MRI Quantification of Placebo Effect in Nonalcoholic Steatohepatitis Clinical Trials

Abstract

Background Several early-phase clinical trials for the treatment of nonalcoholic steatohepatitis (NASH) use liver fat content as measured with the MRI-derived proton density fat fraction (PDFF) for a primary outcome. These trials have shown relative reductions in liver fat content with placebo treatment alone, a phenomenon termed "the placebo effect." This phenomenon confounds the results and limits generalizability to future trials. Purpose To quantify the effect of placebo treatment on change in the absolute PDFF value and to identify variables associated with this observed change. Materials and Methods This is a secondary analysis of prospectively collected data from seven early phase clinical trials that included participants with a diagnosis of NASH based on MRI and/or liver biopsy who received placebo treatment. The primary outcome was a greater than or equal to 30% relative reduction in PDFF after placebo treatment. Normalization of PDFF, relative change in alanine aminotransferase (ALT) level, and normalization of ALT level were also examined. An exploratory linear mixed-effects model was used to estimate an overall change in absolute PDFF and to explore parameters associated with this response. Results A total of 187 participants (median age, 52 years [IQR, 43-60 years]; 114 women) who received placebo treatment were evaluated. A greater than or equal to 30% relative reduction in baseline PDFF was seen in 20% of participants after 12 weeks of placebo treatment (10 of 49), 9% of participants after 16 weeks (two of 22), and 28% of participants after 24 weeks (34 of 122). A repeated-measures linear mixed-effects model estimated a decrease of 2.3 units (median relative reduction of 13%) in absolute PDFF values after 24 weeks of placebo treatment (95% CI: 3.2, 1.4; P < .001). Conclusion In this analysis of 187 participants, a clinically relevant decrease in PDFF was observed with placebo treatment. Based on the study model, assuming an absolute PDFF decrease of approximately 3 units (upper limit of 95% CI) to account for this "placebo effect" in sample size calculations for future clinical trials is suggested. Clinical trial registration nos. NCT01066364, NCT01766713, NCT01963845, NCT02443116, NCT02546609, NCT02316717, and NCT02442687 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Yoon in this issue.

Graphical abstract

Figure 1:

Dot plot shows the mean and standard error for relative change in baseline MRI proton density fat fraction (PDFF) values for all participants (n = 187) in the study at all time points across the seven parent trials.

Figure 2:

Schematic shows the model selection process and variables for the linear mixed-effects model used to evaluate the percentage change in baseline MRI proton density fat fraction (PDFF). ALT = alanine aminotransferase, BMI = body mass index, HbA1c = hemoglobin A_1c, HOMAR-IR = homeostatic model assessment for insulin resistance, NAS = nonalcoholic fatty liver disease activity score.

Figure 3:

Line graph shows absolute change in MRI proton density fat fraction (PDFF) as a function of duration of placebo treatment (weeks) for our repeated-measures linear mixed-effects model, which estimates a mean absolute reduction in baseline MRI PDFF of 2.3 units after 24 weeks of placebo treatment.