Effect of DMR in the Treatment of NASH

Evaluation of Duodenal Mucosal Resurfacing (DMR) for the Treatment of Non Alcoholic Steatohepatitis (NASH), a Proof of Concept Study

Non-alcoholic fatty liver disease (NAFLD) is a frequent disease affecting up to 25% of the USA population, 2-44% in Europe and up to 42,6-69,5% in patients with type 2 diabetes. It is a disease that could progress from simple steatosis to non-alcoholic steatohepatitis (NASH), hepatic cirrhosis and hepatocarcinoma. NASH is part of continuum of metabolic syndrome and constitutes a serious public health concern manifesting by premature cardiovascular disease, end stage diabetes complication and will likely become the first cause of end stage liver disease. Insuline resistance is the hallmark of NASH. Some recent studies both in animals and humans have demonstrated abnormal hypertrophy of the duodenal mucosa, changes in enteroendocrine cell density and number, endocrine hyperplasia, and alterations in gut hormone signaling highlighting the role of the upper intestine gut in glucose homeostasis and thus insulin sensitizing. Given these physiological and pathophysiological features, abrasion of duodenal mucosa was assessed both in animals and humans. The investigators reported an improvement in both glucose homeostasis and transaminases levels suggesting possibly an improvement of NASH. Until now, lifestyle medication is the only recognized efficient treatment for fatty liver disease. Unfortunately, only a minority of patients achieve a significant weight loss and lifestyle modifications. The investigators aim to study the duodenal mucosal resurfacing procedure in patients with NASH biopsy proven in a proof of concept study allowing to assess this technique as a potential treatment to NASH.

Introduction

Non-alcoholic fatty liver disease (NAFLD) is a frequent disease affecting up to 25% of the USA population, 2-44% in Europe and up to 42,6-69,5% in patients with type 2 diabetes. It is a disease that could progress from simple steatosis to non-alcoholic steatohepatitis (NASH), hepatic cirrhosis and hepatocarcinoma. NASH is part of continuum of a metabolic syndrome and constitutes a serious public health concern, manifesting by premature cardiovascular disease, end stage diabetes complication and will likely become the first cause of end stage liver disease.

Insulin resistance is the hallmark of NASH. Some recent studies both in animals and humans have demonstrated abnormal hypertrophy of the duodenal mucosa, changes in enteroendocrine cell density and number, endocrine hyperplasia, and alterations in gut hormone signaling highlighting the role of the upper intestine gut in glucose homeostasis and thus insulin sensitizing.

Given these physiological and pathophysiological features, abrasion of duodenal mucosa was assessed both in animals and humans. The investigators reported an improvement in both glucose homeostasis and transaminases levels suggesting possibly an improvement of NASH.

Until now, lifestyle medication is the only recognized efficient treatment for fatty liver disease. Unfortunately, only a minority of patients achieve a significant weight loss and lifestyle modifications.

The investigators aim to study the duodenal mucosal resurfacing procedure in patients with NASH biopsy proven in a proof of concept study allowing to assess this technique as a potential treatment to NASH.

Design of study The study is designed as a single arm, proof of concept, non-randomized, open label trial to be conducted at one investigational site. All patients with biopsy proven NASH will undergo an upper endoscopy to perform a duodenal mucosal resurfacing procedure. Evolution of liver steatosis (assessed by MRI), insulin resistance (assessed by oral glucose tolerance test), liver damage (evaluated by blood tests), liver elastography (assessed by fibroscan, fibrotest), biometric parameters will be performed pre- and post-procedure.

Primary outcome :

- Feasability and safety of duodenal mucosal resurfacing, using Revita ™ duodenal mucosal resurfacing after submucosal injection, in patients with NASH.

Secondary outcomes:

• Evolution of steatosis assessed by MRI 6 months after the procedure.
• Evolution of liver fibrosis (assessed by Fibroscan, Fibrotest, Fibrosis four score (FIB-4) and NAFLD fibrosis score) at 6 and 12 months after the procedure.
• Evolution of liver tests at 6 and 12 months after the procedure.
• Evolution of insulin resistance at 1,3,6 and 12 months after the procedure.

Inclusion Criteria:

1. Adult subjects (male and female), age 28 to 75 years.

2. NASH histological diagnosis according to the currently accepted definition of both EASL and AASLD, requiring the combined presence of steatosis (any degree> 5%) + lobular inflammation of any degree + liver cell ballooning of any amount, on a liver biopsy performed ≤ 6 months before screening in the study and confirmed by central reading during the periode and (apendix 1)

   1. SAF (steatosis, activity, fibrosis) activity score of 3 or 4 (>2)
   2. SAF steatosis score ≥ 1
   3. SAF fibrosis score < 4

3. No other causes of chronic liver disease and compensated liver disease.

4. If applicable, have a type 2 diabetes with HbA1c <10.0 %

5. BMI (body mass index) ≥ 24 and ≤ 40 kg/m2.

6. Willing to sign an informed consent form.

7. Willing to comply with study requirements

Exclusion Criteria:

1. Evidence of another cause of liver disease.
2. History of sustained alcohol ingestion defined as: daily alcohol consumption > 30 g/day for males and > 20 g/day for females.
3. Previous gastrointestinal surgery such as subjects who have had Billroth 2, Roux-en-Y gastric bypass, or other similar procedures or conditions.
4. Known autoimmune disease, including celiac disease, or symptoms of systemic lupus eythematosus, sleroderma or other auto-immune connective tissue disorder.
5. For type 2 diabetes subjects, no current use of insulin or GLP-1 analogues.
6. Type 1 diabetes.
7. Probable insulin production failure defined as fasting C peptide serum < 1 ng/ml.
8. History of acute or chronic pancreatitis.
9. Active malignancy.
10. Persistent anemia defined as Hb < 10 g/dl.
11. Use of anticoagulation therapy which cannot be discontinued for 7 days before and 14 days after the procedure.
12. Use of P2Y12 inhibitors (clopidrogel, prasugrel, ticagrelor) which cannot be discontinued for 14 days before and14 days after the procedure.
13. History of coagulopathy or upper gastro-intestinal bleeding conditions likely to bleed.
14. Taking corticosteroids or drugs which possibly affect gastrointestinal motility or liver.
15. Unable to discontinue NSAIDs (non-steroidal anti- inflammatory drugs) during the treatment up to 4 weeks after procedure.
16. Use of weight loss medications.
17. Presence of liver cirrhosis (defined by histology)
18. Platelet count < 120 x 109/L.
19. Clinical evidence of hepatic decompensation or severe liver impairment as defined by the presence of any of the following abnormalities:
20. Serum albumin < 32 g/L.
21. INR> 1.3.
22. Direct bilirubin> 1.3 mg/L.
23. ALT or AST > 5x ULN.
24. Alkaline Phosphatase > 3x ULN.
25. History of esophageal varices, ascites or hepatic encephalopathy.
26. Splenomegaly.
27. Human immunodeficiency virus.
28. Contraindications to MRI as defined below.