Current pharmacotherapy for treating pediatric nonalcoholic fatty liver disease.

Review

Current pharmacotherapy for treating pediatric nonalcoholic fatty liver disease 1.

Introduction

2.

Pharmacological approaches

3.

Dietary supplementation:

Claudia Della Corte, Daniela Liccardo, Federica Ferrari, Anna Alisi & Valerio Nobili† †

IRCCS, “ Bambino Ges u” Children’ s Hospital, Hepato-Metabolic Disease Unit, Rome, Italy

omega-3 fatty acids and

Expert Opin. Pharmacother. Downloaded from informahealthcare.com by University of Queensland on 10/13/14 For personal use only.

probiotics 4.

New therapeutic approaches

5.

Expert opinion

Introduction: In the past decade, nonalcoholic fatty liver disease (NAFLD) had rapidly become one of the most common liver diseases. If efficient therapeutic strategies will not reduce the prevalence of NAFLD in children soon, serious deleterious effects on the quality of life of these patients in adulthood are expected. Lifestyle modification is the current first-line therapy for pediatric NAFLD, even though it is difficult to obtain and to maintain. Therefore, lifestyle changes are usually ineffective and long-lasting improvement of the NAFLD-associated liver damage is rarely observed. As guidelines for the management of NAFLD in children are still lacking, the identification of effective treatments represents a challenge for pediatric hepatologists in the near future. Areas covered: Here, we review the existing therapeutic approaches for treating NAFLD in children and overview all ongoing clinical trials for new promising drugs in pediatric setting. Expert opinion: Considering the multifactorial pathogenesis and the wide spectrum of histological and clinical features of NAFLD, we believe that a drug mix, containing agents that are effective against the principal pathogenetic factors, associated with lifestyle modification, could represent the winning choice of treatment for pediatric NAFLD. Keywords: children, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, obesity, treatment Expert Opin. Pharmacother. [Early Online]

1.

Introduction

In industrialized countries, nonalcoholic fatty liver disease (NAFLD) has rapidly become one of the most common liver diseases in children and adolescents, due to the growing prevalence of obesity and overweight at pediatric age [1,2]. The exact prevalence of pediatric NAFLD is hard to determine due to the different ages, sex and ethnicities of the children series evaluated in the available studies [1,2]. Moreover, the wide variety of diagnostic tests used for NAFLD, such as liver biopsy, aminotransferase levels and ultrasound examination, may cause diverse prevalence data. Anyhow, it has been estimated that 20 -- 30% of adults and 3 -- 12% of children in Western countries are affected by NAFLD and this percentage reaches 70 -- 80% in the obese population [1,2]. A predictable increase in the prevalence of pediatric NAFLD should be particularly worrisome considering that the metabolic complications frequently associated with this disease, such as insulin resistance (IR), type 2 diabetes mellitus and dyslipidemia, may also increase the risk of cardiovascular pathologies [3-5]. Pediatric NAFLD is a spectrum of liver diseases characterized by a macrovesicular steatosis (> 5% of hepatocytes) occurring in the absence of alcohol intake and/or other disorders, which may lead to intrahepatic fat deposition [6]. However, the 10.1517/14656566.2014.960389 © 2014 Informa UK, Ltd. ISSN 1465-6566, e-ISSN 1744-7666 All rights reserved: reproduction in whole or in part not permitted

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C. Della Corte et al.

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The escalation of the prevalence of NAFLD in children worldwide represents a worrying phenomenon considering the closely association between NAFLD, advanced liver diseases (up to cirrhosis) and metabolic syndrome. To date, no treatment guideline exists for children with NAFLD and none of the available drug is able per se to treat successfully this disorder. The advances in the knowledge of pathogenesis of NAFLD suggest that a multifactorial approach direct against the principal risk factors and pathogenetic mechanisms of NAFLD should be the winning strategy for treating NAFLD.

disease may include histologically not only the simple steatosis NAFL but also the necroinflammation and hepatocellular ballooning, which define a more aggressive form known as nonalcoholic steatohepatitis (NASH), often accompanied by fibrosis and potentially progressive toward cirrhosis [7]. The natural history and prognosis of pediatric NAFLD with advanced fibrosis or cirrhosis remains unknown, owing to the limited numbers of the studies with long-term follow up [8,9]. Feldstein et al. showed that 6% of children with NAFLD may develop a progressive liver disease, which may evolve to advanced forms of liver damage [8]. The NAFLD pathogenesis is extremely complex and still obscure, even though several endogenous and exogenous factors, including genetic predisposition, epigenetics (changes in genes expression through chemical reactions) and environment, have been widely recognized as crucial [9]. Recent studies reported a central heritable component in development and progression of NAFLD, especially in children [10,11]. The rs738409 C>G polymorphism of patatin-like phospholipase domain-containing protein-3 (PNPLA3), encoding the I148M protein variant, is not only the major genetic determinant of hepatic fat content but also a risk factor for the development of more severe pattern of liver disease in children [12]. Diets enriched in fat and carbohydrates, such as higher Western dietary pattern, are strong risk factors for steatosis at ultrasound in adolescents [13]. Moreover, it has been reported that breastfeeding is protective against progression of the disease [14]. Lifestyle modification remains the first-line therapy for pediatric NAFLD [1,9]. Several studies have shown that weight loss and lifestyle interventions improve obesity and quality of life, reducing also hepatic steatosis and elevation of liver enzymes [15]. Further, lifestyle changes improve hepatic and extrahepatic insulin sensitivity by reducing the delivery of free fatty acids (FFAs) and through better peripheral glucose utilization [16,17]. Interestingly, Nobili et al. reported that a 2-year lifestyle intervention, including personalized diets and increased physical activity, resulted in a significant decrease in serum alanine aminotransferase (ALT) levels, lipid levels and IR and a significant improvement of liver histology [18]. 2

In addition, weight loss and lifestyle changes decrease the production of reactive oxygen substances and adipose tissue inflammation, inhibiting disease progression. To date, clear indications for type of behavioral intervention are lacking [19]. The particular type of dietary modification that may be beneficial in treating young patients with fatty liver is yet unclear [19]. A low-carbohydrate diet (especially fructose), low-intake of saturated/trans-fats and higher intake of polyunsaturated fats (e.g., omega-3) and fibers are generally recommended, resulting in a reduction of IR, de novo lipogenesis and hepatic proinflammatory/fibrogenetic effect [19,20]. A regular physical exercise may be usefully associated principally with improved IR [16]. Since lifestyle change is difficult to obtain and maintain in children and their parents, drug treatments could be more adequate to prevent the progression to severe organ damages [19]. In the past decade, several studies evaluating the efficacy and safety profiles of pharmacological agents to treat NAFLD and its related complications were performed. To date, a systematic review on the pharmacological therapy of pediatric NAFLD concludes that the available data are not sufficient to draw firm guidelines for the treatment of pediatric fatty liver [3]. Therefore, establishing effective therapeutic strategies to treat NAFLD represents a challenge for pediatric hepatologists in the near future. In this article, we review the current therapeutic approaches for treating pediatric NAFLD and provide an overview of ongoing clinical trials for new promising agents.

2.

Pharmacological approaches

To date, no current guidelines for the treatment of NAFLD are available. Weight loss, obtained by regular diet and physical exercise, is widely accepted as the first-line therapy in children, particularly in subjects with uncomplicated simple steatosis. The goals of pharmacological therapies are to stop disease progression and restore metabolic and hepatic homeostasis. Actually, as reported in systematic review on the pharmacological treatment of pediatric NAFLD (3), none of the available drugs is able per se to successfully achieve these objectives and the limited available data do not allow to define the clear guidelines for treatment (3). Based on the new knowledge in terms of risk factors and pathogenesis of NAFLD, in the past 10 years, several studies evaluated the effects of different drugs, such as insulin sensitizers, antioxidants and cytoprotective agents in the treatment of pediatric fatty liver. However, the main limitations in the evaluation of the available studies are represented by the heterogeneity of enrolled patients, including subjects displaying different stage of NAFLD spectrum, by the diversity of end points (histologically, echographic or laboratory) and by the frequent contemporary association of tested drug with lifestyle intervention. Moreover, in some cases, the already-completed randomized clinical trials (RCTs) did not fulfill CONSORT statement criteria.

Expert Opin. Pharmacother. (2014) 15(17)

Double-blind, RCT

ALT: Alanine aminotransferase; DHA: Docosahexaenoic acid; NAFLD: Nonalcoholic fatty liver disease; RCTs: Randomized clinical trials.

4 -- 16 years Echographic evidence of hepatic steatosis NCT01553500 Completed Glucomannan

Completed DHA

NCT00885313

Cysteamine 1 g/mq body surface area (maximum 100 mg b.i.d.) i) experimental arm: 250 mg/day ii) experimental arm: 500 mg/day Glucomannan, 5 g/day NCT00799578 Completed Cysteamine

Antioxidants Oxidative stress is considered a principal pathogenetic factor in the progression of NAFLD-associated liver damage from simple steatosis to NASH. For this reason, antioxidants have been largely evaluated as possible therapeutic agents to prevent disease progression. The a-tocopherol (vitamin E), a fat soluble vitamin, is the most studied among these agents. To date, only conflicting and variable results have been reported in the available studies. Although initially a positive effect of vitamin E supplementation on aminotransferase serum levels was reported [21], subsequent RCTs showed no differences in respect of exclusive lifestyle intervention (Table 1) [22-25]. The large, double-blind RCT, called TONIC [26], have evaluated the effect of 96 weeks of therapy with vitamin E (400 UI twice daily [b.i.d.]), insulin-sensitizer metformin (500 mg b.i.d.) or placebo in 173 children affected by biopsy-proven NAFLD. Also in this trial, vitamin E was not better than placebo in attaining the primary end point, which is a sustained decrease of ALT levels. However, vitamin E treatment resulted in histological improvement of hepatocellular ballooning and NAFLD activity score (NAS) (Table 1) [26]. Attractive preliminary results exist for cysteamine bitartrate, which demonstrated a positive effect on aminotransferase serum levels in a pediatric preliminary study (Table 1) [27]. 2.1

Improvement in lipid and glucose metabolism

[51]

Double-blind, RCT

[27]

Open-label -Preliminary study

[26]

Double-blind, RCT Metformin, 500 mg b.i.d. Vitamin E, 400 IU b.i.d.

8 -- 17 years Biopsy-confirmed NAFLD ALT > 60 U/l Children ‡ 10 years Biopsy-proven NAFLD ALT > 60 U/l 4 -- 16 years Biopsy-proven NAFLD Completed TONIC

NCT00063635

Improvement in liver histology Reduction of £ 50% of serum ALT levels from baseline or £ 40 IU/l Normalization or > 50% of serum ALT levels from baseline Improvement in ALT levels Improvement in serum levels of triglycerides

[24]

Double-blind, RCT Improvement in serum levels of aminotransferases a tocopherol 600 IU/day plus ascorbic acid 500 mg/day 3 -- 20 years Biopsy-proven NAFLD Completed Vitamin E + ascorbic acid

NCT00655018

End points Intervention Patients ClinicalTrial.gov identifier Status Drug

Table 1. Completed RCTs for the treatment of pediatric NAFLD with effective drugs.


Type of study

Ref.

Current pharmacotherapy for treating pediatric nonalcoholic fatty liver disease

Hepatoprotective agents Ursodeoxycholic acid (UDCA), a tertiary hydrophilic bile acid, represents, with its choleretic and hepatoprotective effects, as a useful treatment for cholestatic liver diseases [28-30]. After initial promising results reported in small clinical studies [31,32], further pediatric and adult RCTs demonstrated that UDCA was not effective, even at higher dosage, on aminotransferase levels and echographic and histological features of fatty liver. [33-36]. 2.2

Insulin sensitizer The greater understandings in the pathogenesis of NAFLD have demonstrated that IR plays a pivotal role in the disease development and in the progression of metabolic comorbidities [37]. This is also confirmed by the clinical observation that the vast majority of children with NAFLD are insulinresistant [38]. Although the complex interplay between IR and NAFLD is not yet completely known, it is demonstrated that IR and the accumulation of FFAs in the hepatocytes and in other ectopic tissues are cause/effect-related [37]. Metformin is the principal insulin-sensitizer agent that has been evaluated in children with NAFLD. It exerts its action by the activation of the 5¢ AMP-activated protein kinase pathway, which led to increased lipid and glucose catabolism [39]. The results of studies conducted in children reported divergent results. A 24-week treatment with metformin (500 mg b.i.d.) in 10 non-diabetic children with biopsy-proven NASH and elevated ALT levels produced an improvement in hepatic steatosis (at magnetic resonance spectroscopy 2.3


3



examination) and ALT serum levels [40]. Conversely, in a subsequent 24-month observational study, metformin appears no more effective than lifestyle intervention in ameliorating levels of aminotransferases, steatosis and liver histology [41]. At the same time, despite no significant weight loss, Nadeau et al. showed a remarkable improvement in fatty liver severity and in fasting insulin compared with placebo, in a cohort of 50 obese insulin-resistant adolescents treated with metformin for 6 months [42]. Recently, the TONIC trial demonstrated that, in the same way of vitamin E, metformin had scarce effectiveness in reducing serum ALT levels and had only a positive effect on histological hepatocellular ballooning compared to placebo (Table 1) [26]. Another interesting class of drugs is thiazolidinediones, oral antidiabetic drugs such as pioglitazone and rosiglitazone, which are agonists of the PPAR-g. Although these drugs seem to have a positive effect on liver enzymes and steatosis in adulthood, also reducing inflammation and hepatocytes apoptosis [43,44], because of their reported side effects (cardiotoxicity, fluid retention, osteoporosis and weight gain), they are not evaluated in pediatric patients [45]. 3. Dietary supplementation: omega-3 fatty acids and probiotics

In the past few years dietary supplementations with omega-3 fatty acids and probiotics have played a leading role in the scientific scenario of pharmacological treatment of NAFLD. Many studies have reported interesting results about these new therapeutic options widening the current knowledge on etiopathogenesis of NAFLD. Omega-3 long-chain polyunsaturated fatty acids Omega-3 fatty acids are essential polyunsaturated fatty acids (PUFA) that are contained in fish oil, walnuts and flaxseed. These have well-known anti-inflammatory effects mediated by their active metabolites, such as resolvins and protectins. Moreover, omega-3 fatty acids may regulate the expression of hepatic genes involved in carbohydrate and lipid metabolism, inhibiting de novo lipogenesis and glycolysis and stimulating fatty acids oxidation [46,47]. The other group of PUFA is omega-6, which have proinflammatory and prothrombotic effects by the action of their principal metabolite, the arachidonic acid. Despite the heterogeneity of the available studies, a recent meta-analysis reported the beneficial effects of omega-3 supplementation in humans with NAFLD, describing a positive effect on hepatic steatosis [48]. The optimal dosage has not been determined, but positive effects are described with > 0.83 g/day of omega3 supplementation [48]. Moreover, a significant improvement in IR, dyslipidemia, serum inflammation and oxidative stress markers was reported [49,50]. These interesting results were also recently confirmed in pediatric setting by Nobili et al. [51]. In this RCT (NCT008 85313), after 6 months of docosahexaenoic acid (DHA) supplementation (250 and 500 mg/day), an 3.1

4

improvement in liver steatosis, insulin resistance and triglycerides serum levels was described without any difference between the two different dosage (Table 1). These positive effects were confirmed in a subsequent extension up to 24 months of this trial [52]. Moreover, Nobili et al. investigated the histological and cellular effects of DHA supplementation in a subgroup of children enrolled in the aforementioned trial. As for histological features, a significant reduction in steatosis, ballooning and lobular inflammation was observed after 18 months of treatment, without any effect on liver fibrosis [53]. In addition, after DHA supplementation, a significant decrease in hepatic progenitor cell activation and G-protein-coupled receptor120-positive macrophages were described with exciting antiinflammatory effects [53]. According to the latest evidence showing the important role of genetic factors in the development and progression of pediatric NAFLD, recent data also suggested the possible different response to DHA treatment based on some gene polymorphisms. In particular, recent evidences showed that the homozygosis for the 148M allele of PNPLA3 is associated with lower response of hepatic steatosis after DHA administration [54]. On the contrary, the presence of the 148I allele is related with a greater response to the same treatment. Further studies are needed to elucidate this relationship and to investigate the influences of other possible polymorphisms in the pharmacological response to DHA. Taking in account the results of available studies and the optimal safety profile observed till now, omega-3, especially DHA, may represent in the near future an interesting tool for the treatment of NAFLD. Probiotics The new findings of the latest years in the pathogenesis of NAFLD have given rise to a great interest in the field of the so-called gut-liver axis. Recent animal and human studies have suggested that important endogenous factors in the development of NAFLD are represented by gut microbiota and impaired intestinal barrier integrity [55]. As suggested by several observations, the type of diet and the slowing of intestinal transit, common in the obese population, may promote the small bowel overgrowth (SBO), increasing the production of endotoxins, mainly of gut-derived lipopolysaccharides and TNF-a [56,57]. The associated impaired intestinal permeability, recently demonstrated in pediatric patients with NAFLD [58], resulted in an increased endotoxin circulating levels, promoting the progression of liver damage. Previously, in fact, Miele et al. provided the first evidence that NAFLD in adults was associated with increased intestinal permeability and that this abnormality was related to the increased prevalence of SBO in these patients [59]. Based on these discoveries, it has been proposed that the manipulation of intestinal bacterial microbiota with probiotics may represent an adjunctive therapy in some chronic liver diseases because of their effects on gut-liver axis [60,61]. The specific mechanism explaining the beneficial effects of probiotics in NASH are not completely 3.2



Table 2. RCTs on probiotics in NAFLD.


Authors

Years

Patients

Probiotics

Results

Ref.

Lactobacillus bulgaricus and Streptococcus thermophilus versus placebo for 3 months Lactobacillus GG versus placebo for 2 months

Reduction of ALT, AST, GGT serum levels

[66]

Reduction of ALT serum levels. No modifications in TNF-a levels and liver ultrasound Reduction of AST, LDLcholesterol, PCR, TNF-a, HOMA-IR and NASH activity index Reduction of steatosis at liver ultrasound and BMI Increase of GLP-1 and aGLP-1 levels

[67]

Aller et al.

2011

28 adults with biopsy-proven NAFLD

Vajro et al.

2011

20 children with echographic evidence of NAFLD

Malaguarnera et al.

2012

66 adults with biopsy-proven NAFLD

Bifidobacterium longum plus FoS versus placebo for 6 months

Alisi et al.

2014

48 children with biopsy proven NAFLD

VSL#3 versus placebo

[68]

[65]

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMI: Body mass index; FoS: Fructo-oligosaccharides; GLP-1: Glucagon-like peptide-1; HOMA-IR: Homeostasis model assessment-estimated insulin resistance; LDL: Low-density lipoprotein; NAFLD: Nonalcoholic fatty liver disease; NASH: Nonalcoholic steatohepatitis; PCR: Polymerase chain reaction; RCTs: Randomized clinical trials.

understood, but suppression of pathogenic bacterial growth and modulation of immune system seem to be the more important downstream effectors. VSL#3, consisting of a mixture of eight probiotic strains (Streptococcus salivarius subsp. thermophilus, Bifidobacterium [Bifidobacterium breve, Bifidobacterium infantis, Bifidobacterium longum], Lactobacillus acidophilus, L. plantarum, L. casei and L. delbrueckii subsp. bulgaricus), is the principal probiotic evaluated in clinical studies. In animal models of NASH, the administration of VSL#3 reduces the intestinal inflammation and improves the epithelial barrier function [62,63]. Similarly positive results were reported by Loguercio et al., which demonstrated that the VSL#3 supplementation in patients affected by several types of chronic liver diseases, including NAFLD, may downsize liver damage modifying the serum levels of various cytokines [64]. Recently, Alisi et al. reported the attractive results of the first RCT on the use of VSL#3 in children with NASH [65]. In this study, an improvement of fatty liver at abdominal ultrasound and a significant decrease in body mass index and increased glucagon-like peptide-1 (GLP-1) levels were observed in the treated VSL#3 group. Moreover, further clinical RCTs are now available in humans with NAFLD (Table 2). A significant decrease of aminotransferase serum levels has been reported in adults [66] and children [67] after probiotic administration (Lactobacillus species); in addition, a positive effects on markers of inflammation, such as C-reactive protein and TNF-a, and metabolic parameters, as low-density lipoprotein-cholesterol and insulin resistance, were reported in adults treated with a mixture of B. longum and fructo-oligosaccharides [68]. Considering the results of available studies and the minimal side effects and costs, we believe that probiotics represent a promising treatment for NAFLD, even if further larger randomized trials are still needed.

4.

New therapeutic approaches

Although several therapeutic strategies, including diet, antioxidants and insulin sensitizers have been proven, no commonly accepted therapeutic protocol has yet been established for the treatment of pediatric NAFLD. Even though the pathogenesis of NAFLD remains to be completely understood, it is now accepted that NAFLD is a multi-pathogenetic disorder, in which genetic, epigenetic and environmental factors play a significant role. This multifactorial pathogenesis should be taken into account in designing an adequate therapeutic intervention and in predicting the response to treatment. In this perspective, a multi-targeted therapy, directed against the principal clinical features and molecular mechanisms of NAFLD, seems to be the winning choice for treating NAFLD and preventing its progression to advanced forms. For these reasons, in the past years many clinical trials for the treatment of pediatric NAFLD have been proposed. Some of these have been completed and the results have been published, whereas others are still in progress (Table 3) (clinical trials registered on ClinicalTrial.gov at June 2014). Ongoing clinical trials for treatment of pediatric NAFLD (ClinicalTrial.gov) 4.1.1 Angiotensin-converting-enzyme inhibitors and receptor blockers 4.1

In the past years several studies conducted on animal models and adulthood suggest a potential role of angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers in the treatment of NASH. The rationale for the use of drugs against the renin--angiotensin system (RAS) depends on the ability of this system in recruiting inflammatory cells and promoting fibrosis by activation of hepatic stellate cells.


5

6


Recruiting

Ongoing, but not recruiting

DHA + Vit D

DHA + choline + vitamin E

NCT01934777

NCT02098317

NCT01529268

NCT01913470

ClinicalTrial.gov identifier

4 -- 16 years Biopsy-proven NAFLD

4 -- 16 years Biopsy-proven NAFLD

8 -- 17 years; biopsy-confirmed NAFLD (NAS > 4)

12 -- 19 years BMI > 85% ALT ‡ 3 UNL Biopsy-confirmed NASH

Patients

DHA 500 mg/day Choline 400 mg/day Vitamin E 78 UI/day

900 mg/day for patients > 80 kg DHA 500 mg/day Vitamin D 800 UI/day

750 mg/day for patients 65 -- 80 kg

0.4 mg/kg/day (max. 25 mg) for 1 week and then increased to 0.8 mg/kg/day (max. 50 mg) for 7 additional weeks 600 mg/day for patients £ 65 kg

Intervention

Histological end points: improvement in NAS score; improvement of clinical and laboratory parameters of metabolic syndrome Histological end points: Improvement in NAS score

Histological end points: decrease in NAS of ‡ 2; no worsening of fibrosis

Change in ALT from baseline

End points

Double-blind, RCT

Double-blind, RCT

Double-blind, RCT

Double-blind, RCT

Type of study

ALT: Alanine aminotransferase; BMI: Body mass index; DHA: Docosahexaenoic acid; NAFLD: Nonalcoholic fatty liver disease; NAS: NAFLD activity score; NASH: Nonalcoholic steatohepatitis; RCTs: Randomized clinical trials; UNL: Upper normal level.

Ongoing, but not recruiting

Recruiting

Status

Cysteamine bitartrate delayed-release (CyNCh)

Losartan

Drug

Table 3. Ongoing clinical trials for the pharmacological treatment of pediatric NAFLD.





Further, studies in animal models showed positive effects on liver fibrosis by inhibiting the RAS system [69]. Previous preliminary studies in adulthood demonstrated an improvement of serum liver enzymes levels and blood markers and histological findings of liver fibrosis in a small group of NASH hypertensive patients treated with losartan (50 mg/day) for 48 weeks [70]. The currently ongoing trial is a randomized, doubleblinded, placebo-controlled pilot study to evaluate whether 8 weeks of losartan will decrease inflammatory markers among children aged between 12 and 19 years with a current diagnosis of NAFLD (NCT01913470). Efficacy will be assessed by improvement in ALT levels from baseline. Secondary end points will include aspartate aminotransferase levels, cytokeratin 18 (CK-18) levels and fasting triglyceride concentrations (estimated primary completion date: May 2015). Cysteamine The cysteamine is an amino thiol derived from the coenzyme A degradation. The cysteamine plays an antioxidant role, enhancing the glutathione synthesis and improving cellular redox homeostasis. Moreover, cysteamine upregulates the production of adiponectin, which has anti-inflammatory and insulin-sensitizing effects. Because of its antioxidant, antiinflammatory and insulin-sensitizing effects, the cysteamine has been proposed as a treatment for NAFLD [71]. A preliminary pilot on the use of cysteamine in pediatric NAFLD patients has demonstrated that this drug reduces aminotransferases and CK-18 fragment levels and increases adiponectin concentration, after 48 weeks of therapy, in the absence of weight reduction [27]. Considering these promising observations, another trial on the use of cysteamine is now in progress (NCT01529268) with histological end points, such as reduction in NAS of ‡ 2 points and no worsening of fibrosis at 52 weeks (estimated primary completion date: February 2015). 4.1.2

Vitamin D plus DHA Previous data in adulthood have demonstrated the positive effects of omega-3-fatty acids in terms of hepatic steatosis, insulin-sensitivity and markers of inflammation [47]. Several studies in the past years have focused on interplay between vitamin D levels and obesity and its complications. As for NAFLD, recent studies in adults and children have reported that vitamin D levels are inversely associated with NASH and fibrosis in patients with NAFLD [72]. Based on this observation, vitamin D has been proposed as possible therapy for NASH, especially for the fibrotic component. Recently, the vitamin D--vitamin D receptor axis has been shown to modulate hepatic stellate cells activity and, therefore, the hepatic fibrogenesis [73]. A few months ago the first pediatric study based on the association of DHA (500 mg/day) and vitamin D (800 IU/day) in the treatment of NASH (NCT02098317) is going on in Italy. The main outcome of

this study is represented by improvement of NAS score; secondary outcomes are improvement of clinical and laboratory parameters of metabolic syndrome. The results of this trial should be available by the end of 2015 (estimated primary completion date: May 2015). Vitamin E plus choline plus DHA Choline (Ch) is a micronutrient involved in many physiological functions. It is a crucial component of cellular membranes and is involved in phospholipids synthesis, mitochondrial functions and fatty acid b oxidations [74]. Moreover, recent findings have suggested that Ch is a potent modifier of epigenetic marks on genes. In several animal models, it has been reported that hepatosteatosis and cellular death occur in case of low-Ch diets [75,76]. These observations were reinforced by clinical evidence that patients fed with total parenteral nutrition solutions low in Ch developed fatty liver and liver damage [77]. The individual dietary Ch requirements are regulated by two main factors, such as estrogen and single nucleotide polymorphisms in specific genes involved in Ch and folate metabolism [78]. A recent study conducted on 664 subjects enrolled in the multicenter, prospective NAS Clinical Research Network with baseline data on diet composition reported that postmenopausal women with deficient Ch intake had worse fibrosis; no difference in disease severity was observed in children, men and premenopausal women [79]. Considering the multiple effects of Ch and its role in NAFLD pathogenesis, currently, many studies are intended to evaluate the role of Ch in liver disease. Now, a RCT on the use of association of DHA, Ch and vitamin E in children is ongoing (NCT01934777). In this trial, a multi-target therapy which exploits the antisteatotic and insulin-sensitizing effect of DHA in combination with antioxidant and hepatoprotective effects of Ch and vitamin E are being evaluated (estimated study completion date: October 2014). The primary outcome is represented by a histological improvement of NAS. 4.1.4

4.1.3

Promising future agents Some new agents have been till now evaluated for the possible treatment of NAFLD in animals models or in adulthood, but data regarding pediatric setting are lacking. Among these, new insulin-sensitizer agents, such as dipeptidyl peptidase 4 (DPP4) inhibitors of GLP-1 analogs have been proposed [80]. DPP-4 is a peptidase which acts as inhibiting peptides, such as GLP-1, inducing glucose intolerance and hepatic steatosis. In animal models, DPP-4 inhibitors (i.e., sitagliptin, vildagliptin and saxagliptin) improve hepatic steatosis by ameliorating insulin sensitivity and hepatic triglyceride content [81]. Similar results have been reported in studies conducted in rats with GLP-1 analogs resistant to DPP-4 activity (i.e., exenatide, liraglutide) [82]. Toll-like receptors (TLRs) are a group of receptors that in response to specific ligands lead to inflammatory response 4.2


7


Metformin

PUFA

Insulin resistance


NAFL

Obesity

Gut-liver axis

NASH

Probiotics

Diet + exercise

Proinflammatory pathways

Oxidative stress

Mitochondria

Dyslipidemia PUFA

Antioxidants

Figure 1. Schematic representation of the action of current treatments on critical mechanisms involved in NAFLD pathogenesis. NAFL: Nonalcoholic fatty liver; NASH: Nonalcoholic steatohepatitis; PUFA: Polyunsaturated fatty acids.

during the progression from NAFLD to NASH. This mechanism makes TLR antagonist novel promising agents for treating NASH, even if further studies are needed [83]. Considering its anti-TNF-a activity, pentoxifylline has been evaluated for the treatment of NASH in adulthood. A recent meta-analysis of available RCTs concludes that pentoxifylline reduces the aminotransferase levels and improves some histological features of NASH, such as lobular inflammation, steatosis and fibrosis stage in adults [84]. Large, well-designed, randomized, placebo-controlled studies are required to confirm these results, especially in pediatric setting.

5.

Expert opinion

Following the increasing burden of pediatric obesity, several metabolic disorders, previously observed in adults only, are currently also spreading in pediatric setting. Among these, NAFLD appears particularly worrisome in children. In fact, NAFLD is often asymptomatic and therefore underdiagnosed; the hepatic disease silently progresses over the years in advanced liver injury associated with metabolic complications, worsening -- in some cases -- the quality of life and life expectancy [8]. In fact, the current knowledge described NAFLD as the hepatic manifestation of metabolic syndrome, considering the string association between pathogenetic mechanisms and clinical and laboratory features of these disorders [1]. Therefore, the treatment of NAFLD could determine an improvement of other metabolic impairments, such as IR and lipid profile, leading to a reduction of the risk of other metabolic comorbidities. 8

Despite the scarcity of data about the natural history of pediatric NAFLD, it has been reported that this disease may vary according to the type of histological pattern. In fact, if on one hand, simple fat accumulation in the hepatocytes without signs of inflammation or fibrosis may generally have a benign non-progressive course, on the other hand, the histological pattern of NASH is associated with a potential progressive disease up to advanced forms of liver damages, such as cirrhosis and end-stage liver disease. Therefore, in our opinion, based on the clinical, laboratory and histological data of suspected NASH, behavioral and/or pharmacological interventions should be immediately started independent of age. Recent lines of evidence suggest the presence of an important genetic component for NAFLD, describing subgroups of individuals with high-risk genetic profiles [10]. It remains crucial to identify the children at higher risk of development/progression of NASH, in order to put in place preventive strategies and patient-tailored therapeutic programs. In fact, recent studies describe a possible different response of NAFLD patients to some pharmacological treatments based on the presence of certain polymorphisms in genes involved in NAFLD pathogenesis (i.e., PNPLA3 and DHA). Therefore, in our opinion, many efforts should be made in the near future to identify novel diagnostic tools for the screening on large-scale pediatric populations at risk of NAFLD and to detect in patients with diagnosed disease those at higher risk of progression to NASH and fibrosis. As for treatment, NAFLD should be considered as a complex disorder with a multifactorial pathogenesis and a wide range of histological features. Till now, any attempt to pharmacologically treat NAFLD, at least in children, did not provide complete convincing evidence per se. In fact, all




drugs tested so far are directed versus a single pathogenetic and/or histological target of NAFLD, without allowing a complete resolution of disorder. In this view, we believe that the winning way to treat NAFLD is represented by a drug mix containing agents that are effective on principal secondary hits of NAFLD (oxidative stress, mitochondrial dysfunction, overproduction and release of proinflammatory cytokines, microflora dysregulation and endotoxin-mediated activation of the innate immune response) (Figure 1). This drug mix should be associated with lifestyle modification and dietary intervention, in order to act simultaneously on all clinical, molecular and histological features of this disease in children. According to this concept, the most recent ongoing RCTs for the treatment of pediatric NAFLD are based on the association of drugs with simultaneous effects against the principal pathogenetic mechanisms of NAFLD. In this view, Bibliography

some apparently ineffective drugs used as monotherapy, such as vitamin E, should be reconsidered in combination with other drugs that act on different targets. Hence, a better understanding of NAFLD in terms of risk factors and pathogenetic mechanisms are required in order to identify novel therapeutic strategies and to tune the perfect combo to treat NAFLD.

Declaration of interest The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents, received or pending, or royalties. nonalcoholic fatty liver disease in adolescence. Am J Gastroenterol 2013;108:778-85

Papers of special note have been highlighted as either of interest () or of considerable interest () to readers.

6.

Brunt EM. Pathology of nonalcoholic fatty liver disease. Nat Rev Gastroenterol Hepatol 2010;7:195-203

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Aliment Pharmacol Ther 2014;39:1276-85


Affiliation Claudia Della Corte1, Daniela Liccardo1, Federica Ferrari2, Anna Alisi3 & Valerio Nobili†3,4 † Author for correspondence 1 IRCCS, “Bambino Ges u” Children’s Hospital, Hepato-Metabolic Disease Unit, Rome, Italy 2 “Sapienza” University, Pediatric Gastroenterology and Hepatology Unit, Rome, Italy 3 IRCCS, “Bambino Ges u” Children’s Hospital, Liver Research Unit, Rome, Italy 4 Professor, Head of Hepato-Metabolic Disease Unit, IRCCS, “Bambino Gesu” Children’s Hospital, Hepato-Metabolic Disease Unit, P.le S. Onofrio, 4 -- 00165, Rome, Italy Tel: +39 06 68592192; Fax: +39 06 68592192; E-mail: [email protected]

11

Pharmacotherapy for Nonalcoholic Fatty Liver Disease.

nonalcoholic steatohepatitis.

Pediatric Nonalcoholic Fatty Liver Disease: A Report from the Expert Committee on Nonalcoholic Fatty Liver Disease (ECON).

On the origin of pediatric nonalcoholic Fatty liver disease.

Fructose induced endotoxemia in pediatric nonalcoholic Fatty liver disease.

Clinical advances in pediatric nonalcoholic fatty liver disease.

Nutritional therapy for nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease and cardiovascular disease.

Estimation of fish and ω-3 fatty acid intake in pediatric nonalcoholic fatty liver disease.

Role of docosahexaenoic acid treatment in improving liver histology in pediatric nonalcoholic fatty liver disease.

A comprehensive review of noninvasive liver fibrosis tests in pediatric nonalcoholic Fatty liver disease.

Bariatric surgery and nonalcoholic fatty liver disease.

Biomarkers in nonalcoholic fatty liver disease.

Hepatocellular Carcinoma in Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease and hepatocellular carcinoma.

Obesity-associated nonalcoholic fatty liver disease.

nonalcoholic steatohepatitis.

Histopathology of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

Nonmedicinal interventions in nonalcoholic fatty liver disease.

Endocrine causes of nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease and hepatocellular carcinoma.

Nonalcoholic fatty liver disease: Diagnostic biomarkers.

Extrahepatic Manifestations of Nonalcoholic Fatty Liver Disease.

Circulating homocysteine in nonalcoholic fatty liver disease.