12, 13 ARBs were developed as antihypertensive medications that selleckchem now have utility in a variety of diseases, including heart failure and chronic kidney disease. This versatile therapeutic drug class may also have utility in NASH, because early evidence suggests that they may improve insulin resistance14, 15 and hepatic fibrosis.16 Subsequently, this study was designed to compare the therapeutic efficacy of three treatment regimens in biopsy-proven NASH patients: rosiglitazone

alone, rosiglitazone plus metformin, and rosiglitazone plus losartan. ARB, angiotensin receptor blocker; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BAMC, Brooke Army Medical Center; BMI, body mass index; FDA, the U.S. Food and Drug Administration; HOMA-IR, the homeostasis model assessment for insulin resistance; NAFLD, nonalcoholic fatty liver disease; NAS, Nonalcoholic Fatty Liver Disease Activity Score; NASH, nonalcoholic steatohepatitis; SNPs, single-nucletide polymorphisms; TZD, thiazolinedione. Patients were recruited for this randomized, open-labeled,

prospective, clinical trial from March 2007 to March 2010 from the outpatient Hepatology and Gastroenterology Clinics at Brooke Army Medical Center (BAMC; San Antonio, TX). The protocol was approved by the BAMC Institutional Review Board, MAPK Inhibitor Library cost and all subjects gave written informed consent. The study was investigator-initiated, and no funding was received. Patients 18-70 years of age with biopsy-proven NASH were enrolled. NASH was confirmed on liver biopsy by the presence of steatosis,

hepatocellular TCL inflammation, and hepatocyte ballooning degeneration, with or without fibrosis, utilizing the Brunt criteria.17 Liver biopsy must have been within the 6 months before enrollment, or else a repeat-baseline liver biopsy was required to be eligible for enrollment. Exclusion criteria included the following: patients with New York Heart Association class 3 or 4 heart failure, insulin-requiring diabetics, patients with a history of TZD, metformin, or ARB use in the 3 months before enrollment, alcohol consumption >20 g/day in a female and >30 g/day in a male, serum creatinine on initial screening of greater than 1.4, known hypersensitivity to a study drug, known history of diabetic ketoacidosis, and pregnant or breast-feeding females. Patients were also excluded if there was evidence of coexistent chronic liver disease to include viral hepatitis, Wilson’s disease, autoimmune hepatitis, hemochromatosis, primary biliary cirrhosis, or primary sclerosing cholangitis. Eligible patients were randomly assigned using a computer-generated, random-sequence grid maintained by the principal investigator to one of three treatment arms: rosiglitazone 4 mg by mouth twice-daily, rosiglitazone 4 mg and metformin 500 mg by mouth twice-daily, or rosiglitazone 4 mg twice-daily and losartan 50 mg daily (Fig. 1). All medication doses were selected based on the usual starting does of these medications.