Ahalya Premkumar

A pilot study of pioglitazone treatment for nonalcoholic steatohepatitis

Nonalcoholic steatohepatitis (NASH) is a common chronic liver disease for which there is no known effective therapy. A proportion of patients with NASH progress to advanced fibrosis and cirrhosis. NASH is considered one of the clinical features of the metabolic syndrome in which insulin resistance plays a central role. This prospective study evaluates the role of insulin‐sensitizing agent in treatment of NASH. Eighteen nondiabetic patients with biopsy‐proven NASH were treated with pioglitazone (30 mg daily) for 48 weeks. Tests of insulin sensitivity and body composition as well as liver biopsies were performed before and at the end of treatment. By 48 weeks, serum alanine aminotransferase values fell to normal in 72% of patients. Hepatic fat content and size as determined by magnetic resonance imaging decreased, and glucose and free fatty acid sensitivity to insulin were uniformly improved. Histological features of steatosis, cellular injury, parenchymal inflammation, Mallory bodies, and fibrosis were significantly improved from baseline (all P < 0.05). Using strict criteria, histological improvement occurred in two‐thirds of patients. Pioglitazone was well tolerated; the main side effects were weight gain (averaging 4%) and an increase in total body adiposity. In conclusion, these results indicate that treatment with an insulin‐sensitizing agent can lead to improvement in biochemical and histological features of NASH and support the role of insulin resistance in the pathogenesis of this disease. The long‐term safety and benefits of pioglitazone require further study. (HEPATOLOGY 2004;39:188–196.)

Combination Targeted Therapy With Sorafenib and Bevacizumab Results in Enhanced Toxicity and Antitumor Activity

PURPOSE Sorafenib inhibits Raf kinase and vascular endothelial growth factor (VEGF) receptor. Bevacizumab is a monoclonal antibody targeted against VEGF. We hypothesized that the complementary inhibition of VEGF signaling would have synergistic therapeutic effects. PATIENTS AND METHODS Patients had advanced solid tumors, Eastern Cooperative Oncology Group performance status of 0 to 1, and good end-organ function. A phase I dose-escalation trial of sorafenib and bevacizumab was initiated at below-recommended single-agent doses because of possible overlapping toxicity: sorafenib 200 mg orally twice daily and bevacizumab intravenously at 5 mg/kg (dose level [DL] 1) or 10 mg/kg (DL2) every 2 weeks. Additional patients were enrolled at the maximum-tolerated dose (MTD). RESULTS Thirty-nine patients were treated. DL1 was the MTD and administered in cohort 2 (N = 27). Dose-limiting toxicity in DL2 was grade 3 proteinuria and thrombocytopenia. Adverse events included hypertension, hand-foot syndrome, diarrhea, transaminitis, and fatigue. Partial responses (PRs) were seen in six (43%) of 13 patients with ovarian cancer (response duration range, 4 to 22+ months) and one of three patients with renal cell cancer (response duration, 14 months). PR or disease stabilization >or= 4 months (median, 6 months; range, 4 to 22+ months) was seen in 22 (59%) of 37 assessable patients. The majority (74%) required sorafenib dose reduction to 200 mg/d at a median of four cycles (range, one to 12 cycles). CONCLUSION Combination therapy with sorafenib and bevacizumab has promising clinical activity, especially in patients with ovarian cancer. The rapidity and frequency of sorafenib dose reductions indicates that sorafenib at 200 mg twice daily with bevacizumab 5 mg/kg every 2 weeks may not be tolerable long term, and alternate sorafenib dosing schedules should be explored.

Efficacy and Safety of Troglitazone in the Treatment of Lipodystrophy Syndromes

Obesity causes insulin resistance, a central feature in the pathogenesis of type 2 diabetes (1). Paradoxically, the absence of adipose tissue also causes insulin resistance and diabetes in humans (2, 3) and genetically engineered animal models (4-6). Lipoatrophy and lipodystrophy are features of a group of heterogeneous syndromes characterized by a paucity of fat, insulin resistance, and hypertriglyceridemia (7). If patients develop diabetes, the syndrome is referred to as lipoatrophic diabetes. The disease has several genetic forms, including face-sparing partial lipoatrophy (the Dunnigan syndrome or the KoberlingDunnigan syndrome, OMIM [Online Mendelian Inheritance in Man] 308980), an autosomal dominant form caused by mutations in the lamin A/C gene (8), and congenital generalized lipoatrophy (the SeipBerardinelli syndrome, OMIM 269700), an autosomal recessive form mapping to chromosome 9q34 in some pedigrees (9). These diseases are rare; reported estimated prevalences are less than 1 in 10 million (10), although our experience suggests that the actual prevalences may be somewhat higher. An association between lipoatrophy and autoimmune disease, such as juvenile dermatomyositis, has also been described (11), suggesting that autoimmune destruction of adipose tissue results in a form of lipoatrophy. Thiazolidinediones, a new class of antidiabetic drugs (12), are ligands for peroxisome proliferatoractivated receptor- (PPAR-), a nuclear receptor expressed predominantly in adipose tissue (13). Thiazolidinediones are believed to exert their primary actions in adipose tissue and to indirectly increase insulin sensitivity in other tissues (14). Because thiazolidinediones have been reported to both increase insulin sensitivity (15, 16) and promote adipocyte development (17), these drugs seemed ideally suited to treat lipoatrophic diabetes. Troglitazone, the first thiazolidinedione to be approved for therapeutic use in the United States, has been shown to improve glycemic control and ameliorate hypertriglyceridemia in patients with type 2 diabetes (18). However, the use of troglitazone is complicated by a rare form of severe, irreversible hepatotoxicity. Two additional thiazolidinediones, rosiglitazone and pioglitazone, were recently approved for use. These drugs are also effective in improving glycemic control in patients with type 2 diabetes (19). Although initial studies of rosiglitazone and pioglitazone suggested that they might not be toxic to the liver, recent reports have raised the possibility that rosiglitazone may rarely cause hepatotoxicity (19, 20). Because PPAR- ligands promote adipocyte differentiation in vitro (13), we hypothesized that troglitazone would promote adipocyte development in patients with various forms of lipoatrophy. This hypothesis implicitly assumes that some lipoatrophic patients possess pre-adipocytes that could be stimulated by troglitazone to complete adipocyte differentiation. In addition, we sought to determine whether troglitazone therapy would improve metabolic control in patients with various forms of lipoatrophy. In light of data suggesting that troglitazone exerts its primary effects on adipocytes, it was uncertain whether the drug would be effective in such patients. Methods Patients Potential study participants were referred by multiple physicians in the United States and Canada in response to advertisements placed in medical journals, notices on the Internet, or word-of-mouth. Some patients had been followed at the National Institutes of Health for varying periods of time (up to 20 years). Because of the rarity of the syndrome, it was not practical to conduct population-based recruitment. To be eligible for the study, patients had to have both insulin resistance and lipoatrophy. For our purposes, insulin resistance was defined as either a fasting plasma insulin level greater than 143 pmol/L or impaired response to intravenous insulin (0.15 U/kg). The latter criterion was defined as a decrease in plasma glucose of less than 50% in patients with fasting glucose levels of 11 mmol/L or less ( 200 mg/dL) or a decrease of 5.5 mmol/L or less (<100 mg/dL) in patients with fasting glucose levels greater than 11.1 mmol/L (>200 mg/dL). Of 33 patients screened for this study, 8 were excluded because serum aminotransferase concentrations were abnormal (range, 833 to 6666 nkat/L) and liver biopsies showed steatohepatitis with varying degrees of fibrosis. Five patients were excluded for various reasons, such as the inability to give informed consent or adhere to the study follow-up schedule. The remaining 20 patients were recruited into the study (Table). Table. Characteristics of the Study Patients Fat distribution was assessed by physical examination and magnetic resonance imaging (MRI). A region of the body was defined as affected if MRI showed a marked decrease in fat in that region. Four patients had generalized lipoatrophy, defined as involvement of the following nine regions: face, neck, upper trunk, abdominal subcutaneous fat, visceral fat, and all four extremities. Two of these patients (U1 and P1) had near-total absence of fat throughout their bodies; the other two (A1 and A2) had a generalized decrease in fat but retained some fat in their visceral abdomen. Sixteen patients, including 7 patients with the Dunnigan syndrome, had partial lipoatrophy affecting five to eight fat depots. Six patients had accompanying autoimmune disease or results on three or more laboratory tests that suggested autoimmunity (for example, antinuclear antibody, rheumatoid factor, and elevated erythrocyte sedimentation rate); these patients therefore were presumed to have an autoimmune cause of their lipoatrophy. The cause of lipoatrophy appeared to be genetic in 10 patients; lipoatrophy appeared shortly after birth in 1 patient, and 9 patients had several affected relatives. Seven of these 9 patients had Dunnigan partial lipodystrophy (21) (Table); the 7 patients were members of three pedigrees. After completion of the study, the diagnosis of the Dunnigan syndrome was confirmed by identifying the R482Q mutation in the lamin A/C gene in all three pedigrees (22). In 4 patients, the cause of disease was unknown. Of the 20 study patients (Table), 14 had diabetes and 2 had impaired glucose tolerance according to the 1997 American Diabetes Association criteria (23). Most diabetic patients were receiving pharmacotherapy before study entry. Five patients were receiving insulin (0.5 to 2 U/kg of body weight per day) and 5 were receiving sulfonylureas; patients continued to receive these therapies during the study. Two patients were receiving metformin, but this therapy was discontinued 6 weeks before initiation of troglitazone treatment. Syndromes of lipoatrophy are associated with substantial comorbid conditions. Of the 8 patients with triglyceride levels greater than 4.5 mmol/L (400 mg/dL), 6 had a history of pancreatitis. Seventeen patients had acanthosis nigricans, a dermatologic condition associated with insulin resistance. Twelve of the 18 female participants had histories of irregular menses and polycystic ovaries as documented by ultrasonography; 6 of these women had hirsutism. Of the 6 remaining female participants, 4 were postmenopausal, 1 was perimenopausal, and 1 was prepubertal. Fatty liver is another important feature sometimes associated with lipoatrophy. To be included in the study, patients had to have normal biochemical function of the liver (Table). Nevertheless, results of ultrasonography in 12 patients suggested fatty infiltration of the liver. Lipoatrophic diabetes was associated with chronic complications of diabetes in some patients. Six patients had albuminuria, seven had diabetic polyneuropathy, and three had diabetic retinopathy (one of whom had proliferative retinopathy). One patient had three-vessel coronary artery disease. Design Patients were treated with troglitazone in an open-label prospective trial in which each patient was compared with his or her own baseline state. Because of the rarity of lipoatrophy syndromes and the variability of the clinical features, it was not feasible to use a randomized, placebo-controlled design. The study was approved by the institutional review board of the National Institute of Diabetes and Digestive and Kidney Diseases. Informed consent was obtained from the patient or his or her legal guardian. The decision to analyze the data after 6 months of therapy was made before the study was begun. Patients were evaluated as inpatients at the Clinical Center of the National Institutes of Health before treatment with troglitazone was initiated. They were admitted again after 6 weeks, 3 months, and 6 months of treatment. Before starting troglitazone therapy, diabetic patients were followed for at least 6 weeks while receiving stable doses of medication. Patients receiving insulin or sulfonylureas continued therapy with these drugs; however, metformin therapy was discontinued before troglitazone therapy was initiated. In diabetic patients, troglitazone therapy was started at a dosage of 200 mg/d and was increased to 400 to 600 mg/d over the course of 6 to 12 weeks, with the goal of optimizing glycemic control. The slow titration was chosen to minimize the risk for hypoglycemia. Doses of insulin or sulfonylureas were decreased if this was necessary to prevent hypoglycemia. Patients received stable doses of lipid-lowering medication for at least 6 weeks before starting troglitazone therapy. In nondiabetic adult participants, troglitazone was prescribed at a dosage of 400 mg/d. In one 6-year-old child weighing 15 to 18 kg, the dosage was 100 mg/d. Liver function tests and blood counts were performed every 3 to 4 weeks. Patients completed weekly questionnaires about their symptoms to identify potential side effects. Patients were instructed not to change their diet and exercise habits during this study. Information about dietary habits was collected by using

The effects of discontinuing pioglitazone in patients with nonalcoholic steatohepatitis

A pilot study of a 48‐week course of pioglitazone demonstrated significant improvements in the biochemical and histological features of nonalcoholic steatohepatitis (NASH). The aim of the study was to assess the effects of stopping pioglitazone. Twenty‐one patients with NASH were treated with pioglitazone (30 mg/day) for 48 weeks and underwent baseline and end‐of‐treatment evaluation including liver biopsy. Thirteen patients were followed for at least 48 weeks after stopping therapy and 9 underwent repeat liver biopsy. Statistical comparisons were made to evaluate whether discontinuation of pioglitazone resulted in a reversal of improvements seen on therapy. Stopping pioglitazone was associated with subsequent elevation in serum alanine aminotransferase levels (from 34 ± 13 to 70 ± 39 IU/l), decrease in adiponectin (from 9.7 ± 9.1 to 5.1 ± 4.5 μg/ml), worsening insulin sensitivity (HOMA Index: from 2.9 ± 1.8 to 5.5 ± 5.4), and increase in total hepatic fat (from 30% ± 32% to 71% ± 33%) despite no change in average body weight compared to the end of treatment. Repeat liver biopsy in 9 patients revealed significant worsening of parenchymal inflammation (from 1.2 ± 0.7 to 2.9 ± 1.1) and steatosis (from 0.9 ± 0.6 to 2.1 ± 1.3) but no change in fibrosis (from 1.1 ± 1.2 to 1.2 ± 1.3). NASH was again present on liver biopsy in 7 patients. Conclusion: These findings suggest that long‐term therapy with pioglitazone may be necessary to maintain improvements in disease activity in patients with NASH, although weight gain during treatment may ultimately limit its beneficial effects. (HEPATOLOGY 2007.)

Leptin reverses nonalcoholic steatohepatitis in patients with severe lipodystrophy.

Severe lipodystrophy is characterized by diminished adipose tissue and hypoleptinemia, leading to ectopic triglyceride accumulation. In the liver, this is associated with steatosis, potentially leading to nonalcoholic steatohepatitis (NASH). We investigated the prevalence of NASH and the effect of leptin replacement in these patients. Ten patients with either generalized lipodystrophy (8 patients) or Dunnigans partial lipodystrophy (2 patients) were included in this analysis. Paired liver biopsy specimens were obtained at baseline and after treatment with recombinant methionyl human leptin (r‐metHuLeptin), mean duration 6.6 months. The extents of portal and parenchymal inflammation, steatosis, ballooning, presence of Mallory bodies, and fibrosis in liver biopsy specimens were scored using a previously validated system developed to assess NASH activity. Histological disease activity was defined as the sum of ballooning, steatosis, and parenchymal inflammation scores. We concurrently tested serum triglycerides and aminotransferases and estimations of liver volume and fat content by magnetic resonance imaging. Eight of 10 patients met histological criteria for NASH at baseline. After treatment with r‐metHuLeptin, repeat histological examinations showed significant improvements in steatosis (P = .006) and ballooning injury (P = .005), with a reduction of mean NASH activity by 60% (P = .002). Fibrosis was unchanged. Significant reductions were seen in mean serum triglycerides (1206→226 mg/dL, P = .002), glucose (220→144 mg/dL, P = .02), insulin (46.4→24.8 μIU/mL, P = .004), ALT (54→24 U/L, P = .02), AST (47→22 U/L, P = .046), liver volume (3209→2391 cm3, P = .007), and liver fat content (31→11%, P = .006). In conclusion, r‐metHuLeptin therapy significantly reduced triglycerides, transaminases, hepatomegaly, and liver fat content. These reductions were associated with significant reductions in steatosis and the hepatocellular ballooning injury seen in NASH. (HEPATOLOGY 2005;41:753–760.)

CDB-2914 for Uterine Leiomyomata Treatment: A Randomized Controlled Trial

OBJECTIVE: To evaluate whether 3-month administration of CDB-2914, a selective progesterone receptor modulator, reduces leiomyoma size and symptoms. METHODS: Premenopausal women with symptomatic uterine leiomyomata were randomly assigned to CDB-2914 at 10 mg (T1) or 20 mg (T2) daily or to placebo (PLC) for 3 cycles or 90–102 days if no menses occurred. The primary outcome was leiomyoma volume change determined by magnetic resonance imaging at study entry and within 2 weeks of hysterectomy. Secondary outcomes included the proportion of amenorrhea, change in hemoglobin and hematocrit, ovulation inhibition, and quality-of-life assessment. RESULTS: Twenty-two patients were allocated, and 18 completed the trial. Age and body mass index were similar among groups. Leiomyoma volume was significantly reduced with CDB-2914 administration (PLC 6%; CDB-2914 –29%; P=.01), decreasing 36% and 21% in the T1 and T2 groups, respectively. During treatment, hemoglobin was unchanged, and the median estradiol was greater than 50 pg/mL in all groups. CDB-2914 eliminated menstrual bleeding and inhibited ovulation (% ovulatory cycles: CDB-2914, 20%; PLC, 83%; P=.001). CDB-2914 improved the concern scores of the uterine leiomyoma symptom quality-of-life subscale (P=.04). One CDB-2914 woman developed endometrial cystic hyperplasia without evidence of atypia. No serious adverse events were reported. CONCLUSION: Compared with PLC, CDB-2914 significantly reduced leiomyoma volume after three cycles, or 90–102 days. CDB-2914 treatment resulted in improvements in the concern subscale of the Uterine Fibroid Symptom Quality of Life assessment. In this small study, CDB-2914 was well-tolerated without serious adverse events. Thus, there may be a role for CDB-2914 in the treatment of leiomyomata. Clinical Trial Registration: ClinicalTrials.gov,www.clinicaltrials.gov, NCT00290251 LEVEL OF EVIDENCE: I

Predictors of acquired lipodystrophy in juvenile-onset dermatomyositis and a gradient of severity

We describe the clinical features of 28 patients with juvenile dermatomyositis (JDM) and 1 patient with adult-onset dermatomyositis (DM), all of whom developed lipodystrophy (LD) that could be categorized into 1 of 3 phenotypes, generalized, partial, or focal, based on the pattern of fat loss distribution. LD onset was often delayed, beginning a median of 4.6 years after diagnosis of DM. Calcinosis, muscle atrophy, joint contractures, and facial rash were DM disease features found to be associated with LD. Panniculitis was associated with focal lipoatrophy while the anti-p155 autoantibody, a newly described myositis-associated autoantibody, was more associated with generalized LD. Specific LD features such as acanthosis nigricans, hirsutism, fat redistribution, and steatosis/nonalcoholic steatohepatitis were frequent in patients with LD, in a gradient of frequency and severity among the 3 sub-phenotypes. Metabolic studies frequently revealed insulin resistance and hypertriglyceridemia in patients with generalized and partial LD. Regional fat loss from the thighs, with relative sparing of fat loss from the medial thighs, was more frequent in generalized than in partial LD and absent from DM patients without LD. Cytokine polymorphisms, the C3 nephritic factor, insulin receptor antibodies, and lamin mutations did not appear to play a pathogenic role in the development of LD in our patients. LD is an under-recognized sequela of JDM, and certain DM patients with a severe, prolonged clinical course and a high frequency of calcinosis appear to be at greater risk for the development of this complication. High-risk JDM patients should be screened for metabolic abnormalities, which are common in generalized and partial LD and result in much of the LD-associated morbidity. Further study is warranted to investigate the pathogenesis of acquired LD in patients with DM. Abbreviations: CI = confidence interval, CT = computerized tomography, dlk = delta-like, DM= dermatomyositis, DXA = dual-energy X-ray absorptiometry, HDL = high-density lipoprotein, HIV = human immunodeficiency virus, HOMA-IR = homeostasis model assessment of insulin resistance, IL = interleukin, IR = insulin resistance, JDM = juvenile dermatomyositis, LA = lipoatrophy, LD = lipodystrophy, LDL = low-density lipoprotein, LMNA= lamin A, MRI = magnetic resonance imaging, NASH = nonalcoholic steatohepatitis, NIH = National Institutes of Health, OGTT = oral glucose tolerance test, OR = odds ratio, PCR = polymerase chain reaction, TNF = tumor necrosis factor, TTP = tristetraprolin.

Phase II trial of carboxyamidotriazole in patients with relapsed epithelial ovarian cancer.

PURPOSE Carboxyamidotriazole (CAI) is a cytostatic inhibitor of nonvoltage-operated calcium channels and calcium channel-mediated signaling pathways. It inhibits angiogenesis, tumor growth, invasion, and metastasis. We hypothesized that CAI would promote disease stabilization lasting >/= 6 months in patients with relapsed ovarian cancer. PATIENTS AND METHODS Patients with epithelial ovarian cancer, good end-organ function, measurable disease, and three or fewer prior regimens were eligible. Oral CAI was given daily using a pharmacokinetic-dosing approach to maintain plasma concentrations between 2 and 4 microg/mL. Radiographic imaging to assess response was performed every 8 weeks. Positive outcome included stabilization or improvement of disease lasting >/= 6 months. Plasma vascular endothelial growth factor (VEGF), interleukin (IL)-8, and matrix metalloproteinase (MMP)-2 were measured. RESULTS Thirty-six patients were assessable for primary end point analysis, and 38 were assessable for toxicity. Forty-four percent of patients had three prior regimens, more than 50% had four or more disease sites, and 48% had liver metastases. Thirty-three patients reached the targeted concentration range during the first cycle. Eleven patients (31%) attained the >/= 6-month outcome end point, with one partial response (8 months) and three minor responses (8, 12+, and 13 months). Median time to progression was 3.6 months (range, 1.6 to 13.3 months). CAI was well tolerated, with mostly grade 1 to 2 toxicity. Grade 3 events included fatigue (5%), vomiting (2%), neutropenic fever (2%), and neutropenia (2%). There were no grade 4 adverse events. No associations between VEGF, IL-8, and MMP-2 with CAI concentration or clinical outcome were observed. CONCLUSION CAI is a potential agent for additional study in the stabilization of relapsed ovarian cancer. Given a limited toxicity profile, it may have utility as a maintenance therapeutic agent for this disease.

A prospective analysis of imatinib-induced c-KIT modulation in ovarian cancer: a phase II clinical study with proteomic profiling.

c‐Kit and platelet‐derived growth factor receptor (PDGFR) are potential molecular targets in epithelial ovarian cancer (EOC). Imatinib inhibits the kinase domain and subsequent downstream signaling of these receptor tyrosine kinases. The objective of this study was to investigate biochemical and biologic effects of imatinib on EOC.

Familial testicular germ cell tumors in adults: 2010 summary of genetic risk factors and clinical phenotype

Familial aggregations of testicular germ cell tumor (FTGCT) have been well described, suggesting the existence of a hereditary TGCT subset. Approximately 1.4% of newly diagnosed TGCT patients report a positive family history of TGCT. Sons and siblings of TGCT patients have four- to sixfold and eight- to tenfold increases in TGCT risk respectively. Segregation analyses suggest an autosomal recessive mode of inheritance. Linkage analyses have identified several genomic regions of modest interest, although no high-penetrance cancer susceptibility gene has been mapped yet. These data suggest that the combined effects of multiple common alleles, each conferring modest risk, might underlie familial testicular cancer. Families display a mild phenotype: the most common number of affected families is 2. Age at diagnosis is 2-3 years younger for familial versus sporadic cases. The ratio of familial seminoma to nonseminoma is 1.0. FTGCT is more likely to be bilateral than sporadic TGCT. This syndrome is cancer site specific. Testicular microlithiasis is a newly recognized FTGCT component. Candidate gene-association studies have implicated the Y chromosome gr/gr deletion and PDE11A gene mutations as genetic modifiers of FTGCT risk. Two genomewide association studies of predominantly sporadic but also familial cases of TGCT have implicated the KIT-ligand, SPRY4, and BAK1 genes as TGCT risk modifiers. All five loci are involved in normal testicular development and/or male infertility. These genetic data provide a novel insight into the genetic basis of FTGCT, and an invaluable guide to future TGCT research.