Study of ADI-PEG 20 Versus Placebo in Subjects With NASH

Evaluate efficacy and safety of ADI-PEG 20 in patients with NASH

The safety of ADI-PEG 20 will be assessed during the study through the reporting of adverse events (AEs), clinical laboratory tests, electrocardiogram (ECG), vital sign assessments, body weight, and concomitant medication usage.

An external Data Safety and Monitoring Committee (DSMB) that consists of two hepatologists and a statistician will review the safety of the study. The DSMB will convene after 10 subjects (approximately 5 per treatment group) have completed the Week 4 assessments. The DSMB will receive all reports of serious adverse events (SAEs) and convene as needed to monitor for safety.

The primary efficacy will be assessed via the absolute change from baseline in hepatic fat fraction measured by MRI-PDFF at Week 24.

Eligibility Criteria:
Inclusion Criteria:

1. Males and non-lactating, pregnancy test negative females between 18 - 80 years of age with biopsy proven F1 - F3 NASH. Limit F1 fibrosis to ≤ 20% of total subject population.
2. Willingness to use appropriate contraceptive measures though out study treatment and for 90 days thereafter (see Appendix A).
3. Body mass index (BMI) \> 25 kg/m2
4. Must have confirmation of ≥ 10% liver fat content on MRI-PDFF at screening.
5. Biopsy-proven NASH. Must have had a liver biopsy within 4 weeks of randomization with fibrosis stage 1 to 3 and a non-alcoholic fatty liver disease (NAFLD) activity score (NAS) of ≥ 4 with at least a score of 1 in each of the following NAS components:

   1. Steatosis (scored 0 to 3),
   2. Ballooning degeneration (scored 0 to 2), and
   3. Lobular inflammation (scored 0 to 3).
6. Must have no evidence of worsening of ALT and AST (within 50%) measurements at the screening (-4 weeks) and pre-baseline (-2 weeks) visits.
7. Screening laboratory parameters, as determined by the central laboratory:

   1. Estimated glomerular filtration rate (eGFR) ≥ 60 mL/min, as calculated by the Cockcroft- Gault equation;
   2. HbA1c ≤ 9.5% (or serum fructosamine ≤ 381 µmol if HbA1c is unable to be resulted);
   3. Hemoglobin ≥ 11 g/dL;
   4. INR ≤ 1.3, unless due to therapeutic anticoagulation;
   5. Direct bilirubin ≤ 0.5 mg/dL;
   6. Total bilirubin ≤ 1.3 x upper limit of normal (ULN), unless due to an alternate etiology such as Gilbert's syndrome or hemolytic anemia;
   7. Creatinine kinase \< 3 x ULN;
   8. Platelet count ≥ 150,000/µL;
   9. Serum triglyceride level ≤ 500 mg/dL;
   10. ALT \< 5 x ULN;
   11. AST \< 5 x ULN;
   12. ALP \< 2 x ULN.
8. FibroScan® measurement \> 7.0 kPa
9. Subjects on non-insulin dependent diabetic, weight loss, or lipid-modifying medication(s) must be on stable dose(s) for at least 3 months prior to the diagnostic liver biopsy through randomization.

Exclusion Criteria:

1. Weight gain or loss \> 5% in the 3 months prior to randomization or \> 10% in the 6 months prior to screening.
2. Type 1 and insulin-dependent Type 2 diabetes.
3. Presence of cirrhosis on liver biopsy (stage 4 fibrosis).
4. Poorly controlled hypertension (blood pressure \[BP\] \> 160/100 mmHg).
5. Prior history of decompensated liver disease including ascites, hepatic encephalopathy (HE), or variceal bleeding.
6. Chronic hepatitis B virus (HBV) infection (hepatitis B surface antigen \[HBsAg\] positive).
7. Chronic hepatitis C virus (HCV) infection (HCV antibody \[Ab\] and HCV ribonucleic acid \[RNA\] positive). Subjects cured of HCV infection less than 2 years prior (based on date of RNA polymerase chain reaction \[PCR\] negative confirmation following conclusion of treatment) to the screening visit are not eligible.
8. Prior or planned (during the study period) bariatric surgery (e.g., gastroplasty, roux-en-Y gastric bypass), surgery reversal or removal of intragastric balloon \> 2 years prior to enrollment would be eligible.
9. Other causes of liver disease based on medical history and/or centralized review of liver histology, including but not limited to: alcoholic liver disease, autoimmune disorders (e.g., primary biliary cholangitis \[PBC\], primary sclerosing cholangitis \[PSC\], autoimmune hepatitis), drug-induced hepatotoxicity, Wilson disease, clinically significant iron overload, or alpha-1-antitrypsin deficiency requiring treatment.
10. History of liver transplantation.
11. Current or prior history of hepatocellular carcinoma (HCC).
12. Alcohol intake above an average limit of 2 drinks per day for women and 3 drinks per day for men.
13. Human immunodeficiency virus (HIV) infection.
14. Unstable cardiovascular disease in the 6 months prior to screening.
15. Life expectancy less than 2 years.
16. Use of any investigational medication within 30 days or within 5 half-lives of the investigational medication, whichever is longer, prior to screening and throughout the study is prohibited.
17. Subjects with a history of (12 months prior to screening) or current use of prescription drugs associated with liver steatosis (e.g. methotrexate, amiodarone, high-dose estrogen, tamoxifen, systemic steroids, anabolic steroids, valproic acid) should be excluded.