Hepatobiliary lipids איך טיפול נולד... from bench to bedside Fred M Konikoff, MD, MSc, FAASLD Institute of Gastroenterology and Hepatology, Meir Medical Center, Kfar Saba, and Research Laboratory of Cholesterol Gallstones and Lipid Metabolism in the Liver, Tel Aviv University
GALLSTONE DISEASE Among the most common and costly digestive diseases: Prevalence 10-20% of population #2 GI cause of hospitalization (US) ~5% of the total health budget Donovan JM, Konikoff FM. Schiff s Diseases of the Liver, 10th Edition, 2006 Peery AF, Crockett SD et al Gastroenterology 2015, in press
LAP CHOLECYSTECTOMY Morbidity 0.6-12% (major 2%) Mortality (0.1%) DiBaise JK. Clin Gastroenterol Hepatol 2003,9:818
MEDICAL TREATMENT OF GALLSTONES URSODEOXYCHOLATE (UDCA) Only ~3% suitable patients Prolonged treatment (6-18mos) Recurrence 50% in 5 years Konikoff FM. Medscape General Medicine (Gastroenterology) 2003,5:1
cholesterol
Bile Acids cholesterol Phospholipids Micelles Vesicles Admirand WH, Small DM. J Clin Invest 1968,47:1043 Peled Y, Halpern Z, Eitan B, Goldman G, Konikoff F, Gilat T. Biochim Biophys Acta 1989,1003:246
PHOSPHOLIPIDS Candidates for gallstone treatment? Broken by digestive enzymes Biliary phospholipids cannot be controlled by dietary ingestion Pakula R, Konikoff FM, et al. Lipids 1996,31:295
PHOSPHOLIPIDS IN BILE 16:0 Sn1 Sn2 18:1 18:2 18:3 20:4 Phosphatidylcholine (Lecithin)
Effect of Sn2 chain on cholesterol crystallization 15 10 Crystal observation time (d) 5 0 Control 18:0 18:1 18:2 Ringel Y, Somjen GJ, Konikoff FM et al Biochim Biophys Acta 1998, 1390:293
Candidate for Saturated gallstone treatment? Pakula R, Konikoff FM, et al. Lipids 1996, 31: 295 FM Konikoff, T Gilat. Curr Drug Targets, Immune, Endocrine & Metabolic Disorders 2005, 5:171
T Gilat, G Somjen, Y Mazur, A Frenkel, R Rosenberg, Z Halpern, FM Konikoff. Gut 2001,48: 75 Fatty Acid Bile Acid Conjugate (FABAC) Influence cholesterol solubility & crystallization CH 3 (CH 2 ) n CONH H OH OH COOH Secreted into bile Enterohepatic circulation Fatty Acid SATURATED Bile Acid
Effect of FABACs on cholesterol C20-FABAC crystallization = Aramchol (in vitro) Crystal Observation Time 20 Time (days) 15 10 5 0 Control C16 C18 C20 C22 T Gilat, G Somjen, Y Mazur, A Frenkel, R Rosenberg, Z Halpern, FM Konikoff. Gut 2001,48: 75
Dissolution of crystals by Aramchol (human bile, ex vivo) 3 14 days 2 Cholesterol crystal mass (mmoles) 1 0 Control 10mM 30mM Aramchol T Gilat, I Goldiner, A Frenkel, H Laufer, Z Halpern, FM Konikoff. Lipids 2001,36: 1135
In vivo studies
Prevention of crystallization Lithogenic diet Aramchol 150/mg/kg/d % with crystals 100 75 50 25 0 Mice 0 Time (days) 14
Dissolution of crystals Lithogenic diet Aramchol 150/mg/kg/d % with crystals % with crystals 100 90 80 70 60 50 40 30 20 10 0 10 14 28 42 Time (days) Mice
Prevention of gallstone formation Lithogenic diet STONES (%) 100 75 50 25 0 Aramchol 150/mg/kg/d 25 50 150 mg/kg/d Mice 0 Time (days) 20
Gallstone Dissolution Aramchol: 25mg/kg 150mg/kg Lithogenic diet Regular diet + Saline/Aramchol 100 % of mice with stones 80 60 40 20 0 2 4 months T Gilat, A Leikin-Frenkel, I Goldiner, Z Halpern, FM Konikoff. Hepatology, 35: 597-600, 2002
Aramchol: Prevents cholesterol crystallization and gallstone formation Dissolves cholesterol crystals and gallstones Potential medical treatment for gallstones!
Pharmacodynamics (after 150mg/kg/d by gavage) In vivo concentration of Aramchol: Bile: 1.0-5.2 µmol/l In vitro: 2-30mM Mechanism of action?
Effect on biliary lipids Control Aramchol Cholesterol (mm) 15 10 5 0 Phospholipids (mm) 30 20 10 0 C57L/J mice 8w Bile salts (mm) 180 120 60 0 FM Konikoff, A Leikin-Frenkel, I Goldiner et al. Eur J Hepatol Gastroenterol, 15:1-8, 2003
Bile acid composition +Aramchol 40 30 Hydrophobic index 20 10 0 Regular diet Lithogenic diet
Phospholipid composition 120 100 80 Saturation (16:0/16:1) 60 40 20 0 RD LD LD+Aramchol
Aramchol MODE OF ACTION Bile salt hydrophobicity Phospholipid saturation Cholesterol Crystallization Y. Peled, Z. Halpern, B. Eitan, G. Goldman, F. Konikoff, T. Gilat. Biochim Biophys Acta, 1003: 246, 1989.
Mice on a high fat diet Control Aramchol+ Fatty Liver Normal Liver
LIVER LIPID CONTENT (21 days) 150 100 50 * Mice 0 mg lipid/g liver 200 100 * Hamsters 0 400 * Rats 200 0 *p<0.05 Control HFD HFD+Armchol
Fatty acid synthesis in the liver SCD1
Effect of Aramchol on SCD1 200 Mouse Liver Microsomes 160 Specific Activity (pmol/min/mg) 120 80 40 0 0 0.5 5 25 Aramchol (µg/ml) Inhibition of SCD1
Aramchol: Decreases bile lithogenicity via Bile acid & Phospholipid composition Effective for cholesterol gallstones Effective for fatty liver Inhibits SCD1 Therapeutic agent
Human trials Phase I: - 41 healthy volunteers - Single dose up to 900mg - Repeated doses of 300mg No toxic effects
Phase II trial - Randomized, double blind, placebo controlled - 60 pts with Bx proven NAFLD - Aramchol:100mg/d, 300mg/d, Placebo 3mos - Liver fat assessed by MR spectroscopy Safadi R, Konikoff FM, et al. Clin Gastroenterol Hepatol. 2014, 12: 2085
Change in liver fat content (after 3 mos of treatment) No adverse effects Safadi R, Konikoff FM, et al. Clin Gastroenterol Hepatol. 2014, 12: 2085
Ongoing studies Multicenter International Phase II b fatty liver study (NASH) Gallstone prevention study after bariatric surgery (proof of concept)
Conclusions Observations on cholesterol crystallization in bile Importance of Bile acids and Phospholipids Aramchol - therapeutic potential for: - Gallstones - Fatty liver by a different mechanism than originally planned
Thanks Israel Tuvia Gilat Alicia Leikin-Frenkel Ilana Goldiner Diana Gobbi Zamir Halpern Livna Shoefat Ruth Rosenberg Giora Somjen Ishi Talmon Ran Oren Rifaat Safadi Amsterdam Albert Groen Stockholm Paolo Parini Kurt Einarsson Marseille Huguette Lafont Ulm Michael Fuchs Dietmar Klass Galmed Medical Minerva Center for Gallstones and Lipid Metabolism in the Liver, TAU