Treatment Candidacy for Pharmacologic Therapies for NASH

Abstract

Nonalcoholic steatohepatitis (NASH) has emerged as one of the important causes of cirrhosis and hepatocellular carcinoma, and over 50 therapeutic agents are in various phases of clinical development. Recently, obeticholic acid has achieved the interim histological endpoint of fibrosis improvement with no worsening of NASH in the phase 3 REGENERATE study, and now patients are being followed for long-term clinical outcomes. Several drugs are in Phase 3 trials with a goal to achieve conditional registration under the subpart H pathway by the United States Food and Drug Administration (FDA). It is thus timely to consider the current situation and the way ahead in the management of NASH. In this article, we review the natural history of nonalcoholic fatty liver disease, upcoming treatments for NASH and various assessments. Based on the current knowledge, we discuss what should be the target treatment population and whether noninvasive tests are ready to guide NASH treatments both for patient selection and evaluation of treatment response.

Figure 1.

Natural history of NAFLD. Footnote: HCC, hepatocellular carcinoma; NAFL, nonalcoholic fatty liver; NASH, nonalcoholic steatohepatitis

Figure 2.

Non-invasive tests of liver fibrosis for NAFLD. (A) Optimizing population management in NAFLD. (B) Elastography in assessing advanced fibrosis. Footnote: ARFI, acoustic radiation force impulse; ALT, alanine aminotransferase; BMI, body mass index; CHF, congestive heart failure; ELF, Enhanced Liver Fibrosis score; MRE, magnetic resonance elastography; NFS, NAFLD fibrosis score; NPV, negative predictive value; SWE, shear-wave elastography; VCTE, vibration-controlled transient elastography.

Figure 2.

Non-invasive tests of liver fibrosis for NAFLD. (A) Optimizing population management in NAFLD. (B) Elastography in assessing advanced fibrosis. Footnote: ARFI, acoustic radiation force impulse; ALT, alanine aminotransferase; BMI, body mass index; CHF, congestive heart failure; ELF, Enhanced Liver Fibrosis score; MRE, magnetic resonance elastography; NFS, NAFLD fibrosis score; NPV, negative predictive value; SWE, shear-wave elastography; VCTE, vibration-controlled transient elastography.