Emerging therapeutic options for non-alcoholic fatty liver disease: A systematic review

Table 1 Studies of cyclophilin inhibitors in the treatment of non-alcoholic fatty liver disease

Ref.	Human or animal	Study design	Number of participants	Key inclusion criteria	Investigational product/dose	Study end points	Key findings
Harrison et al[9], 2022	Human	Randomized, single-blind, placebo-controlled, phase 2a study; Duration: 4 wk	n = 49	Patients with presumed F2/F3 NASH	Rencofilstat Placebo vs Rencofilstat (75 or 225 mg daily)	Evaluate the effect of Rencofilstat on ALT, Pro-C3, liver steatosis, and fibrosis measured by FibroScan	ALT in the placebo vs 75 vs 225 mg group was 70.67 vs 42.5 vs 30.56 IU/L. Pro-C3 was reduced in stratified patients with Pro-C3 > 15 (P < 0.01). Fibrosis was 22 vs 14 vs 12 kPa. Steatosis was 351 vs 337 vs 329 dB/m
Kuo et al[6], 2019	Animal	Duration: 30 wk	n = 10	High-fat diet-induced NASH mouse model (n = 10)	CRV431: Control vs 50 mg/kg daily	Evaluate the effect of CRV431 on liver fibrosis measured by Sirius red staining in liver biopsy sections	Fibrosis levels were 37%–46% lower in the treatment vs control group (P < 0.05)
Kuo et al[8], 2019	Animal	Duration: 6 wk	n = 9	CCL4-induced liver fibrosis mouse model (n = 9)	CRV431: Control vs 50 mg/kg daily	Evaluate the effect of CRV431 on liver fibrosis measured by Sirius red staining in liver biopsy sections	Liver fibrosis was lowered by 43% in the treatment vs control group (P < 0.01)
Kuo et al[8], 2019	Animal	Duration: 6 wk	n = 8	High-fat diet-induced NASH mouse model	NV556: Control vs 50 mg/kg daily	Evaluate the effect of NV556 on liver collagen and fibrosis measured by Sirius red staining in liver biopsy sections	Fibrosis was reduced by 60% in the treatment vs control group (P = 0.0281)
Simón Serrano et al[7], 2019	Animal	Duration: 7 wk	n = 20	Choline-deficient high-fat diet-induced model of NASH in mice (n = 10 per group)	NV556: Control vs 100 mg/kg daily	Effect of NV556 on liver fibrosis and collagen production measured by Sirus red staining	Reduction of liver fibrosis by 25% (2% in control vs 1.5% in treatment group P < 0.01)

ALT: Alanine transaminase; AST: Aspartate aminotransferase; NASH: Non-alcoholic steatohepatitis; NAFLD: Non-alcoholic fatty liver disease; CCL4: Carbon tetrachloride; IU: International units.

Table 2 Studies of fibroblast growth factor analogs/agonists in the treatment of non-alcoholic fatty liver disease

Ref.	Human or animal	Study design	Number of participants	Key inclusion criteria	Investigational product/dose	Study endpoints	Key findings
Harrison et al[10], 2021	Human	Randomized, double-blind, placebo-controlled, phase 2a BALANCED study. Duration: 16 wk	n = 80	Patients with biopsy-confirmed NASH (F1-F3)	Efruxifermin: Placebo vs EFX (28, 50, 70 mg)	Absolute change from baseline in HFF measured as MRI-proton density fat fraction at 12 wk of EFX	The mean relative change in HFF at week 12 was -63.2% -70.9%, and -72.3%, respectively, in the treatment groups of 28, 50, and 70 mg (P < 0.0001)
Bao et al[12], 2018	Animal	Duration: 15 d	n = 10	Choline-deficient high-fat diet-induced model of NASH in mice (n = 5 per group)	PsTag600 Control vs 3.7 mg/kg-1 daily	Effect of PSTag600 on attenuation of the development of NASH measured by NAS and oil red O staining	Decrease in NAS in control vs treatment group of 5 vs 1 and area of oil red O of 26% vs 3%, respectively (P < 0.05)
Le et al[11], 2018	Animal	Duration: 4 wk	n = 8	MCD diet-induced NASH mouse model	LY2405319 Control vs 1.5 mg/kg daily	Evaluate the attenuation of fibrosis with the administration of LY2405319 by measuring levels of a-SMA and GPR91 (cells and receptors involved in hepatic fibrogenesis) on liver biopsy after 8 wk	The expression of α-SMA and GPR91 in the liver of mice fed with MCD diet was increased. The treatment group had an attenuated increase of collagen type 1, α-SMA, and GPR91 protein levels (P < 0.05). LY2405319 intraperitoneal administration for 4 wk daily ameliorated hepatic steatosis and fibrosis that was induced by MCD diet
Puengel et al[13], 2022	Animal	Duration: 6 wk	n = 12	Choline-deficient high-fat diet-induced model of NASH in mice (n = 6 per group)	BMS-986171: Control vs 0.6 mg/kg twice weekly	Effect of BMS-986171 on liver steatosis and fibrosis measured NAS on biopsy	NAS of the control vs. treatment group was 5 vs 4 (P < 0.05), hepatic steatosis 2.5 vs 1.5 (P < 0.01), inflammation 3.5 vs 2.5 and ballooning 1.2 vs 0.75 (P < 0.001) respectively

NASH: Non-alcoholic steatohepatitis; n: Number; NAS: NAFLD activity score; EFX: Efruxifermin; HFF: Hepatic fat fraction; MRI: Magnetic resonance imaging; α-SMA: Alpha-smooth muscle actin; MCD: Methionine and choline-deficient.

Table 3 Studies of pan peroxisome proliferator-activated receptor agonists in the treatment of non-alcoholic fatty liver disease

Ref.	Human or animal	Study design	Number of participants	Key inclusion criteria	Investigational product/dose	Study endpoints	Key findings
Abitbol et al[21], 2016	Human	Double-blind, randomized, placebo-controlled, parallel-group study. Duration: 4 wk	n = 45	Patients with biopsy-confirmed NASH and type 2 diabetes on stable doses of metformin	IVA337 (Lanifibranor). Placebo vs IVA337 (400, 800, or 1200 mg daily)	Metabolic effects of IVA337 in diabetic patients	Reduction in triglycerides by 32% and ALT by 10% (P < 0.05)
Cooreman et al[14], 2022	Human	Post-hoc analysis of the phase 2b NATIVE study. Duration: 24 wk	n = 247	Patients with non-cirrhotic biopsy-confirmed NASH	Lanifibranor Placebo vs Lanifibranor (800 or 1200 mg daily)	Effect of Lanifibranor on glycemic control and NASH markers. Efficacy in NASH was measured with SAF score and fibrosis staging	NASH resolution and fibrosis improvement in the treatment group vs placebo was 26% vs 7%, respectively, and a 41% reduction of HbA1c from baseline (P < 0.001)
Francque et al[18], 2021	Human	Randomized, double-blind, placebo-controlled, phase 2b trial. Duration: 24 wk	n = 247	Patients with noncirrhotic, highly active NASH (SAF ≥ 1 or higher for steatosis, hepatocellular ballooning, and lobular inflammation on liver biopsy)	Lanifibranor Placebo vs Lanifibranor (800 or 1200 mg daily)	Decrease of at least 2 points in the SAF score without worsening of fibrosis	48% of patients in the 800 mg group and 55% in the 1200 mg group had a decrease of at least 2 points in the SAF score vs 33% in the placebo group (P = 0.007)
An et al[22], 2017	Animal	Duration: 3 wk	n = 5	Genetically obese mice	MHY2013: Control vs 5 mg/kg daily	Reduction of hepatic steatosis measured via liver triglycerides on biopsy	Liver triglycerides were 10 mg/100 mg of protein in the control vs 7 mg/100 mg of protein in the treatment group (P < 0.05)
An et al[25], 2018	Animal	Duration: 3 wk	n = 6	Aged model mice	MHY2013: Control vs MHY2013 (1 or 3-5 mg/kg daily)	Evaluate the attenuation of hepatic lipid accumulation measured by liver biopsy	The ratio of liver weight/body weight was 0.035, 0.03, and 0.025 in control, 1 and 3-5 mg/kg groups, respectively (P < 0.01)
Barbosa-da-Silva et al[16], 2015	Animal	Duration: 4 wk	n = 20	High-fat diet mice (n = 10 per group)	Bezafibrate: Control vs 100 mg/kg daily	Effect of Bezafibrate on hepatic lipid metabolism measured by liver TG and steatosis on biopsy	Reduction in TG levels and liver steatosis of 30% and 50%, respectively, in the treatment group (P < 0.0001)
Boubia et al[19], 2018	Animal	Duration: 3 wk	n = 16	CCI4-induced liver fibrosis in mice (n = 8 per group)	Lanifibranor: Control vs 30 mg/kg daily	Efficacy of Lanifibranor in reducing fibrosis in NASH measured by hepatic collagen on biopsy	Reduction in hepatic collagen deposition from 0.6% of the area to 0.3% in the control vs treatment group (P < 0.01)
Lefere et al[15], 2020	Animal	Duration: 6 wk	n = 16	Choline-deficient high-fat diet-induced NASH mouse model (n = 8). Isolated hepatic macrophages (n = 8)	Lanifibranor Control vs 30 mg/kg daily	Effect on NAFLD measured by the NAFLD activity score, fibrosis by the Sirus red staining, and hepatic macrophages assessed by IHC	Reduction of NAFLD activity score from 6 to 2 in the treatment vs control group (P < 0.0001), collagen by 5% to 3% (P < 0.01), and liver macrophages from 22% to 8% (P < 0.0001)
Møllerhøj et al[20], 2022	Animal	Duration: 12 wk	n = 13	Gubra-Amylin NASH diet-induced obese mouse with biopsy-confirmed NASH	Lanifibranor: Control vs 30 mg/kg daily	Change in NAS and fibrosis stage measured on biopsy	At least a 2-point improvement in the steatosis score, and only 20% of hepatocytes had lipid droplets vs 80% in the control group (P < 0.001). 50% of mice had a 1-point improvement in fibrosis (P < 0.05)
Nagasawa et al[17], 2006	Animal	Duration: 5 wk	n = 7	Choline-deficient high-fat diet-induced NASH mouse model	Benzafibrate: Control vs Benzafibrate (50, 100 mg/kg daily)	Effect on hepatic lipid content and histopathological changes measured on biopsy by the number of activated hepatic stellate cells	Liver TG was 25, 20, and 55 mg/g in the 50, 100 mg/kg vs placebo groups, respectively (P < 0.01). The activated hepatic stellate cells were 11 number/15 fields vs 1 number/15 fields, respectively
Wettstein et al[24], 2017	Animal	Duration: 3 wk	n = 20	Choline-deficient high-fat diet-induced model of NASH in mice (n = 10 per group)	IVA337 (Lanifibranor) Control vs 30 mg/kg daily	Evaluate the effects of IVA337 on hepatic features associated with NASH measured by hepatic lipid droplet count and lobular inflammation foci count	Prevention of steatosis in 98% of mice and inflammation in 75% of mice (P < 0.001)

ALT: Alanine transaminase; NASH: Non-alcoholic steatohepatitis; n: Number; TG: Triglycerides; CCL4: Carbon tetrachloride; SAF: Steatosis activity fibrosis; NAFLD: Non-alcoholic fatty liver disease; NAS: NAFLD activity score; IHC: Immunohistochemistry.

Table 4 Studies of dual-pan peroxisome proliferator-activated receptor agonists in the treatment of non-alcoholic fatty liver disease

Ref.	Human or animal	Study design	Number of participants	Key inclusion criteria	Investigational product/dose	Study endpoints	Key findings
Boeckmans et al[34], 2019	Human	In vitro study Duration: N/A	N/A	Hepatic cells generated from human skin-derived precursors with induced NASH	Elafibranor	Effect on hepatic steatosis and inflammatory chemokines	Reduction in hepatic lipid load, as well as the expression and secretion of inflammatory chemokines, which are responsible for the recruitment of immune cells
Boeckmans et al[33], 2021	Human	In vitro study. Duration: N/A	N/A	Hepatic cells generated from human skin-derived precursors with induced NASH	Elafibranor	Effect on hepatic steatosis, inflammatory chemokines, and pro-fibrotic gene expression	Attenuated lipid accumulation, inflammatory chemokine secretion, and pro-fibrotic gene expression
Cariou et al[27], 2013	Human	Multicenter, randomized, single-blind, placebo-controlled, crossover study. Duration: 8 wk	n = 22	Abdominally obese insulin-resistant males	GFT505: Placebo vs 80 mg daily	Effect on peripheral and hepatic insulin sensitivity with improvement in GIR	Improved peripheral insulin sensitivity with a 21% increase of the GIR (P = 0.048) and enhanced hepatic insulin sensitivity with a 44% increase in insulin suppression of endogenous glucose production (P = 0.006)
Chaudhuri et al[32], 2023	Human	Single-center, prospective, observational, open-label, single-arm study. Duration: 52 wk	n = 76	Patients with NAFLD and elevated ALT levels along with liver stiffness value ≥ 6 kPa and/or liver steatosis CAP > 290 dB/m	Saroglitazar 4 mg daily	Effect on liver stiffness and steatosis measured by LSM and CAP on FibroScan at baseline, 24 and 54 wk	There was significant improvement of LSM from baseline (11.03 ± 7.19 kPa) to 24-wk (9.29 ± 6.39 kPa) and 52-wk (8.59 ± 6.35 kPa) values, respectively (P < 0.001). There was a significant improvement in median CAP at 24 wk 281 dB/m, (P < 0.001) and 52 wk 287 dB/m, (P < 0.001) as compared with the baseline 328 dB/m
Hassan et al[29], 2019	Animal	Duration: 5 wk	n = 12	Mice with induced NASH by a high-fat emulsion diet (n = 6 per group)	Saroglitazar: Control vs 4 mg/kg daily	Histopathological effects of Saroglitazar by using light microscopy	In the control vs treatment group, steatosis score was 3 vs 0.5, hepatic ballooning was 2 vs 0.5, lobar hepatitis was 3 vs 1, and portal hepatitis was 3 vs 0.25, respectively (P < 0.05)
Padole et al[31], 2022	Human	Single-center prospective study Duration: 3 mo	n = 91	Patients with BMI > 23 kg/m2 diagnosed with NAFLD (CAP > 248 dB/m)	Saroglitazar 4 mg daily	Change from baseline of liver biomarker, hepatic steatosis, and fibrosis in patients who lost > 5% of the weight	Patients with > 5% of weight loss had a median AST of 36 vs 40 at baseline (P = 0.038), ALT 44 vs 53 (P < 0.01), kPa 5.9 vs 6.8 (P = 0.336) and CAP 265 vs 311 (P = 0.128)
Rajesh et al[28], 2022	Human	A single-arm, open-label prospective study Duration: 12 wk	n = 85	Patients with NAFLD (US, CT, or MRI) and type 2 diabetes mellitus, and dyslipidemia	Saroglitazar 4 mg daily	Evaluate the effect of Saroglitazar on liver function test, liver fibrosis score by FibroScan, lipid profiles, and HbA1c	From baseline, there was a reduction in ALT from 49 u/L to 48 (P < 0.05), fibrosis score 10 kPa to 6 (P < 0.0001), TG 359.89 to 103.04 (P = 0.0001), HbA1c 10.29% to 9.85% (P = 0.002)
Jain et al[30], 2018	Animal	Duration: 12 wk	n = 18	CDHFD-induced model of NASH in mice (n = 9 per group)	Saroglitazar: Control vs 3 mg/kg daily	Reversal of CDHFD-induced NASH after 8 wk	In control vs. treatment, respectively, steatosis score was 2.6 vs 0, ballooning 1.4 vs 0, inflammation 3 vs 1.1 (P < 0.1)
Jain et al[30], 2018	Animal	Duration: 12 wk	n = 16	CCL4-induced fibrosis model in mice (n = 8 per group)	Saroglitazar: Control vs 4 mg/kg daily	Reversal of CCl4-induced liver fibrosis after 4 wk	Saroglitazar protected mice from CCl4-induced liver fibrosis measured via Hematoxylin and Eosin stains
Staels et al[26], 2013	Animal	Duration: 7 wk	n = 16	Choline-deficient high-fat diet-induced model of NASH in mice (n = 8 per group)	GFT505: Control vs 10 mg/kg daily	Evaluate the prevention of the development of NASH in CDHFD mice	The percentage of animals with macrosteatosis in control vs treatment was 100% to 0%, inflammation was 100% to 0%, and the percentage of fibrosis was 1.3% to 0.8% (P < 0.01)
Staels et al[26], 2013	Animal	Duration: 7 wk	n = 12	CCl4-induced liver fibrosis in mice (n = 6 per group)	GFT505: Control vs 30 mg/kg daily	Evaluate the prevention of the development of NASH in CCL4 mice	The fibrotic surface of control vs treatment was 8% vs 4% in CCL4 mice (P < 0.001)
Ye et al[23], 2003	Animal	Duration: 2 wk	n = 6	High fat-fed rats	Ragaglitazar: 3 mg/kg-1 daily	Evaluate the benefits of Ragaglitazar on insulin sensitivity and lipid metabolism.	Enhanced insulin suppressibility of hepatic glucose output by 79% (P < 0.001), decrease in liver TG from baseline of 23 μmol/g to 7 μmol/g (P < 0.01)

N/A: Not applicable; NASH: Non-alcoholic steatohepatitis; n: Number; TG: Triglycerides; CCL4: Carbon tetrachloride; NFS: NAFLD fibrosis score; CAP: Controlled attenuation parameter; HbA1c: Hemoglobin A1c; NAFLD: Non-alcoholic fatty liver disease; GIR: Glucose infusion rate; CDHFD: Choline-deficient high-fat diet; BMI: Body mass index; ALT: Alanine transaminase; AST: Aspartate aminotransferase; US: Ultrasound; MRI: Magnetic resonance imaging; CT: Computerized tomography.