Clinical Effects of New Approach on Patients With Non-alcoholic Steatohepatitis

Study Overview
=================
Brief Summary
-----------------
This study aims to evaluate and compare the protective outcomes of using Rosuvastatin, Vitamin E, and N-acetyl cysteine in Egyptian patients with NASH. The primary endpoint of this 3-month study would be an improved degree of fibrosis with no worsening of NASH or NASH resolution with no worsening of fibrosis and steatosis that the study considered successful if either 1ry endpoint is met. The secondary endpoint of this study is the improvement of biochemical markers related to steatosis, inflammation, oxidative stress, insulin resistance, and liver fibrosis.

Detailed Description
-----------------
Nonalcoholic fatty liver disease (NAFLD) is the buildup of excessive fat in the liver without of extensive alcohol consumption and the lack of any secondary cause. The prevalence of NAFLD has risen dramatically, now affecting 20-40% of the population. NAFLD is one of the most frequent chronic liver diseases currently attributed to the rising rates of obesity and type 2 diabetes. The condition can proceed from simple steatosis to nonalcoholic steatohepatitis (NASH), characterized by hepatic damage with inflammatory infiltration, and then on to liver fibrosis, cirrhosis, and hepatocellular cancer. Currently, there is no approved drug for NASH. Consequently adjustments to lifestyle remain the mainstay of treatment despite the considerable disease burden and mortality associated predominantly with advanced diseases, i.e., NASH and fibrosis. Regarding the development of NAFLD, Despite widespread consensus on the two hits hypothesis linking insulin resistance (IR) and oxidative stress, the mechanism of NAFLD was thought to be highly nuanced and unexplained. The free, un-esterified form of cholesterol appears toxic to hepatocytes, leading to inflammation and fibrosis in the liver. In particular, the steatotic liver cells form crown-like structures due to the accumulation of cholesterol crystals within the hepatocytes, which triggers an inflammatory response via activated Kupffer cells surrounding the hepatocytes. In addition, cholesterol crystals stimulate the inflammasome in Kupffer cells by activating the Nucleotide-binding oligomerization domain (NOD), leucine-rich repeats (LRR), and pyrin domain-containing protein 3 (NLRP3). Herein, drugs known as statins block the enzyme 3-hydroxy-3-methyglutaryl coenzyme A reductase. Statins are effective medications for decreasing cholesterol and lowering the risk of cardiovascular events. Because NAFLD is characterized by free cholesterol aggregation in hepatocytes, their ability to reduce cholesterol levels is thought to be helpful. Statins also reduce the production of isoprenoids, which are byproducts of the mevalonate pathway. Isoprenoids modulate the intracellular signalling of many receptors regulating liver inflammation and fibrosis by prenylating/activating small guanosine triphosphate (GTP)ases. The significant anti-inflammatory and anti-fibrotic benefits were shown in an experimental model of NAFLD and NASH after statin-related suppression of this isoprenoid dependent mechanism. Rosuvastatin showed promising results in enhancing liver-specific outcomes of NAFLD in preliminary investigations. Six individuals without diabetes and hypertension who were dyslipidemic and had metabolic syndrome and biopsy-proven NASH had treated with rosuvastatin 10 mg/day. After 12 months, a second biopsy and liver ultrasonography revealed that all symptoms associated with NASH (steatosis, necroinflammation, and fibrosis) had disappeared in 5 of 6 individuals. Rosuvastatin was additionally associated to a 76% and 61% decrease in ALT and AST activity, respectively. Another small prospective study with 23 NAFLD patients with dyslipidemia, rosuvastatin 10mg/day yielded similar results. Recently, oxidative stress is characterized by an imbalance between the production and elimination of free radical species, is a hallmark of metabolic syndrome. Numerous studies have established a connection between elevated oxidative stress indicators and the development of NAFLD. Although oxidative stress is a major factor in how the liver functions in NAFLD, inflammation has also been shown to have a significant role. Interleukin (IL)-6, tumor necrosis factor alpha (TNF-), nuclear factor kappa-light-chain-enhancer of activated B cells (NF-B), and transforming growth factor beta (TGF )-1 are pro-inflammatory mediators that, when elevated for an extended period of time, accelerate NASH and liver fibrosis. The pharmaceutical therapies with strong antioxidant characteristics, such as N-acetyl cysteine (NAC), are crucial in reducing oxidative stress and inflammation caused by metabolic dysfunction. Its efficacy in restoring glutathione (GSH) levels in hepatocytes and decreasing pro-inflammatory cytokines has been demonstrated in animal models of nonalcoholic fatty liver disease. In a comprehensive analysis of literature published in 2015, it has been hypothesized that NAC can reduce oxidative stress and inflammation in the liver, hence enhancing its functional capacity. Since then, a plethora of studies have been published looking at NAC's effectiveness in reducing metabolic syndrome symptoms. Vitamin E is the most abundant lipid-soluble chain-breaking antioxidant in the human body. Vitamin E family compounds are anti-atherogenic, anti-inflammatory and being powerful antioxidants.The American Association for the Study of Liver Diseases (AASLD) and the National Institute for Health and Care Excellence (NICE) recommend 800 IU of vitamin E daily for persons with biopsy-proven NASH. NAFLD is a worldwide epidemic expected to be the leading cause of chronic liver disease in the next decade. Patients with NASH have high risk to develop liver complications such as cirrhosis, cancer, hepatic failure, morbidity and mortality. While numerous drugs have undergone clinical testing, most have shown inconsistent outcomes and have poorly tolerated side effects. Currently, there is no FDA-approved medication for the treatment of NASH. Consequently, exerting great effort is to find specific treatment for patients with NASH.

Official Title
-----------------
Clinical and Biochemical Study of the Effects of Rosuvastatin, Vitamin E, and N-Acetyl Cysteine on Patients With Non-alcoholic Steatohepatitis: a Randomized Controlled Trial

Conditions
-----------------
Non-alcoholic Steatohepatitis

Intervention / Treatment
-----------------
* Drug: Rosuvastatin 20mg
* Drug: N-acetyl cysteine
* Drug: Rosuvastatin and N-acetyl cysteine
* Drug: Vita-E


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: All patients are diagnosed to have fatty liver grading 1, 2 or 3 on abdominal ultrasound with Hepatic steatosis index > 36 to be considered as a NAFLD patient. NASH diagnosis using Fibroscan detecting the degree of steatosis and fibrosis. NASH diagnosis is by non-invasive Scoring such as (FAST Score) Cytokeratin-18 >240 U/L Mild to moderate elevation of hepatic liver enzymes: serum aminotransferases (>2 but <5 times upper normal limit) Stable dietary habits and physical activity pattern. Exclusion Criteria: Current or history of significant alcohol consumption. Use of drugs historically associated with nonalcoholic fatty liver disease (NAFLD) (amiodarone, methotrexate, systemic glucocorticoids, tetracyclines, tamoxifen, estrogens at doses greater than those used for hormone replacement, anabolic steroids, valproic acid, and other known hepatotoxins). Prior or planned bariatric surgery. Uncontrolled diabetes defined as Hemoglobin A1c 9.5% or higher. Evidence of other forms of chronic liver disease as Hepatitis B, Hepatitis C, Wilson's disease, Alpha-1-antitrypsin(A1AT) deficiency, Hemochromatosis, drug-induced liver disease. The presence of contra-indications of NAC or rosuvastatin. Pregnancy, planned pregnancy, potential for pregnancy and unwillingness to use effective birth control during the trial and breast feeding. Use of other drugs known to have possible positive effects on steatosis. If there are any conditions where fibroscan could be contra-indicated. The patients refuse participating or completing study.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This study will be randomized controlled, parallel and prospective 3-months duration study. Accepted patients will be randomized into 4 groups. The size of the sample is calculated using open EPI software (www.openepi.com) and according to NASH prevalence in Egypt.
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Group 1 (Rosuvastatin group):<br>40 patients will receive Crestor (Rosuvastatin 20mg/day orally for 3 months). | Drug: Rosuvastatin 20mg<br>* 40 patients will receive 20mg/day orally for 3 months.<br>|
| Active Comparator: Group 2 (N-acetyl cysteine group (NAC):<br>40 patients will receive high dose of NATURAL TRUTH'S NAC cap 2400 mg /day for 3 months. | Drug: N-acetyl cysteine<br>* 40 patients will receive high dose 2400 mg /day for 3 months.<br>|
| Active Comparator: Group 3 Two separate drugs (N-acetyl cysteine and Rosuvastatin group):<br>40 patients will receive NAC dose 2400 mg and Rosuvastatin 20mg /day for 3 months. | Drug: Rosuvastatin and N-acetyl cysteine<br>* 40 patients will receive NAC dose 2400 mg and Rosuvastatin 20mg /day for 3 months.<br>|
| Placebo Comparator: Group 4 (Control group):<br>40 patients will receive Vitamin E 400 mg twice daily for 3 months. | Drug: Vita-E<br>* 40 patients will receive Vitamin E 400 mg twice daily for 3 months.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Blood pressure | (systolic blood pressure/diastolic blood pressure in mmHg normal blood pressure is 120/80 mmHg). | 3 months | 
| Hight | In meters (m) . | 3 months | 
| Weight | in Kilograms (kg) | 3 months | 
| Waist circumference | in centimeters (cm). | 3 months | 
| Body mass index (BMI) | The BMI calculation divides an adult's weight in kilograms (kg) by their height in meters (m) ^2. (BMI in kg/m^2). | 3 months | 
| Clinical examination | Abdominal ultrasound: to examine right upper quadrant pain or dullness, Mild or moderate hepatomegaly, and The appearance of a hyperechoic liver (showing more echogenicity than the kidneys), vascular blurring, and deep attenuation on ultrasonography are consistent with liver steatosis. and the appearance of bright liver) | 3 months | 
| FibroScan-AST (FAST Score): | Base line and at the end of the study period 3months Steatosis or /and fibrosis Grade of the liver is examined by Fibroscan® of the liver tissue. The FAST score was calculated using [e ˆ(- 1·65 + 1·07 × In(LSM) + 2·66∗10-8 × CAP3 - 63.3 × AST-1)]/[1 + e ˆ (- 1·65 + 1·07 × In(LSM) + 2·66∗10-8 × CAP3 - 63.3 × AST-1)] as carried out by Scoring system were used to determine: A-fibrosis staging (F0-F4). For F0-F1, LSM <7.9 kPa; for F2, LSM of 7.9 to <8.8 kPa; for F3, LSM of 8.8 to <11.7 kPa; and for F4 LSM ≥11.7 kPa. B-steatosis grade (S0-S3) to determine the presence of NAFLD. S0 was defined as a CAP <248 dB/m (<10% steatosis); S1 as CAP of 248 to <268 dB/m (10% to <33% steatosis (mild)); S2 as CAP of 268 to <280 dB/m (33% to <66% steatosis (moderate)); and S3 as CAP ≥280 dB/m (≥66% steatosis (severe)) | 3 months | 
| Liver Fibrosis Index FIB-4 score (FIB-4 score): | Platelets count ( PLT) with FIB-4 score. The formula for FIB-4 is: Age ([yr] x AST [U/L]) / ((PLT [10(9)/L]) x (ALT [U/L])(1/2)). The value of FIB-4 below 1.30 is considered as low risk for advanced fibrosis. The value of FIB-4 over 2.67 is considered as high risk for advanced fibrosis. The value between 1.30 and 2.67 are considered as intermediate risk of advanced fibrosis. | 3 months | 
| Fasting blood glucose level | This is by venous blood sample collection in order to assess: Fasting blood glucose level, Normal level between 70 mg/dL and 110 mg/dL . | 3 months | 
| Homeostasis Model Assessment (HOMA-IR), | This is by venous blood sample collection in order to assess: Fasting insulin with calculation of Homeostasis Model Assessment (HOMA-IR), Less than 1.0 means you are insulin-sensitive which is optimal. Above 1.9 indicates early insulin resistance. Above 2.9 indicates significant insulin resistance. | 3 months | 
| Lipid profile: | This is by venous blood sample collection in order to assess: Lipid profile: Total cholesterol ( normal level lower than 200mg/dL) High density lipoprotein cholesterol (HDL), normal level is between 40 to 60mg/dL Triglycerides, normal in range when in between 10 to 150 mg/dL. Low-density lipoprotein (normal level is between 70 to 130mg/dL). | 3 months | 
| Liver function tests: | This is by venous blood sample collection in order to assess: Alanine transaminase(ALT): The normal range is 4 to 36 U/L Aspartate aminotransferase (AST): The normal range is 8 to 33 U/L Alk. Phospatse:The normal range is 44 to 147 IU/L Gamma-glutamyl transferase (GGT): reference range for adults is 5 to 40 U/L. | 3 months | 
| Kidney function tests: | This is by venous blood sample collection in order to assess: Serum urea ( Normal Range (NR): 5 to 20 mg/dl) Serum creatinine (NR For adult men, 0.74 to 1.35 mg/dL and For adult women, 0.59 to 1.04 mg/dL. | 3 months | 
| Serum Malondialdehyde (MDA) level (nM): | This is by venous blood sample collection in order to assess: -Malondialdehyde (MDA) is one of the final products of polyunsaturated fatty acids peroxidation in the cells. An increase in free radicals causes overproduction of MDA. Malondialdehyde level is commonly known as a marker of oxidative stress and the antioxidant status in cancerous patients: normal level is.120 nM (SD 36.26) | 3 months | 
| The NOD-like receptor family protein 3 (ng /ml) | This is by venous blood sample collection in order to assess: -The NOD-like receptor family protein 3 (Serum NLRP-3 inflammasome): NR is 2.65 (ng /ml), The NLRP3 inflammasome is considered to be a main pathway for proinflammatory cytokine release in the liver and is strongly involved in the pathogenesis of the liver fibrogenesis | 3 months | 
| Serum cytokeratin-18 (U/L) | This is by venous blood sample collection in order to assess: -Serum cytokeratin-18 the normal range is between 68 to 3000 U/L CK-18 levels increase as the mean of NASH CK18 is present in huge amount in liver. It is an intermediate filament protein representing 5% of the hepatic proteins. | 3 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Adverse effects of the intervening drugs | Adverse effects: -Any side effects will be reported and graded according to common terminology criteria for adverse events version 5.00 (CTCAE). Drug- Drug interactions Any potential drug interactions between administered drugs will be monitored for each patient and corrective actions will be taken. | 3 months | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Rosuvastain, N-Acetyl Cysteine, Vitamine E, NASH, Fibroscan