. Methodology 
8.1 Study Overview 
This retrospective and prospective non-interventional study will be conducted in UZ Brussel. Partic-
ipants will be recruited from consultations in both the diabetes- and obesity clinics. All patients with 
T2DM and/or obesity starting a GLP-1 analogue6 are considered for inclusion. Data collection will 
either be retrospective or prospective. 
 
In the first (retrospective) case physicians will screen their patient files (obtained through Primuz) for 
possible candidates using the inclusion and exclusion criteria (see 9.1 and 9.2). Most importantly the 
presence of NAFLD needs to be confirmed and GLP-1 analogues had to be started within 12 months 
prior to inclusion. If selected, the first consultation where GLP-1 analogues were started will act as 
starting point for data collection. If insufficient information exists to decide whether or not exclusion 
is necessary, additional measurement (see 8.2) will be performed during this first (and only) contact 
point. Data collected 12 months earlier will be used as baseline and additional data will be collected 
on the day of inclusion. All measurements are part of the standard of care. 
 
In the second (prospective) case clinicians will evaluate possible inclusion (see 9.1 and 9.2) during 
the first consultation (where GLP-1 analogues are started). Data will be collected during this consul-
tation and a follow-up 12 months later. All measurements are part of the standard of care. 
 
8.2 Data Collection for Inclusion- and Exclusion Criteria 
Most inclusion- and exclusion criteria (see 9.1 and 9.2) require information that cannot be procured 
solely based by anamnesis. On the one hand the presence of NAFLD needs to be confirmed using 
CAP fibroscan and/or the calculated Fatty Liver Index. Respective cutoffs are defined as > 238 dB/m 
and > 60. (14-16) On the other hand a fibroscan or elastography and blood tests are needed to obtain 
additional data regarding possible cirrhosis and liver diseases other than NAFLD, both of which are 
exclusion criteria. Lab test results in the file of the patient will be checked for chronic viral hepatitis 
B and C (HBsAg, anti-HBs Ab, anti-HCV Ab and HCV RNA), hemochromatosis (ferritin and trans-
ferrin saturation), alcoholic liver disease (Hb, Hct, MCV, B12, folic acid, GGT, AST/ALT ratio, 
bilirubin, ferritin and TG), auto-immune hepatitis and primary biliary cholangitis (IgG, IgM, ANA, 
ANCA, anti-mitochondrial antibodies and anti-smooth muscle cell antibodies). After signing the in-
formed consent (see appendix) data collection can proceed. However if incoming results demonstrate 
exclusion, participation will be scraped and already collected data will be deleted. Abovementioned 
measurements are standard of care in UZ Brussel. 
 
8.3 Data Collection 
Data will be obtained from 2 consultations over a period of 12 months. In the case of the retrospective 
branch this includes data from 12 months prior to- and the day of inclusion. In the case of the pro-
spective branch the first contact acts as starting point during which inclusion will be evaluated and 
data collection will start. The second contact (after 12 months) will solely be used for data collection 
                                                 
6All GLP-1 analogues available in Belgium are eligible. These include semaglutide, liraglutide, lixisenatide and dulag-
lutide. 

 
 
 
 
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(and the normal follow-up of the patient). Every measurement performed during these consultations 
is part of the standard of care in UZ Brussel. 
 
Each consultation a physical examination will be performed to measure blood pressure, waist cir-
cumference, weight and length. BMI will be calculated using these last two. Weight, BMI and waist 
circumference will be used as markers of obesity. 
 
Blood will be drawn to assess the evolution of serum markers of glycemic control (sfG, C-peptide 
and HbA1c), lipid control (LDL, HDL and total cholesterol) and liver damage (AST, ALT and GGT). 
(17-19) Platelets will also be measured. IR will be estimated using HOMA-IR. This model uses sfG 
and sfI. 
 
Fibrosis and steatosis will be objectified using calculators (respectively the FIB-4 index and the Fatty 
Liver Index) and a (CAP) fibroscan or elastography. Both absolute and categorial7 values will be 
recorded. The FIB-4 index uses AST, ALT, platelet count and age. (20) In patients < 49 years old a 
FIB-4 index of < 1,05 is categorized as low-, 1,05 – 1,21 as intermediate- and > 1,21 as high risk for 
fibrosis. (21) In patients 50 - 59 years old a FIB-4 index of < 1,24 is categorized as low-, 1,25 – 1,96 
as intermediate- and > 1,96 as high risk for fibrosis. In patients 60 – 69 years old a FIB-4 index of < 
1,88 is categorized as low-, 1,88 – 2,67 as intermediate- and > 2,67 as high risk for fibrosis. In patients 
> 70 years old a FIB-4 index of < 1,95 is categorized as low-, 1,95 – 2,67 as intermediate- and > 2,67 
as high risk for fibrosis. The Fatty Liver Index uses GGT, TG, BMI and waist circumference to cal-
culate the risk of NAFLD. (16) A score < 30 rules out- and a score > 60 rules in NAFLD. This study 
defines fibroscan measurements of 2 - 7 kPa as F0 - F1 (no to mild fibrosis), 7 - 10 kPa as F2 (mod-
erate fibrosis), 10 - 14 as F3 (severe fibrosis), and > 14 kPa as F4 (cirrhosis). This study defines 
elastography measurements of < 7kPa (< 1,53 m/s) as F0-F1, 7 - 9,5 kPa (1,53 – 1,78 m/s) as F2, 9,5 
– 10,5 (1,78 – 1,87 m/s) as F3 and > 10,5 (> 1,87 m/s) as F4. This study defines CAP fibroscan 
measurements of < 238 dB/m as S0 (no steatosis), 238 - 260 dB/m as S1 (mild steatosis), 260 - 290 
dB/m as S2 (moderate steatosis) and > 290 dB/m as S3 (severe steatosis). Abovementioned cutoffs 
were chosen because they are the standards in the institution (UZ Brussel) in which this study will 
take place.  
8.4 Data Protection and Management 
All data will be pseudonymized. After inclusion physicians will add their patients to a protected 
worksheet in Primuz which will only be accessible to the primary investigators. Each participants 
will receive a unique subject number. Data will be retrieved from Primuz and recorded on a stand-
ardized excel sheet (see appendix) which will only differentiate between patients using subject num-
bers. No information will be recorded that could identify a participant’s identity.  
 
 
                                                 
7 No categorization exist for the NAFLD liver fat score. 

 
 
 
 
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8.5 Data Processing 
Once all data is collected it will be exported to SPSS to be analyzed. Each variable will be compared 
to itself at previous time points using the student’s T-test with alpha = 0,05. Changes in categorial 
values will be evaluated using the Pearson's χ2 test with alpha = 0,05. Evidently normal distribution 
of data will first be verified. 
9. Selection of Subjects 
9.1 Selection of Study Population 
Participants will be recruited from consultations in the diabetes- and obesity clinic in UZ Brussel. All 
diabetic and/or obese patients with objectified NAFLD starting a GLP-1 analogue, or whom have 
started a GLP-1 analogue 12 months prior, will be considered as possible candidates. Inclusion is 
final after it is established that patients comply to all inclusion- and exclusion criteria and they agree 
to the informed consent. Patients can withdraw at any point during the study. 
 
9.2 Inclusion Criteria  
 The patient is older than 18 years old. 
 The patient has obesity, defined as a BMI of 30 or higher;  
and/or the patient suffers from T2DM, defined as a twice measured sfG of > 125 mg/dl or higher, 
or a sfG of 100 - 125 mg/dl and a twice measured oral glucose tolerance test (OGTT) with a serum 
glucose (sG) of > 200 mg/dl, or higher after 2 hours, or a random sG of 200 mg/dl or higher in 
symptomatic patients. 
 The patient suffers from NAFLD in any stage, except cirrhosis, objectively diagnosed by either a 
CAP fibroscan (cutoff: > 238 dB/m); or by the calculated Fatty Liver Index (cutoff: > 60), at least 
one of which has to be positive.  
 The patient is starting a GLP-1 analogue as treatment for T2DM or (standard of care); 
or the patient has started a GLP-1 analogue as treatment for T2DM or obesity (standard of care) 
12 months prior to inclusion. 
 If the patient is part of the retro-prospective branch data collected 12 months prior include at least 
a (CAP) fibroscan, a blood sample (measuring AST, ALT, GGT, sfG, sfI, HbA1c, HDL, LDL, 
total cholesterol and platelets) and a physical examination (measuring blood pressure, waist cir-
cumference, weight and length). 
 
 

 
 
 
 
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9.3 Exclusion Criteria 
 The patient suffers from alcohol induced fatty liver disease. Macrocytic anemia; decreased vita-
min B12 and folic acid; increased GGT, bilirubin, ferritin, TG and AST/ALT ratio can be used as 
serum markers of alcohol abuse. Interpretation of these results will be left to the patient’s clinician 
and their clinical expertise. Alternatively a weekly alcohol consumption of 21 units for men and 
14 units for women can be used as a cutoff. (22) 
 The patient suffers from drug induced liver steatosis. Drugs warranting exclusion include gluco-
corticoids, amiodarone, tamoxifen, methotrexate, valproate, tetracycline and chemotherapeutic 
agents. (23) 
 The patient suffers from any other chronic liver disease. This will be checked trough lab test 
results in the patients file.  
 The patient has liver cirrhosis, defined as a fibroscan score of 14 kPa or more;  
or an elastography measurement of 10,5 kPa or more;  
or a FIB-4 index of > 2,67. 
 The patient is pregnant at time of enrolment or at any time during the study. 
 The patient refuses to agree to the informed consent. 
10. Ethical Considerations 
10.1 Ethical conduct of the study 
10.1.1 Declaration of Helsinki 
This study will be performed in accordance with the Declaration of Helsinki, International Confer-
ence on Harmonization (ICH) Good Clinical Practice (GCP) guidelines and local laws and regulation 
as recommended by the European Community. 
 
10.1.2 Ethics Committee 
Approval will be obtained from the appropriate regulatory authority in Belgium prior to the start of 
the study, in this case the Ethical Committee of UZ Brussel. Investigators and personnel are respon-
sible for acting in accordance with their local regulatory requirements. The study will start on-site 
only after approval by the local ethical committee. 
 
10.2 Informed Consent 
All eligible patients should provide a signed and dated informed consent (see appendix) before inclu-
sion into this study. 
10.3 Subject and Study Data Protection  
All data will be pseudonymized. After inclusion physicians will add their patients to a protected 
worksheet in Primuz which will only be accessible to the primary investigators. Each participants 
will receive a unique subject number. Data will be retrieved from Primuz and recorded on a stand-
ardized excel sheet (see appendix) which will only differentiate between patients using subject num-
bers. No information will be recorded that could identify a participant’s identity.  

 
 
 
 
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10.4 Conflict of Interest 
This study reports no conflict of interest. All participating investigators will list their possible con-
flicts of interests. 
 
11. Finance and Insurance 
 
This academic study is sponsored by UZ Brussel. All data collection is part of the standard of care. 
No additional costs will be charged. No compensation will be provided for participation. 
 
Adequate insurance coverage for medical professional and/or malpractice liability and general liabil-
ity will be maintained in full force and effect during the term of this study, and following termination 
of the study to cover any claims arising from the trial. Additionally in accordance to art. 29 of Belgian 
Law relating to experiments on human persons, dated May 7th, 2004 an insurance contract will be 
obtained in order to cover Trial Participants.  
12. Reporting and Dissemination 
Reporting and dissemination requires prior agreement of the principle investigator. 
13. Conflict of interest statement 
This study reports no conflicts of interest. All participating investigators will list their possible con-
flicts of interests. 
 
 

 
 
 
 
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Al-Mrabeh A. Pathogenesis and remission of type 2 diabetes: what has the twin cycle hypothesis 
taught us? Cardiovasc Endocrinol Metab. 2020;9(4):132-42. 
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Khandelwal R, Dassanayake AS, Conjeevaram HS, Singh SP. Non-alcoholic fatty liver disease in 
diabetes: When to refer to the hepatologist? World J Diabetes. 2021;12(9):1479-93. 
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Wondmkun YT. Obesity, Insulin Resistance, and Type 2 Diabetes: Associations and Therapeutic 
Implications. Diabetes Metab Syndr Obes. 2020;13:3611-6. 
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Pouwels S, Sakran N, Graham Y, Leal A, Pintar T, Yang W, et al. Non-alcoholic fatty liver disease 
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Friedman SL, Neuschwander-Tetri BA, Rinella M, Sanyal AJ. Mechanisms of NAFLD development 
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Arab JP, Arrese M, Trauner M. Recent Insights into the Pathogenesis of Nonalcoholic Fatty Liver 
Disease. Annu Rev Pathol. 2018;13:321-50. 
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Nauck MA, Quast DR, Wefers J, Meier JJ. GLP-1 receptor agonists in the treatment of type 2 diabetes 
- state-of-the-art. Mol Metab. 2021;46:101102. 
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Bifari F, Manfrini R, Dei Cas M, Berra C, Siano M, Zuin M, et al. Multiple target tissue effects of GLP-
1 analogues on non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). 
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Shah M, Vella A. Effects of GLP-1 on appetite and weight. Rev Endocr Metab Disord. 2014;15(3):181-
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Drucker DJ. Mechanisms of Action and Therapeutic Application of Glucagon-like Peptide-1. Cell 
Metab. 2018;27(4):740-56. 
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Teshome G, Ambachew S, Fasil A, Abebe M. Efficacy of Glucagon-Like Peptide-1 Analogs in 
Nonalcoholic Fatty Liver Disease: A Systematic Review. Hepat Med. 2020;12:139-51. 
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