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Saul J. Karpen, M.D., Ph.D.
Separating the metabolic benefits from lipoprotein abnormalities
associated with FXR agonists--gut vs. liver effects
Raymond F. Schinazi Distinguished Biomedical Chair
Professor of Pediatrics
Paris July 1, 2016
No Financial Disclosures
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OCA/plac. x 72 w.
ALT
FXR AGONIST • Chol
• HDL
• LDL
• ~ TG
-0,25
-0,15
-0,05
0,05
0,15
0,25
OCA (126)
Plac (131)
Chol HDL LDL TG
D L
ipid
(m
M)
P= 0.0009
P= 0.01
P< 0.0001 P= 0.88
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Gastro 2015 PMID:25500425
0
50
100
150
200
250
300
Chol LDL HDL TG
Plac
OCA (10 mg)
OCA (25 mg)
* *
* *
EO
T [
Day 8
5]
Lip
id L
evels
(m
g/d
l)
FXR AGONIST • Chol #
• HDL
• ~ LDL #
• ~ TG
# : Different from NASH
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17 D
28 D
Pencek, Diabetes, Obesity & Metabolism 2016, PMID:27109453
OCA in 68 Healthy Volunteers: Lipid Analyses
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Transporters & FXR: Ileal & Hepatic Components of the EHC
Ileum
Liver
Schaap, Nat Rev GI Hep 2014
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LXR FXR
MAPK
PI3K
PKC
TGR5
AP1 FAS
TRAIL
PGC1
CAR
VDR
PXR
Cell
Signaling
Apoptosis
Nuclear
Receptors
JNK
p38MAPK
ERK1/2
SHP
FGF19
S1PR2
Multiple Molecular Roles for Bile Acids
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Cholic Acid Chenodeoxycholic acid
Lithocholic Acid Z-Guggulsterone
FXR Agonists
FXR Antagonists
GW4064
EC50: 4-10 M 37-80 nM 20 M
IC50:
Deoxycholic acid
19-50 M
6--ethyl-CDCA
(Obeticholic acid) 99 nM
10 M
Makishima Science 1999
Parks Science 1999
Wang Mol Cell 1999
Urizar Science 2002
Yu JBC 2002
Pellicciari J Med Chem 2002
Hawkins JCI 2002
Dussault JBC 2003
Downes Mol Cell 2003
Carter Ped Res 2007 10-30 M
Stigmasterol
10 M
Fexaramine
25 nM
Fexarine
38 nM
Fexarene
36 nM
AGN31
2 M (also RXR)
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2016, PMID: 26812075 OCA x 24 h: FXR targets
Caveats:
• “The hPCLS used for this study were obtained from patients with a
high BMI (35–43 kg/m2).”
• Dedifferentiated human cells in culture—CYP7A1 & CYP8B1 were not
downregulated.
SHP BSEP OST MDR3 FGF19
Protein
RNA:
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J Clin Invest. 2015;125:386–402.
Intestinal FXR Antagonism
improves NASH in mice
Intestinal FXR Agonism
improves NASH in mice
Essential, but seemingly contradictory effects of FXR & BA signaling in NAFLD
Intestinal FXR ko protects against
HFD-induced hepatic steatosis
Nat Med. 2015;21:159–165.
Fexaramine (Intestinal FXR agonist) improves
HFD-induced hepatic steatosis
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Glyco-Muricholic Acid:
• Intestinal FXR antag.
• Brown Fat activity
• Intest. Ceramides
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NAFLD & NASH:
FXR Agonism or FXR Antagonism
Both work Why?
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Intact Enterohepatic
BA Recirculation
ASBT
Ileal ASBT
Inhibition
Interrupted Enterohepatic
BA Recirculation
ASBT
Ileal ASBT inhibition will
improve the hepatic and
whole body response to
HFD in mice
Hypothesis:
Colon
BA’s
Microbial BA metab.
TGR5 signaling
BA Pool size
Liver
BA Synthesis
Cholesterol
Ileum
BA Uptake
FXR-FGF15/19 signaling
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ALIOS (45% fat; 0.2% cholesterol), + Added Sugars in the Drinking Water
Chow
HFD
Asbti [SC-435] x 16wk
HFD Asbti
HFD:
Asbti: 0.006% SC-435, 10 mg/kg/day
Mice: Male, C57BL6J, 4-6 weeks, n=7-16/group
Study Design & Endpoints
4 8 12 16 . . . . . 0
Weeks • Weekly Body Weights
• Weekly Caloric & fluid intake
• Week 15 GTT, ITT
• Week 16
• Serum Liver Indices
• Feces Bile Acids
• Ileum RNA
• Colon RNA
• Liver Histology
• Lipids & Bile Acids
• RNA-Seq
• RNA & Protein
• Hydroxyproline
• Statistics: Mean ± SD
• ANOVA
Tetri LH. Am J Physiol GI 2008 Nov;295(5):G987–95.
Mells JE J Nutr Biochem. 2015 Mar;26(3):285–92. AASLD 2015
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SC-435 Inhibits Ileal ASBT function
Liver
0
1
2
3
4
Chow HFD HFD Asbti
a
b
a
Cyp7a1
0
1
2
3
4Cyp8b1
a
b
a
Chow HFD HFD Asbti
Rela
tive
gen
e e
xp
res
sio
n
Colon
0
5
1 0
1 5
2 0 Ilbp
a a
b
Chow HFD HFD Asbti
Rela
tive
gen
e e
xp
res
sio
n
ASBT
Fec
al B
ile
Ac
ids
(
M/2
4 h
r)
HFD Asbti
Feces
HFD
a
b
0
1
2
3
Fgf15
a
b
c
Chow HFD HFD Asbti
Ileum
Rela
tive
gen
e e
xp
res
sio
n
Asbt
HFD Asbti
Chow HFD
Shp
a
b
a
AASLD 2015
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Glu
co
se (
mg
/dL
)
Time (mins)
ASBTi Improves Glucose Tolerance
Chow HFD HFD Asbti
* *
*
Chow
HFD + Asbti
HFD
GT
T A
UC
a
b
a
*: Significantly different from HFD + Asbti
GTT
AASLD 2015
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Triglycerides Cholesteryl Ester
(g
/mg
liv
er)
(g
/mg
liv
er)
a
b
a
a
b
a
Chow HFD HFD Asbti
Chow HFD HFD Asbti
ASBTi Reduces Hepatic Lipids, But Not Total Bile Acids
Chow HFD HFD Asbti
(pm
ol/
mg
liv
er
tiss
ue
)
Total Bile Acids
AASLD 2015
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a
b b
Chow HFD HFD Asbti
Liver Wt/Body Wt
ASBTi Improves Hepatic NAS & Steatosis Scores
Chow HFD HFD + Asbti
NAS Score
Chow HFD HFD Asbti
a
b
c
Steatosis Score
Chow HFD HFD Asbti
a
b
c
AASLD 2015
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FXR Antagonist FXR Agonist
HFD
58% 42%
HFD + Asbti
83%
17%
Bile
Aci
d (
pm
ol/
mg
tiss
ue
) ASBTi Markedly Alters Hepatic BA Composition
* * * * * -TMCA b-TMCA w-TMCA THDCA TUDCA -MCA b-MCA
FXR Antagonist
HFD
HFD + Asbti
TCA TCDCA TDCA TLCA CA
*
*
*
FXR Agonist
*
AASLD 2015
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HFD
Insulin resistance
Hyperglycemia Hyperinsulinemia
ChREBP
Lipogenic genes TG
SREBP-1c LXR Hepatic
cholesterol
FXR Hepatic
BA Composition
ASBTi
ASBTi
ASBTi
Hepatic
Steatosis
ASBT
Hypothesized Mechanisms of Action of ASBTi in Liver
FXR Antagonist
FXR Agonist
HFD
58% 42%
HFD + Asbti
83%
17%
Ileal ASBT inhibition Markedly Alters Hepatic BA Composition
TMCA’s THDCA TUDCA
TCA TCDCA TDCA
AASLD 2015
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March 2016, PMID: 26708144
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Nature. 2014 Mar 26.
HFD, 11w of VSG in mice KO = FXR-/-
Intact BA signaling, through its receptor, FXR,
mediates the response to Bariatric Surgery
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Tilg NEJM June 23, 2016
Interaction of Diet (PC), microbes, BAs, Genes (FMO3) CV Disease
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Bile acid based therapeutic trials (~ 200 in clinicaltrials.gov)
FXR agonists: Obeticholic Acid
TGR5 agonists:
ASBT inhibitors:
NorUDCA:
NASH
PBC
PSC PSC
Satiety
Constipation
Pruritus in cholestasis (ALGS, PFIC’s)
IBS-C
PSC
Glycocholic Acid: BA Synthesis Defect
BA Sequestrant: Colesevelam Diabetes
NASH
Obesity
BA diarrhea
Alcohol
Fibrosis
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Summary: FXR & the Lipids in NASH
• Bile acid (BA) biology: Opportunities for discovering new
linked components of the Gut-Liver-Microbe-Gene Axis
– Differential effects of FXR & BAs in Ileum, Colon, Liver, Fat, …
– Individual BA’s have distinct functional properties
• FXR Agonists in NAFLD & NASH: Lipid Issues
– Reduces CYP7A1 & BA synthesis
– Total Cholesterol
– LDL
– HDL
• Further evidence that we will need to attack NASH
from multiple therapeutic angles – FXR Agonism & Antagonism both improve NASH in mice
– ASBT inhibition improves NASH in mice
• Reduces Hepatic TG & Cholesterol
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Saul Karpen, MD, PhD
Paul Dawson, PhD
Astrid Kosters, PhD
Anuradha Rao, PhD
Angelica Amanso, PhD
JP Berauer, MD
Gina Ramirez
Funding (NIH) • R01 DK056239
• R01 DK047987
• Philanthropies:
• Alpard Foundation
• Spain Fund
• Moss Fund
Anya Mezina,MD MSCR
Courtney Ferrebee
Jamie Mells, PhD
Kim Pachura
Jianing Li, PhD
Grace Wynn
Prabhu Shankar, MD
Emory University (Saul-Paul Lab)
Hong Yin, MD (Pathology)
Dean Jones, PhD (Metabolomics)
Sophia Banton
Shuzhao Li
Hao Wu, PhD (School of Public Health)
Emory University
Brad Keller, PhD (Lumena/Shire)
Ken Setchell, PhD
Wujuan Zhang, PhD
Cincinnati Children’s
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HDL Pathway targets LDL Pathway targets
Genes by OCA:
• Abca1
• Tgm2
• Fgl1
• Npc1l1
• Angptl4
• Hif1
• Ghr