A Randomized, Double-Blinded, Placebo-controlled Phase IIa Study to Assess the Efficacy and Safety of a Novel AstraZeneca Compound in Subjects With Non-alcoholic Steatohepatitis (NASH) or Non-alcoholic Fatty Liver Disease (NAFLD)
Phase: PHASE2
Conditions: Non-alcoholic Fatty Liver Disease (NAFLD), Non-alcoholic Steatohepatitis (NASH)
Sponsor: University of Alabama at Birmingham

 
 
 
 
Study Title: Does inhibition of liver specific 11β-
hydroxysteroid dehydrogenase type 1 enzyme 
lower liver fat in NAFLD or NASH? 
 
 
 
Version Date: 04-08-2019 
  
 
NCT Number: NCT02605616 
 
 

PI: R.Basu, 11 Beta HSD inhibitor in NAFLD or NASH 
 
1 
 
Title:  Does inhibition of liver specific 11β-hydroxysteroid dehydrogenase type 1 enzyme lower 
liver fat in NAFLD or NASH? 
 
Protocol Version date:  4-8-19 Edited by R.Basu,MD 
 
Dr Rita Basu (PI) has relocated to University of Virginia Health System (UVa). The study will be 
conducted at both Mayo Clinic and UVa.We have completed enrollment at Mayo Clinic and are 
currently enrolling at UVA only.  
 
Background and Rationale: 
11β-hydroxysteroid dehydrogenase type 1 enzyme pathway: 
Glucocorticoids are potent regulators of glucose, fat and protein metabolism. Tissue specific 
conversion of cortisone to cortisol via 11β-hydroxysteroid dehydrogenase type 1 enzyme pathway 
(11β-HSD-1) results in high local cortisol concentrations (1). 11β-HSD-1 is present in multiple tissues 
including the liver and adipose tissue with activity being greater in omental than subcutaneous fat (2-
5). The 11β-HSD-1 pathway has attracted considerable attention both as a therapeutic target and a 
potential contributor to the pathogenesis of diabetes, obesity and the so called “metabolic syndrome” 
(1; 6; 7). Our observation that the splanchnic bed of obese humans (8) produces large amounts of 
cortisol with all of it occurring within the liver strongly implies that the resultant high local cortisol 
concentrations within the liver could be important determinants of hepatic insulin action. If so, 
inhibitors of hepatic 11β-HSD-1 could have dramatic effects on hepatic insulin action and could 
become an important new therapy for type 2 diabetes. 
 
 
The role of high circulating intra-hepatic cortisol on modulation of insulin action in humans is an area 
of active investigation. Glucocorticoids induce glucose intolerance in humans in a dose and duration 
dependent manner (9-12) by inducing hepatic and extra hepatic insulin resistance (12-21). However, 
the exact mechanism of this effect was unknown. In vitro studies have reported that glucocorticoids 
increase11β-HSD-1 enzyme activity and mRNA expression in rat liver cells (3; 22). Our laboratory 
has developed a non-invasive technique to measure hepatic cortisone to cortisol conversion in 
humans (23). We have recently reported that liver cortisol production is higher in obese humans (8; 
23; 24) through increased activity of hepatic 11β-HSD-1 enzyme. We also have recently completed a 
series of experiments and concluded that glucocorticoid excess stimulates hepatic cortisone to 
cortisol conversion via 11β-HSD-1 enzyme pathway and is associated with hepatic and extrahepatic 
insulin resistance in nondiabetic humans (25 ; 26). This implies targeting hepatic 11β-HSD-1 enzyme 
could ameliorate steroid induced changes in lipid and glucose metabolism. 
 
That the liver is an important regulator of the diabetogenic effects induced by GC use is borne by the 
fact that liver selective GC receptor antagonists have been shown to reduce fasting glucose and 
improve hepatic insulin action during a hyperinsulinemic euglycemic clamp (27). A recent clinical trial 
has shown that 11-HSD inhibition for 12 weeks can reduce liver fat (~14%), and total body weight 
without any effects on insulin induced suppression of glucose production (28). However, to our 
knowledge liver specific inhibitors of 11-HSD have not been rigorously tested in the manner we 
currently propose. 
 
Hepatic fat: 
 
Under physiologic conditions, the liver is exposed to free fatty acids (FFA) derived from food and 
adipose tissue depots. These FFA are taken up by hepatocytes, where they undergo esterification to 

PI: R.Basu, 11 Beta HSD inhibitor in NAFLD or NASH 
 
2 
 
form triglycerides (TG) that are ultimately stored in vacuoles or released to the bloodstream as very-
low-density lipoproteins (VLDL). When equilibrium is disrupted, uptake and/or de novo synthesis of 
FFA is increased relative to fatty acid oxidation; if the rate of TG production is greater than that of 
VLDL synthesis and secretion, TGs accumulate in macrovacuoles within the hepatocyte (29) (termed 
hepatic steatosis). Clinically, hepatic steatosis is defined as macrovesicular fat accumulation in ≥ 5% 
of hepatocytes (30). NASH (non-alcoholic steatohepatitis) is an advanced form of fatty liver disease 
associated with inflammation and fibrosis. Liver enzymes (AST and ALT) are likely to be elevated in 
more than 90% of cases of NASH. In patients with NAFLD (non-alcoholic fatty liver disease), 
approximately 30% with isolated steatosis will progress to NASH. Of those with NASH, approximately 
20% will develop cirrhosis, and of those with cirrhosis, 30–40% will decompensate and succumb to 
liver-related death over a 10-year period (31).  
 
Currently, the favored technique for estimating the liver fat fraction (LFF) is quantitative magnetic 
resonance (MR) imaging (32). MR imaging in general ignores the multispectral nature of hepatic TG 
that can be used to distinguish between saturated fat, monounsaturated fatty acid (MUFA), and 
polyunsaturated fatty acid (PUFA). MR spectroscopy (MRS) of liver fat has been performed, and 
although it suffers from sampling error due to the small voxel size relative to liver size, the wealth of 
spectral information obtained can be used to determine the composition and quantity of hepatic fatty 
acids. Previous MRS studies of the liver (32-37) have used manual fitting techniques that are time 
intensive and operator biased (38-43). LC Model is a semi-automated, widely available MRS fitting 
program that can quantify up to 10 different fat resonances in the liver (38). We have developed a 
reliable, reproducible method for acquiring liver spectra on a 3T MRI scanner to calculate liver fat 
composition. This method was evaluated with 6 nondiabetic subjects scanned during 2 separate 
sessions, 10 days apart. In each session, 4 separate liver fat measurements were taken (8 
scans/subject). Spectra were preprocessed (phased, averaged) and then analyzed using LC Model 
software. Quantified spectral data were combined into 4 liver fat indices: total fatty acids (TFA), 
polyunsaturated fatty acid index (PUFAI), total unsaturated fatty acids (TUFA), and the standard fat 
water ratio (FWR), similar to the LFF. Calculations were performed to evaluate intraclass correlation 
coefficient (ICC) for each index and variability within the cohort (ie, intrascan, interscan, inter-session, 
intersubject). The FWR varied from 0.02 to 0.26, indicating a wide range of liver fat in this healthy 
cohort (normal was defined as FWR0.05).  Liver fat index ICCs for intrascan, interscan, and 
intersession reliability ranged from 0.92 (PUFAI interscan) to 0.99 (FWR intrascan and interscan), 
indicating that our method is highly reproducible. Variance components models (SAS PROC 
NESTED) showed that the majority of variance in the indices resulted from differences between 
subjects (FWR=98%, TFA=90%, TUFA=96%, PUFAI=89%). TFA had a small intersession variance 
(4%), whereas TFA and PUFAI had small scanner-related variance (6% and 9%, respectively). The 
remaining variance components were negligible (39). Mayo Clinic is implementing this scanning 
method for patients being evaluated for liver fat. We recently concluded a nutritional intervention trial 
in which this method was used to measure hepatic fat in subjects with IFG (impaired fasting glucose) 
(40; 41).  
 
Magnetic resonance elastography (MRE) is a non-invasive MRI based technique that measures 
tissue stiffness (42). The widely applied clinical MRE technique was developed at the Mayo Clinic and 
is available at more than 300 centers worldwide. MRE provides a new quantitative parameter "tissue 
stiffness" useful for tissue characterization and differentiation and found useful in the detection and 
staging of liver fibrosis with high technical success and excellent accuracy (43-47) . Liver stiffness is 
affected by the presence of inflammation and fibrosis. MRE by way of measuring elevated liver 

PI: R.Basu, 11 Beta HSD inhibitor in NAFLD or NASH 
 
3 
 
stiffness can differentiate nonalcoholic steatohepatitis  characterized by inflammation and or fibrosis 
from simple steatosis or just fatty liver. Chen et al (45) showed that MRE had excellent accuracy 
(AUROC 0.93, sensitivity 94%) for differentiating simple fatty liver from steatohepatitis. Two studies 
have shown that MRE has excellent accuracy (92-94%) for distinguishing advanced fibrosis and 
cirrhosis in NASH patients from those with lesser degree of fibrosis in patients with NASH study (48; 
49).  Preliminary clinical experience has shown that MRE is useful in assessing treatment response in 
cases that included patients with fibrosis (50). MRE is therefore a useful noninvasive technique for 
detection, staging and assessment of treatment response. Since moving to UVA we are now using a 
Siemens scanner instead of GE so data are slightly different. The Liver fat % is comparable but the 
fibrosis scores are not the same from each scanner. Hence, we are opting to study some people with 
liver fibrosis stage 0 up at UVA. 
 
Glucose tolerance: 
The most frequently described conditions associated with NAFLD are obesity and T2DM, with insulin 
resistance (IR) as the underlying key factor for development of nonalcoholic fatty livers. Cusi et al 
have conducted elegant studies in patients with NAFLD and have shown reduced insulin sensitivity 
(Si) (eg, in liver and muscle), regardless of glucose tolerance status (51). People with impaired fasting 
glucose (IFG; fasting glucose concentration, 100-125 mg/dL) or impaired glucose tolerance (IGT; 2-
hour glucose, 140-199 mg/dL after the standard 75-g oral glucose tolerance test [OGTT]) have a 25% 
to 30% chance of T2DM development within the next 5 to 10 years (52-55). Numerous studies (56-
58) have shown that IGT, either alone or in combination with IFG (IFG/IGT), is associated with 
defects in insulin secretion and action. We will phenotype the subjects to gain better understanding of 
their metabolic status. 
 
 
Approach: 
We propose to combine the triple tracer cortisol technique with voxel matched MRS and MRE liver 
(pre vs. post) to evaluate hepatic cortisol production and hepatic fat and hepatic fibrosis.  We will 
conduct baseline testing in subjects to estimate baseline hepatic cortisone to cortisol conversion. We 
will also establish glucose tolerance status by our established labeled OGTT (6,6 2H2 glucose). 
Following baseline evaluation subjects with NASH, NAFLD, will be randomized to one of two groups 
and treated either with active drug (liver specific 11-HSD type 1 inhibitor) or placebo for 12 weeks +/- 
1 week. OGTT, liver MRS, MRE and triple tracer cortisol study will be repeated. Liver enzymes (AST, 
ALT, ALP) as well as other safety tests (CPK,TSH,INR,T bilirubin) will be measured before, monthly 
during therapy and at one month following therapy. Details in the DSMP. 
 
Specific Aim: Determine if inhibition of hepatic 11-HSD type 1 activity lowers hepatic fat in 
subjects with NAFLD or NASH.  
 
I) Primary Hypotheses:  
 a)  AZD4017 decreases hepatic fat  as compared to placebo.  
 b)  AZD4017 decreases hepatic conversion of [13C] cortisone to [13C] cortisol as compared to 
placebo. 
 
II) Secondary Hypotheses: 
a) Liver enzymes (AST, ALT) will be reduced in subjects treated with AZD4017 as compared to 
placebo. 

PI: R.Basu, 11 Beta HSD inhibitor in NAFLD or NASH 
 
4 
 
b) Liver fibrosis measured with MRE will be reduced in subjects treated with AZD4017 as 
compared to placebo. 
c) Total insulin sensitivity (Si) and hepatic insulin sensitivity (Si liver) will be improved after 
treatment with AZD4017 than at baseline. 
d) Total insulin sensitivity (Si) and hepatic insulin sensitivity (Si liver) will be improved in subjects 
treated with AZD4017 as compared to placebo. 
 
Exploratory Aim (future plan): We wish to analyze biomarkers of fibrosis and 11 β HSD 
polymorphisms since polymorphisms in the 11β-HSD1 gene are also associated with components of 
the metabolic syndrome (59; 60). We wish to test if polymorphisms are likely associated with who 
may or may not respond to the 11 β HSD inhibitor.  
 
Biomarkers: NAFLD, NASH and Inflammation: NAFLD and NASH are increasing in incidence and 
prevalence in the United States and worldwide, in parallel with the increasing rates of obesity (61). 
Both disorders are characterized by the 
presence of hepatic steatosis. NASH is 
distinguished from NAFLD on the basis of 
liver injury and liver inflammation (62). One 
disease pathogenesis paradigm holds 
hepatocyte cell death via lipoapoptotic 
pathways as a central event in the onset of 
progressive forms of NASH; furthermore, 
hepatocyte apoptosis correlates with 
fibrosis stage in NASH patients (63; 64).  
There are many circulating surrogate 
markers for fibrosis in NASH. The enhanced liver fibrosis (ELF) score is a function of serum levels of 
hyaluronic acid (HA), tissue inhibitor of metalloproteinases-1 (TIMP-1), and procollagen III N-terminal 
peptide (PIIINP) is a validated tool for assessing serum fibrosis (65).  Other clinical surrogates include 
the AST/platelet ratio index (APRI) and age-spleen-platelet ratio index (ASPRI); however, the ELF 
test is unique in its incorporation of three molecules involved in the synthesis and breakdown of 
extracellular matrix. Newer serum based scores such as APRI ( AST to platelet ratio index), FIB-4 ( 
Age, ALT,AST, platelet count), NAFLD fibrosis score (age,ALT,AST,platelet count,BMI,albumin, 
impaired fasting glucose/diabetes) and BARD ( ALT/AST ratio,BMI,diabetes) score may be calculated 
using the data gathered. In this study we will be able to correlate MRE results with circulating levels of 
all proposed biomarkers.   
 
Subjects: Detailed information is provided in the DSMP. However, in brief, otherwise healthy (age 
21-75 years), subjects (BMI >19kg/m2) with NAFLD (MRS liver fat ≥ 5%, total bilirubin (TB) <1.5 
xULN, INR <1.3) will be enrolled following IRB approval. Subjects with previous biopsy proven and/or 
MRE proven NASH will be included. Subjects with history suggestive of NAFLD/NASH per recent 
guidelines published by Loomba et al (66) will be invited to participate. If they meet criteria following 
initial screening they will be included in the study if their MRE shows F0 or greater fibrosis. Glucose 
tolerance status will be determined by OGTT. We will include subjects with type 2 diabetes who are 
on stable doses of medications (except pioglitazone) to control hyperglycemia and have baseline 
HbA1c of 10% or lower. Subjects will be chosen from  UVa databases and will be contacted by phone 
or in writing and invited to participate in the study.. If subjects recently (within 3 months) had any of 
the exams, tests or procedures involved in this study conducted as part of their clinical care or as part 
Subjects 
with 
NAFLD 
and 
NASH
Lab tests, 
OGTT
MRS and 
MRE -Liver
Triple Tracer
Cortisol 
study
11 ß HSD-1 
Inhibitor
12 weeks
(n=40)
Placebo
12 weeks
(n=40)
Pre treatment
Post treatment
Randomization
Screening
Consent
Lab tests, 
OGTT
MRS and MRE-
Liver
Triple Tracer
Cortisol study
N=80
Schematic diagram of study outline 

PI: R.Basu, 11 Beta HSD inhibitor in NAFLD or NASH 
 
5 
 
of another study that are accessible they may not need to be repeated. It will be up to the study 
doctor to review and consider if previous findings are appropriate to use. Healthy will indicate that 
they generally are in good health and have no chronic medical condition including hepatic disease, 
stroke, Alzheimer’s disease, alcoholism or  increased alcohol consumption over the ADA guidelines 
or any disorder that may potentially impact the outcome measures. Thyroid medications, statins and 
antihypertensive medications that are metabolically neutral (e.g. low dose thiazides) will be permitted. 
At this time based on a prior human study done using a similar 11-βHSD1 inhibitor (Ref: Stefan et al, 
lancet, May 2014) suggests that usage of drugs potentially associated with non-alcoholic fatty liver 
disease (NAFLD) such as amiodarone, methotrexate, perhexiline, estrogens, tamoxifen, nifedipine, 
diltiazem, choloroquine and other hepatotoxic agents will need to be reviewed if used for more than 2 
consecutive weeks in the 2 years preceding the screen visit. Subjects taking TZD’s, Atazanavir, 
Indinavir, Ketoconazole, Valproic acid, Silybum marianum and Valeriana officinalis will be excluded. 
Additionally if subjects are taking drugs such Vit E, Ursodeoxycholic acid, Gemfibrozil, anti TNF 
therapies and probiotics will be allowed if on stable doses in the preceding 2 weeks and continued 
throughout the study. However as with all concomitant medication usage the study doctors will review 
on case by case basis prior to inclusion in trial. The final decision for enrollment will be based on the 
clinical judgement, discretion of the study doctors. 
Subjects that engage in vigorous physical exercise programs may be included. The level of exercise 
will be assessed by PI to determine if eligible to participate in study. Those actively losing weight will 
be excluded. Dietary advice will be provided by the research dietician to ensure that subjects maintain 
a constant body weight within 2% of their baseline during the trial period. Body composition may be 
measured during the screen visit in the body composition core using Lunar iDXA or similar machine 
at UVa to measure body composition. Mayo uses software version 6.10 (GE Healthcare 
Technologies, Madison, WI) to measure total body fat, and waist–hip measurements will be done to 
look at abdominal adiposity. Screen visit will also include blood and urine tests, height, weight, vital 
signs, ECG, a physical exam and review of their medical history. Hemoglobin must be greater than or 
equal to 12.0 in males and 11.0 in females. Subjects will report to UVa campus for screen visit and 
monthly outpatient visits. 
 
Study testing: Includes out-patient visits for iDXA (screen and 3 month), blood (screen/monthly) and 
urine tests (screen and 3 month), monthly prescription pick up visits, labeled OGTT (screen and 3 
month), MRS, MRE (screen and 3 month) and in-patient visits (see experimental design) to measure 
hepatic cortisone to cortisol conversion using our established triple tracer cortisol technique in 
subjects with NAFLD or NASH.  
 

PI: R.Basu, 11 Beta HSD inhibitor in NAFLD or NASH 
 
6 
 
Treatment: Subjects will be randomized to receive either AZD4017 800 mg/day for three months in 
two divided doses morning (400 mg) and evening (400 mg); matched placebo for three months. Pill 
counting will be done at monthly visits to monitor compliance and adherence to therapy. Unused pills 
will be returned and discarded by the research pharmacy. Both subjects and investigators will be 
masked to the type of treatment. We 
anticipate that 50 subjects in each of the 
two groups (with ~5 anticipated drop 
outs per group) will be sufficient to 
answer our primary hypotheses. 
Once enrolled in the study, subjects will 
be asked not to donate blood 12 weeks 
before and 12 weeks after the study. Per 
Institutional Review Board guidelines 
and blood bank the total amount of blood 
withdrawn in any 12 week period will not 
exceed 1 unit of blood (~550 ml) and this 
includes all screening bloods (~24 ml ), 
monthly safety bloods ( ~8 ml) , OGTT ( ~60 ml), Triple tracer cortisol study (~150 ml). 
 
Experimental design: 
MRS and MRE for liver fat and fibrosis will be done if not done previously following enrollment into 
study. For flexibility of scanning we will allow subjects to undergo MR scans at any time prior to the 
screening visit. A standard 75 gm labeled (6,6-2H2 glucose) OGTT will be performed over 240 mins to 
determine glucose tolerance status. OGTT: The labeled OGTT will enable us to concurrently measure 
various indices of insulin action, insulin secretion, and DI (composite measure of insulin secretion 
accounting for the prevailing level of IR). Furthermore, this protocol also allows measurement of EGP; 
this method was validated (41; 67-73) in various population cohorts in the US and Europe. OGTT will 
not be performed on subjects taking insulin for management of hyperglycemia. Subjects will be 
required to fast overnight and report to the CRTU at Mayo Clinic or  UVa campus on the morning of 
testing. Only sips of water will be allowed until testing is complete. An 18-gauge cannula will be 
inserted in a forearm for blood withdrawal. After baseline sampling (–15 and 0 minutes), a dextrose 
solution (Limeondex [Fisher]) will be consumed within a few minutes; this solution will contain 3 g of 
6,6- 2H2] glucose (~4% enrichment) in 72 g of dextrose. Blood samples will be withdrawn at 10, 20, 
30, 60, 90, 120, 150, 180, 210, and 240 minutes for measurement of glucose, insulin, C-peptide, 
glucagon, and [6,6- 2H2] glucose enrichment. At the end of the study, subjects will be provided a 
snack and dismissed.  
 
Cortisol study: 
Subjects will return on a different day for the in-patient visit.  Subjects will be admitted to the CRTU 
between 4 pm and 6 pm on the evening before the study and will be provided a standard supper 
(carbohydrate: protein: fat in the ratio of 50:20:30). consisting of ~33% of the subject’s total estimated 
calorie intake based on Harris Benedict + 20% calorie requirements. Urine pregnancy test will be 
done in women of child bearing potential. Subjects will be awakened the following morning and a 
catheter will be placed in a forearm vein for tracer infusion and in the dorsum of the opposite hand 
which will be placed in a heated box (~550C) to permit sampling of arterialized venous blood. A 
bladder catheter will be offered on the morning of study if subjects are unable to use a bedpan, urinal 
or bedside commode. A primed (24µCi) continuous (0.24 µCi/min) infusion of [1,2,6,7–3H] cortisol will 
 

PI: R.Basu, 11 Beta HSD inhibitor in NAFLD or NASH 
 
7 
 
be started at minus 120 minutes and blood will be collected for measurement of [3H] cortisol 
concentration at timed intervals in each subject to calculate basal production rate of cortisol. At time 
0, subjects will ingest 1.0 mg of [4-13C] cortisone and 1.0 mg of [9,12,12-2H3] cortisol. At time 0, the 
[3H] cortisol infusion rate will be increased in order to mimic the temporal pattern of change as 
previously published (23). Arterialized venous blood then will be sampled at periodic intervals 
(suggested timelines are -30,  0, 20, 40, 60, 75, 90, 120, 150, 180, 210, 240 minutes) for 
measurement of [2H] cortisol, [2H] cortisone, [13C] cortisone and [13C] cortisol enrichment, and [3H] 
cortisol [3H] cortisone specific activity (23). At UVa subjects will come in to CRU morning of study and 
all other interventions will be similar as outlined above. 
 
Analytical methods 
All blood samples will be immediately placed on ice, centrifuged at 40C, separated and stored at -
800C until analyses. Plasma glucose will be analyzed using YSI (yellow springs Ohio), plasma insulin 
will be measured using a chemiluminescence method with the Access Ultrasensitive 
Immunoenzymatic assay system (Beckman, Chaska, MN) and C-peptide and glucagon measured 
using a radioimmunoassay; Linco Research. Plasma [6,6-2H2] glucose enrichment will be measured 
using gas chromatographic mass spectrometry (74). Plasma cortisol, cortisone, D3 cortisol, D3 
cortisone, 13C cortisone and C13 cortisol enrichments will be measured using liquid chromatography 
tandem mass spectrometry as previously described (23; 75; 76). [3H] cortisol radioactivity will be 
measured using high performance liquid chromatography followed by liquid scintillation counting (23; 
77). Body composition will be measured using Lunar dual energy X-ray absorptiometry software (GE 
Healthcare Technologies). 
 
 
Calculations:  
[3H] cortisol will be used to trace the systemic rate of appearance of both [13C] cortisol and [2H] 
cortisol. Thus, the systemic rate of appearance (ug/min) of [13C] cortisol derived from the ingested 
[13C] cortisone will be calculated by using Steele’s steady state equation. Hepatic [13C] cortisol 
production will be calculated as the area under the curve for the rate of appearance of [13C] cortisol 
divided by one minus the hepatic extraction of [2H] cortisol (23; 78). Insulin sensitivity and secretion 
indices will be calculated using unlabeled and labeled models established by us previously (41; 61-
67) 
 
Statistical Analysis  
Demographics and baseline characteristics will be described by treatment group and the groups 
compared using two-sample t-tests.    
 
Primary analysis 
We will first compare the change in LFF from baseline (time 0) to post treatment (12 week) between 
the two treatment groups, one with patients treated with active drug and the other with patients 
treated with placebo, using analysis of covariance (ANCOVA) including baseline LFF as a covariate.  
This primary analysis will be based upon the intention to treat principle, including all patients 
randomized who have both baseline and post treatment measures of LFF.  
 
Next we will compare rates of hepatic conversion of [13C] cortisone to [13C] cortisol between the 
groups, again using ANCOVA, analogous to the analysis of LFF. 
 

PI: R.Basu, 11 Beta HSD inhibitor in NAFLD or NASH 
 
8 
 
Power for Primary Analysis 
A sample size of 45 in each group will have 80% power to detect a difference in means of 3.1 
assuming a mean square error (MSE) of 4.6 using an ANCOVA and a two-sided test with alpha 0.05.  
The MSE of 4.6 is estimated based upon the study of Stefan et al. (28) where an MSE of 4.6 and a 
difference in group means of 2.6 were observed.  We anticipate that as many as 5 patients could drop 
out of each treatment group and so will recruit additional patients to each treatment group for a total 
of 100 patients.  Based upon this our study is adequately sized to achieve our aims. We will now also 
include subjects with fibrosis score 0 up but with liver fat % >5 % as we believe data from these 
subjects will also be valuable and of interest in the final analyses. Since fibrosis scores are unlikely to 
change in the short duration of this trial and change in fibrosis is a secondary endpoint we believe this 
approach does not distract from our primary endpoint related to lowering of liver fat %.    
 
Secondary Analysis 
The data for the primary outcomes will be explored estimating treatment effects by sex.  These too 
will be tested in the ANCOVA, including interaction terms between treatment and sex.    
Outcomes related to secondary hypotheses will be analyzed analogously to the primary outcomes, 
using ANCOVA.      
 
 
 
Detailed human subjects protection plan/DSMP prepared as a separate document 
 
 
 
 
 
 
 
 
 
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