Clinical Gastroenterology and Hepatology 2019;17:616–629

SYSTEMATIC REVIEWS AND META-ANALYSES
Siddarth Singh, Section Editor

Rates of and Factors Associated With Placebo Response
in Trials of Pharmacotherapies for Nonalcoholic
Steatohepatitis: Systematic Review and Meta-analysis
Ma Ai Thanda Han,*,a Osama Altayar,‡,a Shadi Hamdeh,§ Varun Takyar,k Yaron Rotman,kOhad Etzion,k Eric Lefebvre,¶ Rifaat Safadi,# Vlad Ratziu,** Larry J. Prokop,‡‡
Mohammad Hassan Murad,§§ and Mazen Noureddinkk*Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California; ‡Division of Gastroenterology,
Washington University School of Medicine, St. Louis, Missouri; §Division of Gastroenterology, Hepatology and Motility,
University of Kansas Medical Center, Kansas City, Kansas; kLiver & Energy Metabolism Unit, Liver Diseases Branch, National
Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health, Bethesda, Maryland; ¶Allergan, PLC,
South San Francisco, California; #Liver and Gastroenterology Unit, Division of Medicine, Hadassah University Medical Center,
Jerusalem, Israel; **Institute for Cardiometabolism and Nutrition, Université Pierre et Marie Curie, Paris, France; ‡‡Mayo Clinic
Libraries, Mayo Clinic, Rochester, Minnesota; §§Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern
Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; and kkFatty Liver Program, Division ofDigestive and Liver Diseases, Comprehensive Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e37. Learning Objective–Uponcompletion of this activity, successful learners will be able to assess the natural history of the placebo group in nonalcoholic steatohepatitis (NASH)
randomized clinical trials and identify changes that occur in this group over time.

BACKGROUND & AIMS:

It is important to know the extent of the placebo effect in designing randomized controlled
trials for patients with nonalcoholic steatohepatitis (NASH), to accurately calculate sample sizeand deﬁne treatment endpoints.

METHODS:We performed a systematic review and meta-analysis of the placebo groups from randomized
controlled trials of adults with NASH that provided histologic and/or magnetic resonanceimage-based assessments. We identiﬁed trials through a comprehensive search of MEDLINE,EMBASE, Cochrane Central Register of Controlled Trials, and Scopus, from each database’s
inception through January 2, 2018.

RESULTS:

We identiﬁed 39 randomized controlled trials, comprising 1463 patients who received placebo.
Histologic assessment data (the nonalcoholic fatty liver disease activity scores, NAS) wereavailable from 956 patients; magnetic resonance spectroscopy data were available from 295
patients and magnetic resonance proton density fat fraction measurements from 61 patients.
Overall, 25% of patients given placebo had an improvement in NAS by 2 or more points (95% CI,
21%–29%) with a small amount of heterogeneity (I2 [ 27%). There were improvements by atleast 1 point in steatosis scores of 33% – 3% of patients, in hepatocyte ballooning scores of
30% – 3% of patients, in lobular inﬂammation scores of 32% – 3% of patients, and in ﬁbrosis
scores of 21% – 3% of patients, with a moderate amount of heterogeneity among trials (I2range, 51%–63%). Patients given placebo had a statistically signiﬁcant improvement in NAS (by0.72 – 0.19), with a large amount of heterogeneity (I2 [ 96%). Univariate and multivariate
meta-regression showed that trials with a higher baseline NAS, those conducted in SouthAmerica, and those in which patients had a decrease in body mass index, were associated withgreater improvements in NAS among patients given placebo. Patients given placebo hadaThese authors contributed equally.

Abbreviations used in this paper: ALT, alanine aminotransferase; AST,
aspartate aminotransferase; BMI, body mass index; CI, conﬁdence interval; IHTG, intrahepatic triglyceride; MRI, magnetic resonance imaging;
MRS, magnetic resonance spectroscopy; NAFLD, nonalcoholic fatty liverdisease; NAS, NAFLD activity score; NASH, nonalcoholic steatohepatitis;

PDFF, proton density fat fraction; RCTs, randomized-controlled trials; SD,
standard deviation; SE, standard error of the mean.
Most current article© 2019 by the AGA Institute1542-3565/$36.00
https://doi.org/10.1016/j.cgh.2018.06.011

March 2019

Placebo Response in Pharmacotherapeutic Trials for NASH

617

signiﬁcant reductions in intrahepatic triglyceride, measured by magnetic resonance spectroscopy (by 1.45% – 0.54%) with moderate heterogeneity (I2 [ 40%), and in magnetic resonanceproton density fat fraction (by 2.43 – 0.89), without heterogeneity (I2 [ 0). Mean serum levelsof alanine and aspartate aminotransferases decreased signiﬁcantly (by 11.7 – 3.8 U/L and 5.9 –2.1 U/L, respectively; P < .01 for both).
CONCLUSIONS:In a meta-analysis of randomized controlled trials of NASH, patients given placebo have signiﬁcant histologic, radiologic, and biochemical responses. The placebo response should beconsidered in designing trials of agents for treatment of NASH.

Keywords: MRS; MRI-PDFF; Trial Design; NAFLD.

See editorial on page 607.

ecause nonalcoholic fatty liver disease (NAFLD) isthe most common cause of chronic liver disease,with a prevalence of 25% worldwide,1 and has no
approved therapy, there is great interest in clinical trials
assessing possible treatments. Treatments currently being studied are generally tailored toward the advanced
form of the disease, nonalcoholic steatohepatitis (NASH),
which includes steatosis, inﬂammation, and hepatocyte
ballooning and may progress to cirrhosis.2,3 To assess theeffectiveness of therapies for disease, the gold standard
has long been a randomized, double-blind placebocontrolled clinical trial in which a treatment is considered
beneﬁcial if it is shown to be more effective than the placebo. However, it is important to remember that placebos
may have effects, the likely extent of which may be important to consider for optimal trial design, including sample
size calculations and deﬁnition of treatment endpoints.
The only previous meta-analysis to assess thebiochemical and histologic effects of placebo on patientswith NAFLD in randomized, placebo-controlled trials was
carried out almost a decade ago.4 That meta-analysis
included a total of only 189 patients in the treatment
arms of the studies and 162 patients in the placebo arms,
and only 3 of the 5 studies included in the meta-analysis
reported detailed histologic data both pretreatment
and post-treatment. In that meta-analysis Loomba et al4
showed that patients who received placebo had a significant decrease in the mean level of alanine aminotransferase (ALT) and 31% were found to have a 1-point
improvement in the steatosis score. However, a 2-point
improvement in NAFLD activity score (NAS), typicallyconsidered a meaningful clinical outcome, was rarely
seen. Furthermore, that study did not examine the impactof placebo on liver fat content (intrahepatic triglycerides[IHTG]) as shown by magnetic resonance imaging (MRI)
proton density fat fraction (PDFF), which measures the fat
fraction in all liver segments, or magnetic resonancespectroscopy (MRS), which measures the fat fraction ofa single location in the liver.5 Since the previous metaanalysis, MRI-PDFF has been shown to be accurate fordetection and quantiﬁcation of steatosis degree and it isB

now being used to evaluate treatment efﬁcacy in NASH
clinical trials. In addition, substantially more NASH clinical trials using histologic outcomes have been conducted
in recent years.6 Our aim was to quantify the response toplacebo using the current commonly used endpoints
to clinical trials in NASH. We conducted a systematic
review and meta-analysis of histologic changes, MRIbased IHTG changes, and biochemical changes observedin placebo-treated patients in randomized, placebocontrolled studies in adult patients with NASH.

Materials and Methods
This systematic review was conducted and reported
in compliance with the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses statement.7 The
investigators developed a protocol specifying eligibility
criteria, outcomes of interest, and methods of analysis.
Randomized-controlled trials (RCTs) that compared results between a control intervention and a pharmacologic intervention in adults diagnosed with NAFLD(based on histology or MRI) were included. The control
intervention could be a placebo and/or a lifestyle intervention. Trials comparing different lifestyle interventions
were excluded. Inclusion was limited to trials reporting
histologic data using the NAS and/or IHTG or fat fraction
assessed by MRS or MRI-PDFF. Trials had to reportpaired outcome data before and after placebo to be
included. Trials reporting other histologic scores were
excluded if they did not provide any of the previously
mentioned outcomes. Trials using MRI-PDFF were
excluded if they did not report measuring fat fraction in3 regions of interest in each segment of the liver. We
limited our eligibility criteria to trials reported in English. We excluded nonrandomized studies, noncomparative studies, commentaries, editorials, letters,
reviews, and studies reported solely as abstracts.

Data Sources and Search Strategies
A comprehensive search was conducted of thefollowing databases from each database’s inception to
January 2, 2018: MEDLINE Epub Ahead of Print, Medline
In-Process & Other Non-Indexed Citations, MEDLINE,618

Han et al

EMBASE, Cochrane Central Register of Controlled Trials,
and Scopus. The search strategy was designed and conducted by an experienced librarian with input from thestudy’s principal investigator. Controlled vocabulary
supplemented with keywords was used to search for
RCTs of fat fraction in NAFLD. The actual strategy isavailable in the Supplementary Appendix.

Study Selection and Data Extraction
Independent reviewers (M.A.T.H., O.A., S.H., V.T., O.E.)
reviewed the titles and abstracts of the identiﬁed references for full-text review. The retrieved full-text articles
were then reviewed by the reviewers independently.
Conﬂicts were resolved by consensus and consultation
with an additional reviewer (M.N.). Data were extracted
by the reviewers independently using a Microsoft Excel
extraction form. Discrepancies were resolved by mutual
discussion. The extracted data included inclusion criteria,
study location, sample size, lifestyle modiﬁcations, frequency of follow-up visits, duration of trial, and thepredetermined outcomes as below. If the publishedmanuscript reported assessing 1 of our main outcomesin the methods but did not report the ﬁndings in the
results, we contacted the corresponding and/or seniorauthor to request the missing data.

Outcome Measures
We assessed 3 main outcomes: (1) histologic response,deﬁned as a 2-point improvement in NAS; (2) histologicchange, deﬁned as the change in NAS from baseline to endof treatment; and (3) IHTG change, deﬁned as the change
in MRI-based liver fat content from baseline to end oftreatment. Other outcomes included average changes inindividual components of the NAS (degree of steatosis,
lobular inﬂammation, hepatocyte ballooning); changes inﬁbrosis; percentage of patients with 1-point improvement in individual components of the NAS and ﬁbrosis;changes in biochemical parameters including ALT,
aspartate aminotransferase (AST), alkaline phosphatase,hemoglobin A1c, and insulin resistance measured using
the homeostatic model assessment for insulin resistance;and changes in body mass index (BMI).
We extracted the mean or mean difference and withthe associated standard deviation (SD) for each of thepreviously mentioned continuous outcomes. If a trial
reported the mean or mean difference with othermeasures of variability, such as the standard error (SE)and conﬁdence intervals (CIs), we imputed the SD fromthem. If the study reported the mean or mean difference but did not report any measure of variability, we
imputed the SD from the other studies. If the trial did
not report the mean NAS, we used the NAS components, when provided, and calculated the mean and SD
by summing the means and variances using linear
combination after calculating the covariance from theClinical Gastroenterology and Hepatology Vol. 17, No. 4

What You Need to Know
BackgroundThe effect of placebo in randomized controlled trials
of nonalcoholic steatohepatitis pharmacotherapy is
not well-understood or estimated.
Findings
Placebo treatment is associated with statisticallysigniﬁcant histological, biochemical, and radiologicalresponses. Possible cofactors include the duration of
trial, number of patients, change in weight, baseline
severity of the disease, recommendation of lifestyle
modiﬁcations, and the geographical region where thetrial is conducted.
Implications for patient care
Designing and interpreting trials that assess the
response to pharmacotherapy in patients with nonalcoholic steatohepatitis should consider the effect ofplacebo treatment and its cofactors.

trials. If the trial did not report any of the previously
mentioned but reported the median with the upper andlower limits of the range and/or the ﬁrst and third
quartiles, we used them in addition to the sample size
to impute the mean and SD using the methods proposed by Wan et al.8 If they only provided the medianwith the interquartile range, we imputed the meanfrom the median and the SD as interquartile range/
1.35. If none of the previously mentioned was reported,
we attempted to contact the corresponding and/or
senior author to obtain the missing data. If we did notreceive a response from the authors within 4 weeks,
we excluded the trial.

Risk of Bias Assessment
We used the Cochrane risk of bias tool to evaluate
risk of bias in the individual trials.9 We evaluated theadequacy of randomization, allocation concealment,
blinding (patients, providers, data collectors, andoutcome assessors), extent of missing outcome data, andthe funding source.

Statistical Assessment
We used the random-effects model to estimate thepooled proportion and mean difference of the primaryand secondary outcomes before and after receiving thecontrol intervention.10 We used the Cochran Q test andI2 statistic to assess heterogeneity, where P  .10 or I2>50% indicated the presence of substantial heterogeneity.11 We used univariable and multivariable metaregression and/or subgroup analysis to explore causesof heterogeneity in the main outcomes using theMarch 2019

Placebo Response in Pharmacotherapeutic Trials for NASH

following explanatory variables: geographical region,change in BMI, duration of trial, baseline NAS or IHTG,
number of included patients, central versus local biopsy
reading, and/or recommendation of lifestyle modiﬁcations. For the purpose of the analysis, we categorized
the lifestyle modiﬁcation recommendation into 2 maincategories: dietary recommendations and physical activity recommendations. The dietary recommendations
were then dichotomized into recommendations thatinvolved a dietitian (either throughout the trial durationor only at the beginning of the trial) in 1 category
versus nondietitian dietary advice, trials that did notrecommend dietary changes, and trials that did notreport such recommendations as the other category.
Similarly, physical activity recommendations weredichotomized into trials that recommended exercise (asan advice only or by implementing an exercise program)as one category versus trials that did not report orrecommend physical activity recommendations as theother category. When appropriate, we assessed publication bias by visual inspection of funnel plots and using weighted Egger test.12 To assess the robustness of
our results, we conducted sensitivity analysis byexcluding small trials (n <50), excluding trials at highrisk for bias, excluding trials where we had to imputethe mean and/or SD, and/or excluding trials that reported 2-point improvement in NAS but did clearly statethat ﬁbrosis was unchanged. We used the metafor(version 2.0-0) and meta (version 4.9-0) packages ofR (version 3.4.3) in addition to Comprehensive MetaAnalysis (version 2.2.064) to conduct the different
analyses.13,14

of 71.8% of the trials reported recommending or
implementing lifestyle modiﬁcations, either dietary or
physical activity. Dietitians were involved in the initial
visit in 28.2% of trials, and followed the patients
throughout the trial in 12.8% of the trials. A total of
43.6% of the trials reported providing dietary recommendations without reporting the involvement of a dietitian. Recommendations to increase physical activity
were given in 59% of trials but only 18% of trials reported providing a speciﬁc regimen to the patients. The
median duration of treatment was 48 weeks (range,
8–96 weeks). Characteristics of the included studies aredescribed in Table 1. Excluded studies and the reason of
exclusion are listed in Supplementary Table 1.

Results
With our search strategy we identiﬁed 3997 references. After reviewing the titles and abstracts of theidentiﬁed references, 149 full-text articles were retrieved
for review. After reviewing the full texts, 39 articles
reporting 39 trials met the prespeciﬁed criteria and were
included in the systematic review and meta-analysis(Supplementary Figure 1).15-53 Of these, 14 trials wereconducted in North America, 10 in Europe, 7 in East Asia,
2 in Australia, 2 in South America, 2 in the Middle East,and 2 trials in more than 1 region. A total of 1463 patients were randomized to receive the control intervention, including 956 patients from 30 trials who had
paired histologic data using NAS reported, 830 patientsfrom 24 trials who had a 2-point improvement in NAS
reported, 295 patients from 13 trials who had paired
MRS data reported, 61 patients from 3 trials who had
paired MRI-PDFF data reported, and 245 patients from28 trials who did not have any paired primary outcome
data because of loss from follow-up or withdrawal.
Among 31 trials that reported a histologic outcome, pathology slides were read centrally in 12 trials and locallyin 19 trials. Pathologists were blinded in all trials. A total

619

Risk of Bias
There was a moderate risk of bias in the individual
trials overall. Most trials reported the randomization
method but did not report how the allocation was concealed. Most of the trials blinded the patients, providers,and outcome assessors. The rate of missing or
unreported primary outcome data in the control arm
was less than 20% in 71.8% of the included trials. Mostof the trials reported the different reasons behind themissing outcome data including patients lost to follow-up
and/or withdrawn; however, some of them did notdisclose or clarify that. There was contribution and/or
support from for-proﬁt organizations in 69% of thetrials. Supplementary Figure 2 summarizes the risk ofbias for each individual study using the Cochrane risk ofbias tool.

Meta-Analysis of Paired Histologic Response
The pooled proportion of patients who had
improvement of 2 or more points in the NAS was 25%(95% CI, 21%–29%) with minimal heterogeneity(I2 ¼ 27%; P ¼ .11) (Figure 1). Sensitivity analysis
limited to trials that reported 2-point improvement in
NAS without worsening in ﬁbrosis showed similar results with a pooled proportion of 25% (95% CI, 20%–30%) and with minimal heterogeneity (I2 ¼ 27%;
P ¼ .19) (Supplementary Figure 3).
Placebo treatment was associated with a statisticallysigniﬁcant improvement in NAS of 0.72 points (95% CI,-1.09 to -0.34; P < .01) with considerable heterogeneity(I2 ¼ 96%; P < .01) (Figure 2). Using subgroup interaction tests (Figure 3), there was no signiﬁcant difference between the pooled NAS change when the trials
were subgrouped based on geographic region, trial
duration, recommendation of lifestyle modiﬁcations,administration of placebo pill, number of patients in theplacebo arm with paired biopsies, or the location where
the biopsy was read (central vs local read; P > .1)(Supplementary Figure 4A–F). Using univariate metaregression models (Figure 3), the heterogeneity was

620

Table 1. Baseline Characteristics of the Included Randomized Controlled Trials

Abdelmalek et al, 200915
Alam et al, 201616
Alam et al, 201717
Argo et al, 201518
Armstrong et al, 201619
Belfort et al, 200620
Chachay et al, 201421
Chan et al, 201022
Cui et al, 201623
Cusi et al, 201624
Dasarathy et al, 201525
Friedman et al, 201726

Heebøll et al, 201628
Idilman et al, 200829
Joy et al, 201730
Kim et al, 201731
Le et al, 201232
Leuschner et al, 201033
Loguercio et al, 201234
Loomba et al, 201535

Country: United States
Number of sites: 2
Country: Bangladesh
Number of sites: 1
Country: Bangladesh
Number of sites: 1
Country: United States
Number of sites: 1
Country: United Kingdom
Number of sites: 4Country: United States
Number of sites: 3
Country: Australia
Number of sites: 1
Country: Australia
Number of sites: 1
Country: United States
Number of sites: 1
Country: United States
Number of sites: 1
Country: United States
Number of sites: 2
Countries: Australia, Belgium, France, Germany,
Hong Kong, Italy, Poland, Spain, the United Kingdom,
and the United States
Number of sites: 81
Country: Norway
Number of sites: 1
Country: Denmark
Number of sites: 1
Country: Turkey
Number of sites: 1
Country: Canada
Number of sites: 1
Country: Korea
Number of sites: 5
Country: United States
Number of sites: 4Countries: Germany and Greece
Number of sites: 25
Countries: Italy and Romania
Number of sites: 13
Country: United States
Number of sites: 4

Lifestyle intervention

N: 29
Trial duration: 52
N: 15
Trial duration: 52
N: 10
Trial duration: 52
N: 21
Trial duration: 52
N: 26
Trial duration: 48
N: 25
Trial duration: 26
N: 10
Trial duration: 8
N: 10
Trial duration: 22
N: 25
Trial duration: 24
N: 51
Trial duration: 78
N: 19
Trial duration: 48
N: 144

Diet: nondietitian advice
Physical activity: NR
Diet: nondietitian advice
Physical activity: exercise regimen
Diet: nondietitian advice
Physical activity: advice only
Diet: dietitian with follow-up
Physical activity: exercise regimen
Diet: nondietitian advice
Physical activity: advice only
Diet: dietitian with follow-up
Physical activity: NR
Diet: none
Physical activity: none
Diet: dietitian at initial visit
Physical activity: NR
Diet: NR
Physical activity: NR
Diet: dietitian at initial visit only
Physical activity: NR
Diet: dietitian with follow-up
Physical activity: exercise regimen
Diet: nondietitian advice

Trial duration: 52
N: 24
Trial duration: 26
N: 13
Trial duration: 26
N: 25
Trial duration: 48
N: 6
Trial duration: 24
N: 22
Trial duration: 24
N: 25
Trial duration: 24
N: 91
Trial duration: 78
N: 88
Trial duration: 52
N: 25
Trial duration: 24

Physical activity: advice only
Diet: nondietitian advice
Physical activity: advice only
Diet: nondietitian advice
Physical activity: advice only
Diet: dietitian with follow-up
Physical activity: exercise regimen
Diet: NR
Physical activity: NR
Diet: dietitian at initial visit only
Physical activity: NR
Diet: NR
Physical activity: NR
Diet: NR
Physical activity: NR
Diet: nondietitian advice
Physical activity: advice only
Diet: NR
Physical activity: NR

Outcome measures
Histology
Histology
Histology
Histology
Histology
Histology and MRS-IHTG
MRS-IHTGMRS-IHTGMRS-IHTG and MRI-PDFF
Histology and MRS-IHTG
Histology
Histology

Histology
Histology and MRS-IHTG
Histology
Histology
MRS-IHTG
Histology, MRS-IHTG,
and MRI-PDFF
Histology
Histology
Histology, MRS-IHTG,
and MRI-PDFF

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Haukeland et al, 200927

Location

Han et al

Trial

Number of patients enrolledin placebo arm (N) and trial
duration (wk)

Neuschwander-Tetri et al, 201537
Nogueira et al, 201638
Ratziu et al, 200839
Ratziu et al, 201640

Safadi et al, 201441
Sanyal et al, 201043
Sanyal et al, 201442
Scorletti et al, 201444
Shields et al, 200945
Stefan et al, 201446
Takeshita et al, 201447

Vilar Gomez et al, 200949
Wah Kheong et al, 201750
Wong et al, 201351
Wong et al, 201352
Zein et al, 201153

N: 21
Trial duration: 96
N: 142
Trial duration: 72
N: 28
Trial duration: 26
N: 32
Trial duration: 52
N: 92

Diet: nondietitian advice
Physical activity: advice only
Diet: nondietitian advice
Physical activity: advice only
Diet: NR
Physical activity: NR
Diet: nondietitian advice
Physical activity: advice only
Diet: NR

Trial duration: 52
N: 20
Trial duration: 12
N: 83
Trial duration: 96
N: 75
Trial duration: 52
N: 52
Trial duration: 78
N: 10
Trial duration: 52
N: 41
Trial duration: 12
N: 15
Trial duration: 26
N: 9
Trial duration: 52
N: 30
Trial duration: 26
N: 50
Trial duration: 48
N: 10
Trial duration: 26
N: 20
Trial duration: 24
N: 29
Trial duration: 52

Physical activity: NR
Diet: NR
Physical activity: NR
Diet: nondietitian advice
Physical activity: advice only
Diet: NR
Physical activity: NR
Diet: nondietitian advice
Physical activity: advice only
Diet: dietitian at initial visit only
Physical activity: exercise program
Diet: none
Physical activity: none
Diet: dietitian at initial visit only
Physical activity: exercise program
Diet: nondietitian advice
Physical activity: advice only
Diet: dietitian with follow-up
Physical activity: exercise regimen
Diet: nondietitian advice
Physical activity: advice only
Diet: nondietitian advice
Physical activity: advice only
Diet: nondietitian advice
Physical activity: advice only
Diet: dietitian at initial visit only
Physical activity: advice only

MRI-PDFF, magnetic resonance imaging–based proton density fat fraction; MRS-IHTG, magnetic resonance spectroscopy–based intrahepatic triglyceride quantiﬁcation; NR, not reported.

Histology
Histology
Histology
Histology
Histology

MRS-IHTG
Histology
Histology
MRS-IHTG
Histology
MRS-IHTG
Histology
Histology
Histology
Histology
MRS-IHTG
Histology
Histology

Placebo Response in Pharmacotherapeutic Trials for NASH

Van Wagner et al, 201148

Country: United Kingdom
Number of sites: 11
Country: United States
Number of sites: 8
Country: Brazil
Number of sites: 1
Country: France
Number of sites: 1
Countries: Belgium, France, Germany, Italy, Romania,
Spain, the Netherlands, the United Kingdom,
and the United States
Number of sites: 56
Country: Israel
Number of sites: 11
Country: United States
Number of sites: 11
Country: United States
Number of sites: 37
Country: United Kingdom
Number of sites: 1
Country: United States
Number of sites: 1
Countries: Austria and Germany
Number of sites: 4Country: Japan
Number of sites: 1
Country: United States
Number of sites: 1
Country: Cuba
Number of sites: 1
Country: Malaysia
Number of sites: 1
Country: Hong Kong
Number of sites: 1
Country: Hong Kong
Number of sites: 1
Country: United States
Number of sites: 1

March 2019

McPherson et al, 201736

621

622

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Figure 1. Meta-analysis of proportion of patients with histologic response. Forest plot of random-effects meta-analysis
showing the proportion of patients with 2-point improvement in NAFLD activity score after receiving placebo intervention.

partially explained with a positive association between
the change in NAS and the change in BMI (R2 ¼ 93%;
P < .01), but not trial duration, baseline NAS, or visit
frequency (R2 range, 4%–28%; P > .1) (Supplementary
Figure 5A–D). Multivariate meta-regression showedthat trials from South America and trials with highbaseline NAS were associated with more improvement in
NAS (Supplementary Table 2). Testing for publication
bias was not done because of the substantial heterogeneity. Sensitivity analyses showed statistically signiﬁcant
improvement of NAS when we used studies that included
50 or more patients with paired biopsies by 0.67 points(95% CI, -0.83 to -0.51; I2 ¼ 44%), excluded trials at highrisk for bias by 0.5 points (95% CI, -0.61 to -0.39;
I2 ¼ 0%), or excluded trials where we used imputation
methods by 0.69 points (95% CI, -1.11 to -0.27;
I2 ¼ 97%) (Supplementary Figure 6A–C).
The pooled proportion of patients with 1-point
improvement in steatosis was 33% (95% CI, 27%–40%), in hepatocyte ballooning was 30% (95% CI,
24%–36%), in lobular inﬂammation was 32% (95% CI,
27%–38%), and in ﬁbrosis was 21% (95% CI,

16%–26%). The pooled proportions were limited bymoderate heterogeneity (I2 range, 51%–63%; P < .01)
(Supplementary Figure 7A–D).
There was a statistically signiﬁcant improvement insteatosis of 0.35 points (95% CI, -0.45 to -0.25; P < .01),
0.16 points in ballooning (95% CI, -0.22 to -0.10;
P < .01), and of 0.16 points in lobular inﬂammation score(95% CI, -0.23 to -0.09; P < .01). However, there was no
statistically signiﬁcant change in ﬁbrosis. All the pooledmean differences were limited by substantial heterogeneity between the included trials (I2 range, 52%–79%;
P < .01) (Supplementary Figure 8A–D).

Meta-Analysis of MRI-Based IHTG Response
There was a statistically signiﬁcant improvement in
IHTG. When measured by MRS there was an improvement of 1.45% (95% CI, -2.51 to -0.40; P < .01) withmoderate heterogeneity (I2 ¼ 40%; P ¼ .07) and when
MRI-PDFF was used, an improvement of 2.44% (95% CI,-4.16 to -0.73; P < .01) was seen, without heterogeneity(I2 ¼ 0%; P ¼ .95) (Figure 4A and B). Testing forMarch 2019

Placebo Response in Pharmacotherapeutic Trials for NASH

623

Figure 2. Meta-analysis of mean change in NAFLD Activity Score. Forest plot of random-effects meta-analysis of meanchange in NAS after receiving placebo intervention measured as mean difference between values before and after receiving
placebo. MD, mean difference.

publication bias was not done because of the heterogeneity in the MRS meta-analysis and small number oftrials in the MRI-PDFF meta-analysis.
Using subgroup interaction tests (Figure 5), there wasa signiﬁcant difference between pooled MRS-IHTG
change when the trials were subgrouped based on thenumber of included patients with paired MRS-IHTG andtrial duration (P < .01), but not by recommendation oflifestyle modiﬁcations, administration of placebo pill, or
geographic region (P > .1) (Supplementary Figure 9A–E).

Trials with 40 or more patients and trials with longer
duration were associated with more improvement in
MRS-IHTG. Univariate meta-regression models (Figure 5)
showed that trial duration explained the moderate heterogeneity noticed between MRS trials (R2 ¼ 98%; P ¼.003), but not BMI change, baseline MRS-IHTG, or visit
frequency (R2 range 0%–27%; P > .1) (Supplementary
Figure 10A–D). The multivariate meta-regression model
showed that trials with longer duration and that did notreport or recommend lifestyle modiﬁcations were624

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Figure 3. Investigating the heterogeneity observed in the pooled mean change in NAS in patients receiving placebo (I2 ¼ 97%;
P < .01; number of trials ¼ 30).

associated with more improvement in MRS-IHTG,
whereas trials from the Middle East were associatedwith worsening of MRS-IHTG (Supplementary Table 3).

Meta-Analysis of Biochemical andAnthropometric Response
Mean serum ALT and AST decreased signiﬁcantly inplacebo-treated patients (by 11.7 U/L  SE 1.9 and 5.9
U/L  SE 1.1, respectively; P < .05). However, there wasno statistically signiﬁcant change in mean serum alkaline
phosphatase (P ¼ .55) (Supplementary Figure 11A–C).
There was a statistically signiﬁcant reduction in BMI of
0.28  SE 0.10 (P < .01) and an increase in hemoglobin
A1c of 0.05  SE 0.02 in placebo-treated patients(P ¼ .02), but no signiﬁcant change in homeostatic model
assessment for insulin resistance (P ¼ .87)
(Supplementary Figure 12A–C).

Discussion
In this systematic review and meta-analysis we foundand quantiﬁed the improvement in histologic, radiologic,
and biochemical features in patients with NASH treatedwith placebo, an important ﬁnding that could impact theassessment of the relative effectiveness of various interventions observed in NASH clinical trials. The key
ﬁnding of our work was that in patients with NASH
treated with placebo there was a signiﬁcant improvement in the mean NAS. Although some might notconsider the NAS change of 0.72 points clinically significant, it is important to consider that this level of change
might occur in the placebo arm when designing NASH
clinical trials. Also, because a 2-point change in NAS
without change in ﬁbrosis is currently considered to beclinically meaningful, the possible contribution of a placebo effect of 0.72 (35% of a 2-point change) is important. A total of 1 in 4 placebo-treated patients achieved aMarch 2019

Placebo Response in Pharmacotherapeutic Trials for NASH

625

Figure 4. Meta-analyses of change in MRS-based and IHTG. Forest plots of random-effects meta-analyses of mean change in
MRS-based IHTG (A) and MRI-PDFF based IHTG (B) after receiving placebo intervention measured as mean difference between values before and after receiving placebo. MD, mean difference.

2-point reduction in NAS. There was also a signiﬁcantreduction in liver fat, as shown by MRI-based assessmentof IHTG, and signiﬁcant reductions in ALT and AST inplacebo-treated patients.
With the large and increasing number of clinical trials
testing NASH treatments in recent years, this metaanalysis was able to obtain data from a much larger
number of trials and placebo patients compared with the
only previous meta-analysis on this topic published in
20084 (39 trials vs 5; and 1463 placebo patients vs 162).
In contrast to the previous report, our study showedstatistically signiﬁcant improvement in the individual
NAS components, including steatosis, ballooning, andlobular inﬂammation. Both studies showed a change in
ALT levels but, in contrast to the previous report, we also
found a change in AST level that is plausible. We deﬁned
improvement as a change of 2 points in NAS without
worsening of ﬁbrosis, which is currently considered 1 of

the main outcomes for NASH clinical trials. This was not
the case in the previous report. Finally, we found a 25%
pooled proportion of patients who had improvement of2 points in the NAS in comparison with 14.3% in theprevious meta-analysis. This updated analysis with amuch larger sample size should more accurately represent the changes that can be expected in the placeboarms of NASH clinical trials.
The analysis was limited by some heterogeneity, which
we investigated extensively using different possible
explanatory variables. All the studies used NAS, eliminating diversity of scoring systems as a contributor to theheterogeneity. Sensitivity analyses excluding small trials
and trials at high risk of bias showed statistically signiﬁcant improvement without substantial heterogeneity.
Using univariate meta-regression, there was a statisticallysigniﬁcant positive correlation between the change in BMI
and change in NAS in placebo-treated patients. This is626

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Figure 5. Investigating theheterogeneity observed in
the pooled mean change in
MRS-IHTG in patients
receiving placebo (I2 ¼
40%; P < .07; number oftrials ¼ 13).

consistent with previous studies showing the associationof weight loss with steatosis or NAS reductions.54
We investigated the possible etiologies of the placebo
effect with univariate and multivariate meta-regression
models. It has long been thought possible that patientsin placebo arms may modify their behavior in responseto their awareness of being observed (the Hawthorne
effect), which in these NASH trials might have led todecreased BMI over time. It has been also thought that agreater number of follow-up visits in an RCT may inﬂuence patient behavior because of the increased attention
perceived by the patient, which could potentially increase the likelihood of a behavioral change.55 However,there was no statistically signiﬁcant correlation between
the frequency of follow-up visits and change in NAS.
Additionally, when we subgrouped the MRS trials basedon including 40 or more patients with paired measurements, the interaction test was signiﬁcant. This indicateda difference in the outcome based on the number ofincluded patients, another factor that could explain theheterogeneity. Additionally, the NAS trials were lessheterogeneous after excluding trials with sample sizes
less than 50. This is consistent with previous work
showing that heterogeneity tends to be greater between
small studies compared with larger studies.56
The signiﬁcant correlation of baseline NAS with theobserved change in NAS in the multivariate metaregression suggests that subjects with a higher baseline
NAS might be more likely to respond to placebo or lifestyle modiﬁcation. There was a similar statistically signiﬁcant correlation between the improvement in IHTG
and trial duration. These correlations might indicate thatthe spontaneous improvement is related to the natural
history of the disease or that it reﬂects regression to themean. Multivariable metaregression models of the NAS
and MRS-IHTG showed that the geographic region where
the trial was conducted was another factor that
explained the observed heterogeneity after adjusting for
all the other variables that we evaluated. This could be
related to differences in lifestyles, research methodology,
or underlying pathophysiologic variances in different
populations. The lack of heterogeneity in the MRI-PDFF
studies despite the small number of studies and shortfollow-up may be attributed to the high accuracy of thesetechniques in capturing even small changes in hepatic
steatosis. This was shown previously5,57 and needs to be
explored in future studies.
The decline in ALT in placebo-treated patients in ourstudy supports previously described results.4 The
improvement parallels the histologic and radiologic responses. Serum enzymes are known to ﬂuctuate in NASH
over time as part of the natural history of the disease.
There is concern for selection bias in favor of recruiting
patients who had higher serum liver enzymes into clinical trials because patients with higher transaminase
levels are more likely to be referred to a tertiary carecenter and enrolled into trials compared with those withlower levels. Additionally, the phenomenon of regression
to the mean, or the effect of repeated measurements,
might have contributed to the observed responses.
The current study showed that speciﬁc variables
could explain the differences in the placebo effect. Those
variables should be considered when conducting future
trials. The change of BMI and weight of the patients is a

March 2019

Placebo Response in Pharmacotherapeutic Trials for NASH

627

cofactor that should be considered when analyzing andinterpreting the results of NASH trials. The number ofincluded patients is another factor that should beconsidered, because the results of trials with small
sample sizes were, not surprisingly, heterogeneouscompared with studies with larger sample sizes. Additionally, recommendation of lifestyle modiﬁcations,baseline NAS scores, and trial duration should beconsidered and/or standardized in future trials because
they might affect the changes seen in the placebo population of NASH trials. Such variability can add noise andhide important signals, and subsequently affect the power of these trials to detect signiﬁcant changes. Finally,
the geographic region where the study is being conducted should also be considered when interpreting theresults of NASH trials.
This study has multiple strengths. In trials reporting
biopsy-based outcomes, all the patients had biopsyproven NASH and the sample size exceeded 900
patients. We only included trials that used NAS as ahistologic outcome to eliminate the difﬁculty incomparing the magnitude of change in histologic parameters across trials using different scoring systems.
NAS has been extensively validated and is currently theleading histologic scoring system used for outcome
measurement in NASH trials. We also summarized theevidence of the placebo effect on NASH assessed by MRIbased measures. Because of the variability in MRI-PDFF
protocols and to ascertain reproducible consistent
results between the included trial, we only included trials that clearly stated using 3 regions of interest per
segment. We excluded trials that used different protocols, such as using 1 region of interest per segment as
in Joy et al,30 or did not clearly describe their protocol(Supplementary Table 1). We also conducted comprehensive analyses and used several variables to explain
the heterogeneity between studies and we hope that thisinformation may be useful for design of future trials.
There are several limitations to this systematic review.
The risk of bias of the included trials was moderate overallwith evidence of some heterogeneity; thus, the results
should be interpreted with caution. The adequacy of biopsy specimens was not described in some of the studies.
Although we contacted corresponding authors, there werestill trials that could not be included because of missing
data and lack of response from the authors. The smaller
number of studies using MRI-PDFF limits the interpretation and generalization of those results. We could notassess the publication bias because of the presence of
substantial heterogeneity or small number of trials.
Finally, it is important to recognize the limitations of
the statistical tests that we conducted to investigate theheterogeneity and acknowledge their observational nature with the possibility of false negatives and false
positives. For example, the baseline NAS severity andgeographic region were not statistically signiﬁcant inunivariate analyses but signiﬁcant in the multivariate
metaregression. This observation could be related to the

exclusion of the 5 trials that did not report BMI changes
from the multivariate metaregression model, or could becaused by confounding or model ﬁtting. Another example
is the MRS-IHTG multivariate metaregression, whichshowed that trials that did not report or perform lifestyle
modiﬁcation recommendations were associated withmore improvement in MRS-IHTG after adjusting for all
the other variables included in our model. This may need
to be explored in future MRS-IHTG studies, although they
are less commonly conducted now.
In summary, placebo treatment in NASH is associatedwith histologic, radiologic, and biochemical responses.
This may reﬂect the Hawthorne effect and/or the variability of these measures based on changes in weight,
baseline severity of disease, trial duration, sample size,recommendation of lifestyle modiﬁcation, geographic
location, or the natural history of NAFLD. The responseto placebo should be considered when designing andinterpreting the results of RCTs assessing treatment
response in patients with NASH.

Supplementary Material
Note: To access the supplementary material accompanying this article, visit the online version of Clinical
Gastroenterology and Hepatology at www.cghjournal.org,
and at https://doi.org/10.1016/j.cgh.2018.06.011.

References
1. Younossi ZM, Koenig AB, Abdelatif D, et al. Global epidemiology ofnonalcoholic fatty liver disease: meta-analytic assessment ofprevalence, incidence, and outcomes. Hepatology 2016;64:73–84.
2. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis andmanagement of non-alcoholic fatty liver disease: practiceguideline by the American Association for the Study of Liver
Diseases, American College of Gastroenterology, and theAmerican Gastroenterological Association. Am J Gastroenterol
2012;107:811–826.
3. Rotman Y, Sanyal AJ. Current and upcoming pharmacotherapy
for non-alcoholic fatty liver disease. Gut 2017;66:180–190.
4. Loomba R, Wesley R, Pucino F, et al. Placebo in nonalcoholicsteatohepatitis: insight into natural history and implications for
future clinical trials. Clin Gastroenterol Hepatol 2008;
6:1243–1248.
5. Noureddin M, Lam J, Peterson MR, et al. Utility of magnetic
resonance imaging versus histology for quantifying changes inliver fat in nonalcoholic fatty liver disease trials. Hepatology
2013;58:1930–1940.
6. Singh S, Khera R, Allen AM, et al. Comparative effectiveness ofpharmacological interventions for nonalcoholic steatohepatitis:a systematic review and network meta-analysis. Hepatology
2015;62:1417–1432.
7. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement
for reporting systematic reviews and meta-analyses of studies
that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009;62:e1–e34.
8. Wan X, Wang W, Liu J, et al. Estimating the sample mean andstandard deviation from the sample size, median, range and/orinterquartile range. BMC Med Res Methodol 2014;14:135.

628

Han et al

9. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane
Collaboration’s tool for assessing risk of bias in randomised
trials. BMJ 2011;343:d5928.
10. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control
Clin Trials 1986;7:177–188.
11. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ 2003;327:557–560.
12. Ioannidis JP, Trikalinos TA. The appropriateness of asymmetry
tests for publication bias in meta-analyses: a large survey.
CMAJ 2007;176:1091–1096.
13. R-Core-Team. R: A Language and Environment for StatisticalComputing. Vienna, Austria: R Foundation for StatisticalComputing, 2017.
14. Smith J. Comprehensive meta-analysis. 2nd ed. Englewood, NJ:
Biostat, 2011.
15. Abdelmalek MF, Sanderson SO, Angulo P, et al. Betaine fornonalcoholic fatty liver disease: results of a randomized
placebo-controlled trial. Hepatology 2009;50:1818–1826.
16. Alam S, Kabir J, Mustafa G, et al. Effect of telmisartan on histological activity and ﬁbrosis of non-alcoholic steatohepatitis: a
1-year randomized control trial. Saudi J Gastroenterol 2016;
22:69–76.
17. Alam S, Nazmul Hasan S, Mustafa G, et al. Effect of pentoxifylline on histological activity and ﬁbrosis of nonalcoholicsteatohepatitis patients: a one year randomized control trial.
J Transl Int Med 2017;5:155–163.
18. Argo CK, Patrie JT, Lackner C, et al. Effects of n-3 ﬁsh oil on
metabolic and histological parameters in NASH: a double-blind,randomized, placebo-controlled trial. J Hepatol 2015;62:190–197.
19. Armstrong MJ, Hull D, Guo K, et al. Glucagon-like peptide 1
decreases lipotoxicity in non-alcoholic steatohepatitis.
J Hepatol 2016;64:399–408.
20. Belfort R, Harrison SA, Brown K, et al. A placebo-controlled trialof pioglitazone in subjects with nonalcoholic steatohepatitis.
N Engl J Med 2006;355:2297–2307.
21. Chachay VS, Macdonald GA, Martin JH, et al. Resveratrol does
not beneﬁt patients with nonalcoholic fatty liver disease. Clin
Gastroenterol Hepatol 2014;12:2092–2103.
22. Chan DC, Watts GF, Gan SK, et al. Effect of ezetimibe on
hepatic fat, inﬂammatory markers, and apolipoprotein B-100
kinetics in insulin-resistant obese subjects on a weight loss diet.
Diabetes Care 2010;33:1134–1139.
23. Cui J, Philo L, Nguyen P, et al. Sitagliptin vs. placebo for nonalcoholic fatty liver disease: a randomized controlled trial.
J Hepatol 2016;65:369–376.
24. Cusi K, Orsak B, Bril F, et al. Long-term pioglitazone treatment
for patients with nonalcoholic steatohepatitis and prediabetes ortype 2 diabetes mellitus: a randomized trial. Ann Intern Med
2016;165:305–315.
25. Dasarathy S, Dasarathy J, Khiyami A, et al. Double-blind randomized placebo-controlled clinical trial of omega 3 fatty acids
for the treatment of diabetic patients with nonalcoholic steatohepatitis. J Clin Gastroenterol 2015;49:137–144.

Clinical Gastroenterology and Hepatology Vol. 17, No. 4
treatment for non-alcoholic fatty liver disease. Scand J Gastroenterol 2016;51:456–464.
29. Idilman R, Mizrak D, Corapcioglu D, et al. Clinical trial: insulinsensitizing agents may reduce consequences of insulin resistance in individuals with non-alcoholic steatohepatitis. Aliment
Pharmacol Ther 2008;28:200–208.
30. Joy TR, McKenzie CA, Tirona RG, et al. Sitagliptin in patientswith non-alcoholic steatohepatitis: a randomized, placebocontrolled trial. World J Gastroenterol 2017;23:141–150.
31. Kim W, Kim BG, Lee JS, et al. Randomised clinical trial: theefﬁcacy and safety of oltipraz, a liver X receptor alpha-inhibitory
dithiolethione in patients with non-alcoholic fatty liver disease.
Aliment Pharmacol Ther 2017;45:1073–1083.
32. Le TA, Chen J, Changchien C, et al. Effect of colesevelam onliver fat quantiﬁed by magnetic resonance in nonalcoholicsteatohepatitis: a randomized controlled trial. Hepatology 2012;
56:922–932.
33. Leuschner UF, Lindenthal B, Herrmann G, et al. High-dose
ursodeoxycholic acid therapy for nonalcoholic steatohepatitis: adouble-blind, randomized, placebo-controlled trial. Hepatology
2010;52:472–479.
34. Loguercio C, Andreone P, Brisc C, et al. Silybin combined withphosphatidylcholine and vitamin E in patients with nonalcoholic
fatty liver disease: a randomized controlled trial. Free Radic Biol
Med 2012;52:1658–1665.
35. Loomba R, Sirlin CB, Ang B, et al. Ezetimibe for the treatment of
nonalcoholic steatohepatitis: assessment by novel magnetic
resonance imaging and magnetic resonance elastography in arandomized trial (MOZART trial). Hepatology 2015;61:1239–1250.
36. McPherson S, Wilkinson N, Tiniakos D, et al. A randomised
controlled trial of losartan as an anti-ﬁbrotic agent in nonalcoholic steatohepatitis. PLoS One 2017;12:e0175717.
37. Neuschwander-Tetri BA, Loomba R, Sanyal AJ, et al. Farnesoid X
nuclear receptor ligand obeticholic acid for non-cirrhotic, nonalcoholic steatohepatitis (FLINT): a multicentre, randomised,
placebo-controlled trial. Lancet 2015;385:956–965.
38. Nogueira MA, Oliveira CP, Ferreira Alves VA, et al. Omega-3
polyunsaturated fatty acids in treating non-alcoholic steatohepatitis: a randomized, double-blind, placebo-controlled trial. Clin
Nutr 2016;35:578–586.
39. Ratziu V, Giral P, Jacqueminet S, et al. Rosiglitazone fornonalcoholic steatohepatitis: one-year results of the randomized
placebo-controlled Fatty Liver Improvement with Rosiglitazone
Therapy (FLIRT) Trial. Gastroenterology 2008;135:100–110.
40. Ratziu V, Harrison SA, Francque S, et al. Elaﬁbranor, an agonist of
the peroxisome proliferator-activated receptor-alpha and -delta,
induces resolution of nonalcoholic steatohepatitis without ﬁbrosis
worsening. Gastroenterology 2016;150:1147–1159.
41. Safadi R, Konikoff FM, Mahamid M, et al. The fatty acid-bile acidconjugate aramchol reduces liver fat content in patients withnonalcoholic fatty liver disease. Clin Gastroenterol Hepatol
2014;12:2085–2091.

26. Friedman SL, Ratziu V, Harrison SA, et al. A randomized, placebocontrolled trial of cenicriviroc for treatment of nonalcoholicsteatohepatitis with ﬁbrosis. Hepatology 2018;67:1754–1767.

42. Sanyal AJ, Abdelmalek MF, Suzuki A, et al. No signiﬁcant effectsof ethyl-eicosapentanoic acid on histologic features of nonalcoholic steatohepatitis in a phase 2 trial. Gastroenterology 2014;
147:377–384.

27. Haukeland JW, Konopski Z, Eggesbo HB, et al. Metformin inpatients with non-alcoholic fatty liver disease: a randomized,
controlled trial. Scand J Gastroenterol 2009;44:853–860.

43. Sanyal AJ, Chalasani N, Kowdley KV, et al. Pioglitazone, vitamin
E, or placebo for nonalcoholic steatohepatitis. N Engl J Med
2010;362:1675–1685.

28. Heeboll S, Kreuzfeldt M, Hamilton-Dutoit S, et al. Placebocontrolled, randomised clinical trial: high-dose resveratrol

44. Scorletti E, Bhatia L, McCormick KG, et al. Effects of puriﬁed
eicosapentaenoic and docosahexaenoic acids in nonalcoholicMarch 2019
fatty liver disease: results from the Welcome* study. Hepatology
2014;60:1211–1221.
45. Shields WW, Thompson KE, Grice GA, et al. The effect of
metformin and standard therapy versus standard therapy alone
in nondiabetic patients with insulin resistance and nonalcoholicsteatohepatitis (NASH): a pilot trial. Therap Adv Gastroenterol
2009;2:157–163.
46. Stefan N, Ramsauer M, Jordan P, et al. Inhibition of 11betaHSD1 with RO5093151 for non-alcoholic fatty liver disease: amulticentre, randomised, double-blind, placebo-controlled trial.
Lancet Diabetes Endocrinol 2014;2:406–416.
47. Takeshita Y, Takamura T, Honda M, et al. The effects of ezetimibe on non-alcoholic fatty liver disease and glucose metabolism: a randomised controlled trial. Diabetologia 2014;
57:878–890.
48. Van Wagner LB, Koppe SW, Brunt EM, et al. Pentoxifylline forthe treatment of non-alcoholic steatohepatitis: a randomized
controlled trial. Ann Hepatol 2011;10:277–286.
49. Vilar Gomez E, Rodriguez De Miranda A, Gra Oramas B, et al.
Clinical trial: a nutritional supplement Viusid, in combination with
diet and exercise, in patients with nonalcoholic fatty liver disease. Aliment Pharmacol Ther 2009;30:999–1009.
50. Wah Kheong C, Nik Mustapha NR, Mahadeva S. A randomized
trial of silymarin for the treatment of nonalcoholic steatohepatitis. Clin Gastroenterol Hepatol 2017;15:1940–1949.
51. Wong VW, Won GL, Chim AM, et al. Treatment of nonalcoholicsteatohepatitis with probiotics. A proof-of-concept study. Ann
Hepatol 2013;12:256–262.
52. Wong VW, Wong GL, Chan AW, et al. Treatment of nonalcoholic steatohepatitis with Phyllanthus urinaria: a randomized trial. J Gastroenterol Hepatol 2013;28:57–62.
53. Zein CO, Yerian LM, Gogate P, et al. Pentoxifylline improves
nonalcoholic steatohepatitis: a randomized placebo-controlled
trial. Hepatology 2011;54:1610–1619.

Placebo Response in Pharmacotherapeutic Trials for NASH

629

54. Promrat K, Kleiner DE, Niemeier HM, et al. Randomized
controlled trial testing the effects of weight loss on nonalcoholicsteatohepatitis. Hepatology 2010;51:121–129.
55. McCarney R, Warner J, Iliffe S, et al. The Hawthorne effect: arandomised, controlled trial. BMC Med Res Methodol 2007;7:30.
56. IntHout J, Ioannidis JP, Borm GF, et al. Small studies are moreheterogeneous than large ones: a meta-meta-analysis. J Clin
Epidemiol 2015;68:860–869.
57. Singh S, Venkatesh SK, Loomba R, et al. Magnetic resonanceelastography for staging liver ﬁbrosis in non-alcoholic fatty liverdisease: a diagnostic accuracy systematic review and individual
participant data pooled analysis. Eur Radiol 2016;26:
1431–1440.

Reprint requests
Address requests for reprints to: Mazen Noureddin, MD, Division of Digestiveand Liver Diseases, Comprehensive Transplant Program, Cedars-Sinai Medical
Center, 8900 Beverly Boulevard, Suite 250, Los Angeles, California 90048.
e-mail: mazen.noureddin@cshs.org; fax: þ1 (310) 248-8197.
Acknowledgments
The authors thank Dr Shahinul Alam, Dr Sara Heebøll, Dr Melanie D. Beaton, Dr
Alessandro Federico, Dr Carmelina Loguercio, Dan L. Waitzberg, Dr Mark M.
Smits, Dr Toshinari Takamura, Dr Eduardo Vilar-Gomez, Dr Eric Lefebvre, Dr
Scott L. Friedman, Dr Chan Wah Kheong, Dr Stuart McPherson, and Dr Curtis
K. Argo for their prompt response and assistance in providing additional data.
Conﬂicts of interest
These authors disclose the following: Eric Lefebvre was the Vice President andthe Head of Clinical Research and Development – NASH at Allergan. Rifaat
Safadi has been on the advisory board or a speaker for Intercept, Gilead,
CanFite, and MedImmune; has received research support from Novartis,
Galmed, BioLine, and CanFite; and is a minor shareholder of CanFite. Vlad
Ratziu is a consultant for Boehringer, Bristol Myers Squibb, Galmed, Genﬁt,
Intercept, Pﬁzer, and Alergan. Mazen Noureddin has been on the advisoryboard or a speaker for EchoSens, OWL, Intercept, Gilead, and Abbott; hasreceived research support from Gilead, Galmed, Galectin, Genﬁt, Conatus,
Zydus, and Shire; and is a minor shareholder of Anaetos. The remaining authors disclose no conﬂicts.

629.e1

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary Appendix#

Actual Search Strategy
Ovid
Database(s): Embase 1988 to 2018 Week 01, EBM
Reviews - Cochrane Central Register of Controlled Trials
November 2017, Ovid MEDLINE(R) Epub Ahead ofPrint, In-Process & Other Non-Indexed Citations, Ovid
MEDLINE(R) Daily and Ovid MEDLINE(R) 1946 to
Present Search Strategy:#

Searches

Results1
2

exp Non-alcoholic Fatty Liver Disease/(((“non-alcoholic” or nonalcoholic) and (“fatty
liver*” or steatohepatit* or (liver and steatos*)or “visceral steatos*”)) or NAFLD).mp.
1 or 2
exp nuclear magnetic resonance imaging/exp Magnetic Resonance Imaging/((mr adj tomograph*) or (nmr adj tomograph*) or“chemical shift imaging*” or fmri or fmris or“magnetic resonance” or “magnetizationtransfer imaging*” or “mr imaging*” or “MR
spectroscop*” or mri or mris or nmr or nmrs
or “proton spin tom”).mp.
4 or 5 or 6
(adipose or adiposity or fat or HFF or lipid* or
PDFF or steatosis).mp.
7 and 8(biopsies or biopsy or histolog* or laboratory or
pathologist*).mp.
3 and (9 or 10)
exp controlled study/
exp Randomized Controlled Trial/
exp triple blind procedure/exp Double-Blind Method/
exp Single-Blind Method/
exp latin square design/
exp Placebos/
exp Placebo Effect/((control* adj3 study) or (control* adj3 trial) or(randomized adj3 study) or (randomized adj3
trial) or (randomised adj3 study) or(randomised adj3 trial) or “pragmatic clinical
trial” or (doubl* adj blind*) or (doubl* adj
mask*) or (singl* adj blind*) or (singl* adj
mask*) or (tripl* adj blind*) or (tripl* adj mask*)or (trebl* adj blind*) or (trebl* adj mask*) or“latin square” or placebo* or nocebo* or
random*).mp,pt.
or/12-20
11 and 21(exp animals/ or exp nonhuman/) not exp
humans/((alpaca or alpacas or amphibian or amphibians
or animal or animals or antelope or armadillo

37546
55849

3
4
5
6

7
8
9
10
11
12
13
14
15
16
17
18
19
20

21
22
23
24

55849
7884071229061
2001062

2011632
179714882346
3588323
19839
612845998887618442304475429
351
33564010652
9247173252692472386585
9465408
8305148

27
28

Searchesor armadillos or avian or baboon or baboons
or beagle or beagles or bee or bees or bird or
birds or bison or bovine or buffalo
or buffaloes or buffalos or “c elegans” or“Caenorhabditis elegans” or camel orcamels or canine or canines or carp or catsor cattle or chick or chicken or chickens or
chicks or chimp or chimpanze or
chimpanzees or chimps or cow or cows
or “D melanogaster” or “dairy calf” or “dairy
calves” or deer or dog or dogs or donkey or
donkeys or drosophila or “Drosophilamelanogaster” or duck or duckling or
ducklings or ducks or equid or equids orequine or equines or feline or felines or ferretor ferrets or ﬁnch or ﬁnches or ﬁsh or
ﬂatworm or ﬂatworms or fox or foxes or frog
or frogs or “fruit ﬂies” or “fruit ﬂy” or “G
mellonella” or “Galleria mellonella” or geese
or gerbil or gerbils or goat or goats or
goose or gorilla or gorillas or hamster or
hamsters or hare or hares or heifer or heifers
or horse or horses or insect or insects orjellyﬁsh or kangaroo or kangaroos or kitten
or kittens or lagomorph or lagomorphs orlamb or lambs or llama or llamas or macaqueor macaques or macaw or macaws or
marmoset or marmosets or mice or minipig
or minipigs or mink or minks or monkey ormonkeys or mouse or mule or mules ornematode or nematodes or octopus oroctopuses or orangutan or “orang-utan” ororangutans or “orang-utans” or oxen or
parrot or parrots or pig or pigeon or pigeonsor piglet or piglets or pigs or porcine or
primate or primates or quail or rabbit or
rabbits or rat or rats or reptile or reptiles orrodent or rodents or ruminant or ruminantsor salmon or sheep or shrimp or slug or slugs
or swine or tamarin or tamarins or toad or
toads or trout or urchin or urchins or vole orvoles or waxworm or waxworms or worm or
worms or xenopus or “zebra ﬁsh” orzebraﬁsh) not (human or humans)).mp.
22 not (23 or 24)
limit 25 to (editorial or erratum or letter or note oraddresses or autobiography or bibliography
or biography or blogs or comment or
dictionary or directory or interactive tutorial
or interview or lectures or legal cases orlegislation or news or newspaper article or
overall or patient education handout or
periodical index or portraits or publishederratum or video-audio media or webcasts)[Limit not valid in Embase,CCTR,Ovid
MEDLINE(R),Ovid MEDLINE(R) Daily
Update,Ovid MEDLINE(R) In-Process,Ovid
MEDLINE(R) Publisher; records wereretained]
25 not 26
remove duplicates from 27

Results

5356
102

5254
3852

March 2019

Scopus
1 TITLE-ABS-KEY(((“non-alcoholic” or nonalcoholic)and (“fatty liver*” or steatohepatit* or (liver andsteatos*) or “visceral steatos*”)) or NAFLD)
2 TITLE-ABS-KEY((mr W/1 tomograph*) OR (nmr W/1
tomograph*) OR “chemical shift imaging*” OR fmri
OR fmris OR “magnetic resonance” OR “magnetization transfer imaging*” OR “mr imaging*” OR “MR
spectroscop*” OR mri OR mris OR nmr OR nmrs OR“proton spin tom”)
3 TITLE-ABS-KEY(adipose OR adiposity OR fat OR“fatty acid*” OR HFF OR lipid* OR PDFF OR steatosis)

Placebo Response in Pharmacotherapeutic Trials for NASH 629.e2

OR mouse OR mule OR mules OR nematode OR
nematodes OR octopus OR octopuses OR orangutan
OR “orang-utan” OR orangutans OR “orang-utans” ORoxen OR parrot OR parrots OR pig OR pigeon OR
pigeons OR piglet OR piglets OR pigs OR porcine
OR primate OR primates OR quail OR rabbit OR
rabbits OR rat OR rats OR reptile OR reptiles
OR rodent OR rodents OR ruminant OR ruminants OR
salmon OR sheep OR shrimp OR slug OR slugs OR
swine OR tamarin OR tamarins OR toad OR toads
OR trout OR urchin OR urchins OR vole OR voles OR
waxworm OR waxworms OR worm OR worms OR
xenopus OR “zebra ﬁsh” OR zebraﬁsh) AND NOT(human OR humans))

4 TITLE-ABS-KEY(biopsies OR biopsy OR histolog* ORlaboratory OR pathologist*)

9 7 and not 8

5 1 and ((2 and 3) or 4)

10 DOCTYPE(le) OR DOCTYPE(ed) OR DOCTYPE(bk) OR
DOCTYPE(er) OR DOCTYPE(no) OR DOCTYPE(sh)6 TITLE-ABS-KEY((control* W/3 study) or (control*
W/3 trial) or (randomized W/3 study) or (randomized W/3 trial) or (randomised W/3 study) or(randomised W/3 trial) or “pragmatic clinical trial”or (doubl* W/1 blind*) or (doubl* W/1 mask*) or(singl* W/1 blind*) or (singl* W/1 mask*) or (tripl*
W/1 blind*) or (tripl* W/1 mask*) or (trebl* W/1
blind*) or (trebl* W/1 mask*) or “latin square” orplacebo* or nocebo* or random*)
7 5 and 6
8 TITLE-ABS-KEY((alpaca OR alpacas OR amphibian
OR amphibians OR animal OR animals OR antelope
OR armadillo OR armadillos OR avian OR baboon OR
baboons OR beagle OR beagles OR bee OR bees
OR bird OR birds OR bison OR bovine OR buffalo OR
buffaloes OR buffalos OR “c elegans” OR “Caenorhabditis elegans” OR camel OR camels OR canine OR
canines OR carp OR cats OR cattle OR chick OR
chicken OR chickens OR chicks OR chimp OR chimpanze OR chimpanzees OR chimps OR cow OR cows
OR “D melanogaster” OR “dairy calf” OR “dairy
calves” OR deer OR dog OR dogs OR donkey OR
donkeys OR drosophila OR “Drosophila melanogaster” OR duck OR duckling OR ducklings OR
ducks OR equid OR equids OR equine OR equines
OR feline OR felines OR ferret OR ferrets OR ﬁnch OR
ﬁnches OR ﬁsh OR ﬂatworm OR ﬂatworms OR fox OR
foxes OR frog OR frogs OR “fruit ﬂies” OR “fruit ﬂy”
OR “G mellonella” OR “Galleria mellonella” OR geese
OR gerbil OR gerbils OR goat OR goats OR goose OR
gorilla OR gorillas OR hamster OR hamsters OR hare
OR hares OR heifer OR heifers OR horse OR horses
OR insect OR insects OR jellyﬁsh OR kangaroo OR
kangaroos OR kitten OR kittens OR lagomorph OR
lagomorphs OR lamb OR lambs OR llama OR llamas
OR macaque OR macaques OR macaw OR macaws OR
marmoset OR marmosets OR mice OR minipig OR
minipigs OR mink OR minks OR monkey OR monkeys

11 9 and not 10
12 PMID(0*) OR PMID(1*) OR PMID(2*) OR PMID(3*)
OR PMID(4*) OR PMID(5*) OR PMID(6*) OR
PMID(7*) OR PMID(8*) OR PMID(9*)
13 11 and not 12

References
1. Adams LA, Crawford DH, Stuart K, et al. The impact of phlebotomy in nonalcoholic fatty liver disease: a prospective, randomized, controlled trial. Hepatology 2015;61:1555–1564.
2. Aithal GP, Thomas JA, Kaye PV, et al. Randomized, placebocontrolled trial of pioglitazone in nondiabetic subjects withnonalcoholicsteatohepatitis.
Gastroenterology
2008;
135:1176–1184.
3. Alisi A, Bedogni G, Baviera G, et al. Randomised clinical trial: thebeneﬁcial effects of VSL#3 in obese children with non-alcoholicsteatohepatitis. Aliment Pharmacol Ther 2014;39:1276–1285.
4. Aller R, De Luis DA, Izaola O, et al. Effect of a probiotic on liveraminotransferases in nonalcoholic fatty liver disease patients: adouble blind randomized clinical trial. Eur Rev Med Pharmacol
Sci 2011;15:1090–1095.
5. Aller R, Izaola O, Gomez S, et al. Effect of silymarin plus vitamin
E in patients with non-alcoholic fatty liver disease. A randomized
clinical pilot study. Eur Rev Med Pharmacol Sci 2015;
19:3118–3124.
6. Amin MA, Sabry D, Kassem M, et al. Effect of pentoxifylline onserum hyaluronic acid in patients with non-alcoholic fatty liverdisease. Arab J 2009;10:102–105.
7. Arendt BM, Allard JP. Effect of atorvastatin, vitamin E and C on
nonalcoholic fatty liver disease: is the combination required. Am
J Gastroenterol 2011;106:78–80.
8. Athyros VG, Mikhailidis DP, Didangelos TP, et al. Effect ofmultifactorial treatment on non-alcoholic fatty liver disease inmetabolic syndrome: a randomised study. Curr Med Res Opin
2006;22:873–883.
9. Balas B, Belfort R, Harrison SA, et al. Pioglitazone treatment
increases whole body fat but not total body water in patientswith non-alcoholic steatohepatitis. J Hepatol 2007;47:565–570.

629.e3

Han et al

10. Balmer ML, Schmitter K, Dufour JF. The effect of ursodeoxycholic acid (UCDA) in combination with vitamin E on adipokines in patients with NASH. J Hepatol 2008;48(Suppl 2):S337.
11. Barchetta I, Del Ben M, Angelico F, et al. No effects of oralvitamin D supplementation on non-alcoholic fatty liver diseasein patients with type 2 diabetes: a randomized, double-blind,placebo-controlled trial. BMC Med 2016;14:92.
12. Bugianesi E, Gentilcore E, Manini R, et al. A randomized
controlled trial of metformin versus vitamin E or prescriptive dietin nonalcoholic fatty liver disease. Am J Gastroenterol 2005;
100:1082–1090.
13. Cariou B, Hanf R, Lambert-Porcheron S, et al. Dual peroxisome
proliferator-activated receptor alpha/delta agonist GFT505 improves hepatic and peripheral insulin sensitivity in abdominallyobese subjects. Diabetes Care 2013;36:2923–2930.
14. Celinski K, Konturek PC, Slomka M, et al. Effects of treatment
with melatonin and tryptophan on liver enzymes, parameters of
fat metabolism and plasma levels of cytokines in patients with
non-alcoholic fatty liver disease: 14 months follow up. J Physiol
Pharmacol 2014;65:75–82.
15. Chen S, Zhao X, Ran L, et al. Resveratrol improves insulin
resistance, glucose and lipid metabolism in patients with nonalcoholic fatty liver disease: a randomized controlled trial. Dig
Liver Dis 2015;47:226–232.
16. Cichoz-Lach H, Celinski K, Konturek PC, et al. The effects of Ltryptophan and melatonin on selected biochemical parametersin patients with steatohepatitis. J Physiol Pharmacol 2010;
61:577–580.
17. Charles ED, Tetri BA, Luo Y, et al. A phase 2 study of BMS986036 (Pegylated FGF21) in obese adults with type 2 diabetes and a high prevalence of fatty liver. Hepatology 2016;
63(Suppl 1):17A.
18. Choi JY, Lee K, Lee SM, et al. Efﬁcacy and safety of humanplacental extract for alcoholic and nonalcoholic steatohepatitis:
an open-label, randomized, comparative study. Biol Pharm Bull
2014;37:1853–1859.
19. Coskun BDO, Yucesoy M, Gursoy S, et al. Effects of ursodeoxycholic acid therapy on carotid intima media thickness,
apolipoprotein A1, apolipoprotein B, and apolipoprotein B/A1
ratio in nonalcoholic steatohepatitis. Eur J Gastroenterol Hepatol 2015;27:142–149.

Clinical Gastroenterology and Hepatology Vol. 17, No. 4
25. Ekhlasi G, Kolahdouz Mohammadi R, Agah S, et al. Do symbiotic and Vitamin E supplementation have favorite effects innonalcoholic fatty liver disease? A randomized, double-blind,placebo-controlled trial. J Res Med Sci 2016;21:106.
26. Ersoz G, Gunsar F, Karasu Z, et al. Management of fatty liverdisease with vitamin E and C compared to ursodeoxycholic acidtreatment. Turk J Gastroenterol 2005;16:124–128.
27. Fard SJ, Ghodsbin F, Kaviani MJ, et al. The effect of follow up(telenursing) on liver enzymes in patients with nonalcoholic fatty
liver disease: a randomized controlled clinical trial. Int J Community Based Nurs Midwifery 2016;4:239–246.
28. Federico A, Dallio M, Conti V, et al. Effects of silybin administration on the redox state and oxidative stress response ofhuman endothelial cells in patients with non-alcoholic steatohepatitis. Dig Liver Dis 2016;48:e178.
29. Fernández Vega D, Pedro Evelio VM, Nasiff Hadad A, et al.
Effect of treatment with oral red propolis extract on nonalcoholic
teatohepatitis. Rev Cuba Med 2014;53:282–290.
30. Ferolla SM, Couto CA, Costa-Silva L, et al. Beneﬁcial effect ofsynbiotic supplementation on hepatic steatosis and anthropometric parameters, but not on gut permeability in a population
with nonalcoholic steatohepatitis. Nutrients 2016;8:28.
31. Georgescu EF, Ionescu R, Niculescu M, et al. Angiotensinreceptor blockers as therapy for mild-to-moderate
hypertension-associated non-alcoholic steatohepatitis. WorldJ Gastroenterol 2009;15:942–954.
32. Gianturco V, Troisi G, Bellomo A, et al. Impact of combined
therapy with alpha-lipoic and ursodeoxycolic acid on nonalcoholic fatty liver disease: double-blind, randomized clinical trial ofefﬁcacy and safety. Hepatol Int 2013;7:570–576.
33. Gonciarz M, Gonciarz Z, Bielanski W, et al. The pilot study of
3-month course of melatonin treatment of patients withnonalcoholic steatohepatitis: effect on plasma levels of liver
enzymes, lipids and melatonin. J Physiol Pharmacol 2010;
61:705–710.
34. Gonciarz M, Gonciarz Z, Bielanski W, et al. The effects of longterm melatonin treatment on plasma liver enzymes levels andplasma concentrations of lipids and melatonin in patients withnonalcoholic steatohepatitis: a pilot study. J Physiol Pharmacol
2012;63:35–40.

20. Cotrim HP, Freitas LA, Alves E, et al. Effects of light-tomoderate alcohol consumption on steatosis and steatohepatitis in severely obese patients. Eur J Gastroenterol Hepatol 2009;
21:969–972.

35. Han Y, Shi J-P, Ma A-L, et al. Randomized, vitamin E-controlled
trial of bicyclol plus metformin in non-alcoholic fatty liver disease patients with impaired fasting glucose. Clin Drug Invest
2014;34:1–7.

21. Cussons AJ, Watts GF, Mori TA, et al. Omega-3 fatty acidsupplementation decreases liver fat content in polycystic ovary
syndrome: a randomized controlled trial employing proton
magnetic resonance spectroscopy. J Clin Endocrinol Metab
2009;94:3842–3848.
22. Daubioul CA, Horsmans Y, Lambert P, et al. Effects of oligofructose on glucose and lipid metabolism in patients withnonalcoholic steatohepatitis: results of a pilot study. Eur J Clin
Nutr 2005;59:72372–72376.

36. Harrison SA, Torgerson S, Hayashi P, et al. Vitamin E andvitamin C treatment improves ﬁbrosis in patients withnonalcoholic steatohepatitis. Am J Gastroenterol 2003;
98:2485–2490.

23. Della Corte C, Carpino G, De Vito R, et al. Docosahexanoic acid
plus vitamin D treatment improves features of NAFLD in children
with serum vitamin D deﬁciency: results from a single centre
trial. PLoS One 2016;11:e0168216.
24. Dufour J-F, Oneta CM, Gonvers J-J, et al. Randomized
placebo-controlled trial of ursodeoxycholic acid with vitamin E
in nonalcoholic steatohepatitis. Clin Gastroenterol Hepatol
2006;4:1537–1543.

37. Harrison SA, Fecht W, Brunt EM, et al. Orlistat for overweightsubjects with nonalcoholic steatohepatitis: a randomized, prospective trial. Hepatology 2009;49:80–86.
38. Harrison SA, Marri SR, Chalasani N, et al. Randomised clinicalstudy: GR-MD-02, a galectin-3 inhibitor, vs. placebo in patients
having non-alcoholic steatohepatitis with advanced ﬁbrosis.
Aliment Pharmacol Ther 2016;44:1183–1198.
39. Hashemi SJ, Hajiani E, Sardabi EH. A placebo-controlled trial ofsilymarin in patients with nonalcoholic fatty liver disease. Hepatology 2009;9:265–270.
40. Hickman IJ, Byrne NM, Croci I, et al. The effect of exercise on
the metabolic and histological features of non-alcoholic fatty
liver disease. J Hepatol 2012;56:S509.

March 201941. Hoofnagle JH, Van Natta ML, Kleiner DE, et al. Vitamin E andchanges in serum alanine aminotransferase levels in patientswith non-alcoholic steatohepatitis. Aliment Pharmacol Ther
2013;38:134–143.
42. Sanyal AJ, Chalasani N, Kowdley KV, et al. Pioglitazone, vitamin
E, or placebo for nonalcoholic steatohepatitis. N Engl J Med
2010;362:1675–1685.
43. Hussain M, Majeed Babar MZ, Hussain MS, et al. Vildagliptin
ameliorates biochemical, metabolic and fatty changes associated with non alcoholic fatty liver disease. Pak J Med Sci 2016;
32:1396–1401.
44. Hussein O, Grosovski M, Schlesinger S, et al. Orlistat reverse
fatty inﬁltration and improves hepatic ﬁbrosis in obese patientswith nonalcoholic steatohepatitis (NASH). Dig Dis Sci 2007;
52:2512–2519.
45. Janczyk W, Lebensztejn D, Wierzbicka-Rucinska A, et al.
Omega-3 fatty acids therapy in children with nonalcoholic fatty
liver disease: a randomized controlled trial. J Pediatr 2015;
166:1358–1363.
46. Jeong JY, Sohn JH, Baek YH, et al. New botanical drug, HL
tablet, reduces hepatic fat as measured by magnetic resonancespectroscopy in patients with nonalcoholic fatty liver disease: aplacebo-controlled, randomized, phase II trial. World J Gastroenterol 2017;23:5977–5985.
47. Ji G, Fan J-G, Chen J-J, et al. Effectiveness of Danning Tablet inpatients with non-alcoholic fatty liver of damp-heat syndrome
type: a multicenter randomized controlled trial. Zhong Xi Yi Jie
He Xue Bao 2008;6:128–133.
48. Junker AE, Gluud L, Hall GV, et al. Effect of glucagon-like
peptide-1 on glucagon secretion, endogenous glucose production and whole body lipolysis in patients with nonalcoholic
liver disease. Diabetologia 2015;1:S267.
49. Junker AE, Gluud LL, van Hall G, et al. Effects of glucagon-like
peptide-1 on glucagon secretion in patients with non-alcoholic
fatty liver disease. J Hepatol 2016;64:908–915.

Placebo Response in Pharmacotherapeutic Trials for NASH 629.e4
induction, and alleviates insulin resistance: results of a phase IIa
blinded placebo-controlled trial. J Clin Immunol 2015;35:399–407.
57. Lalazar G, Zigmond E, Weksler-Zangen S, et al. Oral administration of beta-glucosylceramide for the treatment of insulin
resistance and nonalcoholic steatohepatitis: results of a doubleblind, placebo-controlled trial. J Med Food 2017;20:458–464.
58. Lavine JE, Schwimmer JB, Van Natta ML, et al. Effect of vitamin
E or metformin for treatment of nonalcoholic fatty liver diseasein children and adolescents: the TONIC randomized controlled
trial. JAMA 2011;305:1659–1668.
59. Lee Y-M, Sutedja DS, Wai C-T, et al. A randomized controlled
pilot study of pentoxifylline in patients with non-alcoholicsteatohepatitis (NASH). Hepatol Int 2008;2:196–201.
60. Li Y-H, Yang L-H, Sha K-H, et al. Efﬁcacy of poly-unsaturated
fatty acid therapy on patients with nonalcoholic steatohepatitis. World J Gastroenterol 2015;21:7008–7013.
61. Lin SC, Heba E, Bettencourt R, et al. Assessment of treatment
response in non-alcoholic steatohepatitis using advanced
magnetic resonance imaging. Aliment Pharmacol Ther 2017;45:844–854.
62. Loomba R, Sirlin CB, Ang B, et al. Ezetimibe for the treatment of
nonalcoholic steatohepatitis: assessment by novel magnetic
resonance imaging and magnetic resonance elastography in arandomized trial (MOZART trial). Hepatology 2015;
61:1239–1250.
63. Lindor KD, Kowdley KV, Heathcote EJ, et al. Ursodeoxycholicacid for treatment of nonalcoholic steatohepatitis: results of arandomized trial. Hepatology 2004;39:770–778.
64. Loguercio C, Andreone P, Brisc MC, et al. Silybin as supplementary food: a possible cooperative instrument in the management of patients with chronic hepatitis. Eur J Clin Invest
2010;40:83.
65. Loomba R, Lawitz E, Mantry PS, et al. The ASK1 inhibitor
selonsertib in patients with nonalcoholic steatohepatitis: a randomized, phase 2 trial. Hepatology 2018;67:549–559.

50. Kakazu E, Kondo Y, Ninomiya M, et al. The inﬂuence of pioglitazone on the plasma amino acid proﬁle in patients withnonalcoholic steatohepatitis (NASH). Hepatol Int 2013;
7:577–585.

66. Merat S, Malekzadeh R, Sohrabi MR, et al. Probucol in thetreatment of non-alcoholic steatohepatitis: a double-blind randomized controlled study. J Hepatol 2003;38:414–418.

51. Kargiotis K, Athyros VG, Giouleme O, et al. Resolution of nonalcoholic steatohepatitis by rosuvastatin monotherapy in patients with metabolic syndrome. World J Gastroenterol 2015;
21:7860–7868.

67. Malaguarnera M, Gargante MP, Russo C, et al. L-carnitine
supplementation to diet: a new tool in treatment of nonalcoholicsteatohepatitis. A randomized and controlled clinical trial. Am J
Gastroenterol 2010;105:1338–1345.

52. Kazemi R, Aduli M, Sotoudeh M, et al. Metformin in nonalcoholic steatohepatitis: a randomized controlled trial. Middle East
J 2012;4:16–22.

68. Malaguarnera M, Vacante M, Antic T, et al. Biﬁdobacterium
longum with fructo-oligosaccharides in patients with non
alcoholic steatohepatitis. Dig Dis Sci 2011;1–9.

53. Kedarisetty CK, Bhardwaj A, Bhadoria AS, et al. A randomized
controlled trial to study the efﬁcacy of combination of pentoxiphylline and vitamin E versus vitamin E in patients with nonalcoholic steatohepatitis. J Hepatol 2014;1:S344.

69. Morita Y, Ueno T, Sasaki N, et al. Nateglinide is useful for
nonalcoholic steatohepatitis (NASH) patients with type 2
diabetes. Hepatogastroenterology 2005;52:1338–1343.

54. Khoo J, Hsiang J, Taneja R, et al. Comparative effects of liraglutide 3 mg vs structured lifestyle modiﬁcation on bodyweight, liver fat and liver function in obese patients with nonalcoholic fatty liver disease: a pilot randomized trial. Diabetes
Obes Metab 2017;19:1814–1817.
55. Komshilova KA, Troshina EA, Ershova EV, et al. Effect of metformin on cardiometabolic risk factors in patients with abdominal obesity and non-alcoholic fatty liver disease (NAFLD).
Obesity Facts 2015;8:208–209.
56. Lalazar G, Mizrahi M, Turgeman I, et al. Oral Administration of
OKT3 MAb to patients with NASH, promotes regulatory T-cell

70. Naganuma A, Ogawa Y, Hoshino T, et al. Effect of the medical
walking and leucine enriched amino acid containing food forfemale nonalcoholic fatty liver disease: randomized controlled
trial. Clin Nutr 2016;35:S62–S63.
71. Nelson A, Torres DM, Morgan AE, et al. A pilot study using
simvastatin in the treatment of nonalcoholic steatohepatitis: arandomized placebo-controlled trial. J Clin Gastroenterol 2009;
43:990–994.
72. Nobili V, Manco M, Devito R, et al. Effect of vitamin E onaminotransferase levels and insulin resistance in children with
non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2006;
24:1553–1561.

629.e5

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

73. Nobili V, Manco M, Devito R, et al. Lifestyle intervention andantioxidant therapy in children with nonalcoholic fatty liver disease: a randomized, controlled trial. Hepatology 2008;
48:119–128.

88. Santos VN, Lanzoni VP, Szejnfeld J, et al. A randomized doubleblind study of the short-time treatment of obese patients withnonalcoholic fatty liver disease with ursodeoxycholic acid. Braz
J Med Biol Res 2003;36:723–729.

74. Nobili V, Bedogni G, Alisi A, et al. Docosahexaenoic acid supplementation decreases liver fat content in children with nonalcoholic fatty liver disease: double-blind randomised
controlled clinical trial. Arch Dis Child 2011;96:350–353.

89. Sanyal AJ, Mofrad PS, Contos MJ, et al. A pilot study of vitamin
E versus vitamin E and pioglitazone for the treatment of
nonalcoholic steatohepatitis. Clin Gastroenterol Hepatol 2004;
2:1107–1115.

75. Omer Z, Cetinkalp S, Akyildiz M, et al. Efﬁcacy of insulinsensitizing agents in nonalcoholic fatty liver disease. Eur J
Gastroenterol Hepatol 2010;22:18–23.
76. Paciﬁco L, Bonci E, Di Martino M, et al. A double-blind, placebocontrolled randomized trial to evaluate the efﬁcacy of docosahexaenoic acid supplementation on hepatic fat and associatedcardiovascular risk factors in overweight children with nonalcoholic fatty liver disease. Nutr Metab Cardiovasc Dis 2015;
25:734–741.

90. Savvidou S, Karatzidou K, Gagalis A, et al. The effects of shortterm exenatide on circulating adiponectin levels in patients with
type 2 diabetes mellitus (DMT2) with or without non-alcoholic
fatty liver disease (NAFLD): a randomized, open-label,
controlled intervention trial. J Hepatol 2015;62:S720–S721.

77. Pan J, Wang M, Song H, et al. The efﬁcacy and safety of Traditional Chinese Medicine (Jiang Zhi Granule) for nonalcoholic fatty
liver: a multicenter, randomized, placebo-controlled study. Evid
Based Complement Alternat Med 2013;2013:965723.
78. Panahi Y, Kianpour P, Mohtashami R, et al. Efﬁcacy and safetyof phytosomal curcumin in non-alcoholic fatty liver disease: arandomized controlled trial. Drug Res (Stuttg) 2017;67:244–251.
79. Polyzos SA, Kountouras J, Zafeiriadou E, et al. Effect of spironolactone and vitamin E on serum metabolic parameters andinsulin resistance in patients with nonalcoholic fatty liver disease. J Renin Angiotensin Aldosterone Syst 2011;12:498–503.
80. Petit JM, Cercueil JP, Loffroy R, et al. Effect of liraglutide
therapy on liver fat content in patients with inadequately
controlled type 2 diabetes: the Lira-NAFLD study. J Clin
Endocrinol Metab 2017;102:407–415.
81. Ratziu V, Charlotte F, Bernhardt C, et al. Long-term efﬁcacy ofrosiglitazone in nonalcoholic steatohepatitis: results of the fatty
liver improvement by rosiglitazone therapy (FLIRT 2) extension
trial. Hepatology 2010;51:445–453.
82. Ratziu V, Giral P, Jacqueminet S, et al. Rosiglitazone fornonalcoholic steatohepatitis: one-year results of the randomized placebo-controlled Fatty Liver Improvement with Rosiglitazone Therapy (FLIRT) Trial. Gastroenterology 2008;
135:100–110.
83. Ratziu V, de Ledinghen V, Oberti F, et al. A randomized
controlled trial of high-dose ursodesoxycholic acid for nonalcoholic steatohepatitis. J Hepatol 2011;54:1011–1019.
84. Ratziu V, Sheikh MY, Sanyal AJ, et al. A phase 2, randomized,
double-blind, placebo-controlled study of GS-9450 in subjects
with nonalcoholic steatohepatitis. Hepatology 2012;55:419–428.
85. Razavizade M, Jamali R, Arj A, et al. The effect of pioglitazone
and metformin on liver function tests, insulin resistance, andliver fat content in nonalcoholic fatty liver disease: a randomized
double blinded: a double-blind clinical trial. Hepatology 2013;
13:e9270.
86. Rosqvist F, Kullberg J, Johansson L, et al. Overfeeding polyunsaturated fat from vegetable oil prevents liver fat accumulation compared with saturated fat in overweight and obese
subjects-a double-blind randomized trial (LIPOGAIN-2). Obes
Rev 2016;17:51–52.
87. Samson SL, Sathyanarayana P, Jogi M, et al. Exenatide decreases hepatic ﬁbroblast growth factor 21 resistance in nonalcoholic fatty liver disease in a mouse model of obesity andin a randomised controlled trial. Diabetologia 2011;54:
3093–3100.

91. Scherer T, Wolf P, Smajis S, et al. Chronic intranasal insulin
does not affect hepatic lipids, but lowers circulating BCAAs in
healthy male subjects. J Clin Endocrinol Metab 2017;16:16.
92. Scorletti E, Bhatia B, McCormick KG, et al. Potential beneﬁts of
puriﬁed long chain omega-3 fatty acid treatment in non-alcoholic
fatty liver disease (NAFLD): a potential treatment for early NAFLD
in metabolic syndrome and type 2 diabetes? Results from the
WELCOME study. Diabet Med 2014;31:1.
93. Scorletti E, Bhatia L, McCormick KG, et al. Effects of puriﬁed
eicosapentaenoic and docosahexaenoic acids in nonalcoholic
fatty liver disease: results from the Welcome* study. Hepatology
2014;60:1211–1221.
94. Sharma BC, Kumar A, Garg V, et al. A randomized controlled
trial comparing efﬁcacy of pentoxifylline and pioglitazone on
metabolic factors and liver histology in patients with nonalcoholic steatohepatitis. J Clin Exp Hepatol 2012;2:333–337.
95. Shavakhi A, Minakari M, Firouzian H, et al. Effect of a probiotic
and metformin on liver aminotransferases in non-alcoholicsteatohepatitis: a double blind randomized clinical trial. Int J
Prev Med 2013;4:531–537.
96. Shavakhi A, Torki M, Khodadoostan M, et al. Effects of cuminon nonalcoholic steatohepatitis: a double blind, randomised,
controlled trial. Adv Biomed Res 2015;4:212.
97. Shenoy KT, Balakumaran LK, Mathew P, et al. Metadoxine
versus placebo for the treatment of non-alcoholic steatohepatitis: a randomized controlled trial. Journal of Clinical & Experimental Hepatology 2014;4:94–100.
98. Smits MM, Tonneijck L, Muskiet MH, et al. Twelve week
liraglutide or sitagliptin does not affect hepatic fat in type 2
diabetes: a randomised placebo-controlled trial. Diabetologia
2016;59:2588–2593.
99. Soleimani D, Paknahad Z, Askari G, et al. Effect of garlic powder
consumption on body composition in patients with nonalcoholic
fatty liver disease: a randomized, double-blind, placebocontrolled trial. Adv Biomed Res 2016;5:2.
100. Taniai M, Hashimoto E, Tobari M, et al. Treatment of nonalcoholic steatohepatitis with colestimide. Hepatology 2009;
39:685–693.
101. Targher G, Bertolini L, Scala L, et al. Associations between
serum 25-hydroxyvitamin D3 concentrations and liver histology
in patients with non-alcoholic fatty liver disease. Nutr Metab
Cardiovasc Dis 2007;17:517–524.
102. Torres DM, Jones FJ, Shaw JC, et al. Rosiglitazone versus
rosiglitazone and metformin versus rosiglitazone and losartan in
the treatment of nonalcoholic steatohepatitis in humans: a 12month randomized, prospective, open-label trial. Hepatology
2011;54:1631–1639.
103. Troisi G, Crisciotti F, Gianturco V, et al. The treatment withursodeoxycholic acid in elderly patients affected by NAFLD andMarch 2019metabolic syndrome: a case-control study. Clin Ther 2013;
164:203–207.
104. Tuncer I, Uygan I, Dulger H, et al. The comparative effects ofpentoxifylline and ursodeoxycholic acid on IL-1beta, IL-6, IL-8
and TNF-alpha levels in nonalcoholic fatty liver. East J Med
2003;8:27–32.
105. Uygun A, Kadayifci A, Bagci S, et al. L-Carnitine therapy in
non-alcoholic steatohepatitis. Turk J Gastroenterol 2000;11:
196–201.
106. Uygun A, Kadayifci A, Isik AT, et al. Metformin in the treatmentof patients with non-alcoholic steatohepatitis. Aliment Pharmacol Ther 2004;19:537–544.

Placebo Response in Pharmacotherapeutic Trials for NASH 629.e6
109. Vos M, Jin R, Welsh J, et al. Losartan improves hepatic
inﬂammation in children with non-alcoholic fatty liver disease.
Gastroenterology 2016;1:S1036.
110. Watanabe T, Tamura Y, Kakehi S, et al. Effects of sitagliptin on
ectopic fat contents and glucose metabolism in type 2 diabetic
patients with fatty liver: a pilot study. Journal of Diabetes
Investigation 2015;6:164–172.
111. Yari Z, Rahimlou M, Eslamparast T, et al. Flaxseed supplementation in non-alcoholic fatty liver disease: a pilot randomized, open labeled, controlled study. Int J Food Sci Nutr 2016;
67:461–469.

107. Vajro P, Mandato C, Licenziati MR, et al. Effects of Lactobacillus
rhamnosus strain GG in pediatric obesity-related liver disease.
J Pediatr Gastroenterol Nutr 2011;52:740–743.

112. Zelber-Sagi S, Kessler A, Brazowsky E, et al. A double-blind
randomized placebo-controlled trial of orlistat for the treatmentof nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol
2006;4:639–644.

108. Valenti L, Fracanzani AL, Dongiovanni P, et al. A randomized
trial of iron depletion in patients with nonalcoholic fatty liverdisease and hyperferritinemia. World J Gastroenterol 2014;
20:3002–3010.

113. Zhang PW, Chen FX, Li D, et al. A CONSORT-compliant, randomized, double-blind, placebo-controlled pilot trial of puriﬁed
anthocyanin in patients with nonalcoholic fatty liver disease.
Medicine (Baltimore) 2015;94:758.

629.e7

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary Figure 1. Flow chart of study selection
process.

Supplementary Figure 2. Assessment of risk of bias in theindividual studies. Risk of bias summary (A) and graph (B)based on the Cochrane risk of bias tool.

March 2019

Placebo Response in Pharmacotherapeutic Trials for NASH 629.e8

Supplementary
Figure 2. (continued).

Supplementary
Figure 3. Sensitivity analysis of meta-analysis of
proportion of patientswith histologic response.
Sensitivity analysis using
random-effects
metaanalysis of the proportionof patients with 2-point
improvement in NAFLD
activityscore
without
worsening in ﬁbrosis after
receiving
placebointervention.

629.e9Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary
Figure 4. Subgroup analyses to assess heterogeneity in the meta-analysisof change in NAS. Exploratory analyses to investigate the heterogeneity
noted in the meta-analysisof mean change in NAS
after receiving placebointervention.
Subgroupinteraction tests based on
geographic region where
the trial was conducted (A),trial duration (B), lifestyle
modiﬁcation (C), receiving
placebo versus lifestyle interventions only (D), number of patients with paired
preplacebo and postplacebo data in the placebo arm (E), and thelocation where the biopsy
was read, central versus
local (F). MD, mean difference; NR, not recommended or reported.

March 2019

Supplementary
Figure 4. (continued).

Placebo Response in Pharmacotherapeutic Trials for NASH

629.e10

629.e11

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary Figure 5. Meta-regression to assess heterogeneity in the meta-analysis of change in NAS. Exploratory analyses to investigate the heterogeneity noted in the meta-analysis of mean change in NAS after receiving placebo intervention.
Bubble plots of meta-regression using change in BMI (A), trial duration (B), baseline NAS (C), and frequency of site visit (D) as
explanatory variables.

March 2019

Supplementary
Figure 6. Sensitivity analyses of meta-analysis ofchange in NAS. Sensitivity
analyses using randomeffects meta-analyses ofthe mean change in NAS
after receiving the placebointervention by excluding
trials that had less than 50
patients with paired preplacebo and post-placebointervention
data
(A),
excluding trials at highand moderate-risk of bias
(B), and excluding imputed
data (C). MD, meandifference.

Placebo Response in Pharmacotherapeutic Trials for NASH

629.e12

629.e13

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary
Figure 6. (continued).

March 2019

Supplementary
Figure 7. Meta-analyses of
proportion of patients withimprovement in individual
histologic scores. Forest
plots of random-effects
meta-analyses
showing
the proportions of patientswith 1-point improvement
in steatosis score (A), hepatocyte ballooning score(B), lobular inﬂammation
score (C), and ﬁbrosis
grade (D) after receiving
placebo intervention.

Placebo Response in Pharmacotherapeutic Trials for NASH

629.e14629.e15

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary
Figure 7. (continued).

March 2019

Placebo Response in Pharmacotherapeutic Trials for NASH

629.e16

Supplementary Figure 8. Meta-analyses of change in individual histologic scores. Forest plots of random-effects metaanalyses of the mean change in steatosis score (A), hepatocyte ballooning score (B), lobular inﬂammation score (C), andﬁbrosis grade (D) after receiving placebo intervention measured as mean difference between values before and after receiving
placebo. MD, mean difference.

629.e17

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary
Figure 9. Subgroup analyses to assess heterogeneity in the meta-analysisof change in MRS-based
IHTG. Exploratory analyses to investigate theheterogeneity noted in themeta-analysis of the meanchange in MRS-based
IHTG after receiving placebo intervention. Subgroup interaction tests
based on number of patients in the placebo arm(A), trial duration (B),recommendation of lifestyle modiﬁcation (C),receiving placebo versus
lifestyle interventions only(D), and the geographic
region where the trial was
conducted (E). MD, meandifference; NR, not recommended or reported.

March 2019

Supplementary
Figure 9. (continued).

Placebo Response in Pharmacotherapeutic Trials for NASH

629.e18

629.e19

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary
Figure10. Metaregression
toassessheterogeneity in the metaanalysis of mean changeinMRS-based
IHTG.
Exploratory analyses toinvestigate the heterogeneity noted in the metaanalysis of the meanchange in MRS-based
IHTG after receiving placebo intervention. Bubble
plots of meta-regression
using trial duration (A),change in BMI (B), baseline
MRS-based IHTG (C), andfrequency of site visit (D) as
explanatory variables.

March 2019

Supplementary
Figure 11. Meta-analysesof change in liver enzymes.
Forest plots of randomeffects meta-analyses ofthe mean change in alanine
aminotransferase(A),
aspartateaminotransferase (B), and alkaline
phosphatase
(C)
after
receiving placebo intervention measured as meandifference between values
before and after receiving
placebo. ALP, alkaline
phosphatase; MD, meandifference.

Placebo Response in Pharmacotherapeutic Trials for NASH

629.e20

629.e21

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary
Figure 11. (continued).

March 2019

Supplementary
Figure 12. Meta-analysesof change in BMI andbiochemical parameters.
Forest plots of randomeffects meta-analyses ofthe mean change in bodymass index (A), hemoglobin A1c (B), and homeostatic model assessmentof insulin resistance (C) after
receiving
placebointervention measured asmean difference between
values before and after
receiving placebo. HbA1c,
hemoglobin A1c; HOMA-IR,
homeostatic
model
assessment for insulin
resistance; MD, meandifference.

Placebo Response in Pharmacotherapeutic Trials for NASH

629.e22629.e23

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary
Figure 12. (continued).

March 2019

Placebo Response in Pharmacotherapeutic Trials for NASH

629.e24

Supplementary Table 1. Excluded References and Reason for Exclusion
Reference
Adams 20151
Aithal 20082

Reason for exclusion

Did not clearly report the methods used in calculating MRI PDFF. No other outcomes of interest reported.
Did not report any of the main outcomes of interest. The reported histologic outcome was not reported according to the
NAFLD Activity Score.
Alisi 20143
Did not report any of the main outcomes of interest. Pediatric population.
Did not report any of the main outcomes of interest.
Aller 20114
Aller 20155
Did not report any of the main outcomes of interest.
Amin 20096
Did not report any of the main outcomes of interest.
Arendt 20117
A commentary.
No placebo group.
Athyros 20068
Balas 20079
Did not report any of the main outcomes of interest.
Balmer 200810
Did not report any of the main outcomes of interest.
Used 1 region of interest per liver segment when measuring MRI PDFF.
Barchetta 201611
Bugianesi 200512
Did not report any of the main outcomes of interest.
Cariou 201313
Did not report any of the main outcomes of interest.
Celinski 201414
No placebo group.
Did not report any of the main outcomes of interest.
Chen 201515
Cichoz-Lach 201016 No placebo group.
Charles 201617
Having NAFLD was not 1 of the inclusion criteria.
Choi 201418
Did not report any of the main outcomes of interest.
No placebo group.
Coskun 201519
Cotrim 200920
Did not report any of the main outcomes of interest.
Cussons 200921
Not all patients had nonalcoholic fatty liver disease because it was not 1 of the inclusion criteria.
No placebo group.
Daubioul 200522
Della 201623
Pediatric population.
Dufour 200624
Did not report any of the main outcomes of interest. The reported histologic outcome was not reported according to the
NAFLD Activity Score.
Did not report any of the main outcomes of interest.
Ekhlasi 201625
Ersoz 200526
No placebo group.
Fard 201627
Did not report any of the main outcomes of interest.
Federico 201628
Did not report any of the main outcomes of interest.
Not in English language.
Fernández Vega
201429Ferolla 201630
Some patients had baseline MRI PDFF less than 5%.
Georgescu 200931 No placebo group.
Did not report any of the main outcomes of interest.
Gianturco 201332
Gonciarz 201033
Did not report any of the main outcomes of interest.
Gonciarz 201234
Did not report any of the main outcomes of interest.
No placebo group.
Han 201435
Harrison 200336
Did not report any of the main outcomes of interest. The reported histologic outcome was not reported according to the
NAFLD Activity Score.
Harrison 200937
No placebo group.
Did not report any of the main outcomes of interest.
Harrison 201638
Hashemi 200939
Did not report any of the main outcomes of interest.
Hickman 201240
No placebo group.
Hoofnagle 201341 A secondary analysis of an included trial.42
Hussain 201643
Did not report any of the main outcomes of interest.
Hussein 200744
No placebo group.
Janczyk 201545
Did not report any of the main outcomes of interest. Pediatric population.
Not all the patients had NAFLD/NASH.
Jeong 201746
Ji 200847
No placebo group.
Junker 201548
Not a randomized controlled trial. Did not report any of the main outcomes of interest.
Junker 201649
Not a randomized controlled trial. Did not report any of the main outcomes of interest.
Did not report any of the main outcomes of interest.
Kakazu 201350
Kargiotis 201551
No placebo group.
Kazemi 201252
Did not report any of the main outcomes of interest.
Kedarisetty 201453 No placebo group.
Did not specify how many regions per liver segment when measuring MRI.
Khoo 201754
Komshilova 201555 Did not report any of the main outcomes of interest.
Lalazar 201556
Did not report any of the main outcomes of interest.
Lalazar 201757
Did not use Kleiner histologic score.
Pediatric population.
Lavine 201158
Lee 200859
Did not report any of the main outcomes of interest.
Li 201560
Did not report any of the main outcomes of interest.

629.e25

Han et al

Clinical Gastroenterology and Hepatology Vol. 17, No. 4

Supplementary Table 1. Continued
Reference
Lin 201761
Lindor 200463

Reason for exclusion
A secondary analysis of an included trial.62
Did not report any of the main outcomes of interest. The reported histologic outcome was not reported according to the
NAFLD Activity Score.
Did not report any of the main outcomes of interest.
No placebo group.
Did not report any of the main outcomes of interest.
Did not report any of the main outcomes of interest.

Loguercio 201064
Loomba 201765
Merat 200366
Malaguarnera
201067
Malaguarnera
Did not report any of the main outcomes of interest.
201168Morita 200569
Use Brunt histology score.
Naganuma 201670 Did not report any of the main outcomes of interest.
Nelson 200971
Did not report any of the main outcomes of interest.
Did not report any of the main outcomes of interest.
Nobili 200672
Nobili 200873
Pediatric population.
Nobili 201174
Did not report any of the main outcomes of interest.
Omer 201075
No placebo group.
Pediatric population.
Paciﬁco 201576
Pan 201377
Did not report any of the main outcomes of interest.
Panahi 201778
Did not report any of the main outcomes of interest.
No placebo group.
Polyzos 201179
Petit 201780
Having NAFLD was not 1 of the inclusion criteria.
Ratziu 201081
An extension of a previous trial82 with no more placebo group.
Ratziu 201183
Did not report any of the main outcomes of interest.
Did not report any of the main outcomes of interest.
Ratziu 201284
Razavizade 201385 No placebo group.
Rosqvist 201686
No placebo group.
Samson 201187
No placebo group.
Did not report any of the main outcomes of interest.
Santos 200388
Sanyal 200489
No placebo group.
Savvidou 201590
No placebo group.
Healthy volunteers.
Scherer 201791
Scorletti 201492
A duplicate publication of an included trial.93
Sharma 201294
No placebo group.
Shavakhi 201395
Did not report any of the main outcomes of interest.
No placebo group.
Shavakhi 201596
Shenoy 201497
Did not report any of the main outcomes of interest.
Smits 201698
Having NAFLD was not 1 of the inclusion criteria.
Soleimani 201699
Did not report any of the main outcomes of interest.
Did not report any of the main outcomes of interest.
Taniai 2009100
Targher 2007101
The comparison group consisted of healthy volunteers.
Torres 2011102
No placebo group.
Troisi 2013103
Did not report any of the main outcomes of interest.
Did not report any of the main outcomes of interest.
Tuncer 2003104
Uygun 2000105
Could not obtain full text.
Uygun 2004106
Did not report any of the main outcomes of interest.
Pediatric population. Did not report any of the main outcomes of interest.
Vajro 2011107
Valenti 2014108
Did not report any of the main outcomes of interest
Vos 2016109
Pediatric population. Did not report any of the main outcomes of interest.
Watanabe 2015110 No placebo group.
Did not report any of the main outcomes of interest.
Yari 2016111
Zelber-Sagi 2006112 Did not report any of the main outcomes of interest.
Zhang 2015113
Did not report any of the main outcomes of interest.

MRI, magnetic resonance imaging; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; PDFF, proton density fat fraction.

March 2019

Placebo Response in Pharmacotherapeutic Trials for NASH

Supplementary Table 2. Multivariable Meta-Regression of
Trials That Used NAS (P < .0001)
Variable

Slope coefﬁcient

P value

Intercept
BMI
Follow-up duration
Baseline NAS
Visit frequency
Lifestyle: dietitian – NR
Lifestyle: no dietitian/NR – exercise
Lifestyle: no dietitian/NR – NR
Placebo pill provided
Region: East Asia
Region: Europe
Region: Middle East
Region: North America
Region: South America
Biopsy read: local

1.13300.0574-0.0016-0.3300-0.0072-0.43650.0454-0.29220.2808-0.6617-0.5940-0.4313-0.2482-1.9855
0.3215

.2669
.8055
.7419
.0242
.7764
.2541
.8905
.3505
.4972
.2085
.1416
.6094
.4665
.0063
.3273

NOTE. Boldface indicates statistical signiﬁcance.
BMI, body mass index; NAS, nonalcoholic fatty liver disease activity score;NR, not recommended or reported.

Supplementary Table 3. Multivariable Meta-Regression of
Trials That Used MRS (P ¼ .0351)
Variable

Slope coefﬁcient

P value

Intercept
BMI
Follow-up duration
Region: Australia
Region: Europe
Region: Middle East
Region: North America
Baseline MRS IHTG
Visit frequency
Lifestyle: no dietitian/NR – exercise
Lifestyle: no dietitian/NR – NR

5.9662
3.3667-0.1321-1.14160.45077.58720.6451-0.1799
0.2894-1.4898-2.9858

.1200
.1857
.0020
.7299
.8377
.0356
.7405
.2309
.1239
.5148
.0147

NOTE. Boldface indicates statistical signiﬁcance.
BMI, body mass index; IHTG, intrahepatic triglyceride; MRS, magnetic resonance spectroscopy; NR, not recommended or reported.

629.e26