norUrsodeoxycholic acid improves cholestasis in primary sclerosing cholangitis
Full text
no U sodeoxycholic acid imp o es choles asis in
p ima y scle osing cholangi is
G aphical abs ac Au ho s
Highligh s
The e is an u gen need o no el d ugs o PSC.
In his phase II clinical ial, no UDCA educed se um ALP
le els wi hin 12 weeks.
no UDCA’s e ec s on li e enzymes we e dose-dependen .
The sa e y p o ile o no UDCA was excellen .
Pe e Ficke , Gideon M. Hi sch ield,
Ge ald Denk, ..., Ma kus P öls,
Michael P. Manns,Michael T aune
Co espondence
michael. au[email p o ec ed]
(M. T aune )
Lay summa y
E ec i e medical he apy o p ima y
scle osing cholangi is (PSC) is u gen ly
needed. In his phase II clinical s udy in
PSC pa ien s, a side chain-sho ened
de i a i e o u sodeoxycholic acid,
no u sodeoxycholic acid (no UDCA), sig-
ni ican ly educed se um alkaline phos-
pha ase le els in a dose-dependen
manne du ing a 12-week ea men .
Impo an ly, no UDCA showed a a o able
sa e y p o ile, which was simila o pla-
cebo. The use o no UDCA in PSC pa ien s
is p omising and will be u he e alua ed
in a phase III clinical s udy.
h p://dx.doi.o g/10.1016/j.jhep.2017.05.009
Ó2017 Eu opean Associa ion o he S udy o he Li e . Published by Else ie B.V. All igh s ese ed. J. Hepa ol. 2017, 67, 549–558
Resea ch A icle
no U sodeoxycholic acid imp o es choles asis in p ima y
scle osing cholangi is
Pe e Ficke
1
, Gideon M. Hi sch ield
2
, Ge ald Denk
3
, Hanns-Ul ich Ma schall
4
, Is an Al o jay
5
,
Ma i Fä kkilä
6
, Ch is oph Sch amm
7
, Ul ich Spengle
8
, Roge Chapman
9
, Annika Be gquis
10
,
E ik Sch ump
11
, F ede ik Ne ens
12
, Palak T i edi
2
, Flo ian P. Rei e
3
, Is an To nai
5
,
Emina Halilbasic
13
, Roland G einwald
14
, Ma kus P öls
14
, Michael P. Manns
15
, Michael T aune
13,
⇑
,
o he Eu opean PSC no UDCA S udy G oup
y
1
Di ision o Gas oen e ology and Hepa ology, Depa men o In e nal Medicine, Medical Uni e si y o G az, G az, Aus ia;
2
Cen e o Li e
Resea ch and NIHR Biomedical Resea ch Uni , Uni e si y o Bi mingham, Uni ed Kingdom;
3
Depa men o Medicine II, Li e Cen e Munich,
Ludwig Maximilians Uni e si y (LMU), Munich, Ge many;
4
Depa men o Molecula and Clinical Medicine, Sahlg enska Academy, Ins i u e o
Medicine, Uni e si y o Go henbu g, Go henbu g, Sweden;
5
Depa men o Gas oen e ology, School o Medicine, Deb ecen Uni e si y, Deb ecen,
Hunga y;
6
Uni e si y o Helsinki and Clinic o Gas oen e ology, Helsinki Uni e si y Hospi al, Helsinki, Finland;
7
1s Depa men o Medicine,
Uni e si y Medical Cen e Hambu g-Eppendo , Hambu g, Ge many;
8
Depa men o In e nal Medicine 1, Rheinische F ied ich-Wilhelm’s
Uni e si y Bonn, Bonn, Ge many;
9
T ansla ional Gas oen e ology Uni , John Radcli e Hospi al, Ox o d, Uni ed Kingdom;
10
Depa men o
Gas oen e ology and Hepa ology, Ka olinska Uni e si y Hospi al, Ka olinska Ins i u e, Huddinge, S ockholm, Sweden;
11
Sec ion o
Gas oen e ology, Depa men o T ansplan a ion Medicine, Di ision o Cance Medicine, Su ge y and T ansplan a ion, Oslo Uni e si y Hospi al,
Rikshospi ale , Oslo, No way;
12
Hepa ology, Uni e si y Hospi al Gas huisbe g, KU Leu en, Leu en, Belgium;
13
Di ision o Gas oen e ology and
Hepa ology, Depa men o In e nal Medicine III, Medical Uni e si y o Vienna, Vienna, Aus ia;
14
D . Falk Pha ma GmBH, F eibu g, Ge many;
15
Depa men o Gas oen e ology, Hepa ology and Endoc inology, Hanno e Medical School, Hanno e , Ge many
See Edi o ial, pages 446–447
Backg ound & Aim: P ima y scle osing cholangi is (PSC) ep e-
sen s a de as a ing bile duc disease, cu en ly lacking e ec i e
medical he apy. 24-no u sodeoxycholic acid (no UDCA) is a side
chain-sho ened C
23
homologue o UDCA and has shown po en
an i-choles a ic, an i-in lamma o y and an i- ib o ic p ope ies
in a p eclinical PSC mouse model. A andomized con olled ial,
including 38 cen e s om 12 Eu opean coun ies, e alua ed he
sa e y and e icacy o h ee doses o o al no UDCA (500 mg/d,
1,000 mg/d o 1,500 mg/d) compa ed wi h placebo in pa ien s
wi h PSC.
Me hods: One hund ed six y-one PSC pa ien s wi hou concomi-
an UDCA he apy and wi h ele a ed se um alkaline phos-
pha ase (ALP) le els we e andomized o a 12-week ea men
ollowed by a 4-week ollow-up. The p ima y e icacy endpoin
was he mean ela i e change in ALP le els be ween baseline
and end o ea men isi .
Resul s:no UDCA educed ALP le els by 12.3%, 17.3%, and
26.0% in he 500, 1,000, and 1,500 mg/d g oups (p= 0.029,
p= 0.003, and p 0.0001 when compa ed o placebo), espec-
i ely, while a +1.2% inc ease was obse ed in he placebo g oup.
Simila dose-dependen esul s we e ound o seconda y end-
poin s, such as ALT, AST,
c
-GT, o he a e o pa ien s achie ing
ALP le els 1.5ULN. Se ious ad e se e en s occu ed in se en
pa ien s in he 500 mg/d, i e pa ien s in he 1,000 mg/d, wo
pa ien s in he 1500 mg/d g oup, and h ee in he placebo g oup.
The e was no di e ence in epo ed p u i us be ween ea men
and placebo g oups.
Conclusions:no UDCA signi ican ly educed ALP alues dose-
dependen ly in all ea men a ms. The sa e y p o ile o no UDCA
was excellen and compa able o placebo. Consequen ly, hese
esul s jus i y a phase III ial o no UDCA in PSC pa ien s.
Lay summa y: E ec i e medical he apy o p ima y scle osing
cholangi is (PSC) is u gen ly needed. In his phase II clinical s udy
in PSC pa ien s, a side chain-sho ened de i a i e o u sodeoxy-
cholic acid, no u sodeoxycholic acid (no UDCA), signi ican ly
educed se um alkaline phospha ase le els in a dose-dependen
manne du ing a 12-week ea men . Impo an ly, no UDCA
showed a a o able sa e y p o ile, which was simila o placebo.
The use o no UDCA in PSC pa ien s is p omising and will be u -
he e alua ed in a phase III clinical s udy.
ClinicalT ials.go numbe : NCT01755507.
Ó2017 Eu opean Associa ion o he S udy o he Li e . Published
by Else ie B.V. This is an open access a icle unde he CC BY-NC-
ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
Jou nal o Hepa ology 2017 ol. 67 j549–558
Keywo ds: Alkaline phospha ase; Bile acid ea men ; Choles asis; Scle osing
cholangi is; Side chain-sho ened bile acids; Cholehepa ic shun ing;
U sodeoxycholic acid.
Recei ed 21 Decembe 2016; ecei ed in e ised o m 12 Ap il 2017; accep ed 6 May
2017; a ailable online 18 May 2017
⇑
Co esponding au ho . Add ess: Depa men o In e nal Medicine III, Medical
Uni e si y o Vienna, Waeh inge Gue el 18-20, A-1090 Vienna, Aus ia. Tel.: +43
1 40 40047410.
E-mail add ess: [email p o ec ed] (M. T aune ).
y
Full lis s udy pa icipan s is lis ed a he end o he manusc ip .
Resea ch A icle
In oduc ion
P ima y scle osing cholangi is (PSC) is a ch onic choles a ic li e
disease o unknown e iology cha ac e ized by a ch onic in lam-
ma o y and ib o-obli e a i e des uc ion o ex a-, and in ahep-
a ic bile duc s.
1
Cu en ly he e a e no medical he apies wi h
p o en bene i s on PSC pa ien s’ su i al. The lis o d ugs ha
ha e ailed in PSC ea men is long, comp ising o aza hiop ine,
cyclospo ine, me ho exa e, ac olimus, penicillamine,
cholchicine, and in liximab.
2
Consequen ly, li e ansplan a ion
is he only ea men op ion o PSC pa ien s wi h end-s age li e
disease. The use o u sodeoxycholic acid (UDCA) in he ea men
o PSC is highly con o e sial.
3–5
Nume ous s udies showed
biochemical o his ological imp o emen s, bu ailed o demon-
s a e signi ican di e ences in dea h a es, ansplan - ee su -
i al, o de elopmen o cholangioca cinoma.
4–11
A andomized
con olled ial es ing doses o UDCA anging om 17 o
23 mg/kg/day showed a a o able biochemical end bu lacked
signi ican e ec s on ha d clinical endpoin s including
ansplan - ee su i al, p obably due o being unde powe ed.
10
Tes ing e en highe doses o UDCA (28–30 mg/kg/day) in PSC
pa ien s e ealed an o e all imp o emen in se um li e es s
bu we e associa ed wi h a highe isk o dea h, a need o li e
ansplan a ion, and inc eased a es o se ious ad e se e en s
(SAEs).
11
In e es ingly, a s udy on he e ec s o UDCA wi hd awal
in PSC pa ien s showed a signi ican de e io a ion o li e bio-
chemis y and symp oms wi hin 3 mon hs.
12
Taken oge he ,
e ec i e medical he apy o PSC is s ill an unme clinical need
and no el d ugs a e u gen ly needed.
2
24-no u sodeoxycholic acid (no UDCA) is a side chain-
sho ened C
23
homologue o UDCA and was p e iously shown
o be highly e ec i e in p eclinical mouse models o choles a ic
and ib o ic li e diseases.
13–17
Compa ing he he apeu ic
e ec s o UDCA and no UDCA in Abcb4 knockou mice
(Abcb4
/
) as a model o scle osing cholangi is and bilia y
ib osis e ealed speci ic and supe io an i-in lamma o y, an i-
ib o ic, and an i-p oli e a i e e ec s o no UDCA.
14–16
The ela-
i e esis ance o no UDCA o N-acyl-amida ion wi h au ine o
glycine leads o cholehepa ic shun ing o no UDCA. This means
ha unconjuga ed no UDCA, as a weak acid, can be eabso bed
by cholangiocy es, e u ning o he sinusoids and hepa ocy es
ia he pe iduc ula capilla y plexus, and is e-sec e ed in o
bile.
13,18–21
This p ocess o cholehepa ic shun ing esul s in duc-
al a ge ing and leads o p o ound s imula ion o cholangiocel-
lula bica bona e sec e ion and consequen ly induc ion o bile
acid-independen bile low and lushing o bile duc s. In addi-
ion, bilia y bica bona e sec e ion may p o ec cholangiocy es
as a bica bona e umb ella
22
agains hei a he un iendly en i-
onmen , whe e he apical su ace memb anes ha e o con inu-
ously ace millimola concen a ions o po en ially oxic bile
acids.
23
Mo eo e , no UDCA and i s me aboli es when sec e ed
in o human bile a e p esen in mos ly monome ic a he han
micella o m, enhancing i s osmo ic e ec hus making no -
UDCA a highly po en chole e ic d ug.
18
These a o able mech-
anisms o no UDCA and excellen ole abili y in phase I
s udies p omp ed us o ini ia e a mul icen e placebo-
con olled phase II clinical ial (NUC-3/PSC) in PSC pa ien s.
We aim o: (i) e alua e he e icacy o h ee doses o no UDCA
s. placebo; (ii) iden i y e icacious no UDCA dose(s) o u he
e alua ion in a u u e phase III clinical ial; and (iii) o s udy
sa e y and ole abili y o no UDCA.
Pa ien s and me hods
This s udy was designed as a Eu opean mul icen e , double-blind, andomized,
placebo-con olled, compa a i e, and explo a o y phase II dose inding ial wi h
ou ea men g oups. The o e all s udy design is summa ized in Fig. 1. Pa ien s
we e andomized o 500 mg/d, 1,000 mg/d o 1,500 mg/d no UDCA o placebo a
38 cen e s om 12 coun ies. Since he he apeu ic e icacy o UDCA in PSC is
unclea i seemed jus i iable o in oduce a placebo a m. UDCA was he e o e dis-
con inued a leas 8 weeks p io o baseline isi in 113 o 161 pa ien s en olled.
F om 159 pa ien s ecei ing he s udy medica ion 40 we e documen ed as UDCA-
naï e, 58 classi ied as UDCA esponde s, and 55 as UDCA non- esponde s.
Response was de ined as (pa ial) no maliza ion o se um alkaline phospha ase
(ALP) a he in es iga o ’s disc e ion (Table 2) and his s udy he e o e lacks a
s ic de ini ion o UDCA esponse. Impo an ly, all UDCA exposed pa ien s dis-
con inued UDCA a leas o 8 weeks p io o s udy inclusion. The biochemical
pa e ns ollowing discon inua ion o UDCA we e in line wi h a p e ious epo
12
showing an inc ease in ALP (+27% in UDCA esponde , +15% in UDCA non-
esponde s). A 12-week ea men phase was ollowed by a 4-week ollow-up
pe iod. The ial was pe o med be ween Janua y 2013 and Sep embe 2015 ol-
lowing he p inciples o good clinical p ac ice and in acco dance wi h he e hical
p inciples o he Decla a ion o Helsinki, was egis e ed wi h Eud aCT (No. 2011-
002754-31), and app o ed by he independen local e hics commi ees esponsi-
ble o he pa icipa ing in es iga o s.
All pa ien s p o ided w i en in o med consen . Male o emale PSC pa ien s
aged P18 and 80 yea s we e included. PSC was e i ied by wo o he h ee ol-
lowing c i e ia: (i) ch onic choles a ic li e disease o a leas 6 mon hs du a ion;
(ii) e og ade, ope a i e, pe cu aneous, o magne ic esonance cholangiog aphy
demons a ing in ahepa ic and/o ex ahepa ic bilia y duc changes such as
beading o na owing consis en wi h PSC wi hin 1 yea p io o baseline; o
(iii) li e biopsy a ailable o e iew and compa ible wi h he diagnosis o PSC.
ALP had o be ele a ed P1.5uppe limi o no mal (ULN) a baseline. Bo h
PSC pa ien s wi h o wi hou i i able bowel disease (IBD) we e included. Pa ien s
wi hou a de ini e diagnos ic exclusion o IBD equi ed a colonoscopy wi h seg-
men al biopsies p io o he baseline isi . Women o childbea ing po en ial
had o apply a highly e ec i e me hod o bi h con ol.
Key exclusion c i e ia included his o y o p esence o o he concomi an li e
diseases such as seconda y scle osing cholangi is, p ima y bilia y cholangi is,
cholangiocellula ca cinoma, hepa i is B o C in ec ion, Wilson’s disease,
haemoch oma osis, au oimmune hepa i is, ch onic alcoholic consump ion (daily
consump ion [30 g/d), o biopsy p o en NASH. Child-Pugh sco e B/C li e ci ho-
sis and pa ien s wi h his o y o p esence o hepa ic decompensa ion we e
excluded. In addi ion, pa ien s we e excluded i ecei ing immunosupp essi e
d ugs such as chlo ambucil, pen oxy ylline, penicillamine, pi enidone, ib a es,
biologicals (e.g. an i- umo nec osis ac o -
a
he apy), o i ampicin ea men
3 mon hs p io o baseline eco ding. Endoscopic ea men o bile duc s enosis
needed o planned wi hin 5 mon hs pos andomiza ion da e and ea men o
dominan bile duc s enosis wi hin 6 mon hs p io o baseline isi we e also
excluded. Mo eo e , pa ien s wi h a o al bili ubin [3.0 mg/dl ([50
l
mol/L) a
sc eening o baseline o ise in o al bili ubin o a leas 50% wi hin he las
6 mon hs p io o baseline we e excluded om his ial.
Placebo
no UDCA 500 mg/d
no UDCA 1,000 mg/d
no UDCA 1,500 mg/d
Randomiza ion
UDCA naï e
o
ollowing 8 wk
UDCA washou
Sc eening Follow−up
no UDCA
washou
Timeline
Day −70
Baseline
−14 −2
0W2W4W6W8W10W12
EOT
W16
4 wk
Fig. 1. T ial design o he NUC-3 PSC s udy. Pa ien s we e sc eened o eligibili y
and eligible pa ien s we e andomized in an equal a io o ei he 500 mg/d,
1,000 mg/d, 1,500 mg/d no UDCA, o placebo. A e andomiza ion, con ol isi s
we e pe o med a week 0, 2, 4, 6, 8, 10, and 12. A ollow-up isi was pe o med
4 weeks a e end o s udy (week 16). UDCA, u sodeoxycholic acid; no UDCA,
no u sodeoxycholic acid; wk o w, weeks; EOT, end o ea men .
Resea ch A icle
550 Jou nal o Hepa ology 2017 ol. 67 j549–558
Pa ien s we e o ake 250 mg capsules o no UDCA o o al use. G oups we e
di ided as ollows: g oup A, 2 x 250 mg capsules no UDCA; g oup B, 4 x 250 mg
capsules no UDCA; g oup C, 6 x 250 mg capsules no UDCA; g oup D, 0 (placebo).
All pa ien s we e o ake 6 capsules al oge he ( e um + placebo) in he mo ning
o gua an ee he blinding. The appea ance, size, and as e o he placebo capsules
o o al use we e indis inguishable om he e um capsules.
S udy assessmen s
A e andomiza ion, pa ien s we e moni o ed a baseline isi , in e im isi s a
weeks 2, 4, 6, and 8, end o ea men (EOT) a week 12, and ollow-up isi a
week 16 (Fig. 1). A all isi s i al signs, weigh , elec oca diog aphy and body
empe a u e we e con olled and labo a o y assessmen s included ou ine se um
biochemis y (alanine [ALT] and aspa a e amino ans e ases [AST], gamma-
glua myl anspep idase [
c
-GT], alkaline phospha ase [AP], o al and conjuga ed
bili ubin, albumin, c- eac i e p o ein [CRP], o al p o ein, se um c ea inine, lipase
lac ic dehyd ogenase [LDH]), hema ology (blood coun and di e en ial blood
coun ), and blood coagula ion es s (in e na ional no malized a io [INR], pa ial
h omboplas in [PTT]). Abdominal ul asound examina ion was done a he
sc eening isi and EOT. This allowed o li e size and echogenici y, he bile duc
sys em, gall bladde abno mali ies, po osys emic colla e als, spleen size, and any
o he abno mali ies o be e alua ed. Pa ien s su e ing om ulce a i e coli is
we e asked o s a a dia y one week be o e baseline un il he EOT isi , o eco d
he ou sub-sco es: numbe o s ools, blood in o on s ool, gene al wellbeing, and
abdominal pain/c amps. This dia y was used a e e y isi o calcula e he clinical
ac i i y index (CAI) acco ding o Rachmilewi z gene a ed by he elec onic Case
Repo Fo m. P u i us was assessed by isual analogue scale (VAS) by making a
e ical line om no i ching (0) o unbea able i ching (100). Fa igue was assessed
by ques ionnai e adap ed om he PBC-40 ques ionnai e.
24
Each i em was sco ed
on a 5-poin scale and he a igue sco e was calcula ed as he sum o sco es o
he ele en i ems. To assess he physician’s gene al o e all clinical imp ession o
he he apeu ic e ec and changes in he pa ien ’s condi ion he physician’s glo-
bal assessmen (PGA) scale was used.
25
The sho heal h scale (SHS) is a simpli ied
ou -i em ques ionnai e and was used o es ing he pa ien s’ quali y o li e.
26
Compliance was eco ded by coun ing he e u ned daily boxes o s udy medica-
ions. Ad e se e en s (AEs) ep esen ing any un a o able and unin ended sign
and symp om including abno mal labo a o y indings we e eco ded a each con-
ol isi . T ea men eme gen AEs we e de ined as any e en om he s a o
medica ion and occu ing wi hin he pe iod o ea men . SAEs included dea h,
any li e- h ea ening e en , equi emen o in-pa ien hospi aliza ion o p olon-
ga ion o exis ing hospi aliza ion, e en s wi h pe sis en o signi ican disabil-
i y/incapaci y, and congeni al anomaly/bi h de ec s.
S udy endpoin s
The p ima y e icacy a iable in his clinical ial was he ela i e change (%) in
ALP be ween he baseline isi and he EOT isi (LOCF), as se um ALP is a ele an
su oga e ma ke o p ognosis in PSC pa ien s.
27–29
This was calcula ed o each
pa ien as ollows:
100 ðALP½LOCFALP½baselineÞ=ALP½baseline
A alue o 25% calcula ed o a pa ien means a educ ion by 25%, i.e. he ALP
alue a EOT was h ee-qua e s he alue ha was measu ed a he baseline isi .
Seconda y e icacy endpoin s included a leas a 50% educ ion in ALP be ween
baseline and EOT; no maliza ion ( ULN) o pa ial no maliza ion ( 1.5ULN)
o ALP, absolu e and ela i e changes o ALP,
c
-GT, AST, ALT, and se um bili ubin
le els ( o al bili ubin and conjuga ed bili ubin) a each s udy isi (sc eening o
ollow-up), absolu e and ela i e changes o p u i us cou se measu ed by VAS,
a igue cou se, and success and he apeu ic bene i acco ding o PGA.
S a is ical me hods
The p ima y e icacy a iable was subjec o a con i ma o y s a is ical analysis
(p= 0.025, one-sided) in he con ex o a wo-s age g oup-sequen ial adap i e
s udy design. The sample size has been chosen o ensu e adequa e powe o
de ec absolu e di e ences in he mean ela i e change (%) in se um AP o abou
20%. Di e ences o his magni ude we e ega ded o be clinically meaning ul in
his p oo o concep s udy. The sample size equi ed was calcula ed using nQue y
Ad iso 6.01. This was done o an e ec size o 0.20/0.25 = 0.8 and a powe o
80%, wi h he esul ha 39 pa ien s pe ea men g oup we e equi ed. This cal-
cula ion did no ye ake he g oup-sequen ial adap i e s udy design in o accoun .
The s udy was conduc ed acco ding o a 2-s age g oup-sequen ial es design
wi h possible sample size adap a ion a he in e im analysis. To p ese e he
o e all (expe imen -wise) one-sided ype I e o a e o
a
= 0.025 in he analysis
o he p ima y endpoin , bounda ies calcula ed acco ding o O’B ien and Fleming
we e applied wi h a c i ical alue a he inal analysis o 2.015. The in e se no -
mal me hod o combining p alues was used wi h p ospec i ely planned in o ma-
ion a es o 0.75 and 1.0
30
a he in e im analysis and a he inal analysis,
espec i ely. This means ha a sample size o 40 pa ien s pe ea men g oup
was adequa e (40/39 = 1.0256). The planned sample size was he e o e 160
pa ien s (1:1:1:1 andomiza ion, i.e. abou 40 pa ien s pe ea men g oup) in
he ull analysis se (FAS) i he s udy was comple ed wi hou modi ica ion ol-
lowing he in e im analysis, which was planned a e and pe o med based on
120 FAS pa ien s (abou 30 pe g oup). A e he in e im analysis, no sample size
adap a ion was equi ed. The p ima y e icacy endpoin in his clinical ial was
he mean ela i e change (%) in se um ALP le els be ween he baseline isi
and he EOT isi . The absolu e change om baseline o a subsequen isi and
o he EOT isi was calcula ed as he alue a he isi minus he baseline alue.
Compa isons be ween ea men g oups we e pe o med in wo s eps: The i s
analysis s ep compa ed each no UDCA ea men g oup agains placebo, he sec-
ond analysis s ep was used o pai wise compa isons among he h ee no UDCA
ea men g oups. Only i all h ee hypo heses o he i s s ep had been ejec ed,
he second s ep was o be pe o med in a con i ma o y sense. In o de o adjus
o mul iplici y wi hin each analysis s ep, a closed es ing p ocedu e using Simes
in e sec ion es s
31
was applied o each s ep. The in e se no mal p ocedu e was
applied o Simes adjus ed p alues. Co esponding p alues we e combined, i.e.
he p alues o he global hypo hesis based on pa ien s included in he in e im
analysis was combined wi h he p alue based on he emaining pa ien s, he
pai wise in e sec ion p alues we e combined wi h hei coun e pa s, as well
as he p alues o he elemen a y hypo heses. The global hypo hesis (in e sec ion
o he 3 elemen a y hypo heses) could be ejec ed i he global es s a is ic (FAS)
esul ing om he in e se no mal me hod exceeded he c i ical alue. In his case,
i was o be de e mined which o he elemen a y hypo heses could be ejec ed by
he closed es ing p ocedu e. One-sided p alues o he analysis o he p ima y
endpoin we e calcula ed using Wilcoxon ank sum es s. Calcula ions we e pe -
o med using SAS
Ò
( e sion 9.3, SAS Ins i u e, USA) and using ADDPLAN
Ò
(licensed by ADDPLAN, Inc., an ICON Clinical Resea ch, LLC company). Desc ip i e
s a is ical me hods we e used o analyze all a iables. Con inuous a iables a e
summa ized using he numbe o obse a ions, a i hme ic mean, and s anda d
de ia ion. Ca ego ical da a a e desc ibed using absolu e and ela i e equencies.
The e was no conside able numbe o cen e s con ibu ing a leas h ee pa ien s
pe ea men g oup. The e o e, a possible cen e e ec was no explo ed. A pos-
sible e ec o geog aphical clus e was explo ed by p esen ing desc ip i e sum-
ma y s a is ics o he p ima y e icacy endpoin s a i ied by geog aphical
clus e . The ollowing geog aphical clus e s we e used: Aus ia, Ge many, Hun-
ga y, Uni ed Kingdom, Scandina ia (Denma k, Finland, No way, Sweden), Benelux
(Belgium, The Ne he lands), and o he coun ies (Li huania, Spain).
Fo u he de ails ega ding he ma e ials used, please e e o he CTAT
able.
ClinicalT ials.go numbe : NCT01755507.
222 sc eened
161 andomized
159 ecei ed s udy
medica ion
In en ion o ea (ITT)
analysis
51 P s. iola ed inclusion/exclusion c i e ia
5 P s. wi hd ew hei consen
2 P s. used p ohibi ed concomi an medica ion
1 P . had a 50% ise in bili ubin du ing sc eening
1 P . had a p e ea men SAE
1 P . due o gene al s op o andomiza ion
2 wi hd ew p io o dosing
61 sc eening ailu es (27.5%):
Fig. 2. Pa ien ec ui men . O 222 pa ien s assessed o eligibili y, 161 we e
andomized and 159 ecei ed he s udy medica ion. The sample size equi ed
was calcula ed using nQue y Ad iso 6.01. This was done o an e ec size o 0.20/
0.25 = 0.8 and a powe o 80%, wi h he esul ha 39 pa ien s pe ea men
g oup we e equi ed. ITT, in en ion o ea ; SAE, se ious ad e se e en ; P s,
pa ien s; Pa , pa ien .
JOURNAL OF HEPATOLOGY
Jou nal o Hepa ology 2017 ol. 67 j549–558 551
Resul s
In o al, 231 sc eenings we e pe o med in 222 pa ien s. Six y-
one ou o 222 sc eened pa ien s we e no eligible o andomiza-
ion. The main eason o sc eening ailu e was iola ion o inclu-
sion o exclusion c i e ia in 51 pa ien s. The s udy low cha and
addi ional easons o sc eening ailu e a e gi en in Fig. 2. Da a o
sc eening ailu es and da a o wo pa ien s who did no ake he
s udy medica ion (one was wi hd awn because o lack o coope -
a ion, he o he because o iola ion o an exclusion c i e ion a e
andomiza ion) we e no included in he s a is ical analysis. Con-
sequen ly, 159 ecei ed he s udy medica ion comp ising he
in en ion o ea (ITT) analysis popula ion. Ou o he
159 pa ien s who we e ea ed wi h s udy medica ion,
21 pa ien s discon inued he ea men phase p ema u ely (no -
UDCA 500 mg: 10, 25.6%; no UDCA 1,000 mg: 4, 9.8%; no UD-
CA 1,500 mg: 3, 7.7%, placebo: 4, 10.0%). The mos equen
p ima y easons we e iola ion o inclusion o exclusion c i e ia
(coming o ligh a e andomiza ion) o in ake o p ohibi ed con-
comi an medica ion. The numbe o pa ien s e mina ing he
ea men phase because o lack o e icacy was: no UD-
CA 500 mg: 1 pa ien , no UDCA 1,000 mg: 0 pa ien , no UDCA
1,500 mg: 1 pa ien , and wo in he placebo g oup.
Pa ien cha ac e is ics
The main baseline cha ac e is ics o he 159 pa ien s ea ed a e
shown in Table 1. O e all and o each ea men g oup, he
majo i y o pa ien s we e male (109/159; 68.6%), e lec ing he
na u al gende dis ibu ion in PSC pa ien s. The e was no signi -
ican di e ence be ween s udy g oups wi h ega d o age, weigh ,
heigh , BMI, and ALP se um le els a baseline indica ing ha he
ou ea men g oups we e well balanced a en ollmen . A ange
om 6 o 8 o newly diagnosed PSC pa ien s was compa able
be ween he di e en ea men g oups, anging om 15% and
20% (Table 1), wi h he highes pe cen age in he placebo g oup.
The a e o concomi an IBD was highes wi hin he no UDCA 500
mg g oup (77%) and lowes wi hin he placebo g oup (50%), how-
e e his di e ence did no each s a is ical di e ences. The e
was no co ec ion o IBD p esence wi h espec o alloca ion o
ea men g oups. In he ac i e ea men g oups, he median
ime since he i s symp oms o IBD was abou 13.5 yea s, and
he median du a ion o IBD disease was abou 11.5 yea s
(Table 1). The median du a ion o PSC was 6.9 yea s in he pla-
cebo g oup and 6.9, 3.7, and 4.3 yea s in he 500, 1,000, and
1,500 mg no UDCA g oup espec i ely ( a ia ion no g ea e han
expec ed by chance). Se um ALP alues we e p o oundly ele a ed
a baseline in all ea men g oups anging om 369 IU/L in he
no UDCA 1,000 mg g oup o 495 IU/L in he no UDCA 500 mg
g oup, indica ing ha all ea men g oups had p onounced
choles asis. Ou o 159 s udy pa ien s, 113 (71.0%) we e UDCA
expe ienced, 58 (51.3%) o hese we e UDCA esponde s de ined
by pa ial no maliza ion o ALP a in es iga o ’s disc e ion and
55 (48.7%) UDCA non- esponde s. Fo y ou o 159 (25.2%)
pa ien s we e UDCA naї e, he esponse o p e ious UDCA ea -
men was unknown o no applicable o he emaining 6/159
(3.8%) andomized pa ien s (Table 1). In he ac i e ea men
g oups, he p opo ion o UDCA non- esponde s anged be ween
51.8% in no UDCA 1,500 mg g oup and 54.8% in he no UDCA
1,000 mg g oup, whe eas in he placebo g oup only 33.3% we e
UDCA non- esponde s, de ined acco ding o he in es iga o s’
disc e ion (and he e o e lacking a uni e sal de ini ion). The
UDCA doses we e in a simila ange (be ween 12 and 15 mg/kg/
d) in UDCA esponde s and non- esponde s (Table 1). The e
was no di e ence be ween he g oups wi h ega d o cu en p u-
i us o p e ious p u i us episodes epo ed by pa ien s anging
om 40.0% in he placebo g oups o 64.1% in he no UDCA 500
mg g oup. Fa igue a baseline was epo ed om 45.0% in he pla-
cebo g oup up o 70.7% in he no UDCA 1,000 mg g oup.
Table 1.Demog aphic and baseline cha ac e is ics o andomized and ea ed pa ien s.
Placebo
(N = 40)
no UDCA
500 mg
(N = 39)
no UDCA
1,000 mg
(N = 41)
no UDCA
1,500 mg
(N = 39)
Male, N (%) 25 (62.5%) 27 (69.2%) 28 (68.3%) 29 (74.4%)
Female, N (%) 15 (37.5%) 12 (30.8%) 13 (31.7%) 10 (25.6%)
Age (y ), (mean SD) 44.1 (14.89) 40.9 (12.24) 42.3 (13.08) 41.0 (13.11)
Weigh (kg), (mean SD) 78.7 (13.63) 75.5 (13.51) 79.1 (15.37) 77.7 (15.65)
Heigh (cm), (mean SD) 176.0 (12.14) 176.0 (9.01) 175.7 (8.06) 176.9 (11.30)
BMI (kg/m
2
), (mean SD) 25.5 (3.93) 24.3 (3.87) 25.6 (4.94) 24.8 (3.78)
Du a ion o PSC (Mon hs), (median ange) 83 (2–343) 83 (1–345) 45 (2–242) 52 (2–311)
New diagnosis o PSC, N (%) 8 (20.0%) 6 (15.4%) 8 (19.5%) 7 (17.9%)
IBD a sc eening
Ulce a i e coli is, N (%)
C ohn‘s disease, N (%)
50%
15 (37.5%)
5 (12.5%)
77%
27 (69.2%)
3 (7.7%)
65%
22 (53.7%)
5 (12.2%)
64%
24 (61.5%)
1 (2.6%)
Time since i s IBD symp oms
(Mon hs), (median ange)
162 (36–451) 183 (10–416) 151 (4–526) 140 (11–476)
ALP a baseline (U/L), (mean SD) 456 (234.4) 495 (282.4) 369 (200.6) 464 (241.6)
UDCA naï e, N (%) 12 (30.0%) 9 (23.1%) 9 (22.0%) 10 (25.6%)
UDCA p e- ea men , N (%) 27 (67.5%) 28 (71.8%) 31 (75.6%) 27 (69.2%)
Responde , N (%)
Mean p e ious dose, mg/kg/d
18 (66.7%)
14.5
13 (46.4%)
13.7
14 (45.2%)
12.2
13 (48.2%)
13.3
Non- esponde , N (%)
Mean p e ious dose, mg/kg/d
9 (33.3%)
14.3
15 (53.6%)
13.0
17 (54.8%)
14.4
14 (51.8%)
15.3
Unknown UDCA exposu e, N (%) 1 (2.5%) 2 (5.1%) 1 (2.4%) 2 (5.1%)
Resea ch A icle
552 Jou nal o Hepa ology 2017 ol. 67 j549–558
No UDCA signi ican ly educes se um ALP le els in a dose-dependen
ashion in PSC pa ien s
The ela i e educ ion o se um ALP alues was chosen as he p i-
ma y endpoin o his s udy, since ALP le els cu en ly ep esen
he bes a ailable su oga e pa ame e o PSC pa ien s and
he e o e appea ed mos sui able o his sho - e m s udy.
27–29
In each no UDCA g oup, he ela i e educ ion o se um ALP
was s a is ically signi ican ly supe io o placebo in he analysis
o he p ima y endpoin showing dose-dependen educ ions by
12.3%, 17.3%, and 26.0% in he 500, 1,000, and 1,500 mg/d
no UDCA g oups espec i ely (Fig. 3). Thus, he s udy was posi-
i e on ITT o all no UDCA ea men g oups. S a is ically signi -
ican di e ences compa ed o placebo we e also seen o all h ee
no UDCA g oups in he pe p o ocol se (da a o pe p o ocol
analysis no shown). Possible con ounding e ec s o geog aphical
clus e s we e no de ec ed by s a i ied analysis o he ela i e
educ ion o se um ALP (da a no shown). The pe cen age o ea-
ed pa ien s eaching p ognos ically meaning ul educ ions o
ALP de ined as se um le els 61.5- old he ULN
27,28
was: 12.5%
(5/40) in he placebo g oup, 12.8% (5/39) in he no UDCA 500
mg g oup, 41.5% (17/41) in he 1,000 mg g oup ( he g oup s a -
ing wi h he lowes ALP le els), and 30.8% (12/39) in he 1,500 mg
g oup. ALP le els wi hin ULN we e ound in 2/40 (5.0%) o he
placebo g oup, 1/39 (2.6%) o he no UDCA 500 mg g oup, 5/41
(12.2%) in he 1,000 mg g oup, and 4/39 (10.3%) o he
1,500 mg g oup. Mo eo e , all h ee no UDCA doses induced a
apid dec ease in se um ALP le els wi hin 4 weeks, which was
again mos p onounced in he highes no UDCA ea men g oup
(Fig. 4A). A pos -hoc analysis wi h espec o he daily no UDCA
dose/kg body weigh con i med he main esul o his s udy, as
well as a dose selec ion o he phase III p og am (da a no
shown). Se um ALP le els emained ela i ely s able h oughou
he ea men pe iod in he no UDCA ea men a ms, bu
e u ned nea ly o baseline le els a he end o he ollow-up pe -
iod, indica ing a p onounced ebound o se um ALP le els ollow-
ing discon inua ion o no UDCA ea men . In con as , in he
placebo g oup ALP le els inc eased 1.2% du ing he s udy pe iod
un il EOT (Fig. 3). In e es ingly, ALP se um le els dec eased in he
placebo g oup om EOT o he ollow-up isi . This could a leas
in pa be ela ed o mo e equen ein oduc ion o UDCA ea -
men in he placebo a m (9/40 = 22.5% pa ien s; s. 4/39 = 10.3%
no UDCA 500 mg; 2/41 = 4.9% no UDCA 1,000 mg; 5/39 = 12.8%
no UDCA 1,500 mg) ollowing he ac i e ea men pe iod upon
physician’s disc e ion. I may also be o in e es o no e ha 8
ou o hese 9 pa ien s we e classi ied as UDCA esponde s be o e
s udy en y and ha he p opo ion o pa ien s ecei ing UDCA
a e placebo in he ollow-up pe iod was abou double he num-
be in he ac i e ea men g oups (Table S1). Se um bili ubin
le els did no signi ican ly di e be ween ea men g oups a
he di e en ime poin s (Table S2).
No UDCA signi ican ly educes
c
-GT, ALT, and AST se um le els in
PSC pa ien s
No UDCA signi ican ly educed se um
c
-GT le els in a dose-
dependen ashion, and was mos p onounced wi h a mean
educ ion o 33.9% in he no UDCA 1,500 mg g oup ( o absolu e
alues see Fig. 4B). No ably, he dose-dependency o he bio-
chemical no UDCA e ec s in he educ ion o se um enzyme
le els was mos appa en o se um
c
-GT compa ed o he o he
se um pa ame e s (Fig. 4). In pa allel o he educ ion o he cho-
les a ic li e enzymes, he median educ ion o se um AST le els
was 20.5% and 33.1% in ALT le els a EOT ( o absolu e alues see
Fig. 4C and D, espec i ely). As obse ed o ALP, ollowing a sig-
ni ican educ ion unde no UDCA ea men , a p onounced
0
−10
−20
−30
−40
−50
Change in ALP (%)
Placebo
(N = 40)
NU 500 mg
(N = 39)
NU 1,000 mg
(N = 41)
NU 1,500 mg
(N = 39)
+1.2 %
−12.3 %
−17.3 %
−26 %
*
*
*#
Fig. 3. Pe cen age change in se um le els o ALP a e 12 weeks compa ed o
baseline alues. Se um ALP le els dec eased in a dose-dependen manne in
esponse o no UDCA ea men wi h he mos p onounced educ ion in he
1,500 mg no UDCA a m. NU, no U sodeoxycholic acid.*Indica es p 0.01 com-
pa ed o placebo; #Indica es p 0.025 compa ison o NU 1,500 mg s. NU 500 mg.
A closed es ing p ocedu e using Simes in e sec ion es s
31
was applied o each
g oup compa ison (compa ison o each no UDCA ea men g oup agains placebo
and pai wise compa isons among he h ee no UDCA ea men g oups). The
in e se no mal p ocedu e was applied o Simes adjus ed p alues. One-sided p
alues o he analysis o he p ima y endpoin we e calcula ed using Wilcoxon
ank sum es s.
0
−40
−80
−120
—160
U/L
Δ ALP
Baseline
W4
W8
W12
Follow−up
0
−60
−180
−240
−360
Δ γGT
20
0
−20
−60
−80
Δ ALT
−120
−300
−40
20
0
−20
−60
−80
−40
Δ AST
Baseline
W4
W8
W12
Follow−up
Baseline
W4
W8
W12
Follow−up
Baseline
W4
W8
W12
Follow−up
Placebo
NU 500 mg
NU 1,000 mg
NU 1,500 mg
Fig. 4. Absolu e changes in se um ALP,
c
GT, ALT, and AST le els h oughou he s udy pe iod. Y axis indica es absolu e changes (U/L) compa ed o baseline le els. NU,
no U sodeoxycholic acid. Placebo g oup, g ay ci cles; 500 mg NU g oup, black ci cles; 1,000 mg NU g oup ligh diamonds; 1,500 mg NU g oup, da k squa es. Desc ip i e
s a is ical me hods we e used o analyze all a iables. Con inuous a iables a e summa ized using he numbe o obse a ions, a i hme ic mean, and s anda d de ia ion.
JOURNAL OF HEPATOLOGY
Jou nal o Hepa ology 2017 ol. 67 j549–558 553
ebound o
c
-GT, AST, and ALT se um le els was e iden om
EOT o he ollow-up isi .
No UDCA esponse is no p edic ed by p e ious UDCA ea men ,
p e ious UDCA esponse, p esence o IBD, o du a ion o PSC
Impo an ly, a dose-dependen educ ion o ALP was obse ed in
bo h sexes and independen o p e ious UDCA-p e ea men and
esponse (Table 2). Simila ly, p esence o IBD, du a ion o PSC and
baseline ALP le els had no impac on he dose-dependen
esponse o no UDCA (Table 2). No ably, he pe cen age o
pa ien s wi hou he apeu ic esponse o no UDCA (de ined as
an ALP a EOT abo e sc eening alues when mos pa ien s we e
s ill on UDCA) declined sha ply wi h inc easing no UDCA doses,
again independen ly o p e ious UDCA p e ea men and
esponse (Fig. S1).
Pa ien ela ed ou comes
Body weigh , body empe a u e, and i al signs did no show any
ele an changes om baseline o EOT in all ou ea men
g oups. I is in e es ing o no e, ha 7 (17.9%) pa ien s showed
enla ged spleen a baseline in he no UDCA 500 mg g oup, 3
(7.3%) in he 1,000 mg g oup, and 3 in he 1,500 mg g oup. A
EOT his numbe was educed o 4 (10.3%), 0, and 0 pa ien s in
each e um- ea ed g oup espec i ely, while he numbe o
pa ien s wi h enla ged spleen was 2 (5%) in he placebo g oup
a baseline and inc eased o 3 (7.5%) a EOT. The mean alues
o CAI sum we e low in all ea men g oups a baseline and
EOT (1.3/1.7 no UDCA 500 mg g oup, 0.9/1.0 1,000 mg g oup,
2.0/1.3 1,500 mg g oup, and 2.1/1.5 in he placebo g oup). The
sub-sco es wi h he highes mean alues a baseline we e; sco e
o numbe o s ools, sco e o gene al wellbeing, sco e o bloody
s ools, sco e o abdominal pain/c amps and labo a o y indings.
Sub-sco es showed some a iabili y bu no end among ea -
men g oups. In addi ion, he e was no s a is ical signi ican di -
e ence in SHS sco es be ween ea men g oups bu indica ed a
sligh imp o emen om baseline o EOT o he no UDCA
1,500 mg g oup o each indi idual dimension. Using he sum
o ele en ques ions o he calcula ion o he a igue sco e he e
was no signi ican di e ence om baseline (placebo: 23.0, no -
UDCA 500 mg: 21.0, 1,000 mg: 19.7, 1,500 mg: 23.3) o EOT (pla-
cebo 21.3, no UDCA 500 mg: 20.7, 1,000 mg: 19.8; 1,500 mg:
20.2) and be ween ea men g oups. Howe e , a sligh imp o e-
men o symp oms acco ding o PGA o e icacy could be achie ed
a EOT o 43.6% o pa ien s in he 1,500 mg no UDCA g oup,
29.3% in he 1,000 mg, 23.1% in he 500 mg, and 30% in he pla-
cebo g oup. These di e ences did no each s a is ical
signi icance.
No UDCA showed a a o able sa e y p o ile
Tole abili y o he s udy medica ion was desc ibed as e y good
in he as majo i y o pa ien s and in es iga o s. A poo ole a-
bili y was desc ibed only by wo pa ien s (4.9%) in he no UDCA
1,000 mg g oup and by one pa ien (2.5%) in he placebo g oup.
Tole abili y was desc ibed as equally good in all ea men a ms.
No pa ien died du ing he cou se o his s udy. The pe cen age o
ea men eme gen AEs was 80%, 59%, 73%, and 67% in he pla-
cebo g oup, o he no UDCA 500 mg, he no UDCA 1,000 mg
g oup, and no UDCA 1,500 mg g oups espec i ely. In o al eigh
ea men eme gen SAEs we e no ed in 8 pa ien s, 3 in he no -
UDCA 500 mg g oup, 1 in he no UDCA 1000 mg, 1 in he 1500
no UDCA g oup, 3 in he placebo g oup. The numbe o ea men
eme gen SAEs was he e o e simila be ween ea men g oups.
Only one SAE in he placebo g oup was desc ibed by an in es i-
ga o as possibly being ela ed o in es iga ional medicinal p o-
duc (IMP) (ocula ic e us/lack o clinical e icacy). An
addi ional i e SAEs, no ela ed o ea men , we e also ca ego-
ized as ‘‘disease p og ession/lack o clinical e icacy”. The
emaining wo SAEs we e a emo al o meniscus and a diagnosis
o colon cance 4 days a e s a o ea men . T ea men eme -
gen AEs epo ed in mo e han 10 pa ien s we e abdominal pain
(11), a igue (13), nasopha yngi is (30), headache (13), and p u i-
us (17). The e we e no di e ences in he incidence o AEs
be ween ea men g oups ela ed o dose-dependen e ec s,
and none compa ed o placebo. In addi ion, he pe cen age o
ad e se d ug eac ions was compa able in all g oups wi h 28%,
23%, 32%, and 28% in he placebo g oup, o he no UDCA
500 mg, he no UDCA 1,000 mg, and no UDCA 1,500 mg g oups
espec i ely. The mos common AEs wi h he mos p ominen
being nasopha yngi is in all ea men g oups a e lis ed in Table 3.
No ably, p u i us occu ed simila ly ac oss ea men a ms and
gene ally a low equencies: 7 e en s in he 500 mg/d g oup, 7
in he 1,000 mg/d g oup, 12 in he 1,500 mg/d g oup, and 10 in
he placebo g oup. Impo an ly p u i us was mild and no pa ien
Table 2.Rela i e changes (%) in ALP se um le els om baseline o EOT acco ding o UDCA p e ea men as well as UDCA ea men esponse and o he clinical
pa ame e s.
Placebo
(N = 40)
no UDCA
500 mg
(N = 39)
no UDCA
1,000 mg
(N = 41)
no UDCA
1,500 mg
(N = 39)
Male, mean % (N) +4.7% (25) 14.1% (27) 13.9% (28) 27.8% (29)
Female, mean % (N) 4.6% (15) 8.3% (12) 24.7% (13) 20.5% (10)
UDCA esponde , mean % (N) 6.2% (18) 9.9% (13) 16.4% (14) 19.5% (13)
UDCA non- esponde , mean % (N) 3.5% (9) 10.1 (15) 14.9% (17) 27.3% (14)
UDCA naï e, mean % (N) +12.3% (12) 14.9% (9) 24.8% (9) 32.0% (10)
ALP[3ULN, mean % (N) 0.9% (25) 14.4% (23) 19.7% (17) 26.2% (22)
ALP 63ULN, mean % (N) 4.8% (15) 9.2% (16) 15.6% (24) 25.7% (17)
PSC wi h IBD, mean % (N)
*
5.8% (20) 10.4% (29) 14.5% (27) 24.0% (27)
PSC wi hou IBD, mean % (N)
*
4.8% (18) 21.8% (8) 22.8% (14) 29.9% (11)
PSC du a ion 65 y , mean % (N)
**
8.3% (15) 10.5% (17) 20.3% (22) 28.2% (20)
PSC du a ion [5 y , mean % (N)
**
3.0% (24) 13.7% (22) 13.4% (18) 23.7% (19)
*
In N = 5 no classi ica ion o IBD o non-IBD was possible.
**
In N = 2 da a om he i s PSC diagnosis was no documen ed.
Resea ch A icle
554 Jou nal o Hepa ology 2017 ol. 67 j549–558
discon inued ea men . The e we e no signi ican di e ences o
sco es o p u i us be ween baseline isi (placebo 15.4, 500 mg
9.9, 1,000 mg 14.8, 1,500 mg 16.5; scale 0–100 mm) and EOT
(placebo 15.3, 500 mg 10.8, 1,000 mg 20.9, 1,500 mg 15.2) and
be ween all ea men g oups. The e was no e ec on IBD
ac i i y. Taken oge he he sa e y p o ile o no UDCA seems o
be a o able and no wa ning signs eme ged om he da a o his
s udy.
Discussion
Fo decades he e has been no signi ican p og ess in he medical
he apy o PSC. This double-blind, andomized, placebo-
con olled, dose inding s udy is a p oo o concep s udy and
he i s human s udy wi h no UDCA o assess i s e icacy, sa e y
and ole abili y in PSC pa ien s. The main indings o he s udy
a e: (i) no UDCA esul ed in a signi ican educ ion o ALP alues
in PSC pa ien s wi hin 12 weeks o ea men compa ed o pla-
cebo, (ii) he posi i e e ec s occu ed in a dose-dependen man-
ne , and (iii) he sa e y p o ile o no UDCA was compa able o
placebo in ou s udy.
All h ee no UDCA doses es ed in his s udy esul ed in a sig-
ni ican educ ion in ALP, which was mos p onounced in he
1,500 mg a m and consequen ly all no UDCA ea men a ms
eached he p ima y e icacy endpoin a ITT analysis as de ined
o his s udy. In addi ion, he decline in ALP le els was pa alleled
by signi ican educ ions in ALT, AST, and
c
-GT le els. In pa icu-
la , he ime cou se o
c
-GT le els unco e ed he mos
p onounced ela ionship be ween no UDCA doses and i s
biochemical e ec . In addi ion o se ing as a biochemical pa am-
e e o choles asis in PSC pa ien s, se um
c
-GT le els may also
e lec in lamma ion- igge ed hepa ic oxida i e s ess,
32–34
which may be signi ican ly educed upon no UDCA ea men as
obse ed p e iously in p eclinical models.
14–17
Since spleen size
may also e lec PSC ac i i y
35
i is wo h no ing ha 13 e um-
ea ed pa ien s showed inc eased spleen size a baseline bu only
4 pa ien s a EOT. Po en ial an i-in lamma o y e ec s o no UDCA
need de ailed u u e mechanis ic s udies. In e es ingly, pa ien s in
he placebo a m showed a dec ease in all se um pa ame e s es ed
in he ollow-up pe iod o he s udy compa able o he e ec o
no UDCA in he e um g oup. This maybe p ima ily ela ed o
he mo e equen ein oduc ion o UDCA ea men in his s udy
g oup o pa ien s who con inued o show p o oundly ele a ed
choles asis pa ame e s h oughou he ea men pe iod, a e
discon inua ion o UDCA in he p e-s udy washou phase. I is also
impo an o no e ha he mos p onounced ela i e dec ease in
se um ALP le els was obse ed in he 1,500 mg no UDCA g oup
wi h a 26% educ ion indica ing a dose-dependen e ec o no -
UDCA. This obse a ion, as well as he ac he 1,500 mg no UDCA
dose was also well ole a ed, is also ele an o he dose selec ion
o u u e phase III clinical ial in PSC pa ien s. Impo an ly 12.8%
o pa ien s achie ed a educ ion o se um ALP le els 61.5 he
ULN in he no UDCA 500 mg g oup, 41.5% in he 1,000 mg no -
UDCA g oup, 30.8% in he 1,500 mg no UDCA g oup, and 12.5%
in he placebo g oup, which was p e iously shown o be o po en-
ial p ognos ic impo ance in PSC pa ien s.
28,36,37
Al hough a di ec compa ison o he cu en s udy wi h p e i-
ous UDCA ials in PSC is no possible due o subs an ial di e -
ences in s udy design, UDCA has also demons a ed p onounced
ALP educ ion in he ange obse ed o no UDCA he ein o e en
highe .
6–8
Along hese lines, i is also impo an o no e ha in
he pos -hoc analyses o he e y high dose UDCA ials as
epo ed by S anich e al.
27
and o he Scandina ian UDCA ial
by Linds öm e al.,
38
pa ien s wi h no maliza ion o ALP had a
be e p ognosis, al hough his was no necessa ily ela ed o
UDCA use. This may unde sco e he p ognos ic ele ance o ALP
no maliza ion in PSC pa ien s, bu also poin s owa ds a po en ial
dissocia ion om ac i e d ug (UDCA) ea men . Impo an ly,
based on ou p eclinical indings no UDCA can be expec ed o
ha e p o oundly di e en /addi ional mechanisms han UDCA,
which may no be ully e lec ed by biochemical imp o emen
in sho - e m phase II s udies. Fo ou cu en s udy, i is essen ial
o no e ha he obse ed esponse o no UDCA ea men was
independen o whe he pa ien s we e UDCA-naï e o -
expe ienced and whe he he physicians ca ego ized hem as
UDCA non- esponde o esponde s. The e may howe e s ill be
PSC pa ien s who may bene i om UDCA ea men , po en ially
hose wi h a signi ican educ ion in ALP se um le els. In e es -
ingly, he no UDCA-induced all in se um ALP le els was mos
p onounced wi hin he i s wo weeks o ea men . Conse-
quen ly, i appea s plausible ha no UDCA may educe he is-
cosi y o bile immedia ely a e s a ing he ea men , since i
ep esen s a po en pha macological induce o bilia y bica bon-
a e sec e ion and he e o e p o ec s he li e .
39
The sa e y p o ile o no UDCA as obse ed in ou s udy was
e y encou aging. Mos impo an ly he e was no s a is ical di -
e ence wi h ela ion o ea men eme gen AEs be ween no -
UDCA and placebo a ms. The mos equen ly epo ed
complain s we e ela ed o nasopha yngi is, which was also com-
pa able be ween all ea men a ms. The numbe o epo ed
SAEs was gene ally low and equally in all ea men a ms. Conse-
quen ly, he epo ed AEs in his s udy do no aise ala m o no -
UDCA ea men in PSC pa ien s. This is pa icula ly impo an o
p u i us, which was no mo e equen ly obse ed in he no -
UDCA a ms, as p u i us may ep esen a se ious p oblem associ-
a ed wi h bile acid ea men in choles a ic pa ien s.
40–42
We did
no obse e any signi ican di e ences conce ning a igue sco e,
CAI, and PGA be ween baseline and EOT in all ea men a ms.
Howe e , i may be o e ambi ious o expec signi ican di e -
ences wi hin 12 weeks o no UDCA ea men ; no ably we also
obse ed no wo sening in hese sco es, which indica es a leas
ha no UDCA was well ole a ed in all ac i e ea men a ms.
Impo an ly, his no UDCA s udy, he i s conduc ed in humans,
excluded pa ien s wi h main bile duc s ic u es o ecen need
o endoscopic he apy, as we had po en ial conce ns ega ding
he po en chole e ic ac ions o no UDCA obse ed p eclini-
cally.
23,14,15
P edic ing he ela i e isk o po en ial agg a a ion
o po al hype ension o he de elopmen o bile in a c s in
Table 3.Mos common ad e se e en s.
Placebo
(N = 40)
no UDCA
500 mg
(N = 39)
no UDCA
1,000 mg
(N = 41)
no UDCA
1,500 mg
(N = 39)
Abdominal pain 5 (12.5%) 1 (2.6%) 4 (9.8%) 1 (2.6%)
Dia hea 4 (10.0%) 0 (0.0%) 1 (2.4%) 3 (7.7%)
Fa igue 4 (10.0%) 2 (5.1%) 2 (4.9%) 5 (12.8%)
Nasopha yngi is 7 (17.5%) 6 (15.4%) 9 (22.0%) 8 (20.5%)
A h algia 4 (10.0%) 1 (2.6%) 1 (2.4%) 0 (0.0%)
Back pain 4 (10.0%) 1 (2.6%) 0 (0.0%) 3 (7.7%)
Headache 3 (7.5%) 2 (5.1%) 1 (2.4%) 7 (17.9%)
P u i us 4 (10.0%) 3 (7.7%) 4 (9.8%) 6 (15.4%)
Numbe o pa ien s (%) wi h ea men eme gen ad e se e en s.
JOURNAL OF HEPATOLOGY
Jou nal o Hepa ology 2017 ol. 67 j549–558 555
no UDCA- ea ed PSC pa ien s wi h mo e ad anced disease o
main bile duc s ic u es will be e y challenging. This may
become e en mo e complex when combina ion he apy o no -
UDCA wi h UDCA is conside ed in u u e s udies, since he com-
pounds may ha e addi i e bene icial e ec s.
23
The e o e closely
spaced, clinical, and biochemical con ols will be necessa y o
he bes sa e y o ou pa ien s in a u u e phase III clinical ial.
This no UDCA phase II dose inding s udy in PSC has se e al
limi a ions including he lack o C4 bile acids and FGF19 se um
le els. The p ima y e icacy a iable o his phase II clinical ial
was de ined as he ela i e change (%) in se um ALP be ween
he baseline isi and he EOT, since ALP, ansien elas og aphy,
and his ology a e cu en ly seen as he mos p omising candida e
su oga e endpoin s o clinical ials in PSC pa ien s.
29,36,43,44
Howe e , p onounced changes in li e s i ness o li e his ology
may be a he ambi ious o expec wi hin a sho ea men pe -
iod o 12 weeks in PSC pa ien s and he e o e ha e no been cho-
sen as p ima y endpoin s o his s udy. Mo eo e , he obse ed
signi ican educ ion in ALP alues in all no UDCA ea men a ms
in ou s udy should no be o e es ima ed a his s age. A andom-
ized con olled ial es ing high doses o UDCA (17 o 23 mg/kg/-
day) showed a a o able biochemical end bu lacked signi ican
e ec s on ha d clinical endpoin s such as ansplan - ee su i al
and was in addi ion p obably unde powe ed.
10
Tes ing e en
highe doses (28–30 mg/kg/day) in PSC pa ien s again e ealed
an imp o emen in se um li e es s including ALP bu we e
associa ed wi h ad e se clinical ou comes.
11
In he cu en s udy,
PSC pa ien s wi h mo e ad anced disease wi h Child-Pugh class B
and C and hose wi h se um bili ubin le els highe han 3 mg/dl
ha e been excluded due o po en ial sa e y easons. Conse-
quen ly, i is cu en ly unclea whe he no UDCA will be sa e o
use in hese pa ien s.
In summa y, he he ein p esen ed indings jus i y a phase III
clinical ial o no UDCA ea men in PSC pa ien s. The design
o such a ial poses se e al key ques ions: (i) a u u e s udy
should conside combined endpoin s wi h se um ALP le els, an-
sien elas og aphy, p ope assessmen o spleen size, and li e
his ology. Ha d clinical endpoin s such as need o li e ans-
plan a ion o dea h will be un ealis ic s udy endpoin s o such
a a e disease wi h a highly a iable clinical cou se. (ii) The di e -
en he apeu ic mechanisms and pha macodynamics o no UDCA
and i s mo he compound UDCA may p o ide a po en ial a io-
nale o combining no UDCA and UDCA in he ea men o PSC,
which has o be demons a ed in a combina ion he apy a m.
(iii) Based on ou cu en da a he daily no UDCA dose o
1,500 mg was p o en o be e icacious and sa e, and he e o e
should be u he es ed in a phase III clinical ial.
Financial suppo
This s udy was sponso ed by D . Falk Pha ma GmbH, F eibu g,
Ge many.
Con lic o in e es
The Medical Uni e si y o G az has iled wo pa en s o he use
o no UDCA in he ea men o li e diseases and a e ioscle osis,
and P.F. and M.T. a e lis ed as co-in en o s (publica ion numbe s
WO2006119803 and WO20099013334).
P.F.: Speake o Falk Founda ion, ad iso y boa ds o D . Falk
Pha ma GmBH and In e cep ; a el g an s and un es ic ed
esea ch g an s om Falk Founda ion and un es ic ed esea ch
g an om Gilead.
G.M.H.: Suppo ed by he Na ional Ins i u e Fo Heal h
Resea ch (NIHR) Bi mingham Li e Biomedical Resea ch Uni
(BRU). This pape p esen s independen esea ch and he iews
exp essed a e hose o he au ho (s) and no necessa ily hose
o he NHS, he NIHR o he Depa men o Heal h. Clinical ial
ac i i ies we e pe o med in he Bi mingham NIHR Clinical
Resea ch Facili y. G.M.H has been an in es iga o o clinical ials
in choles asis o GSK, D . Falk Pha ma GmbH, In e cep , Gilead,
FF Pha ma, No a is, Cymabay, and Shi e. G.M.H. has been on
ad iso y boa ds o In e cep , GSK, and No a is. G.M.H. has
ecei ed un es ic ed g an suppo om D . Falk Pha ma GmbH.
G.M.H. has been a speake o he Falk Founda ion.
G.D.: Speake o Falk Founda ion, CMS, and In e cep ; ad i-
so y boa ds o In e cep ; a el g an s om Gilead and CMS.
H.U.M.: Speake o Falk Founda ion; ad iso y boa ds o
Albi eio and In e cep ; a el g an s om Falk Founda ion.
I.A.: T a el g an s om Falk Founda ion.
M.F.: Speake o Cook LTD, Takeda, MSD, Tillo s; consul an
o BMS, AbbVie, Medi i AB, Takeda, P ize , In e cep , Cook I e-
land; g an s om MSD, Gilead Sciences, AbbVie;
C.S.: Speake o Falk Founda ion; ad iso y boa ds o In e -
cep .; esea ch g an s om D . Falk Pha ma GmbH.
U.S.: Ad iso y boa ds o D . Falk Pha ma GmbH, In e cep ,
BMS, Gilead, Janssen, MSD; ecei ed a el g an s om AbbVie,
Gilead, and Baye .
R.C.: Speake o Falk Founda ion; ad iso y boa ds o D . Falk
Pha ma GmbH, Gilead, and In e cep .
A.B.: none
F.N.: Ad iso y boa ds o As ellas, Janssen-Cilag, AbbVie,
Gilead, CAF, In e cep , Go e, BMS, No a is, MSD, Janssen-Cilag,
P ome he a Biosciences, Ono Pha ma, Du ec , Roche, Fe ing,
Janssen-Cilag. Resea ch g an s om Roche, Fe ing, and No a is.
P.T.: none
F.P.R.: Speake o Falk Founda ion.
I.T.: none
E.S.: none
E.H.: Ad iso y boa ds o In e cep and No a is; a el g an s
om Falk Founda ion.
R.G.: Employee o D . Falk Pha ma GmbH
M.P.: Employee o D . Falk Pha ma GmbH
M.P.M.: Speake o Falk Founda ion, ad iso y boa ds o D .
Falk Pha ma GmbH, In e cep , and No a is; esea ch suppo
om Falk Founda ion
M.T.: Speake o Falk Founda ion; ad iso y boa ds o D . Falk
Pha ma GmbH, Albi eo, Gilead, In e cep , No a is; a el g an s
om Falk Founda ion and un es ic ed esea ch g an s om D .
Falk Pha ma GmbH, Albi eo and In e cep .
Please e e o he accompanying ICMJE disclosu e o ms o
u he de ails.
Au ho s’ con ibu ions
All au ho s con ibu ed o acquisi ion o da a, e iew and c i ical
e ision o he manusc ip and app o ed he inal e sion o he
manusc ip . P.F.: s udy design/concep ion, in e p e a ion o da a,
manusc ip w i ing; R.G.: s udy design/concep ion: M.P.: s udy
Resea ch A icle
556 Jou nal o Hepa ology 2017 ol. 67 j549–558