Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial

BACKGROUND Non-alcoholic steatohepatitis (NASH) is a common type of chronic liver disease that can lead to cirrhosis. Obeticholic acid, a farnesoid X receptor agonist, has been shown to improve the histological features of NASH. Here we report results from a planned interim analysis of an ongoing, phase 3 study of obeticholic acid for NASH. METHODS In this multicentre, randomised, double-blind, placebo-controlled study, adult patients with definite NASH, non-alcoholic fatty liver disease (NAFLD) activity score of at least 4, and fibrosis stages F2-F3, or F1 with at least one accompanying comorbidity, were randomly assigned using an interactive web response system in a 1:1:1 ratio to receive oral placebo, obeticholic acid 10 mg, or obeticholic acid 25 mg daily. Patients were excluded if cirrhosis, other chronic liver disease, elevated alcohol consumption, or confounding conditions were present. The primary endpoints for the month-18 interim analysis were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of fibrosis, with the study considered successful if either primary endpoint was met. Primary analyses were done by intention to treat, in patients with fibrosis stage F2-F3 who received at least one dose of treatment and reached, or would have reached, the month 18 visit by the prespecified interim analysis cutoff date. The study also evaluated other histological and biochemical markers of NASH and fibrosis, and safety. This study is ongoing, and registered with ClinicalTrials.gov, NCT02548351, and EudraCT, 20150-025601-6. FINDINGS Between Dec 9, 2015, and Oct 26, 2018, 1968 patients with stage F1-F3 fibrosis were enrolled and received at least one dose of study treatment; 931 patients with stage F2-F3 fibrosis were included in the primary analysis (311 in the placebo group, 312 in the obeticholic acid 10 mg group, and 308 in the obeticholic acid 25 mg group). The fibrosis improvement endpoint was achieved by 37 (12%) patients in the placebo group, 55 (18%) in the obeticholic acid 10 mg group (p=0·045), and 71 (23%) in the obeticholic acid 25 mg group (p=0·0002). The NASH resolution endpoint was not met (25 [8%] patients in the placebo group, 35 [11%] in the obeticholic acid 10 mg group [p=0·18], and 36 [12%] in the obeticholic acid 25 mg group [p=0·13]). In the safety population (1968 patients with fibrosis stages F1-F3), the most common adverse event was pruritus (123 [19%] in the placebo group, 183 [28%] in the obeticholic acid 10 mg group, and 336 [51%] in the obeticholic acid 25 mg group); incidence was generally mild to moderate in severity. The overall safety profile was similar to that in previous studies, and incidence of serious adverse events was similar across treatment groups (75 [11%] patients in the placebo group, 72 [11%] in the obeticholic acid 10 mg group, and 93 [14%] in the obeticholic acid 25 mg group). INTERPRETATION Obeticholic acid 25 mg significantly improved fibrosis and key components of NASH disease activity among patients with NASH. The results from this planned interim analysis show clinically significant histological improvement that is reasonably likely to predict clinical benefit. This study is ongoing to assess clinical outcomes. FUNDING Intercept Pharmaceuticals

Microclimatic buffering by logging residues and forest edges reduces clear-cutting impacts on forest bryophytes

Question: The practice of extracting logging residues after clear-cutting for bioenergy purposes is spreading. Logging residues constitute a shelter in clear-cut areas and therefore concerns have been expressed that their removal could make the ground and its vegetation more exposed to extreme micro¬climatic conditions. We asked whether logging residues and forest edges can protect ground-dwelling forest bryophytes from fatal microclimate events following clear-cutting. Location: Boreal forests of central Sweden. Methods: Using transplants of eight forest floor bryophyte species we experimentally analysed the sheltering effect (less solar radiation and less wind) of logging residues and forest edges in seven clear-cut areas. Transplants were placed in two contrasting positions in each area; near a north-facing forest edge and in the centre of the clear-cut area. In each position, half of the transplants were covered by a layer of spruce branches and the other half was left uncovered. We estimated proportion of apparently living shoots (apparent vitality) and measured radial growth of transplants during one growing season. Results: Position in the clear-cut area, but not cover of spruce branches, clearly influenced radial growth. Vitality scores were higher among transplants covered with branches and the lowest apparent vitality was observed in uncovered transplants in the middle of clear-cut areas. The change in area of apparently liv¬ing shoots during the course of the experiment (growth minus mortality) was unaffected by branch cover close to the edge but positively affected in the centre of the clear-cut area. In general, the effect of branch cover on bryophytes was higher in the centre of clear-cut areas. Here, climatic measurements showed that branch cover buffers during periods of extreme microclimates. Conclusions: Extraction of logging residues after clear-felling may reduce the survival of some ground-dwelling forest organisms. The additional sheltering provided by branches was unimportant close to forest edges. We suggest smaller clear-cut areas, green-tree retention and other ways to make logged areas shadier and less windy to mitigate the reduced shelter caused by harvest of logging residues