25 In uncontrolled human trials, losartan was shown to down-regulate hepatic stellate cells26 and improve serum aminotransferases as well as hepatic histology.27 The apparent ineffectiveness of losartan in this study is disheartening, but does not rule out this class of medications as being potentially efficacious in NASH patients. Again, the dose of losartan may have been inadequate to have a synergistic effect. However, the study patients were not selected

based on hypertension, and there was concern that treating normotensive patients with higher doses of losartan Venetoclax may have led to unintended negative consequences. Alternatively, in relation to NAFLD, it appears that

other ARBs may be more efficacious than losartan. In rat models, telmisartan has shown comparable efficacy to pioglitazone in improving hepatic steatosis, necroinflammation, and fibrosis.28, 29 This is likely attributable to its pleiotrophic effects on peroxisome proliferator-activated receptor gamma up-regulation.30 A subsequent trial by Georgescu et al. in 54 hypertensive NASH patients studied the effects of telmisartan 20 mg daily versus valsartan 80 mg daily for 20 months, buy AT9283 and found that HOMA-IR significantly improved in both groups, but more so in the telmisartan group. Additionally, the NAS was significantly lower in the telmisartan group, compared with the valsartan group.28 The importance of liver biopsy to determine histologic change warrants mention. Changes in serum aminotransferases or insulin resistance did not predict histologic improvement and, therefore, should not be used as surrogate markers in evaluating the effectiveness of therapy. This underscores the need for pre- and postliver biopsy in all NASH clinical treatment trials, because proven, noninvasive tests to determine

NAFLD severity are still lacking. Limitations of this type of study Baf-A1 molecular weight are realized. The lack of blinding and a placebo control is apparent. However, given that four previously published double-blind, randomized, placebo-controlled trials with TZD therapy have already been completed and have generally shown benefit, it seemed unethical to treat biopsy-proven NASH patients with a placebo for 1 year and then subject them to a repeat liver biopsy. An additional limitation was the type of TZD chosen for this trial. During the course of this study, a black-box warning was issued by the FDA, and rosiglitazone use became quite restricted as a result of an association with myocardial ischemia.31 Subsequently, study enrollment was halted at 137 patients, short of the enrollment goal of 150. Because of additional patient dropout, the possibility of a type II error cannot be excluded.