Clinical trial NCT06588699: Digoxin In NASH (CODIN)
Official title: Clinical Trial of Oral Digoxin In NASH (CODIN)
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: PHASE2
Conditions: NASH
NAFLD
MASH - Metabolic Dysfunction-Associated Steatohepatitis
Mash
MASH With Fibrosis
MASLD
Fatty Liver Disease
Fatty Liver Disease, Nonalcoholic
Keywords: NASH
MASH
Metabolic dysfunction associated steatohepatitis
Digoxin
Drug repurposing
Liver fibrosis
Fatty liver disease
NAFLD
Lead sponsor: Yale University
Sponsor class: OTHER
Collaborators: name: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
First posted: 2024-09-19
Enrollment: 144
Sex: ALL
Minimum age (years): 18
Maximum age (years): 75
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: A centrally administered randomization strategy will be used to randomize patients.
Primary purpose: TREATMENT

Brief summary: Nonalcoholic steatohepatitis (NASH) is a severe subtype of nonalcoholic fatty liver disease (NAFLD) which affects 1 in 3 Americans. The mainstay of treatment for NASH, which was recently renamed metabolic associated steatohepatitis (MASH), involves lifestyle interventions to promote weight loss and to treat comorbidities such as hypertension, hyperlipidemia, and diabetes mellitus. There is thus, a substantial unmet need for pharmacological therapies that are effective for treatment of NASH, especially in those with fibrosis which is the main predictor of disease progression and mortality among NASH patients. The repurposing of presently available drugs would help expedite the search for agents effective in treating NASH. The cardiac glycoside digoxin is currently used in the management of heart failure and supraventricular tachyarrhythmias. The investigators and other groups have demonstrated that digoxin protects the liver from various forms of acute and chronic liver injury. The investigators preliminary data in healthy human subject indicate an immunomodulatory effect of low dose oral digoxin with no adverse side effects. This study proposes to demonstrate the clinical benefits of digoxin on NASH and on liver fibrosis, thus supporting the repurposing of digoxin as treatment for NASH.

Detailed description: Prospective, randomized, double-blind, placebo-controlled, single center trial of digoxin in patients with nonalcoholic steatohepatitis (NASH).

Primary objective:

To compare the effect of digoxin oral, administered once daily (QD) either as titration-based or weight-based dose, versus placebo on histologic resolution of NASH

Key secondary objectives:

To investigate the effect of digoxin oral, administered once daily (QD) either as titration-based or weight-based dose, compared to placebo on histologic, imaging, and biochemical markers of NASH, and to assess the safety and tolerability of digoxin compared to placebo

Eligibility criteria: Inclusion Criteria

* Stable body weight (≤ 5% self-reported change in body weight) in the 30 days prior to screening
* Biopsy-confirmed non-alcoholic steatohepatitis (NASH) as defined by the NASH clinical research network (NASH CRN) histological scoring system, with non-alcoholic fatty liver disease score (NAS) ≥4 and with a score ≥1 for each of the three components (steatosis, hepatocellular ballooning, and lobular inflammation) on a liver biopsy performed within 6 months of screening
* Histological fibrosis stage 2 or 3 based on pathologist evaluation of a liver biopsy performed up to 6 months before screening
* Agrees to have a liver biopsy performed to assess baseline histology if one has not been performed up to 6 months before screening, and at 24 weeks after randomization Exclusion Criteria

Liver-related:

* Documented causes of chronic liver disease other than NASH
* History or clinical evidence of cirrhosis or portal hypertension
* History of positive HBsAg, positive anti-HIV, positive HCV-RNA
* AST or ALT \> 5 times upper limit of normal (ULN) at screening
* Total bilirubin \> 1.5 mg/dL at screening unless conjugated bilirubin is \< 1.5 × ULN
* International normalized ratio (INR) \> 1.3 at screening
* Known or suspected alcohol use \> 20 g/day for women or \> 30 g/day for men
* Treatment initiation or dose adjustment of vitamin E, pioglitazone, GLP-1RA, or SGLT-2 inhibitors within 30 days of signing the informed consent or 30 days prior to liver biopsy
* Treatment initiation or anticipated treatment (\>14 consecutive days) with medications known to affect steatosis (e.g., systemic corticosteroids, tamoxifen, valproic acid, methotrexate, tetracycline or amiodarone) within 30 days of signing the informed consent or 30 days prior to liver biopsy

Cardiac related:

* Heart rate less than 60 bpm at screening (visit 1) or at baseline (visit 2)
* Current diagnosis of severe aortic valve disease
* History of Accessory arterio-ventricular pathway (e.g., Wolf-Parkinson-White syndrome)
* History of complete heart block or second degree arterio-ventricular block without pacemaker or implantable cardiac device
* Current diagnosis of permanent atrial fibrillation
* Any of the following within the previous 6 months of signing informed consent: myocardial infarction, percutaneous intervention, pacemaker/implantable cardiac device implantation, cardiac surgery, or stroke
* Current use of the following medications: inotropic drugs such as (dopamine, dobutamine, noradrenaline, milrinone), anti-arrhythmics (amiodarone, dofetilide, sotalol, dronedarone, digoxin), parathyroid hormone analog (teriparatide), sympathomimetics (epinephrine, norepinephrine, dopamine), neuromuscular blocking agents (succinylcholine), calcium supplement, nondihydropyridine calcium channel blockers, ivabradine, and disulfiram.

Obesity related:

* Treatment initiation (in the 30 days prior to signing the informed consent or 30 days prior to liver biopsy) with orlistat, zonisamide, topiramate, phentermine, bupropion, and naltrexone alone or in combination or any other medication that could promote weight loss in the opinion of the investigator
* Participation (in the 30 days prior to signing the informed consent or 30 days prior to liver biopsy) in an organized diet-based weight reduction program (e.g., WeightWatchers, Optifast)
* Recent surgical treatment (\<6 months of signing informed consent) for obesity

General safety related:

* Presence or history of malignant neoplasms (in the past 5 years prior to screening), except basal and squamous cell skin cancer and any carcinoma in-situ
* Surgery scheduled or anticipated during the trial period, except for minor surgical procedures, in the opinion of the investigator
* Language barrier, mental incapacity, unwillingness, or inability to adequately understand or comply with study procedures
* Known or suspected hypersensitivity to the trial product or related products including allergy to milk, egg, soy, peanuts, and sulfites
* Recent participation (within 90 days prior to signing the informed consent) in any clinical trial of an approved or non-approved investigational medicinal product
* Female who is pregnant, breast-feeding or intends to become pregnant or is of childbearing potential and not using an adequate contraceptive method
* Renal impairment measured as estimated Glomerular Filtration Rate (eGFR) value of eGFR \< 30 ml/min/1.73 m2
* TSH \> 6 mIU/L or \< 0.4 mIU/L at screening
* Current use of the following medications: calcium supplementation, parathyroid hormone analog (teriparatide), neuromuscular blocking agents (succinylcholine) and disulfiram.
* Claustrophobia to an extent that would prevent tolerance of MRI
* Metallic implant that would prevent MRI examination including, metallic foreign body, aneurysm clips, vascular grafts or cardiac implants, neural stimulator, cochlear implant, metallic contraceptive device, body piercing that cannot be removed, cochlear implant, or any other contraindication to MRI

Primary outcomes:
measure: Resolution of nonalcoholic steatohepatitis (NASH) without worsening of fibrosis
timeFrame: 24 weeks
Secondary outcomes:
measure: Improvement in liver fibrosis without worsening of NASH
timeFrame: 24 weeks
measure: Improvement in NAS without worsening of fibrosis
timeFrame: 24 weeks
measure: Change in enhanced liver fibrosis (ELF) score
timeFrame: 24 weeks
measure: Change in alanine aminotransferase (ALT)
timeFrame: 24 weeks
measure: Change in aspartate aminotransferase (AST)
timeFrame: 24 weeks
measure: Change in gamma glutamyl transferase (GGT)
timeFrame: 24 weeks
measure: Change in liver stiffness measure (LSM) and controlled attenuation parameter (CAP)
timeFrame: 24 weeks
measure: Change in magnetic resonance imaging proton density fat fraction (MRI-PDFF)
timeFrame: 24 weeks
measure: Change in Magnetic resonance elastography (MRE)
timeFrame: 24 weeks
Other outcomes:
Locations:
city: New Haven
country: United States
facility: Yale New Haven Health
state: Connecticut
city: New Haven
country: United States
facility: Yale New Haven Hospital
state: Connecticut
Study officials:
affiliation: Yale University
name: Bubu A Banini, MD, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Jamshed F, Dashti F, Ouyang X, Mehal WZ, Banini BA. New uses for an old remedy: Digoxin as a potential treatment for steatohepatitis and other disorders. World J Gastroenterol. 2023 Mar 28;29(12):1824-1837. doi: 10.3748/wjg.v29.i12.1824.
citation: Dashti F, Jamshed F, Ouyang X, Mehal WZ, Banini BA. Digoxin as an emerging therapy in noncardiac diseases. Trends Pharmacol Sci. 2023 Apr;44(4):199-203. doi: 10.1016/j.tips.2022.10.002. Epub 2022 Nov 14.
citation: Agyapong G, Dashti F, Banini BA. Nonalcoholic liver disease: Epidemiology, risk factors, natural history, and management strategies. Ann N Y Acad Sci. 2023 Aug;1526(1):16-29. doi: 10.1111/nyas.15012. Epub 2023 Jul 3.
citation: Ilagan-Ying YC, Banini BA, Do A, Lam R, Lim JK. Screening, Diagnosis, and Staging of Non-Alcoholic Fatty Liver Disease (NAFLD): Application of Society Guidelines to Clinical Practice. Curr Gastroenterol Rep. 2023 Oct;25(10):213-224. doi: 10.1007/s11894-023-00883-8. Epub 2023 Sep 28.