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NGM282 for treatment of non-alcoholic steatohepatitis:


a multicentre, randomised, double-blind, placebo-controlled,
phase 2 trial
Stephen A Harrison, Mary E Rinella, Manal F Abdelmalek, James F Trotter, Angelo H Paredes, Hays L Arnold, Marcelo Kugelmas, Mustafa R Bashir,
Mark J Jaros, Lei Ling, Stephen J Rossi, Alex M DePaoli, Rohit Loomba

Summary
Background Non-alcoholic steatohepatitis is a chronic liver disease characterised by the presence of hepatic steatosis, Published Online
inflammation, and hepatocellular injury, for which no Food and Drug Administration (FDA)-approved treatment March 5, 2018
http://dx.doi.org/10.1016/
exists. FGF19 is a hormone that regulates bile acid synthesis and glucose homoeostasis. We aimed to assess the safety
S0140-6736(18)30474-4
and efficacy of NGM282, an engineered FGF19 analogue, for the treatment of non-alcoholic steatohepatitis.
See Online/Comment
http://dx.doi.org/10.1016/
Methods In this randomised, double-blind, placebo-controlled, phase 2 study, we recruited patients aged 18–75 years S0140-6736(18)30425-2
with biopsy-confirmed non-alcoholic steatohepatitis as defined by the non-alcoholic steatohepatitis clinical research Radcliffe Department of
network histological scoring system, from hospitals and gastroenterology and liver clinics in Australia and the USA. Medicine, University of Oxford,
Key eligibility criteria included a non-alcoholic fatty liver disease activity score of 4 or higher, stage 1–3 fibrosis, and at Oxford, UK
(Prof S A Harrison MD); Division
least 8% liver fat content. Patients were randomly assigned (1:1:1) via a web-based system and stratified by diabetic of Gastroenterology and
status to receive either 3 mg or 6 mg subcutaneous NGM282 or placebo. The primary endpoint was the absolute Hepatology, Northwestern
change from baseline to week 12 in liver fat content. Responders were patients who achieved a 5% or larger reduction University, Chicago, IL, USA
(Prof M E Rinella MD); Duke
in absolute liver fat content as measured by MRI-proton density fat fraction. Efficacy analysis was by intention to treat.
University, Durham, NC, USA
This trial is registered with ClinicalTrials.gov, number NCT02443116. (Prof M F Abdelmalek MD);
Clinical Research and
Findings Between July 14, 2015, and Aug 30, 2016, 166 patients were screened across 18 sites in Australia and the USA. Education, Texas Digestive
Disease Consultants, Dallas, TX,
82 patients were randomly assigned to receive 3 mg NGM282 (n=27), 6 mg NGM282 (n=28), or placebo (n=27). At
USA (J F Trotter MD); Division of
12 weeks, 20 (74%) patients in the 3 mg dose group and 22 (79%) in the 6 mg dose group achieved at least a Gastroenterology and
5% reduction in absolute liver fat content from baseline (relative risk 10·0 [95% CI 2∙6–38∙7] vs 11∙4 [3∙0–43∙8], Hepatology, Brooke Army
respectively; p<0·0001 for both comparisons) versus two (7%) in the placebo group. Overall, 76 (93%) of 82 patients Medical Center, San Antonio,
TX, USA (A H Paredes MD);
experienced at least one adverse event, most of which were grade 1 (55 [67%]), and only five (6%) were grade 3 or
Gastroenterology Consultants
worse. The most commonly (≥10%) reported adverse events were injection site reactions (28 [34%]), diarrhoea of San Antonio, Live Oak, TX,
(27 [33%]), abdominal pain (15 [18%]), and nausea (14 [17%]). These adverse events were reported more frequently in USA (H L Arnold MD);
the NGM282 groups compared with the placebo group. No life-threatening events or patient deaths occurred during Hepatology, South Denver
Gastroenterology, Englewood,
the study.
CO, USA (M Kugelmas MD);
Department of Radiology,
Interpretation NGM282 produced rapid and significant reductions in liver fat content with an acceptable safety profile Duke University Medical
in patients with non-alcoholic steatohepatitis. Further study of NGM282 is warranted in this patient population. Center, Durham, NC, USA
(M R Bashir MD); Summit
Analytical, Denver, CO, USA
Funding NGM Biopharmaceuticals. (M J Jaros PhD); NGM
Biopharmaceuticals, Inc,
Introduction coexisting obesity, type 2 diabetes, insulin resistance, San Francisco, CA, USA
(L Ling PhD, S J Rossi PharmD,
Non-alcoholic fatty liver disease encompasses a spectrum hypertension, or dyslipidaemia.1 A M DePaoli MD); and
of chronic hepatic diseases ranging from simple steatosis Although the mechanism underlying the development Non-Alcoholic Fatty Liver
(fatty liver) to the more aggressive non-alcoholic and progression from simple steatosis to non-alcoholic Disease Research Center,
steatohepatitis. Non-alcoholic steatohepatitis involves a steatohepatitis and cirrhosis is poorly understood, insulin Division of Gastroenterology
and Epidemiology, University
fatty liver with inflammation and hepatocellular in­ resistance, lipotoxicity, cytokines, oxidative stress, and of California San Diego,
jury (with or without fibrosis).1 The prevalence of other inflammatory mediators are believed to promote San Francisco, CA, USA
non-alcoholic fatty liver disease is increasing, with the development of non-alcoholic steatohepatitis and its (Prof R Loomba MD)
estimates ranging from 20% to 40% of adults in countries extrahepatic complications.4 Excess lipotoxic metabolites Correspondence to:
adopting a western diet with the disease, 10–20% of in the liver are believed to provide the primary insult Dr Stephen A Harrison, Pinnacle
Clinical Research Group, Live Oak,
whom progress to non-alcoholic steatohepatitis.1 Patients in the pathogenesis of non-alcoholic steatohepatitis, TX 78233, USA
with non-alcoholic steatohepatitis are at increased risk of but evidence supporting a role for bile acids in the sharrison@pinnacleresearch.
cirrhosis and hepatocellular carcinoma, and non- pathogenesis of liver inflammation and fibrosis is com
alcoholic steatohepatitis is projected to be the lead­ emerging.5 Accumulation of bile acids within hepatocytes
ing indication for liver transplant in 2020.2,3 Further, can cause mitochondrial dysfunction, endoplasmic
most patients with non-alcoholic steatohepatitis have reticulum stress, and immune cell infiltration that can

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Research in context
Evidence before this study (AST), and non-invasive serum fibrosis biomarkers
Non-alcoholic fatty liver disease includes a spectrum of (pro-C3 and enhanced liver fibrosis score). The greatest
chronic hepatic diseases, with non-alcoholic steatohepatitis treatment effect was recorded in patients with more severe
being the most aggressive phenotype, leading to an increased disease (high baseline liver fat content and ALT). Decreases in
risk of developing cirrhosis and hepatocellular carcinoma. To liver fat content were strongly correlated with decreases in
identify clinical trials of the treatment of non-alcoholic fatty 7α-hydroxy-4-cholesten-3-one (C4), ALT, AST, and increases
liver disease and non-alcoholic steatohepatitis, we searched in low-density lipoprotein cholesterol (LDL-C). Overall, these
PubMed for English language articles published from data are the most impressive to date among pharmacological
Jan 1, 2007, to Oct 15, 2017, with the search terms, “NAFLD”, agents previously and currently being tested in
“NASH”, “fatty liver”, and “FGF19”. We found no controlled non-alcoholic steatohepatitis. Both doses of NGM282 were
clinical trials investigating an FGF19 analogue in the generally well tolerated with mild adverse events. Significant
treatment of non-alcoholic steatohepatitis, and therefore the decreases in serum C4 concentrations, and the ensuing
current study represents a first-in-class trial in this patient increases in LDL-C were recorded with NGM282, consistent
population. NGM282 is a non-tumorigenic analogue of with potent target engagement and inhibition of CYP7A1.
FGF19 that retains the ability to suppress CYP7A1 without Studies are ongoing to elucidate whether NGM282-related
activating STAT3 signalling. Based on the established increases in LDL-C can be mitigated with concomitant
preclinical biological activity, NGM282 is currently statin use.
being assessed for the treatment of non-alcoholic
Implications of all the available evidence
steatohepatitis.
There is an unmet need in the treatment of non-alcoholic
Added value of this study steatohepatitis, and no Food and Drug
Our findings show that 3 mg and 6 mg doses of NGM282 Administration-approved treatments currently exist. The
produced rapid and sustained improvements in liver fat results of our phase 2 study show the efficacy of NGM282 in
content over 12 weeks as measured by MRI–proton density rapidly decreasing liver fat content and markers of
fat fraction (MRI-PDFF). Hepatic imaging with MRI-PDFF is inflammation and fibrosis, highlighting its therapeutic
highly sensitive to changes in liver fat content compared with potential in non-alcoholic steatohepatitis. Larger clinical trials
histological evaluation. NGM282 also significantly decreased of longer duration are now needed to fully assess the safety
alanine aminotransferase (ALT), aspartate aminotransferase and efficacy of NGM282.

ultimately lead to inflammation, cell death, and liver non-alcoholic steatohepatitis. NGM282 (also known
injury. Individuals with non-alcoholic steatohepatitis are as M70) differs from wild-type FGF19 in the amino
reported to have elevated hepatic and circulating terminus, a key region of the protein involved in receptor
concentrations of bile acids, as well as increased interactions and signalling modulation. In NGM282,
concentrations of faecal and urine bile acids.6,7 a 5-aminoacid deletion (P24–S28) coupled with the
Fibroblast growth factor 19 (FGF19), an endocrine substitution of three aminoacids at crucial positions
gastrointestinal hormone, regulates bile acid, carbo-​ (Ala30Ser, Gly31Ser, and His33Leu) within the amino
hydrate, and energy homoeostasis.8,9 The hormone terminus enable biased FGFR4 signalling so that
controls bile acid metabolism via actions on NGM282 retains the ability to potently repress CYP7A1
CYP7A1, the first and rate-limiting enzyme in the expression.13 Importantly, unlike FGF-19, NGM282
classic pathway of bile acid synthesis from cholesterol. does not activate signal transducer and activator of
FGF19 also exerts insulin-like actions on glycogen transcription 3 (STAT3), a signalling pathway essential
synthesis and gluconeogenesis, thus having the for FGF19-mediated hepatocarcinogenesis.14 Further­
potential to regulate multiple pathways involved in more, NGM282 can block hepatocarcinogenesis associ­
non-alcoholic steato​ hepatitis pathogenesis. Notably, ated with human FGF19.13 In animal models of
circulating FGF19 concentration is reduced in patients non-alcoholic steatohepatitis, treatment with NGM282
with non-alcoholic steatohepatitis,10,11 further suggesting resulted in a rapid and robust reduction in concentrations
that dysregulated FGF19 expression might contribute of alanine aminotransferase (ALT) and aspartate amino­
to mecha­nisms governing non-alcoholic steatohepatitis- transferase (AST), as well as a clear improvement in
related pro­gressive liver diseases. However, the thera­ all histological features associated with non-alcoholic
peutic potential of FGF19 has been hindered by its steatohepatitis, including hepatic steatosis, inflammation,
hepatocarcino­genicity, as shown by findings of studies ballooning degeneration, and fibrosis.15 NGM282 was
in which mice expressing an FGF19 transgene dev­ safe and well tolerated in healthy volunteers and was
eloped hepatocellular carcinoma.12 associated with reduction in serum concentrations of
NGM282, a non-tumorigenic variant of FGF19, is a 7 α-hydroxy-4-cholesten-3-one (C4), a biomarker of
recombinant protein being studied for treatment of hepatic CYP7A1 activity.16

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We aimed to assess the efficacy and safety of NGM282 4 (≥1 point in each component of steatosis, lobular
versus placebo in adult patients with non-alcoholic inflammation, and hepatocellular ballooning); stage 1, 2, or
steatohepatitis using MRI-proton density fat fraction 3 fibrosis; liver fat content 8% or higher as assessed by
(PDFF) to assess changes in liver fat content. MRI-PDFF; and elevated ALT concentrations (≥19 IU/L in
women and ≥30 IU/L in men). These eligibility criteria
Methods were amended on Sept 2, 2015, while blinded from
Study design and participants previous criteria of non-alcoholic fatty liver disease activity
In this multicentre, international, randomised, double- score of 5 or higher and liver fat content of at least 10%,
blind, placebo-controlled, phase 2 trial, patients with which were deemed too restrictive. Exclusion criteria
biopsy-confirmed non-alcoholic steatohepatitis were included clinically significant acute or chronic liver
enrolled across 18 hospitals and gastroenterology and disease unrelated to non-alcoholic steatohepatitis; evi­
liver clinics in Australia and the USA. The study protocol dence of drug-induced steatohepatitis; history or presence
and relevant supporting data were approved by local of compensated or decompensated cirrhosis; liver
ethics committees before study initiation. The study was transplantation; any cardiovascular event or evidence of
done in compliance with International Conference active cardiovascular disease within 6 months of screen­
on Harmonisation, E6 Good Clinical Practice. Dose ing; and type 1 diabetes (appendix p 3). Patients See Online for appendix
selection was based on phase 1 ascending dose were required to remain on stable regimen of their
studies showing 3 mg as the lowest dose with maximal previous type 2 diabetes and lipid-lowering treatments
C4 reduction (unpublished data). The 12-week treat­ during the study period. All patients provided written
ment duration was selected based on previous trials informed consent.
investigating liver fat content.17,18
Patients were eligible if they met the following inclusion Randomisation and masking
criteria: aged 18–75 years at the time of screening; biopsy- Patients were randomly assigned (1:1:1) via Interactive
confirmed non-alcoholic steatohepatitis diagnosis as Web Response System in randomly permuted blocks
defined by the non-alcoholic steatohepatitis clinical (block size six) to receive 3 mg or 6 mg subcutaneous
research network histological scoring system,19 with a NGM282 or placebo once a day. The placebo was provided
minimum non-alcoholic fatty liver disease activity score of as identical pre-filled syringes in identical containers

166 patients screened

84 excluded
18 did not meet histology criteria
18 did not meet MRI criteria
11 withdrew consent or were lost to follow-up
37 did not meet criteria (other)

82 randomly assigned

27 assigned to and received 27 assigned to and received 28 assigned to and received


placebo 3 mg NGM282 6 mg NGM282

2 discontinued treatment 3 discontinued treatment 4 discontinued treatment


1 patient choice due to adverse event but 3 due to adverse event
1 lost to follow-up still completed EOT MRI 1 patient choice
exam 2 still completed EOT MRI
exam
2 did not have EOT MRI

27 had both baseline and 27 had both baseline and 26 had both baseline and
week 12/EOT MRI week 12/EOT MRI week 12/EOT MRI

27 included in intention-to-treat analysis 27 included in intention-to-treat analysis 28 included in intention-to-treat analysis

Figure 1: Trial profile


FC=liver fat content. MRI=magnetic resonance imaging. EOT=end of treatment.

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labelled with unique code numbers, in keeping with Procedures


Good Manufacturing Practice for medicinal products During the screening period and before randomisation,
guidelines. A master control list of the pack identification patients underwent a liver biopsy or provided a liver
numbers and treatment was accessible by the statistician biopsy tissue specimen obtained within the previous
who prepared the randomisation schedule and had no 6 months. Tissue samples were prepared and read by
other roles in the trial. The list was also provided to the a qualified local pathologist to verify non-alcoholic
emergency un-blinding service of the contract research steatohepatitis and determine the non-alcoholic fatty
organisation. Patients were stratified according to liver disease activity score (NAS) grade. On day 1, study
diabetic status (yes or no) to ensure equitable distrib­ drug self-administration instructions and training were
ution across the treatment groups. Investigators, staff, provided to patients, and a weekly study drug kit was
patients, funder, and medical monitor remained masked dispensed. The first dose of study drug and doses at
throughout the study period. weeks 1, 2, 4, 6, 8, and 12 were self-administered in the
clinic; all other doses were administered at home.
Placebo 3 mg NGM282 6 mg NGM282 Patients were instructed to inject the study drug at the
(n=27) (n=27) (n=28) same time every morning.
Age (years) 52∙8 (11∙3) 52∙0 (7∙1) 56∙4 (7∙8) Patients underwent MRI-PDFF during screening and at
Sex the end of treatment or early withdrawal visits to assess
Male 7 (26%) 11 (41%) 12 (43%) liver fat content. Scans were performed on qualified and
Female 20 (74%) 16 (59%) 16 (57%) standardised instruments at high field strength (3T at
Race eight sites, 1·5T at ten sites), without oral or intravenous
Asian 0 1 (4%) 1 (4%) contrast. Local MRI facilities completed a qualification
Black 2 (7%) 0 0 and quality assurance process before performing study
White 25 (93%) 25 (93%) 24 (86%) MRI examinations. MRI-PDFF acquisition protocols
Pacific Islander 0 0 1 (4%) included a six-echo 2D gradient recalled echo sequence,
Other 0 1 (4%) 2 (7%)
and image data were transferred to the Center for
Ethnic origin
Advanced Magnetic Resonance Development at Duke
Hispanic or Latino 12 (44%) 8 (30%) 8 (29%)
University, Durham, NC, USA, for central calculation and
measurement of MRI-PDFF using an established
Liver enzymes
technique.20,21 After the end of the trial, MRI data
Alanine aminotransferase (IU/L) 71∙1 (42) 67∙4 (54) 61∙8 (34)
were randomly assigned with respect to timepoint, and
Aspartate aminotransferase (IU/L) 59∙2 (30) 50∙4 (32) 43∙1 (22)
the central reader measured MRI-PDFF data masked
Alkaline phosphatase (U/L) 97∙7 (39∙7) 106∙1 (67∙3) 91∙5 (30∙5)
to treatment group, clinical data, local site of origin,
γ-glutamyl transpeptidase (U/L) 79∙5 (66∙8) 97∙4 (98∙5) 87∙5 (88∙4)
and timepoint.
Total bilirubin (mg/dL) 0∙3 (0∙2) 0∙5 (0∙3) 0∙4 (0∙2)
Patients were assessed at weeks 1, 2, 4, and 8 for
Lipids
on-treatment assessments, at the end of treatment
Cholesterol (mmol/L) 4·8 (0·9) 4·8 (1·5) 4·8 (1·2)
on week 12, and at follow-up 4 weeks after the last
HDL cholesterol (mmol/L) 1·0 (0·3) 1·1 (0·6) 1·0 (0·3)
dose. Bodyweight, BMI, and waist circumferences were
LDL cholesterol (mmol/L) 2·6 (0·8) 2·2 (1·1) 2·6 (1·0)
measured at screening, day 1, and weeks 12 and end of
Triglycerides (mg/dL) 1·9 (1·2) 2·2 (1·5) 1·8 (0·9)
treatment and 16. A fasting lipid panel was obtained on
C4 (ng/mL) 32∙0 (23∙6) 49∙8 (54∙0) 29∙4 (22∙3) day 1 and weeks 4 and 12. Additionally, C4 concentrations
Hematology were obtained on day 1 and week 12, and we measured
Hemoglobin (g/L) 13∙6 (1∙4) 14∙7 (1∙6) 14∙1 (1∙4) haemoglobin A1c (HbA1c) concentrations, insulin concen­
Hematocrit 42∙0% (4∙0) 44∙7% (4∙5) 43∙7% (4∙5) trations, and homoeostasis model assessment-estimated
Mean corpuscular volume (FL) 91∙0 (5∙4) 91∙0 (3∙8) 89∙6 (4∙0) insulin resistance (HOMA-IR) at screening, day 1, and
White blood cell count (K/UL) 7∙3 (2∙0) 7∙8 (2∙8) 7∙4 (2∙3) week 12. We assessed adverse events and concomitant
Platelet count (K/UL) 241∙9 (75∙8) 225∙4 (59∙0) 248∙4 (68∙5) drugs at each study visit.
Chemistries
Bicarbonate (mmol/L) 22∙9 (2∙6) 24∙4 (2∙4) 24∙2 (2∙3) Outcomes
Calcium (mg/dL ) 9∙1 (0∙5) 9∙1 (0∙5) 9∙2 (0∙3) The primary outcome was the absolute change in liver fat
Phosphate (mg/dL ) 3∙4 (0∙6) 3∙4 (0∙5) 3∙4 (0∙5) content from baseline to week 12. Responders were
Creatinine (mg/dL ) 0∙8 (0∙2) 0∙8 (0∙2) 0∙8 (0∙2) patients who achieved a clinically meaningful reduction
Uric acid (mg/dL ) 5∙4 (1∙5) 6∙7 (1∙3) 5∙9 (1∙3) of at least 5% in absolute liver fat content as measured by
Albumin (g/dL) 4∙1 (0∙38) 4∙3 (0∙33) 4∙3 (0∙33) MRI-PDFF and assessed by the central radiology core
Other laboratory results facility at Duke University. Secondary outcomes included
INR 1∙1 (0∙1) 1∙1 (0∙1) 1∙1 (0∙1) absolute and relative change in liver fat content C4 (Mayo
(Table 1 continues on next page) Clinic, Rochester, MN, USA), normalisation of liver fat
content (decrease to <5%) at week 12, and changes from

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baseline and normalisation in ALT concentrations.


Placebo 3 mg NGM282 6 mg NGM282
Adverse events were assessed using the Common (n=27) (n=27) (n=28)
Terminology Criteria for Adverse Events (version 4.03;
(Continued from previous page)
appendix p 4). Exploratory outcomes included changes in
Metabolic factors
lipids and lipoprotein particles (LabCorp/LipoScience),
Glucose (mg/dL) 129∙2 (58∙0) 116∙7 (35∙7) 120∙8 (42∙9)
as well as fibrosis biomarkers, including released
HbA1c 6∙7% (1∙4) 6∙5% (1∙0) 6∙7% (1∙2)
N-terminal pro-peptide of type III collagen (pro-C3;
Insulin (pmol/L) 4∙0 (3∙2) 5∙3 (5∙1) 3∙6 (2∙9)
Nordic Bioscience) and total enhanced liver fibrosis score
HOMA-IR 12∙2 (22∙1) 11∙3 (14∙7) 7∙3 (5∙8)
(including the N-terminal pro-peptide of collagen III
Weight (kg) 97∙8 (19∙6) 95∙5 (22∙2) 98∙2 (17∙6)
[PIIINP], the tissue inhibitor of metalloproteinase 1
BMI (kg/m²) 35∙6 (5∙8) 34∙0 (8∙7) 34∙7 (5∙5)
[TIMP-1], and hyaluronic acid).
Waist circumference (cm) 113∙03 (12∙3) 106∙08 (13∙7) 110∙2 (17∙9)
Vital signs
Statistical analysis
Systolic blood pressure (mm Hg) 129∙3 (17∙8) 123∙4 (12∙5) 127∙2 (13∙0)
A minimal sample size of 75 patients was selected for the
pre-study power calculation. Allowing for a 10% dropout Diastolic blood pressure (mm Hg) 82∙6 (9∙0) 77∙0 (11∙1) 79∙5 (11∙1)

rate, sample size calculations were based on a minimum Comorbidities

of 22 patients per group. As shown by findings of previous Type 2 diabetes 17 (63%) 15 (56%) 17 (61%)
studies, an absolute change in liver fat content of 5% is Hyperlipidaemia 8 (30%) 10 (37%) 15 (54%)
the minimal clinically relevant difference between active Hypertension 21 (78%) 15 (56%) 18 (64%)
treatment and placebo, and correlates with improvements Concomitant medications
in liver histology.17,22,23 Sample size power calculations Antidiabetic
were based on varying common standard deviations to Metformin 14 (52%) 13 (48%) 14 (50%)
achieve an overall (overall F test) significant treatment Insulin 4 (15%) 3 (11%) 5 (18%)
effect of 6% or higher reduction from baseline in liver fat GLP-1 agonists 3 (11%) 3 (11%) 5 (18%)
content with 3 mg or 6 mg NGM282, and a reduction of DPP4 inhibitors 1 (%) 3 (11%) 0
1% or lower in the placebo group (all at a significance SGLT2 inhibitors 3 (11%) 0 2 (7%)
level of 5%). The efficacy population was used to assess Other 4 (15%) 2 (7%) 4 (14%)
efficacy and pharmacodynamic endpoints, and included Antilipidaemic
all randomly assigned and enrolled patients who received Statins 7 (26%) 12 (44%) 14 (50%)
at least one dose (full or partial) of study drug and had a Non-statins 8 (30%) 8 (30%) 8 (29%)
baseline and week 12 or end of treatment MRI-PDFF with Antihypertensives 25 (93%) 21 (78%) 23 (82%)
at least one valid, non-missing post-dose efficacy or Other
pharmacodynamic parameter value. We analysed efficacy Pioglitazone 0 0 1 (4%)
with the intention-to-treat population defined as all Vitamin E 2 (7%) 2 (7%) 0
patients who underwent randomisation. Patients in each Histopathology
treatment group were categorised as either responders or Fibrosis stage
non-responders. The two patients in the NGM282 6 mg 1 11 (41%) 11 (41%) 10 (36%)
group who did not have an end of treatment MRI-PDFF 2 7 (26%) 7 (26%) 12 (43%)
imaging were imputed as non-responders. 3 9 (33%) 9 (33%) 6 (21%)
We compared the absolute change in liver fat content Total NAS activity score 5∙1 (1∙1)* 5∙1 (1∙0) 5∙1 (0∙9)
from baseline to week 12 between treatment groups Hepatocyte ballooning score
using analysis of covariance (ANCOVA), with treatment 0 (none) 0 0 0
group and diabetic status as cofactors and baseline liver
1 (few ballooned cells) 13 (48%) 15 (56%) 21 (75%)
fat content and ALT as a covariate at the 5% level of
2 (many ballooned cells) 13 (48%) 12 (44%) 7 (25%)
significance. Least-squares (LS) means with stand­
Steatosis score
ard errors (SE), differences in LS means with SE,
0 (<5%) 0 0 0
95% confidence intervals (CIs), and the corresponding
1 (5–33%) 6 (22%) 6 (22%) 3 (11%)
p values were calculated. Categorical endpoints were
2 (34–66%) 14 (52%) 12 (44%) 15 (54%)
analysed using χ² test or Fisher’s exact test. To adjust for
3 (>66%) 6 (22%) 9 (33%) 10 (36%)
multiple comparisons, the step down Bonferroni method
Lobular inflammation score
was used for analysis between treatment groups.
0 (none) 0 0 0
Normalisation was defined as patients with an MRI-PDFF
1 (<2) 10 (37%) 12 (44%) 12 (43%)
value of 5% or lower at end of treatment. We analysed
2 (2-4) 14 (52%) 14 (52%) 16 (57%)
secondary and exploratory endpoints with the same
methods as for the primary outcome. For continuous 3 (>4) 2 (7%) 1 (4%) 0

outcomes measured repeatedly over weeks, all values (Table 1 continues on next page)
were summarised at each timepoint and comparisons to

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6 mg NGM282 (11∙4; 95% CI 3∙0–43∙8; p<0∙0001) met


Placebo 3 mg NGM282 6 mg NGM282
(n=27) (n=27) (n=28) the primary endpoint versus only two (7%) of 27 in the
placebo group (figure 2A). Reductions in absolute liver
(Continued from previous page)
fat content were significantly greater in patients given
Liver fat content by MRI-PDFF
3 mg NGM282 (LS mean difference −8∙8 [SE 1∙4],
Liver fat content (%) 16∙8 (6∙7) 18∙1 (7∙3) 19∙5 (7∙8)
95% CI −11∙6 to −6∙1; p<0∙0001) and 6 mg NGM282
Fibrosis
(−11∙1 [1∙4], −13∙9 to −8∙3; p<0∙0001) compared with
Pro-C3 (ng/mL) 18∙9 (14∙7) 19∙2 (12∙3) 14∙9 (6∙0)
those given placebo (table 2, figure 2B). We recorded no
ELF score 9∙9 (1∙0) 9∙7 (0∙8) 9∙6 (0∙9)
significant differences between the NGM282 groups
Hyaluronic acid (UG/L) 85∙6 (90∙3) 58∙7 (47∙4) 65∙6 (67∙6)
with regard to absolute liver fat content (p=0∙112).
PIIINP (UG/L) 11∙8 (3∙9) 12∙5 (4∙5) 10∙7 (3∙1)
Findings of post-hoc analysis showed that the greatest
TIMP-1 (UG/L) 297∙0 (91∙1) 271∙6 (65∙8) 265∙8 (69∙5)
reductions in liver fat content from baseline to
Data are mean (SD), n (%), unless stated otherwise. C4=serum 7-α-hydroxy-4-cholesten-3-one. DPP4=dipeptidyl week 12 were in patients with baseline liver fat content
peptidase 4. ELF=enhanced liver fibrosis. GLP-1=glucagon-like peptide 1 receptor agonists. HbA1C=glycated higher than 20% as measured by MRI-PDFF (3 mg
haemoglobin. HDL=high-density lipoprotein. HOMA-IR=homoeostasis model assessment–estimated insulin resistance.
NGM282: −12∙9 [SE 8∙8], 95% CI −19∙6 to −6∙2];
INR=international normalised ratio. LDL=low-density lipoprotein. MRI-PDFF=magnetic resonance imaging-proton
density fat fraction. NAFLD=non-alcoholic fatty liver disease. NAS=NAFLD activity score. PIIINP=N-terminal pro-peptide p=0∙002; 6 mg NGM282: −18∙9 [6∙3], −22∙9 to −14∙9;
of collagen III. Pro-C3=N-terminal type III collagen pro-peptide. SGLT2=sodium-glucose cotransporter-2 inhibitors. p<0∙001; table 3).
TIMP-1=tissue inhibitor of metalloproteinase 1. *One patient in the placebo group had total NAS score but not Patients who received either 3 mg or 6 mg NGM282
component values in the histopathology report.
achieved greater relative reductions in liver fat content
Table 1: Baseline demographics from baseline to week 12 than those in the placebo group
(p<0∙0001 for both comparisons; figure 2C). Overall,
placebo were evaluated by ANCOVA. We used SAS 23 (85%) of 27 and 24 (86%) of 28 patients receiving 3 mg
(version 9.4) for all analyses. or 6 mg NGM282, respectively, achieved a clini­
Safety and tolerability analyses were done with the cally meaningful relative change in liver fat content
safety population (all randomly assigned and en­ (≥30% reduction; 3 mg NGM282: RR 11∙5, 95% CI
rolled patients who received at least one dose, full or 3∙0–44∙0; 6 mg NGM282: 12∙5, 3∙3–47∙5; p<0∙0001 for
partial, of study drug and had at least one post-dose both comparisons). These changes have been shown to
safety evaluation). All safety endpoints were analysed be associated with histological improvement in non-
descriptively. alcoholic steatohepatitis in previous studies.22,24 Liver fat
This trial is registered with ClinicalTrials.gov, number content completely normalised in seven (26%) patients in
NCT02443116, and was overseen by the funder’s medical the 3 mg dose group and 11 (39%) in the 6 mg dose group;
monitor and clinical research associate. no patients receiving placebo achieved normalisation
(table 2). Findings of post-hoc analysis showed that
Role of the funding source improve­ments in liver fat content were consistent across
This study was designed by expert consultants in the a broad range of patient populations with no significant
non-alcoholic steatohepatitis field in conjunction with effect of baseline sex, race or ethnic origin, dia­betes status,
representatives of the funder. Data were collected by BMI, ALT concentration, fibrosis stage, or concomitant
investigators, and managed, validated, and analysed by statin use (appendix p 10).
INC Research (Raleigh, NC, USA). The corresponding We recorded greater reductions from baseline in ALT
author and the funder had full access to all data in the concentrations for both NGM282 groups (3 mg group: LS
study and had full responsibility for the decision to mean difference −35∙1 [SE 6∙0]; 95% CI −47∙1 to −23∙1;
submit for publication. p<0∙0001; 6 mg group: −36∙5 [6∙1]; −48∙7 to −24∙2;
p<0∙0001) at week 12 compared with placebo (table 3,
Results figure 3, appendix p 11). Consequently, the relative
Between July 14, 2015, and Aug 30, 2016, 166 patients were decreases in ALT concentrations from baseline to
screened, and 82 eligible patients were randomly assigned week 12 were also significant in the 3 mg group and 6 mg
to receive 3 mg NGM282 (n=27), 6 mg NGM282 (n=28), or group (3 mg group: −44∙9 [SE 8∙8], 95% CI −62∙5 to −27∙3;
placebo (n=27; figure 1). 82 patients were included in the p<0∙0001: 6 mg group: −47∙4 [9∙0], −65∙4 to −29∙5;
efficacy analyses; two patients in the 6 mg dose group did p<0∙0001) compared with placebo (appendix p 11). In
not complete MRI-PDFF imaging for liver fat content patients with a baseline ALT concentration higher than
assessment because of early withdrawal, and were imputed 60 IU/L, significant reductions in ALT concentrations were
as non-responders. 82 patients were included in the safety recorded in patients given 3 mg NGM282 (−56 [SD 42∙8],
analysis. Baseline demographics and disease character­ 95% CI −84∙8 to −27∙3; p=0∙0001) and 6 mg NGM282
istics of the three dosing groups were similar (table 1). (−45∙9 [23∙2]; 95% CI −60∙6 to −31∙1; p<0∙0001) by week 2.
At 12 weeks, 20 (74%) of 27 patients who received 3 mg In 13 (24%) of 55 patients in the NGM282 groups, ALT
NGM282 (relative risk [RR], 10∙0; 95% CI 2∙6–38∙7; concentrations achieved normalisation by week 2, and in
p<0∙0001), and 22 (79%) of 28 patients who received 20 (36%) patients by week 12.

6 www.thelancet.com Published online March 5, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30474-4


Articles

Similarly, treatment with NGM282 resulted in signifi­ A B


cant reductions in AST from baseline to 100 –0
week 12 compared with placebo (3 mg group: LS mean
–2 –0·9
difference −20∙4 [SE 4·7], 95% CI −29·8 to −11∙0, 79
80 74
p<0∙0001; 6 mg group: −22·5 [5∙0], 95% CI –4

Absolute change in LFC (%)


−32∙4 to −12∙7; p<0·0001; table 3, figure 3B, appendix
–6
p 5). There were no significant changes from baseline in 60

Response (%)
alkaline phosphatase among the treatment groups –8
(table 3, figure 3C). Of note, despite rebound, 40 –10
concentrations of ALT and AST remained significantly –9·7
reduced at week 16 follow-up, 4 weeks after cessation of –13 p<0·0001
–11·9
treatment (appendix). Re­ductions in C4 concentrations 20
7 –14 p=0·112
from baseline to week 12 were significant for both
p<0·0001
NGM282 groups (p<0∙0001); these changes were also 0 –16
Placebo (n=27) 3 mg (n=27) 6 mg (n=28) Placebo 3 mg 6 mg
significant when compared with the placebo group
(p<0∙0001 for both comparisons; table 3, figure 3D). C D
More than 65% of participants were at or below the limit –0
–3
of quantification for the C4 assay (0·9 ng/mL) as soon as 40%
–10
week 1 of NGM282 treatment. Despite significant
Absolute to relative change in LFC (%)

inhibition of the classic pathway of de novo bile acid –20 Baseline


MRI-PDFF=24·1%
synthesis as evidenced by C4 reduction, we noted no
–30
significant changes in serum vitamin D concentrations,
0%
an indicator of fat-soluble vitamin absorption, in patients –40
given NGM282 (appendix p 6). At week 12, the absolute
–50 –48
change in liver fat content was significantly correlated 40%

with change in ALT (Spearman correlation, r=0∙46; p<0·0001


–60
12 weeks
p=0∙0001), AST (r=0∙37; p=0∙0008), and C4 (r=0∙53; –60
MRI-PDFF=3·6%
p<0∙0001) by post-hoc analysis (appendix p 7). –70 p=0·144

At week 12, reductions in triglyceride concentrations p<0·0001


–80 0%
were significantly greater in the NGM282 6 mg group Placebo 3 mg 6 mg
(p=0·01) compared with the placebo group (table 3, Figure 2: Treatment response (A), absolute change in liver fat content (B), relative change in liver fat
appendix p 12). Low-density lipoprotein-C (LDL-C) content (C), and normalisation of liver fat content with 6 mg NGM282 (D), from baseline to week 12
concentrations were significantly increased in both the Absolute and relative change values expressed as least squares means. LFC=liver fat content.
3 mg NGM282 group and the 6 mg group (40∙7 [8∙5], MRI-PDFF=MRI–proton density fat fraction.
23∙7–57∙6) compared with placebo (both p<0∙0001).
We noted no increase in LDL-C in the placebo
Placebo 3 mg 6 mg 3 mg NGM282 p value 6 mg NGM282 p value
group (table 3, appendix p 12). NGM282-associated group NGM282 NGM282 group vs group vs
LDL-C increase was driven mainly by an increase in (n=27) group group placebo group placebo group
large, buoyant LDL-C particles (appendix p 8), with (n=27) (n=28)
concomitant reductions in the large triglyceride- Liver fat content by MRI-PDFF
rich lipoprotein particles. Addition­ally, we recorded no Response 2 (7%) 20 (74%) 22 (79%) 10∙0 (2∙6–38∙7) <0∙0001 11∙4 (3∙0–43∙8) <0∙0001
changes in high-density lipo­protein (table 3, appendix Normalisation 0 7 (26%) 11 (39%) ∙∙ ∙∙ ∙∙ ∙∙
p 13). Significant reductions in lipoprotein insulin ≥30% decrease 2 (7%) 23 (85%) 24 (86%) 11∙5 (3∙0–44∙0) <0∙0001 12∙5 (3∙3–47∙5) <0∙0001
resistance index and insulin resistance diabetes risk ALT
factor, which are lipid-based algorithms measuring Normalisation 1 (4%) 10 (37%) 10 (36%) 9∙6 (1∙3–70∙0) 0∙005 9∙3 (1∙3–67∙6) 0∙005
hepatic and peripheral insulin resistance,25 were also
Data are n (%), relative risk (95% CI), unless otherwise stated. ALT=alanine aminotransferase. MRI-PDFF=MRI-proton
recorded in NGM282 groups (appendix p 8). The density fat fraction.
appendix (p 9) shows changes from baseline to
week 12 in additional laboratory parameters. Table 2: Categorical outcomes at week 12
Assessments of non-invasive fibrosis biomarkers
showed decreases after 12 weeks of NGM282 treatment. (p=0∙1) for NGM282 3 mg and 6 mg, respectively, but
Pro-C3 and PIIINP are markers of collagen formation these differences were not significant compared with
reflecting fibrogenic activity. Reductions in pro-C3 placebo. TIMP-1 is a downstream marker of fibrogenic
concentrations at week 12 were greater in participants in signalling. We noted significant reductions in TIMP-1 in
the 6 mg NGM282 group than the placebo group. the NGM282 3 mg group and 6 mg group (p=0·01)
Reductions in PIIINP concentrations from baseline to compared with the placebo group (p=0·02). We noted
week 12 were −2∙9 UG/L (p=0∙02) and −1∙5 UG/L reductions in enhanced liver fibrosis (ELF) score from

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Articles

Change from Change from Change from LS mean difference, 3 mg p value LS mean difference, 6 mg p value
baseline to week baseline to week 12, baseline to week NGM282 group vs placebo NGM282 group vs placebo
12, placebo group 3 mg NGM282 12, 6 mg NGM282 group group
(n=27) group (n=27) group (n=28)
Liver fat content by MRI-PDFF
Liver fat content (%) −0∙1 (3∙03) −9∙6 (6∙92) −12∙5 (7∙94) −8·8 (1∙4; −11∙6 to −6∙1) <0·0001 −11∙1 (1∙4; −13∙9 to −8∙3) <0∙0001
Baseline 8–15% −0∙22 (3∙3) −5∙43 (3∙2) −6∙28 (4∙1) ∙∙ ∙∙ ∙∙ ∙∙
Baseline >15–20% 0∙62 (2∙5) −11∙5 (3∙0) −12 (2∙4) ∙∙ ∙∙ ∙∙ ∙∙
Baseline >20% −0∙3 (3∙3) −12∙9 (8∙8) −18∙9 (6∙3) ∙∙ ∙∙ ∙∙ ∙∙
ALT
Overall ALT (IU/L) −2∙2 (21∙1) −35∙0 (44∙6) −32∙1 (35∙3) −35·1 (6∙0; −47∙1 to −23∙1) <0·0001 −36∙5 (6∙1; −48∙7 to −24∙2) <0∙0001
Baseline ALT >60 (IU/L) −9∙5 (22∙6) −63∙1 (58∙6) −54∙5 (42∙4) ∙∙ ∙∙ ∙∙ ∙∙
Baseline ALT 40-60 (IU/L) 0 (18∙9) −24∙4 (7∙3) −21∙5 (17∙2) ∙∙ ∙∙ ∙∙ ∙∙
Baseline ALT <40 (IU/L) 12∙7 (22∙0) −6∙8 (12∙5) −9∙1 (8∙6) ∙∙ ∙∙ ∙∙ ∙∙
7α-hydroxy-4-cholesten-3-one (C4)
C4 (ng/mL) 11∙7 (32∙4) −48∙5 (57∙1) −25∙9 (26∙2) −43·2 (7∙4; −58∙0 to −28∙4) <0·0001 −39∙3 (7∙2; −53∙6 to −25∙0) <0∙0001
Liver function
AST (IU/L) −0∙6 (23∙9) −17∙9 (20∙8) −17∙0 (21∙2) −20·4 (4∙7; −29∙8 to −11∙0) <0·0001 −22∙5 (5∙0; −32∙4 to −12∙7) <0∙0001
ALP (IU/L) −0∙1 (21∙9) −0∙5 (19∙8) 2∙3 (16∙5) 0·7 (5∙2; −9∙6 to 11∙0) 0·90 1∙7 (5∙1; -8∙4 to 11∙9) 0·74
GGT (IU/L) 0∙3 (32∙7) 10∙3 (62∙3) −3∙3 (53∙3) 11·6 (13∙7; −15∙8 to 40∙0) 0·40 −4∙2 (14∙0; −32∙1 to 23∙7) 0·77
Total bilirubin 0 (0∙1) 0 (0∙2) 0 (0∙2) 0·1 (0; 0 to 0∙2) 0·11 0∙1 (0; 0 to 0∙2) 0·09
Albumin (g/L) 0 (0∙3) 0∙2 (0∙4) 0∙1 (0∙3) 0·2 (0∙1; 0 to 0∙4) 0·08 0∙2 (0∙1; 0 to 0∙3) 0·12
Fibrosis biomarkers
Pro-C3 (ng/mL) −1∙21 (10∙7) −5∙4 (10∙7) −3∙6 (8∙3) −4·0 (2∙2; −8∙3 to 0∙3) 0·07 −4∙6 (2∙1; −8∙9 to −0∙4) 0·0342
Patients with >15% decrease 6/25 (24%) 17/23 (74%) 19/25 (76%) ∙∙ 0·0005 ∙∙ 0·0002
in pro-C3
ELF score 0 (0∙5) −0∙3 (0∙6) −0∙1 (0∙6) −0·3 (−0∙2; 0∙7 to 0) 0·047 −0∙2 (0∙2; −0∙5 to 0∙2) 0·33
Hyaluronic acid (UG/L) 7∙0 (55∙9) −5∙5 (32∙0) 22∙6 (107∙4) −7·5 (21∙4; −50∙5 to 35∙4) 0·73 21∙7 (22∙3; −23 to 66∙3) 0·34
PIIINP (UG/L) 0 (3∙1) −2∙9 (5∙6) −1∙5 (4∙3) −2·5 (1∙3; −5 to 0) 0·052 −2∙2 (1∙3; −4∙8 to 0∙4) 0·10
TIMP-1 (UG/L) 5∙2 (69∙4) −25∙9 (39∙2) −18∙0 (41∙0) −40·7 (14∙2; −69∙1 to −12∙3) 0·006 −35∙1 (14∙8; −64∙8 to −5∙4) 0·021
Lipids
Triglycerides (mmol/L) –0∙1 (0∙8) –0∙4 (1∙3) –0∙5 (0∙8) –0·1 (0∙2; –0∙5 to 0∙2 0·51 –0∙5 (0∙2; –0∙8 to –0∙1) 0·012
Cholesterol (mmol/L) 0 (0∙6) 1∙1 (1∙0) 0∙8 (0∙8) 1·1 (0∙2; 0∙6 to 1∙5) <0·0001 0∙8 (0∙2; 0∙4 to 1∙2) 0·0002
HDL (mmol/L) 0 (0∙2) 0 (0∙3) 0 (0∙3) 0 (0; –0∙1 to 0∙1) 0·74 0 (0; –0∙1 to 0∙2) 0·57
LDL (mmol/L) 0 (0∙5) 1∙2 (1∙0) 1∙0 (0∙8) 1·2 (0∙2; 0∙7 to 1∙6) <0·0001 ∙0 (0∙2; 0∙6 to 1∙5) <0∙0001
Concomitant statin 0∙2 (0∙5) 1∙1 (0∙7) 1∙0 (0∙6) ∙∙ ∙∙ ∙∙ ∙∙
No concomitant statin –0∙1 (0∙5) 1∙2 (1∙3) 1∙0 (0∙9) ∙∙ ∙∙ ∙∙ ∙∙
Metabolic factors
Glucose (mg/dL) −1∙7 (60∙6) 2∙9 (31∙3) 2∙9 (29∙7) −4·1 (8∙6; −21∙3 to 13∙2) 0·64 −0∙1 (8∙8; −17∙6 to 17∙4) 0·99
HbA1c (%) −0∙1 (1∙0) −0∙2 (0∙7) −0∙1 (0∙5) −0·2 (0∙2; −0∙5 to 0∙2) 0·37 0 (0∙2; −0∙4 to 0∙3) 0·85
Insulin (pmol/L) –0∙5 (2∙0) –0∙9 (4∙9) 0∙2 (2∙3) 0·2 (0∙8; -1∙4 to 1∙9 ) 0·78 0∙6 (0∙9; -1∙2 to 2∙3) 0·50
HOMA-IR 1∙13 (6∙7) −0∙9 (8∙7) 0∙7 (7∙8) −1·4 (2∙2; −5∙8 to 2∙9) 0·51 −0∙5 (2∙2; −5 to 3∙9) 0·81
Weight (kg) −0∙8 (2∙4) −1∙2 (3∙5) −2∙7 (3∙4) −0·4 (0∙8; −2∙0 to 1∙3) 0·67 −2∙0 (0∙9; −3∙7 to −0∙3) 0·023
BMI (kg/m²) −0∙2 (0∙9) −0∙4 (1∙6) −0∙9 (1∙3) −0·3 (0∙3; −0∙9 to 0∙4) 0·42 −0∙8 (0∙3; −1∙5 to −0∙1) 0·024
Waist circumference (cm) −2∙5 (12∙8) −0∙3 (4∙5) −4∙6 (12∙6) 3·1 (2∙9; −2∙8 to 8∙9) 0·30 −1∙4 (3∙0; −7∙3 to 4∙5) 0·65

Data are mean (SD), SE (95% CI), unless otherwise stated. ALP=alkaline phosphatase. ALT=alanine aminotransferase. AST=aspartate aminotransferase. ELF=enhanced liver fibrosis. GGT=α -glutamyl
transpeptidase. HbA1C=glycated haemoglobin. HDL=high-density lipoprotein. HOMA-IR=homoeostasis model assessment-estimated insulin resistance. LDL=low-density lipoprotein. LS=least squares.
MRI-PDFF=MRI-proton density fat fraction. PIIINP=N-terminal pro-peptide of collagen III. Pro-C3=N-terminal type III collagen pro-peptide. SD=standard deviation∙ SE=standard error. TIMP-1=tissue inhibitor of
metalloproteinase 1.

Table 3: Continuous outcomes at week 12

baseline to week 12 in participants given 3 mg NGM282 metabolic factors including glucose, HbA1c, insulin,
compared with those in the placebo group (table 3). HOMA-IR, or waist circumference (all p>0∙05). Patients
We recorded no significant placebo-adjusted changes in the 6 mg NGM282 group reported significant
from baseline to week 12 for the NGM282 groups in reductions in weight and BMI compared with placebo

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A B
Placebo 3 mg 6 mg
80 80

70 70

60 60

50 50
*

AST (IU/L)
ALT (IU/L)


40 * † 40 *
* * * * † *
30 * * 30 *
* * *
20 * 20 †

10 End of 10 End of
treatment Follow-up treatment Follow-up
0 0

C D
80 80

60
70

50
50
C4 (ng/mL)
ALP (IU/L)

40
30
20
End of
10 treatment
End of 10 *
* * *
treatment Follow-up
0 0 * * * *
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18
Week Week

Figure 3: Levels of alanine aminotransferase (A), aspartate aminotransferase (B), alkaline phosphatase (C), and 7α-hydroxy-4-cholesten-3-one (D) over time
*p<0·001. †p<0·01.

(table 3), but the reductions in liver fat content were pain in 15 (18%), and nausea in 14 (17%; table 4). These
independent of weight loss and BMI. adverse events were reported more frequently in the
Six (22%) of 27 patients in the 3 mg dose group and NGM282 groups than the placebo group. Treatment-
seven (25%) of 28 in the 6 mg dose group tested positive related adverse events occurred in 60 patients; the
for antidrug antibodies; only three patients had titres majority of which were mild (grade 1/2; table 4).
above background (one patient from the NGM282 3 mg Two (7%) patients in the 3 mg dose group had treatment-
cohort had a titre of 1:22, two patients from the 6 mg related grade 3 adverse events (one patient with
cohort had titres of 1:18 and 1:23, respectively). Titres were aggravated abdominal pain, one patient with acute
low in the remaining ten patients (all with a titre of 1:3), pancreatitis) compared with two (7%) in the 6 mg dose
which were considered background levels because a titre group (one patient with nausea or abdominal pain, one
of 1:3 was also detected in two patients in the placebo patient with depression), and one (4%) patient in the
group. Absolute liver fat content changed from 26·9% at placebo group (increased hepatic enzyme). No grade 4
baseline to 14·0% at end of treatment for the patient with treatment-related adverse events were reported in any
a titre of 1:22 in the 3 mg cohort, from 15·0% to 7·0% for treatment group. One patient in the 3 mg dose group
the patient with a titre of 1:18 in the 6 mg cohort, and experienced a serious adverse event (acute pancreatitis),
from 14·0% to 18·0% for the patient with a titre of 1:23 in which was resolved with standard clinical support. This
the 6 mg cohort. The NGM282 levels (Cmin) were singular case of pancreatitis was unlikely to be related to
16·6 ng/mL, 14·3 ng/mL, and 46·9 ng/mL at end of study drug because the patient was on other medications
treatment in these three patients, respectively. None of known to be associated with pancreatitis and the
the antidrug antibodies tested positive for neutralising patient also previously had a cholecystectomy. Study
activity against FGF19. drug withdrawal because of adverse events occurred in
Overall, 76 (93%) of 82 patients reported at least one three (11%) of 27 patients in the 3 mg NGM282 group
adverse event, most of which were grade 1 (55 [67%]), (four events in three patients; aggravated abdominal
and only five (6%) experienced adverse events that were pain, acute pancreatitis and increased lipase, aggravated
grade 3 or worse. The most commonly (≥10%) re­ nausea) and three (11%) of 28 patients in the 6 mg
ported adverse events were injection site reactions in dose group (three events in three patients; loose
28 (34%) patients, diarrhoea in 27 (33%), abdominal stools, injection site reaction, and depression). No

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changes and has been used in non-alcoholic steatohepatitis


Placebo 3 mg 6 mg
group NGM282 NGM282 clinical trials for quantitative fat assessment.26 Using
(n=27) group (n=27) group (n=28) paired MRI-PDFF and liver histology data, Patel and
Most common adverse events (>10%) colleagues have shown that an absolute change in liver fat
Injection site reactions 2 (7%) 11 (41%) 15 (54%) content of –4·1% with a relative change of –29·3% is
Diarrhoea 6 (22%) 11 (41%) 10 (36%)
associated with histological improvements of 2 or more
Abdominal pain 2 (7%) 8 (30%) 5 (18%)
point reduction in NAS (with 1 point each for steatosis and
Nausea 1 (4%) 9 (33%) 4 (14%)
ballooning).22 This suggests that change in liver fat may
be a surrogate for early hepatocellular injury as well.
Headache 5 (19%) 3 (11%) 5 (18%)
Furthermore, weight-loss studies have demonstrated a
Abdominal distension 1 (4%) 3 (11%) 4 (14%)
clinically meaningful decrease of 4·7–4·8% in absolute
Vomiting 0 2 (7%) 5 (18%)
liver fat content between the beginning and the end of
Frequent bowel 2 (7%) 3 (11%) 1 (4%)
movements the interventions.23 Based on these considerations and in
Increased appetite 0 2 (7%) 4 (14%) line with recent trials in the field, we have chosen a
Constipation 1 (4%) 3 (11%) 1 (4%) ≥5% reduction in absolute liver fat content as responder
Injection site bruising 3 (11%) 2 (7%) 0
criteria for primary outcome, and a relative 30% reduction
Weight decreased 0 0 3 (11%)
as a clinically meaningful change in liver fat content.
At least one serious 0 1 (4%)* 0
NGM282-associated reductions in absolute liver fat
adverse event content and relative liver fat content change exceed these
At least one adverse event 1 (4%) 5 (19%) 9 (32%) criteria and thus are clinically important.
leading to study drug Findings of preclinical animal studies have demons­
temporary interruption or trated that treatment with NGM282 leads to resolution of
discontinuation
non-alcoholic steatohepatitis and improve­ment in fibrosis
Treatment-related adverse events by severity grade
through several mechanisms. In addition to suppressing
Grade 1 14 (52%) 18 (67%) 23 (82%)
the classic pathway of de novo bile acid synthesis, NGM282
Grade 2 4 (15%) 11 (41%) 12 (43%)
inhibits fatty acid synthesis and de novo lipo­ genesis,
Grade 3 1 (4%) 2 (7%) 2 (7%)
presumably through mechanisms that eliminate or
Grade 4 0 0 0
decrease hepatic bile acid toxicity and lipo­toxicity, factors
*Acute pancreatitis. believed to be essential for the progression of non-alcoholic
steatohepatitis to advanced liver diseases.15 In view of the
Table 4: Adverse events
rapid and robust improvement in ALT and AST, in addition
to the unparalleled reduction in liver fat content by
life-threatening events (grade 4) or patient deaths a pharmacological agent in the current study, NGM282
(grade 5) occurred during the study. could regulate multiple pathways to deliver weight-
independent anti-steatotic, anti-inflammatory, and anti-
Discussion fibrotic activities, and represent a potentially promising
In this randomised, placebo-controlled, double-blind treatment for patients with non-alcoholic steatohepatitis.
study, NGM282 3 mg and 6 mg produced rapid and However, after cessation of NGM282 treatment, levels of
sustained improvements in liver fat content over transaminases increased toward baseline.
12 weeks of treatment. Greater treatment effect was Like FGF19, NGM282 potently suppresses expression
recorded in patients with higher baseline liver fat content of CYP7A1 via the FGFR4-βKlotho (KLB) receptor
and ALT. In addition to changes in absolute liver fat complex, reducing cholesterol catabolism.16 Consistent
content, NGM282 produced significant improvements in with this mechanism of action, NGM282 significantly
ALT, AST, and non-invasive serum fibrosis biomarkers decreased serum C4 levels and produced significant
(pro-C3 and ELF score). Decreases in liver fat content increases in LDL-C, especially the large, buoyant LDL-C
were correlated with decreases in C4, ALT, AST, and particles that are thought to be less atherogenic. The
increases in LDL-C, consistent with a treatment effect elevation in LDL-C has been previously shown in
on multiple pathways relevant to non-alcoholic steato­ studies involving obeticholic acid, an agonist of farnesoid
hepatitis pathogenesis. The presence of antidrug X receptor that induced FGF19 secretion.27 Considering
antibodies in a small number of patients did not seem to the increased cardio­ vascular risk associated with non-
have discernible effects on efficacy and safety outcomes, alcoholic steatohepatitis, it is important to explore the
with none having neutralising activity against FGF19. use of concomitant lipid-lowering therapies to support
NGM282 was generally well tolerated at both doses, chronic administration of NGM282. Of note, treatment
with most treatment-related adverse events being mild with SGLT-2 inhibitors for type 2 diabetes was associated
in severity. with a beneficial impact on cardiovascular outcome
Liver fat content quantification via MRI-PDFF has been despite significant increases in large particle LDL-C.28
previously shown to be sensitive in detecting liver fat Further­more, recent data have shown that concomitant

10 www.thelancet.com Published online March 5, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30474-4


Articles

administration of a statin can mitigate NGM282-related content, as well as markers of liver inflammation and
increases in LDL-C.29 fibrosis. Additionally, both doses were generally well
A strength of this trial was the use of non-invasive tolerated. These results support the further exploration
MRI-PDFF to evaluate changes in liver fat content as of NGM282 for the safe and effective treatment of
opposed to histological evaluation. Subjects enrolled in non-alcoholic steatohepatitis.
this study had both pre- and post-treatment MRI exams, Contributors
and MRI scans were read centrally in a manner similar to SAH, MER, MFA, MK, SJR, AMD, and RL participated in study design.
that described previously.26 MRI-PDFF is highly sensitive SAH, MER, MFA, JFT, AHP, HLA, MK, MRB, RL were responsible for
data collection. SAH, MJJ, LL, SJR participated in data analysis.
to changes in liver fat content, is non-invasive and highly SAH, MER, MFA, JFT, AHP, HLA, MK, MRB, LL, SJR, AMD,
repeatable, provides quantitative estimates of overall liver RL participated in data interpretation. All authors participated in
fat content, and is less vulnerable to sampling error than manuscript review and writing. SAH, LL, SJR were responsible for
liver biopsy alone. Importantly, MRI-PDFF has been preparation of the tables and figures.

shown to correlate well with improvements in liver Declaration of interests


histology. Both absolute change in liver fat content SAH reports grant and research support from Allergan, Conatus,
Galectin, Galmed, Genfit, Gilead, Immuron, Intercept, Madrigal,
(≥4·1% reduction) and relative change in liver fat content NGM Bio, and TaiwanJ; participates on Speakers’ Bureaus for Alexion
(≥29·3% reduction) are associated with histological and Gilead; is a consulting adviser for Allergan, Chronic Liver Disease
improvements of a 2 or more point reduction in NAS (with Foundation, Cirius, Echosens, Fibrogen, Galmed, Genfit, Gilead,
Intercept, Madrigal, NGM Bio, Novartis, Perspectum, and Pfizer.
1 point each for steatosis and ballooning, respectively),22
MER reports being on advisory committees or review panels for
and are more sensitive than histology-determined steatosis Intercept, Abbvie; consulting for Intercept, Novartis, NGM Bio, Shire,
grade in quantifying liver fat changes.24 Additionally, MRI and Fibrogen. MFA reports grant and research support from
examinations were randomised at final reading with NIH/NIDDK, Allergan, Conatus, Galectin, Galmed, Genfit, Gilead,
Immuron, Intercept, Madrigal, Shire, NGM Bio, BMS, Excelenz,
regard to timepoint to reduce bias that might have resulted Boehringer Ingelheim, Prometheus and TaiwanJ; is on Speakers’
from knowledge of timepoints. Other strengths of this Bureaus for Alexion; is a consulting adviser for Allergan, TaiwanJ,
study include the correlation of measures of improvement NGM Bio, BMS, and Pfizer. MRB reports grant and research support
with target engagement. Additionally, the robust treatment from NGM Bio, TaiwanJ, Madrigal, Siemens Healthineers, General
Electric Healthcare, non-alcoholic steatohepatitis Clinical Research
effect was observed across a broad range of patient Network; is a consulting adviser for RadMD. MJJ reports consulting
populations with disease characteristics commonly seen in for NGM Bio. SJR, LL, and AMD report being employees and
non-alcoholic steatohepatitis. stockholders of NGM Bio. RL reports grant and research support from
Limitations of this study include a relatively short Daiichi Sankyo, AGA, Merck, Promedior, Kinemed, Immuron,
Adheron; is on advisory committees or review panels for Galmed,
treatment period and small overall number of participants. Tobira, Arrowhead; consulting for Gilead, Corgenix, Janssen, Zafgen,
Additional limitations include a lack of histology at the Celgene, Alnylam, Enanta, NGM Bio and Deutrx. All other authors
end of treatment, despite reductions in ALT, in addition to declare no competing interests.
liver fat content, having been associated with histological Acknowledgments
improvement in non-alcoholic fatty liver disease activity We thank all of the patients who participated in this study, and the
investigators, study coordinators, and staff of all of the participating
score and fibrosis scores.30 Furthermore, the selection of
clinical centres for their support and assistance; Heather King and
5% reduction in absolute liver fat content to define Claudette Knight of Percolation Communications, LLC for medical
responders might have underestimated treatment effect, editorial assistance. Medical editorial assistance was funded by
as patients with lower baseline liver fat content are less NGM Biopharmaceuticals, Inc.
likely to achieve this endpoint. Another limitation was that References
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