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 oneaccompanying 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 endpointsfor 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

Decimative Multiplication of Entropy Arrays, with Application to Influenza

The use of the digital signal processing procedure of decimation is introduced as a tool to detect patterns of information entropy distribution and is applied to information entropy in influenza A segment 7. Decimation was able to reveal patterns of entropy accumulation in archival and emerging segment 7 sequences that were not apparent in the complete, undecimated data. The low entropy accumulation along the first 25% of segment 7, revealed by the three frames of decimation, may be a sign of regulation at both protein and RNA levels to conserve important viral functions. Low segment 7 entropy values from the 2009 H1N1 swine flu pandemic suggests either that: (1) the viruses causing the current outbreak have convergently evolved to their low entropy state or (2) more likely, not enough time has yet passed for the entropy to accumulate. Because of its dependence upon the periodicity of the codon, the decimative procedure should be generalizable to any biological system

Decimative Multiplication of Entropy Arrays, with Application to Influenza

The use of the digital signal processing procedure of decimation is introduced as a tool to detect patterns of information entropy distribution and is applied to information entropy in influenza A segment 7. Decimation was able to reveal patterns of entropy accumulation in archival and emerging segment 7 sequences that were not apparent in the complete, undecimated data. The low entropy accumulation along the first 25% of segment 7, revealed by the three frames of decimation, may be a sign of regulation at both protein and RNA levels to conserve important viral functions. Low segment 7 entropy values from the 2009 H1N1 swine flu pandemic suggests either that: (1) the viruses causing the current outbreak have convergently evolved to their low entropy state or (2) more likely, not enough time has yet passed for the entropy to accumulate. Because of its dependence upon the periodicity of the codon, the decimative procedure should be generalizable to any biological system

Information Entropy of Influenza A Segment 7

Information entropy (H) is a measure of uncertainty at each position within in a sequence of nucleotides.H was used to characterize a set of influenza A segment 7 nucleotide sequences. Nucleotide locations of high entropy were identified near the 5’ start of all of the sequences and the sequences were assigned to subsets according to synonymous nucleotide variants at those positions: either uracil at position six (U6), cytosine at position six (C6), adenine (A12) at position 12, guanine at position 12 (G12), adenine at position 15 (A15) or cytosine (C15) at position 15. H values were found to be correlated/corresponding (Kendall tau) along the lengths of the nucleotide segments of the subset pairs at each position. However, the H values of each subset of sequences were statistically distinguishable from those of the other member of the pair (Kolmogorov-Smirnov test). The joint probability of uncorrelated distributions of U6 and C6 sequences to viral subtypes and to viral host species was 34 times greater than for the A12:G12 subset pair and 214 times greater than for the A15:C15 pair. This result indicates that the high entropy position six of segment 7 is either a reporter or a sentinel location. The fact that not one of the H5N1 sequences in the dataset was a member of the C6 subset, but all 125 H5N1 sequences are members of the U6 subset suggests a non-random sentinel function

Thompson, W.A. et al. Decimative Multiplication of Entropy Arrays, with Application to Influenza. Entropy, 2009, 11, 351-359

The sentence sixth line from the end of paragraph two on page 355, “The second synonymous mutation was another G=>A transition at position 600 that converted the CAG codon to CAA, without change of encoded amino acid.

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