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THE NASH Tsunami audience came to know Jörn Schattenberg in the Fall of 2020 when he shared a paper he had recently co-authored on why NASH drug trials failed. This week, the same group that discussed that paper – Jörn, Stephen Harrison, Louise Campbell and Roger Green – reflect on what has improved in the intervening time period and what has not. The group suggest that researchers are making progress in reducing screen fail rates, but not in the critical issues of accessibility and equity.

In this excerpt, Jörn asks whether these new, more focused approaches might lead to investigators overfitting patients. The positive of this outcome, he notes, is that sweet spot patients will be in a position to respond to drug. Louise takes on an additional issue: what is the affect of patient lifestyle mitigation on these trials. Her concern: patients who work hard enough to improve their liver condition after learning they have the disease may be so successful that they no longer qualify by the time they would be called for biopsy. 

The conversation strays into discussing the high value of bring artificial intelligence assists into histopathological interpretation before Stephen returns to the question of recruiting more patients. He notes that the goal is not merely to pull more patients into the first stages o recruitment ("the top of the funnel") but to improve our distribution of different kinds of minorities and subpopulations with high rates of NASH. He points out the fallacy of treating only mainstream Caucasian Americans and assuming results of these trials will hold true for everyone given what we now know about the important of genotyping and mutations tied to race or ethnicity. 

As this conversation ends, Stephen outlines potential solutions based on shifting recruitment out of brick-and-mortar trial sites and to recruiting and testing at primary care offices or even patients' homes.