The therapeutical efficacy of senolytic drugs in the treatment of non-alcoholic fatty liver disease with fibrosis - the truth study

Non-Alcoholic Fatty Liver Disease (NAFLD) is estimated to affect approximately
25-30% of the population in Western countries and is now the leading cause of
chronic liver disease globally. NAFLD is a progressive liver disease and
approximately 30% of individuals progress from simple steatosis to
Non-Alcoholic Steatohepatitis (NASH), which can further progress to cirrhosis
and hepatocellular carcinoma. In the Netherlands, it is estimated that 2.5
million people have NAFLD. This number is thought to increase by 50% in the
next 10 years. This is mainly due the rising prevalence of obesity and type 2
diabetes, and an aging population, which are main drivers of NAFLD. Independent
of other cardiometabolic diseases, cardiovascular disease is the leading cause
of death in individuals with NAFLD, followed by extrahepatic malignancies and
liver-related complications. NAFLD results in sustained healthcare costs and
economic losses, and reduced health-related quality of life.

It is now widely accepted that liver fibrosis is a result of liver injury
secondary to NAFLD and is a major predictor for liver-related and overall
mortality in individuals with NAFLD. The process of fibrosis progression is not
completely understood, and it can vary considerably from one individual to
another. Several risk factors for fibrosis progression have been identified
including age, hypertension, obesity and type 2 diabetes. As of to date, no
treatment is available that proved to be successful to target hepatic fibrosis.
The only therapeutic options currently available therefore are diet and
lifestyle changes and control of concomitant metabolic diseases. Unfortunately,
this inevitably leads to polypharmacy, which decreases treatment adherence and
increases the risk of adverse events and interactions with other drugs.


Considering the role of senescence in NAFLD-related fibrosis, dasatinib plus
quercetin might be an interesting therapeutic intervention to meet the high
unmet clinical need for NAFLD. Importantly, dasatinib and quercetin have a
strong long-term safety profile. We therefore aim to perform a double*blind
randomized controlled proof*of*principle study in which patients with
NAFLD-related liver fibrosis will be treated with dasatinib plus quercetin. The
treatment will be intermittent (three days per week for three weeks) followed
by a four-week medication-free period. This treatment cycle will be repeated
three times.

This study has been transitioned to CTIS with ID 2024-517593-21-00 check the CTIS register for the current data.

To examine the effect of oral dasatinib plus quercetin on liver fibrosis as
assessed by histology in individuals with biopsy-proven NAFLD with fibrosis by
performing a double*blind randomized controlled proof*of*principle study. The
primary endpoint is the binary outcome improvement of fibrosis with at least
1-point without worsening of fibrosis and NAFLD score based on histology after
21 weeks (yes/no).

Double*blind randomized controlled proof*of*principle study in which 30
patients with fibrotic NAFLD will use dasatinib plus quercetin intermittently
three days per week for three weeks, followed by a four-week medication-free
period. This treatment cycle will be repeated three times and thus a total of
21 weeks.

Intermittent oral administration of a combination of Quercetin and Dasatinib or
a placebo

Schedule (total of 21 weeks):
3 weeks: 3 days a week a daily dose of 1000 mg Quercetine +100 mg Dasatinib, or
placebo.
Followed by a medication free period of 4weeks.
This cycle will be repeated 3 times.

With the help of the Nederlandse Leverpatienten Vereniging (NLV, director drs
J. Willemse), we estimated that the total study burden is in balance with
potential risks and benefits of participation for patients with liver disease
in in this study. Nevertheless, the study can be considered extensive and
invasive for the participants due to following procedures:

1. Liver biopsy: Study participants will undergo a liver biopsy at the end of
the study (or at baseline when no baseline biopsy was performed within six
months prior to the start) because a Fibroscan, MRI or ultrasound, although
non-invasive, are inferior for the accurate diagnosis and are therefore not
used in clinical trials for primary endpoints1 Although a liver biopsy is an
invasive procedure, it remains the gold standard for the diagnosis of NAFLD and
is therefore required for the interpretation of the results.

Given the fact that the individuals are recruited via our outpatient NAFLD
clinic, oftentimes a biopsy of the liver has already been performed. Therefore,
only one additional biopsy is necessary for this trial. Liver biopsies are
performed after informed consent, via the AMC intervention radiology department
or gastroenterology department for an ultrasound-guided liver biopsy to assess
NAFLD/NASH histology. As an experienced hepatologist or interventional
radiologist will perform the liver biopsy, the risk of complications will be
very low (<0.1%) and comprises mostly bleeding at the biopsy sites (see METC
2017_311, 2019_61 and 2022_236). Bleeding disorders therefore are an exclusion
criterion.

2. Safety and tolerability: A possible pitfall is the safety and tolerability
of the senolytic drug. However, intermittent dasatinib plus quercetin treatment
has an exceptionally good safety profile. Worldwide, hundreds of individuals
are enrolled in clinical trials using dasatinib plus quercetin (Table 2, page
25-26) for a variety of conditions, with no severe or serious side effects so
far. Dasatinib alone has been approved as prescription drug in the EU for
various cancers and for fibrotic diseases (scleroderma, progressive systemic
sclerosis), usually at doses of 100 mg/day for life. Of interest, in contrast
to other tyrosine kinase inhibitors, dasatinib usage is not associated with an
increased risk of hepatotoxicity. Recently, the suggestion that dasatinib is
associated with improved glucose metabolism and decreased need for glucose
lowering medication was further substantiated. Side-effects of dasatinib
include abdominal pain, vomiting, diarrhea, musculoskeletal pain, tiredness,
and myelosuppression. Another side effect, which may occur after months of
continuous use, include peripheral edema and pleural effusions. Importantly, it
has been described that a twice daily dasatinib regimen, as well as a history
of cardiac or autoimmune disease, are suspected as predisposing factors. To
minimize such risks, these predisposing factors are exclusion criteria in the
present RCT. In addition, pleural effusion is driven by a reactive oxygen
species (ROS) dependent mechanism. Importantly, these sides effects are
reversible. In addition, a recent study showed that the increased endothelial
permeability, which drives the side-effects, can be counteracted using
antioxidants such as quercetin. Hence, quercetin is not only a senolytic agents
by itself, but the combination of dasatinib plus quercetin appears a highly
effective and safe drug combination to selectively target age-related diseases
via an intermittent treatment strategy.

3. Treatment adherence: In the past decades, extensive research has given
important insight into the many complex factors that determine how and why
individuals take prescribed drugs. The focus has been on the consumers factors
that relate to non-compliance. However, there is also growing awareness that
factors beyond consumers' control can affect adherence. It is now widely
accepted that communication in its entirety is critical, and it is increasingly
accepted that interventions to improve adherence should focus more broadly on
patient context and healthcare system. Patient*centered care and shared
decision*making, together with increased attention to barriers that may be
targets for interventions is pivotal.

With the input of the NLV (Dutch Liver Patient Society), we created a
fundamental basis to make our intermittent treatment strategy attractive and to
increase compliance similar to once weekly GLP-1 injections or vitamin D
supplementation treatment strategy. In this regard, the NLV was closely
involved in the currently acquired ZONMW GGG grant (number 10140262110036) that
provided funding to execute this TRUTH trial. The NLV mentioned that regular
contact with patients should be implemented in the study to remind the
individuals to take their medication to increase adherence. If an individual is
found to be non-compliant, the investigator will remind the individual of the
importance of following the treatment instructions. Treatment compliance of the
trial products will be assessed by asking individuals about missed doses and
monitoring of dosing diaries. Information about compliance and missed doses
will be descried in the individual*s medical record.

All in all, the proposed trial is important considering the fact that there is
currently no registered treatment for NAFLD. Moreover, patients with NAFLD/NASH
often have cardiometabolic comorbidity, which can lead to polypharmacy with
associated health risks and non-compliance. Senolytics can be orally
administrated intermittently, which reduces the risks of adverse effects and
drug interactions. In view of the expired patent of dasatinib, targeting
senescence might be a safe and innovative way to use generic and safe
medication to reverse progressive stages of NAFLD/NASH.