Effect of Oral Anti-diabetic Medication on Liver Fat in Subjects With Type II Diabetes and Non-alcoholic Fatty Liver

Which Oral Combination of Anti-diabetes Medication May Work Better in Subjects With Type 2 Diabetes and Nonalcoholic Fatty Liver Disease: a Randomized Control Trial

This randomized clinical trial aims to compare the effect of the pioglitazone and SGLT2 inhibitor combination on liver fat mass, as compared to either drug used alone, with or without background medical therapy of metformin and/or DDP4 inhibitors.

Study Overview

• Status: Recruiting
• Conditions: Diabetes Mellitus, Type 2; NAFLD; NASH - Nonalcoholic Steatohepatitis
• Intervention / Treatment: Drug: Pioglitazone; Drug: Empagliflozin; Drug: Pioglitazone + Empagliflozin

Detailed Description

To compare the effect of pioglitazone with or without Metformin and/or DPP4 inhibitor (no SGLT2 inhibitor) on improvement of NAFLD parameters, versus

The effect of SGLT inhibitor with or without metformin and/or DPP4 inhibitor (no pioglitazone) on NAFLD parameters and versus

Pioglitazone with or without metformin and/or DPP4 inhibitor, plus empagliflozin on improvement of NAFLD parameters.

• Study Type: Interventional
• Enrollment (Anticipated): 123
• Phase: Phase 4

Contacts and Locations

• Study Contact: Name: Azra Rizwan, FCPS; Phone Number: +923212655271; Email: azra.rizwan@aku.edu

Study Locations

• Pakistan
  • Sindh
    • Karachi, Sindh, Pakistan, 74800
      • Recruiting
      • Aga Khan University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 60 years (Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patient who give informed consent voluntarily
• Type 2 diabetic patient having age from 18 years to 60 years
• HbA1C ≥ 7.0 %
• Diabetes diagnosis of ≤ 5 years (longer duration more likely to be associated with use of multiple drug regimens for glycemic control which may affect liver fat mass)
• Either treatment naïve or on metformin alone or metformin/DPP4i combination
• Absolute weight < 100kg; BMI < 45 (fibro scan machine cannot accommodate heavier individuals)
• Documented hepatosteatosis (If the fibroscan reveals S1 (mild fatty liver: 11-33% fatty liver) to S3 (severe fatty liver: > 67% fatty liver) liver fat

Exclusion Criteria:

• Hba1c ≥ 9% and/or blood sugar > 250mg/dl
• History of uncontrolled Endocrine disorder (for example uncontrolled hypothyroidism, or that requiring frequent dose adjustment, or Cushings syndrome)
• History of anti-obesity medication use within 3 months of consent for study enrollment or weight loss procedure(bariatric surgery) within same duration
• History of use of SGLT 2 inhibitors, glitazones, Glucagon-like peptide (GLP) 1 agonists 3 months prior to study enrollment as they influence liver fat
• History of use of insulin/sulphonylurea 3 months prior to study enrollment owing to weight gain and potential increase in liver fat conferred by these agents
• History of vitamin E use (400mg twice daily) within 3 months of study enrollment
• Drug induced liver disease or active substance abuse (cannabonnoid-derived substances like heroin, cocaine, amphetamines) based on history and/or laboratory tests
• Drugs known to be associated with hepatic steatosis like steroids, traditional homeopathic medication (likely to contain steroids), methotrexate, valproate, tamoxifen, amiodarone.
• Alcohol use (History of alcoholism or a greater than recommended alcohol intake (> 21 standard drinks on average per week in men and > 14 standard drinks on average per week in women)
• Severe hepatic impairment (ALT levels > 3 times upper limit normal)
• Hepatitis B/C hepatitis (based on positive Hepatitis B surface antigen, Anti Hepatitis C antibodies positive
• Autoimmune hepatitis (in case of females), based on positive Anti-nuclear Antibody (ANA) (homogenous, high titre)
• Positive Human Immunodeficiency Virus ( HIV) test as this could influence liver functions
• Pregnant or lactating women/ plans for pregnancy over proceeding 13 months
• Obstructive liver disease on the basis of laboratory and imaging studies
• Chronic renal failure, or Glomerular Filtration Rate (GFR) < 30 mls/minute (as estimated by the MDRD equation)
• Chronic heart failure, history of acute coronary artery disease or cerebrovascular accident within 3 months of consent for study enrollment, based on history and/or cardiac imaging
• History of recurrent Urinary Tract Infections (UTI's) or mycotic infections
• Presence of ketones on Urine Analysis

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Pioglitazone; The starting dose would be 15mg/day for pioglitazone and 500 to 1500mg per day for metformin (depending on blood glucose levels). Starting dose for DPP4 inhibitors would be 50 to 100mg daily.	Drug: Pioglitazone; Pioglitazone with (or without) metformin and/or DPP4 inhibitor (no SGLT2 inhibitor). The maximum dose for metformin would be 2.5 g/day, while for pioglitazone would be 45mg/day. The maximum dose for DPP4 inhibitor would be 100mg/day.; Other Names: Zolid
Active Comparator: Empagliflozin; The starting dose would be 500-1500mg/day of metformin, plus 5/10/12.5mg empagliflozin (depending on blood glucose levels). Starting dose for DPP4 inhibitors would be 50 to 100mg daily.	Drug: Empagliflozin; Empagliflozin with (or without) metformin and/or DPP4 inhibitor (no pioglitazone). The maximum dose for metformin would be 2.5g/day, while for empagliflozin would be 25mg/day depending on follow up blood sugar levels and tolerability. The maximum dose 100mg daily.; Other Names: Diampa
Active Comparator: Pioglitazone + Empagliflozin; The starting dose would be 15mg/day for pioglitazone and 500 to1500mg per day for metformin and 5/10/12.5mg/25mg/day empagliflozin and 50 to 100mg daily for DPP4 inhibitors depending on blood sugar levels.	Drug: Pioglitazone + Empagliflozin; Pioglitazone with (or without) metformin and/or DPP4 inhibitor, plus empagliflozin. The maximum dose for metformin would be 2.5g/day; for pioglitazone would be 45mg/day and 25mg/day for empagliflozin, and 100mg daily for DPP4 inhibitors (depending on follow up blood sugar levels and tolerability).; Other Names: Zolid + Diampa

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in radiologic liver parameters	Number of participants reported change in liver fat content from baseline, as quantified by fibroscan	12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in liver enzymes	Number of participants reported change in liver enzymes levels including ALT, AST and GGT	12 months
Change in Fibrosis-4 (FIB-4) Score and NAFLD Fibrosis Score	Number of participants reported change in FIB-4 Score and NAFLD Fibrosis Score. Fibrosis-4 scores range from 0 to 4, where <1.45 indicates absence of cirrhosis; score between 1.45 - 3.25 are deemed inconclusive and score >3.25 indicates cirrhosis.	12 months
Change in body weight	Number of participants reported change in body weight from baseline (treat to target response of at least 5% of baseline at 6 months, 10% baseline over 12 months).	12 months
Change in waist circumference (WC)	Number of participants reported change in waist circumference (WC)	12 months
Change in liver fat mass with total body fat (TBF)	Comparison of baseline and end of treatment liver fat mass with total body fat (TBF) using a Body Composition Monitor	12 months
Change in HbA1C levels (< 7.0%)	Number of participants reported change in HbA1C levels from baseline to end of treatment	12 months
Change in Fasting Blood Sugar (FBS)	Number of participants reported change in Fasting Blood Sugar (FBS) from baseline to end of treatment	12 months
Change in Lipid profile	Number of participants reported change in Fasting triglycerides (TG), Low-Density Lipoprotein (LDL), High-Density Lipoprotein (HDL) from baseline to end of treatment	12 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Urine Albumin to Creatinine Ratio (UACR)	Number of participants reported change in Urine Albumin to Creatinine Ratio (UACR) from baseline to end of treatment	12 months
Change in Systolic and Diastolic blood pressure	Number of participants reported change in Systolic and Diastolic blood pressure from baseline to end of treatment	12 months

Collaborators and Investigators

• Sponsor: Getz Pharma

Study record dates

Study Major Dates

• Study Start (Actual): September 15, 2021
• Primary Completion (Anticipated): May 15, 2023
• Study Completion (Anticipated): November 15, 2023

Study Registration Dates

• First Submitted: July 19, 2021
• First Submitted That Met QC Criteria: July 19, 2021
• First Posted (Actual): July 26, 2021

Study Record Updates

• Last Update Posted (Actual): March 18, 2022
• Last Update Submitted That Met QC Criteria: March 17, 2022
• Last Verified: March 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Glucose Metabolism Disorders; Metabolic Diseases; Endocrine System Diseases; Liver Diseases; Diabetes Mellitus; Diabetes Mellitus, Type 2; Fatty Liver; Non-alcoholic Fatty Liver Disease; Hypoglycemic Agents; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Sodium-Glucose Transporter 2 Inhibitors; Pioglitazone; Empagliflozin
• Other Study ID Numbers: AKUH-GTZ-DM-005-21

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No