Non‐alcoholic fatty liver disease (NAFLD) may occur as an expression of a metabolic syndrome or in association with hepatitis C virus (HCV) chronic infection. The contemporaneous presence of NAFLD in this later group of patients may negatively affect the progression of fibrosis and the response to antiviral treatment.1,2 It has been suggested that in the future a therapeutic approach to chronic liver disease would consist of a number of complementary approaches considering the multitude of pathogenic mechanisms.3 Silybin is a natural flavonoid that has been conjugated to vitamin E and phospholipids to improve its bioavailability, and antioxidant and antifibrotic activity.4
After approval of the ethics committee and informed consent, 85 outpatients were consecutively enrolled in the study: 59 were affected by primitive NAFLD (group A) and 26 by HCV related chronic hepatitis C in combination with NAFLD, all HCV genotype 1b, and non‐responders to previous antiviral treatment (group B). All patients with a diagnosis of liver disease in the two years prior to the study, according to histological criteria,5,6 were enrolled over six consecutive months and further divided into two subgroups using a systematic random sampling procedure: 53 (39 NAFLD and 14 HCV) were treated with 4 pieces/day of the complex silybin‐vitamin E‐phospholipids (Realsil (RA); IBI‐Lorenzini Pharmaceutical, Italy) for six months followed by another six months of follow up, while the other 32 patients (20 NAFLD and 12 HCV) served as a control group (no treatment). One piece contained 94 mg of silybin, 194 mg of phosphatidylcholine, and 90 mg of vitamin E.
At 0, 6, and 12 months, we evaluated: body mass index (BMI), bright liver by ultrasonography (US), aspartate aminotransferase, alanine aminotransferase, and gamma glutamyl‐transpeptidase (γGT) levels, blood glucose and insulin plasma levels with a contemporaneous determination of insulin resistance by HOMA test7 and, as indices of liver fibrosis, plasma levels of transforming growth factor β, hyaluronic acid, and metalloproteinase 2, by commercial ELISA kits.8 Results were analysed by ANOVA, the Wilcoxon and χ2 tests to evaluate differences among groups and percentages of frequency, and by the Pearson bivariate correlation test to evaluate correlations among data.
There were no adverse events during the treatment and study compliance was absolute. All patients were asked to follow a well balanced individual diet during the study. BMI increased in approximately 70% of cases under basal conditions and did not vary significantly between groups, with the exception of HCV treated patients. In fact, only in this group, at six and 12 months, did the percentage of overweight patients decrease significantly (44%; p<0.01 v basal and other group data). US steatosis, graded from 0 to 3,9 was significantly improved in the NAFLD treated group (p<0.01 v others). Table 1 summarises the other results.
Table 1 Results in the two groups; group A had primitive non‐alcoholic fatty liver disease and group B had hepatitis C virus (HCV) related chronic hepatitis C in combination with NAFLD, all HCV genotype 1b, and were non‐responders to previous antiviral treatment.
| Treated | Not treated | |||||
|---|---|---|---|---|---|---|
| Basal | 6 months | 12 months | Basal | 6 months | 12 months | |
| Group A | ||||||
| ALT (nv <40 U/l) | 79 (51) | 40 (15)** | 59 (5)** | 54.2 (20) | 55.2 (24) | 45.2 (34) |
| γGT (nv <50 U/l) | 75 (112) | 59 (100)** | 60 (33)** | 64 (20) | 72 (24) | 64 (35) |
| Insulinaemia (nv 5–25 μU/ml) | 41.5 (34) | 29.6 (26.4)* | 30.6 (15.4)* | 48.3 (17) | 45.2 (12) | 40.2 (11) |
| HOMA | 12.3 (6.4) | 6.2 (3.9)** | 6.4 (3.2)** | 13 (6) | 11 (4) | 11 (5) |
| Hyaluronic acid (nv <120 ng/ml) | 383 (627) | 176 (184)* | 331.1 (293,2) | 422 (504) | 517 (283) | 498 (145) |
| MMP‐2 (nv 117–410 ng/ml) | 151 (132) | 141 (84)* | 158.2 (165.5) | 160 (183) | 173 (102) | 183 (97) |
| TGF‐β (nv 34.7–63.9 ng/ml) | 45.3 (17.3) | 32.9 (24.3)* | 42.9 (22) | 41.2 (22) | 43.3 (27.3) | 44.7 (31) |
| US score (median (range)) | 2 (2–3) | 1 (1–2)** | 1 (1–2)** | 2 (2–3) | 2 (2–3) | 2 (2–3) |
| Group B | ||||||
| ALT (U/l) | 69 (28) | 45 (18)** | 62 (16) | 47.8 (30) | 50.3 (32) | 60.3 (33) |
| γGT (U/l) | 118 (70) | 56 (20)** | 83 (24) | 115 (60) | 100 (53) | 150 (13) |
| Insulinaemia (μU/ml) | 36.2 (1.5) | 27.4 (1.5)* | 28.9 (6.5)* | 35.4 (3) | 34.2 (5.7) | 38.2 (4.7) |
| HOMA | 8.4 (7.3) | 6 (4.8)* | 6.2 (5.1)* | 9.8 (5.6) | 8.4 (5.1) | 8.2 (4.8) |
| Hyaluronic acid (ng/ml) | 1295 (259) | 625 (122)* | 586.7 (496.2)* | 1180 (703) | 1372 (806) | 1332 (452) |
| MMP‐2 (ng/ml) | 292 (201) | 137 (53)* | 196.6 (94.2)* | 280 (300) | 311 (278) | 299 (123) |
| TGF‐β (ng/ml) | 54.1 (21.7) | 27 (12.2)* | 21.2 (17.4)* | 53.3 (18.3) | 45.2 (28.5) | 49.6 (30) |
| US score (median (range)) | 2 (2–3) | 2 (2–3) | 2 (2–3) | 2 (2–3) | 2 (2–3) | 2 (2–3) |
*p<0.05, **p<0.01 versus basal values.
Values are reported as the mean (SD).
ALT, alanine aminotransferase; γGT, gamma‐glutamyl‐transpeptidase; MMP‐2, metalloproteinase 2; TGF‐β, transforming growth factor β; US, ultrasonography; nv, normal value.
Liver enzyme levels showed an improvement in treated individuals but this only persisted in group A. Hyperinsulinaemia, present in both groups, was significantly reduced only in treated patients. Treatment with RA significantly reduced all indices of liver fibrosis in both treated groups, with a persistent effect only in group B.
A significant correlation among indices of fibrosis, BMI, insulinaemia, degree of US steatosis, and γGT was found (p<0.01). Despite two main drawbacks in this study (absence of a placebo treatment and no histological examination at the end of the study), the data suggest that this new complex of silybin‐vitamin E‐phopsholipids should be tested in a well controlled larger trial to further confirm its possible therapeutic effect on insulin resistance and liver damage, particularly when other drugs are not indicated or have failed, or as a complementary treatment associated with other therapeutic programmes.
Footnotes
Conflict of interest: None declared.
References
- 1.Patrick L. Hepatitis C. Epidemiology and review of complementary/alternative medicine treatments.Altern Med Rev 19994220–238. [PubMed] [Google Scholar]
- 2.Younossi Z M, McCullough A J, Ong J P.et al Obesity and non‐alcoholic fatty liver disease in chronic hepatitis C. J Clin Gastroenterol 200438705–709. [DOI] [PubMed] [Google Scholar]
- 3.Bean P. The use of alternative medicine in the treatment of hepatitis C. Am Clin Lab 20022119–21. [PubMed] [Google Scholar]
- 4.Zhao J, Agarwal R. Tissue distribution of silibinin, the major active constituent of silymarin, in mice and its association with enhancement of phase II enzymes: implications in cancer chemoprevention. Carcinogenesis 1999202101–2108. [DOI] [PubMed] [Google Scholar]
- 5.Brunt E M. Nonalcoholic steatohepatitis: definition and pathology. Semin Liver Dis 2001213–16. [DOI] [PubMed] [Google Scholar]
- 6.Ishak K, Baptista A, Bianchi L.et al Histological grading and staging of chronic hepatitis. J Hepatol 199522696–699. [DOI] [PubMed] [Google Scholar]
- 7.Melchionda N, Forlani G, Marchesini G.et al WHO and ADA criteria for the diagnosis of diabetes mellitus in relation to body mass index. Insulin sensitivity and secretion in resulting subcategories of glucose tolerance. Int J Obes Relat Metab Disord 20022690–96. [DOI] [PubMed] [Google Scholar]
- 8.Rosenberg W M, Voelker M, Thiel R.et al Serum markers detect the presence of liver fibrosis: a cohort study. Gastroenterology 20041271704–1713. [DOI] [PubMed] [Google Scholar]
- 9.Joseph A E, Saverymuttu S H, al‐Sam S.et al Comparison of liver histology with ultrasonography in assessing diffuse parenchimal liver disease.Clin Radiol 1991991–94. [DOI] [PubMed] [Google Scholar]