s-adenosylmethionine in alcoholic liver cirrhosis: a...

Journal of Hepatology 1999; 30: 1081-1089 Printed in Denmark . All rights reserved

Mmksgaard Copenhagen

Copyright 0 European Association for the Study of the Liver 1999

Journal of Hepatology

ISSN 01684278

S-Adenosylmethionine in alcoholic liver cirrhosis: a randomized, placebo-controlled, double-blind, multicenter clinical trial

Jose M. Mato’, Javier Camara’, Javier Fernandez de Paz3, Llorenc Caballeria4, Susana Co115,

Antonio Caballero6, Luisa Garcia-Buey7, Joaquin Beltran8, Vicente Benita3, Joan Caballeria4, Ricard Solas,

Ricardo Moreno-Otero7, Felix Barrao*, Antonio Martin-Duce3, Jose A. Correa7, Albert Pares4,

Elena Barrao8, Inmaculada Garcia-Magaz2, Jose Luis Puerta2, Jorge Moreno2, Gabrielle Boissardg,

Pablo 0rtiz2 and Joan RodCs4

‘Department of Medicine, Division of Hepatology and Gene Therapy, University of Navarra, Pamplona, 2Medical Department, Europharma, S.A. grupo Boehringer Ingelheim Esparia, S.A., Madrid, 3Unidad de Digestivo, Hospital Principe de Asturias, Alcaki de Henares, Madrid 4Alcohol

and Liver Units, Hospital Clinic i Provincial, University of Barcelona, Barcelona, 5Servicio de Aparato Digestivo, Hospital del Mar, Universitat Autdnoma de Barcelona, Barcelona, 6Servicio de Aparato Digestivo, Hospital Clinic0 Universitario de Granada, Granada, 7Unidad de

Hepatologia, Hospital de la Princesa, Madrid and ‘Servicio de Digestivo. Hospital Clinic0 Universitario de Zaragoza. Zaragoza, Spain; and 9Biometrics Unit, Knoll Farmaceutici Spa, Liscate, Milan, Italy

Background/Aim: The efficacy of S-adenosyhnethion- ine (AdoMet) in the treatment of liver cell injury has been demonstrated in several experimental models. The aim of this study was to investigate the effects of AdoMet treatment in human alcoholic liver cirrhosis. Methods: A randomized, double-blind trial was performed in 123 patients treated with AdoMet (1200 mg/day, orally) or placebo for 2 years. All patients had alcoholic cirrhosis, and histologic confirmation of the diagnosis was available in 84% of the cases. Sev- enty-five patients were in Child class A, 40 in class B, and 8 in class C. Sixty-two patients received AdoMet and 61 received placebo, Results: At inclusion into the trial no significant differences were observed between the two groups with respect to sex, age, previous episodes of major complications of cirrhosis, Child classification and liver function tests. The overall mortality/liver transplantation at the end of the trial decreased from 30% in

M?R METHIONDTE metabolism starts with the syn- L thesis of S-adenosylmethionine (AdoMet). This reaction involves the transfer of the adenosyl moiety of ATP to methionine, and is catalyzed by the enzyme

Received IO September; revised II December: accepted 17 December 1998

Correspondence: Jose M. Mato, Department of Medicine, Division of Hepatology and Gene Therapy, University of Navarra, S/N, 3 1080-Pamplona, Spain. Tel: 34 948 425618. Fax: 34 948 425677. E:mail: [email protected]

the placebo group to 16% in the AdoMet group, although the difference was not statistically significant (p=O.O77). When patients in Child C class were excluded from the analysis, the overall mortality/liver transplantation was significantly greater in the placebo group than in the AdoMet group (29% vs 12%, p=O.O25), and differences between the two groups in the 2-year survival curves (defined as the time to death or liver transplantation) were also statistically significant (p=O.O46). Conclusions: The present results indicate that long- term treatment with AdoMet may improve survival or delay liver transplantation in patients with alcoholic liver cirrhosis, especially in those with less advanced liver disease.

Key words: AdoMet; Alcohol; Cirrhosis; S-adenosylmethionine.

methionine adenosyltransferase (MAT) (1,2). AdoMet acts as the methyl donor for essentially all known bio- logical methylation reactions, provides the propyl- amine group for the synthesis of polyamines, and par- ticipates in the synthesis of glutathione (GSH) through the transsulfuration pathway (2). AdoMet synthesis and metabolism take place mainly in the liver. Up to 85% of all methylation reactions and as much as 48% of methionine metabolism occur in the liver (3).

In mammals there are two genes coding for MAT, one expressed exclusively in the adult liver and a sec-

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ond enzyme present in all tissues, including fetal liver (4). Molecular studies indicate that liver MAT exists in two forms: as a homodimer and as a homotetramer of the same oligomeric subunit (.5,6). The activity of the liver-specific isoforms is markedly reduced in human liver cirrhosis (7-9) probably by interaction with free radicals (10,l l), and this is the main cause of the impaired metabolism of methionine (12,13), and reduced levels of hepatic GSH (14) observed in these subjects.

The efficacy of AdoMet in the treatment of liver cell injury has been demonstrated using various experimental models: in liver injury induced by the metabolism of chemicals (CC14, acetaminophen, galactosamine) (15- 23), in ischemia reperfusion cell injury (24), and cholestasis induced by a variety of agents (estrogen, cyclosporine A, leukotriene D4 and others) (25-29). With respect to alcohol-induced liver damage, in chronically alcohol-fed baboons there is a significant depletion of hepatic AdoMet, and it has been demonstrated that Ad- oMet supplementation restores hepatic GSH deposits and attenuates liver injury (30). In humans, AdoMet administration increases hepatic GSH levels in patients with alcoholic and non-alcoholic liver disease (14) and, in several clinical trials, the short-term efficacy of Ad- oMet in patients with cholestasis in pregnancy (31,32), and in cholestasis in patients with chronic liver disease (33,34), was also determined.

Based on these experimental and clinical results, we designed a study aimed to investigate the effects of Ad- oMet treatment in human alcoholic liver cirrhosis in a double-blind, randomized, placebo-controlled trial, over a 24-month period.

Patients and Methods Patients

The study was carried out in 123 alcoholic patients, 106 men and 17 women, with hepatic cirrhosis diagnosed in six Spanish hospitals from December 1987 to June 1995. Eligible patients gave written informed consent to participate in the study, and the protocol was approved by the ethics committee of each hospital. To enter the trial patients had to be over 18 years and have a diagnosis of alcoholic liver cirrhosis established by history (ethanol consumption over 80 g per day for women, and over 120 g per day for men, for more that 5 years in both cases), physical examination, and biochemical tests. In 84’% of the patients diagnosis of alcoholic cirrhosis was confirmed by liver histology. Patients were excluded if they had a total serum bilirubin ~3 mg/dl, refractory ascites or if they had an episode of gastrointestinal bleeding or encephalopathy within 1 week before entry into the trial. Patients who received other treatments such as colchicine, malo- tilate. silymarin, penicillamine or corticosteroids, those with other known etiologies for liver cirrhosis and patients with hepatocellular carcinoma were also excluded. The flow of patients into the trial during recruitment was between 5 and 35 per year.

Treatment

According to centralized randomization by a number table, patients were assigned to receive orally either AdoMet (Ademetionine, Knoll Farmaceutici Spa, Liscate MI. Italy), 400 mg tablets three times per day, or a placebo of identical appearance, smell and taste, with the

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same schedule. The distribution of patients in both groups was well balanced in each center.

Follow-up At entry, a complete history including alcohol intake was taken and physical examination was performed. Liver-function tests including serum total bilirubin, albumin, aspartate aminotransferase, alanine aminotransferase, y-glutamyltransferase, alkaline phosphatase and prothrombin index were performed, and the Child status (35) was obtained for each patient. Blood erythrocyte, leukocyte and platelet count as well as mean corpuscular volume of erythrocytes were also measured. Viral hepatitis B and C markers were determined at entry in 58% and 39% of the patients, respectively. At the end of the trial viral hepatitis B and C markers were available for 93% and 76% of the patients, respectively.

Physical examination. assessment of alcohol abstinence. compliance with treatment and adverse effects were monitored monthly during the first 6 months of treatment, and then every 3 months for up to 2 years. All patients were advised to abstain from alcohol intake, which was estimated by questioning the patients and their relatives and by assessing alcohol in urine as well as serum markers such as y- GT and mean corpuscular volume (MCV). Persistence of alcohol intake was considered when either any analytical evidence was found or alcohol intake was admitted by the patient on at least one occasion during the control visits. Patients received medication for the period until the next scheduled visit. Counting the unused tablets served to establish compliance with treatment. Biochemical and hematological tests were performed every 6 months in all patients.

Analysis of the ejjicac:,, of the treatment The efficacy of the treatment was analyzed in terms of mortality from any cause or liver transplantation during a period of up to 2 years. For this purpose, the observation time was extended up to the last possible contact with each patient, even if the patient was a previous drop-out. To guarantee the alive or dead status of patients who left the trial, personal or telephone contact was maintained.

Statistical una!ysis

Efficacy was calculated as the length of time between the date of entry into the trial and the date of death, liver transplantation or last follow-up. The assumption was made that patients in the placebo group would have a 50% chance of survival during follow-up, and that a clinically relevant difference would have increased this probability to 80% in the treated group. According to these estimates, with ((~=5’%, a 90% power, and the use of a two-sided log-rank test, the minimum sample size in each group was 58 patients. The Kaplan-Meier method and log-rank test were used to evaluate the association of the treatment with survival. The global mortality proportions were compared by Pearson’s x2 test. Multivariate analysis was performed using the Cox regression model: a variable had to be significant at the 0.25 level to be selected and at the 0.15 level to remain in the model, For liver laboratory parameters, values at the endpoint (2 years) were compared betmreen groups, after a logarithmic transformation, by a covariance analysis, considering baseline values as the covariate. The results were expressed as geometric means of the final values and their 95% confidence interval. Baseline characteristics of patients at entry were compared between groups using Student’s t-test for quantitative variables and Pearson’s x2 test for categorical data (Fisher’s exact 2- tail test in case of cells with expected frequencies less than 5). Statisti- cal analyses were performed with SAS 6.10 (SAS Institute, Inc: Cary, NC, USA), and a p-value 50.05, based on a two-tailed test, was considered to indicate statistical significance.

The decision concerning the eliribilitv of individual patients was taken prior to the study being unbinded.

Results Characteristics of the patients

Of the 123 patients enrolled, 61 signed to the placebo group and

were randomly as- 62 to the AdoMet

S-Adenosylmethionine in alcoholic liver cirrhosis

TABLE 1

Demographic, clinical and biochemical characteristics of the 123 patients at entry

Characteristics Placebo AdoMet p-value* (n=61) (n=62)

Sex Male 53 (87%) 53 (85%) NS (0.82) Female 8 (13%) 9 (15%)

Age (years; meant SD) 51.2210.2 52.5?10.0 NS (0.49)

Alcoholic cirrhosis confirmed by biopsy 49 (80%) 54 (87%) NS (0.31)

Patients with previous episodes of: G.I. bleeding 23 (38%) 30 (48%) NS (0.23) Encephalopathy 7 (12%) 8 (13%) NS (0.86) Ascites 31 (51%) 36 (58%) NS (0.42)

Child class NS (0.74) A 37 (61%) 38 (61%) B 21 (34%) 19 (31%) C 3 (5%) 5 (8%)

STB (mgidl) 1.60 (0.3-7.6) 1.35 (0.3-5.7) NS (0.32) Albumin (g/dl) 3.7 (2.13-5.25) 3.6 (2.10-5.10) NS (0.35) AST (U/l) 53.0 (16467) 47.5 (17-271) NS (0.39) ALT (U/1) 39.0 (12-270) 37.5 (1 l-363) NS (0.73) )I-GT (U/l) 127.0 (18-1116) 76.5 (27-944) NS (0.11) AP (U/l) 264 (87-624) 247 (46599) NS (0.69) PTT (%) 74 (40-120) 75 (33-117) NS (0.84)

*Categorical variables were compared by x2 test (Fisher exact 2-tail test in case of cells with expected frequencies less than 5). Quantitative variables were compared by Student’s t-test. Data are expressed as no. (%) or median and range, except for the age. For laboratory variables the comparison was performed after a logarithmic transformation. NS: non-significant difference between the two groups; G.I.: gastrointestinal; STB: serum total bilirubin; AST: aspartate aminotransferase; ALT: alanine aminotransferase; y-GT: y-glutamyl transferase; AP: alkaline phosphatase; PTT: prothrombin time.

group. At entry, the two groups were well matched re- garding sex, age, serum bilirubin, albumin, aspartate aminotransferase, alanine aminotransferase, y-gluta- my1 transferase, alkaline phosphatase, prothrombin time and Child’s score (Table 1). The numbers of patients with previous major complications of cirrhosis were also similar in both groups. Histologic confirmation of alcoholic cirrhosis at entry into the trial was obtained in 49 of the 61 patients treated with placebo (80%) and in 54 of the 62 patients treated with Ad- oMet (87%). Features of severe alcoholic hepatitis were not observed in liver biopsies. The persistence and amount of alcohol intake were similar in both groups (52% and 50% of patients remained abstinent in the placebo and AdoMet group, respectively. The mean daily alcohol intake, determined in a subgroup of 26 patients from those who continued drinking during the trial, was 425 31 g in the placebo group and 47239 g in the AdoMet group; p: N.S.). The presence of viral markers of hepatitis at the time of entry into the study was also similar in both groups: two out of 38 patients in the placebo group and three out of 33 in the Ad- oMet group had hepatitis B markers, and seven out of 24 in the placebo group and five out of 24 in the Ad- oMet group had antibodies against the hepatitis C vi-

rus. Serum hepatitis markers were determined in most of the patients throughout the study, and the positivity of these markers remained similar in both groups of patients: two out of 58 patients in the placebo group and three out of 56 in the AdoMet group had hepatitis B markers, and nine out of 45 patients in the placebo group and 11 out of 48 patients in the AdoMet group had antibodies against the hepatitis C virus.

TABLE 2

Distribution of patients

Group

All included patients

Placebo AdoMet

*Child Classes A and B

Placebo AdoMet

Number of patients 61 62 58 57 Deaths/liver 1513 9/l 1413 611

transplants p-value 0.077 0.025

*Three patients in the placebo group and five patients in the AdoMet group were in Child C class at entry and were therefore not included in this subgroup.

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Analysis of efficacy

A total of 28 patients (18 receiving placebo and 10 receiving AdoMet) died or were transplanted during the trial (Table 2). Thus, the overall mortality/liver transplantation decreased from 30”s in the placebo group to 16% in the AdoMet group, although the difference was not statistically significant (p=O.O77, Table 2). There were no significant differences in the cumulative 2-year survival curves (described as the time to death or liver transplantation) between the two groups of patients (Fig. 1). In the placebo group 13 patients died of liver failure and/or complications of liver cirrhosis, one, who had a low prothrombin index and platelet count, died of brain hemorrhage and one, who was still drinking and suffered two gastrointestinal bleeding episodes in the previous year, died because of head injury; in the AdoMet group nine patients died of liver failure and/or complications of cirrhosis (Table 3). In a multivariate analysis the factors that statistically in- fluenced survival (time to death or liver transplantation) were treatment, the presence of previous episodes of gastrointestinal bleeding and ascites, the serum values of total bilirubin, alkaline phosphatase, albumin, positivity of viral markers and the ASTiALT ratio (Table 4). Treatment with AdoMet (p=O.O26), the increment in one unit of albumin (p=O.O26) or of the

TABLE 3

Cause of patient death

Placebo AdoMet

Gastrointestinal hemorrhage 6* 6 Hepato-renal syndrome 2 I Spontaneous bacterial peritonitis 1* 1 Liver failure (ascites, encephalopathy) 4 1 Brain hemorrhage 1 Head injury 1 _.

*One patient of those who died of gastrointestinal hemorrhage and the patient who died of peritonitis also had hepatocellular carcinoma.

ASTiALT ratio (p=O.O40) were independent variables increasing efficacy (Table 4). The estimated risk ratio for mortality or liver transplantation in the AdoMet patients was 0.39 (95% confidence limits, 0.17-0.89).

The initial and final values of the liver function tests from both groups of patients are shown in Table 5. Only the decrease in the ALT values in the AdoMet group was statistically significant. The number of patients who did not develop severe complications related to liver cirrhosis (gastrointestinal bleeding, ascites, encephalopathy and sepsis) during the trial was 42 in the placebo group and 36 in the AdoMet group (p: N.S.). The changes in the Child stage between the two groups were not different during the follow-up. Fur-

0.6

t

0.5 :

0 3 6 9 12 15 18 21 24

95 % C.I. 0.72 - 0.92

95 % C.I. 0.56 - 0.80

Survival time

(months)

Placebo 61 61 59 59 56 48 40 39 32 Patients still at risk

0 2 2 3 9 15 16 18 No. Events (cumulative)

AdoMet 62 61 59 54 51 47 45 42 37 Patients still at risk

0 I 5 5 7 8 9 10 No. Events (cumulative)

Fig. 1. Cumulative survival of the 123 alcoholic cirrhotic patients included in the study, treated with placebo (0, n=61) or AdoMet (0, n=62). The difference between the groups is not statistically significant by the log rank test (p=O.14). Survival is described as the time to death or liver transplantation. CI: confidence interval.

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TABLE 4

Cox’s multivariate proportional hazard model for survival of all 123 patients enrolled in the clinical trial

Variable Risk 95% Confidence x2 p ratio limits

Treatment 0.39 0.17-0.89 4.96 0.026 Gastrointestinal 2.37 1.065.28 4.41 0.036

bleeding Alkaline phosphatase 1.51 1.12-2.04 7.13 0.008 Serum total bilirubin 1.59 1.21-2.10 10.79 0.001 Albumin 0.42 0.20.90 4.97 0.026 Ascites 1.84 0.88-3.83 2.63 0.105 Virus B 5.62 1.1427.75 4.49 0.034 Virus C 4.50 1.40-14.44 6.41 0.011 Ratio ASTIALT 0.46 0.22-0.97 4.22 0.040

AST: aspartate aminotransferase; ALT: alanine aminotransferase.

thermore, two patients in the placebo group and none in the AdoMet group developed hepatocellular carcinoma during the study.

Ten patients (8%) were lost to follow-up (three patients in the placebo group and seven patients in the AdoMet group), and their survival status was unknown at the close of the study, although four of the ten patients (two in each group) were alive in the months 23-24 of follow-up.

Analysis of the efficacy of the treatment in patients in Child classes A and B As shown in Table 1, eight out of the 123 patients included in the trial were in Child C class: three patients in the placebo group and five patients in the AdoMet group. To determine whether AdoMet treatment was more effective in those patients with less severe liver


disease, we performed an analysis of efficacy, excluding patients in Child C class. The final number of patients for the analysis of efficacy in this subgroup was therefore 115; 58 in the placebo group and 57 patients in the AdoMet group (Table 2). At entry there were no significant differences between the two groups with respect to sex, age, Child classification and liver function tests. The percentage of alcohol abstinence was also similar in both groups (data not shown).

At the end of the 2-year period the overall mortality/ liver transplantation in the subgroup of patients in Child classes A and B decreased significantly from 29% (17 patients out of 58) in the placebo group, to 12% (seven patients out of 57) in the AdoMet group (p= 0.025, Table 2). The percentage of deaths and transplants in patients in Child class A was 19% in the placebo group and 8% in the AdoMet group; and the percentage of deaths and transplants in patients in Child class B was 48% in the placebo group and 21% in the AdoMet group. Of the 14 deaths reported in the placebo group, 12 were attributed to liver failure, one to brain hemorrhage and one to head injury; of the six deaths reported in the AdoMet group, all were due to liver failure (Table 3). Fig. 2 shows the cumulative 2- year survival curves (described as the time to death or liver transplantation) for the 115 patients in Child classes A and B treated with placebo or AdoMet. Treatment with AdoMet significantly reduced the mortality or liver transplantation of patients in Child classes A and B (p=O.O46).

Differences between the two groups were still statistically significant when the mortality rate, excluding transplants, was analyzed (p=O.O5); or when the two

TABLE 5

Baseline and endpoint liver laboratory parameters for the patients who had at least one value after baseline

Placebo AdoMet p-value*

n Baseline Endopoint n Baseline Endopoint

STB (mg/dl) 55 1.50 1.58 50 1.32 1.44 0.965 (1.26-1.78) (1.30-1.92) (1.08-1.61) (1.161.80)

Albumin (g/dl) 54 $63.83) 3.62 43 3.55 3.73 0.302 (3.40-3.85) (3.34-3.78) (3.464.01)

AST (U/l) 55 53.3 51.5 50 51.0 44.1 0.166 (46.1-61.8) (43.5-61.00) (42661.0) (38.3-50.9)

ALT (U/l) 55 38.0 41.3 49 37.6 34.0 0.026 (32.145.1) (35.1-48.5) (30.8-45.9) (29.639.0)

y-GT (U/l) 53 113.3 83.1 48 88.1 74.4 0.628 (88.6145.0) (65.9-104.8) (69.3-112.1) (56.0-98.8)

AP (U/l) 55 254.1 224.2 50 238.9 218.9 0.805 (227.2-284.3) (190.4-264.0) (208.6273.5) (189.5-253.0)

Pi-f (%) 52 72.3 72.6 48 75.0 76.2 0.644 (67.9-77.0) (67.9-77.7) (69.9-80.4) (68.7-84.6)

*Covariance analysis for difference between treatment groups. Results are expressed as geometric means and their 95% confidence interval. STB: serum total bilirubm, AST: aspartate aminotransferase; ALT: alanine aminotransferase; y-GT: y-glutamyl transferase; AP: alkaline phosphatase; PTT: prothrombin time; n, number of patients for each variable and each treatment with a baseline and endpoint values.

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J. M. Mato et al

” 0.6 1.

95 % C.I.

0.76 - 0.96

95 % C.I.

0.56 - 0.81

Survival time

(months)

Placebo 58 58 56 56 53 47 39 38 3 1 Patients still at risk


AdoMet 57 56 55 52 49 45 43 40 36 Patients still at risk


Fig. 2. Cumulative survival of the 115, Child A and B, alcoholic cirrhotic patients, treated with placebo (e, n=58) or AdoMet (0, n=57). The difference between the groups is statistically sigmyicant by the log rank test (p=O.O46). Survival is described as the time to death or liver transplantation. CI: confidence interval.

patients in the placebo group who died of head injury and brain hemorrhage were excluded from the analysis @=O.OS).

Compliance and tolerability

The compliance with treatment was greater than 75% in 68% and 69% of patients in the placebo group and in the AdoMet group, respectively, and was lower than 25% in only five patients. AdoMet treatment was, in general, well tolerated during the complete duration of the study, and no severe adverse events were reported. Of the 123 patients enrolled, six (one in the placebo group and five in the AdoMet group) left the trial because of adverse events; four due to nausea (one in the placebo and three in the AdoMet group), one due to diarrhea and one due to pyrosis (these last two patients were in the AdoMet group). These patients discontinued the treatment after 1 to 12 months (5.124.1 months).

Discussion The results of the current study indicate that, in a double-blind, randomized, placebo-controlled trial over a 2-year period in alcoholic liver cirrhosis, patient survival and the need for liver transplantation were not significantly improved by AdoMet treatment (1.2 g per day, orally) although there was a trend to a reduced

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overall mortality/liver transplantation in treated patients compared to those receiving placebo. However, AdoMet treatment significantly reduced the overall mortality/liver transplantation in the subgroup of patients in Child classes A and B, in whom AdoMet treatment also significantly decreased the probability of death or liver transplantation, as analyzed by the Kaplan-Meier method. These results suggest that patients with alcoholic cirrhosis and less severe hepatic dysfunction (Child A and B patients) are the best can- didates for AdoMet treatment. The present results also show that to have a beneficial effect, AdoMet treatment should be maintained for a period longer than 1

year. During the first 12 months of treatment there were no differences between the survival curves (time to death or liver transplantation) of patients treated with AdoMet and those receiving placebo. However, after 1 year of treatment, the rate of mortality/liver transplantation in the group of patients treated with AdoMet markedly diminished when compared with that of the group of patients treated with placebo.

At randomization both groups of patients were well matched with respect to sex, age, liver function tests, number of patients with previous episodes of major complications of cirrhosis and Child classification. This balance between the two groups was also observed for the subgroup of patients in Child classes A


and B. Therefore, the beneficial effect of AdoMet can- not be attributed to differences between the two groups at the beginning of the trial. Moreover, the estimation of alcohol intake during the trial was similar in both groups. Although 50% of the patients were not total abstainers, the alcohol intake was lower than before- hand and in most cases it was also intermittent. This fact could explain why, in this study, alcohol intake did not influence the outcome of patients in contrast with other series of patients with alcoholic cirrhosis that showed a significantly higher survival rate among the abstainers (36,37). It is known that alcoholic patients with cirrhosis and antibodies against hepatitis C virus have more severe liver dysfunction (38) and, specially those who continue drinking, also have a significantly lower survival rate (39). In the current study the percentage of incomplete abstainer patients with anti- hepatitis C antibodies who died was 45%, much higher than that of the overall series. However, the number of patients (abstainers and non-abstainers) with anti- hepatitis C antibodies was similar in both groups and, thus, the coexistence of hepatitis C infection did not influence the results of the study. In our study alcoholic patients with anti-hepatitis C antibodies were included because at the beginning of the study these antibodies were still not routinely determined and, moreover, the significance of the association of alcohol and hepatitis C infection in alcoholics was unknown. However, we believe that in further therapeutic studies in alcoholic cirrhosis, patients with anti-hepatitis C antibodies should be excluded or, at least, randomized separately.

The lack of differences in the liver function tests before and on conclusion of the study could be explained by the fact that the initial values were not very abnor- mal, because there were no cases of associated severe alcoholic hepatitis at entry, and because a great number of patients from both groups remained compen- sated throughout the study.

There were no statistical differences between the number of patients lost to follow-up in the AdoMet group and in the placebo group (p=O.32). Further- more, four of the ten patients were alive in months 23- 24 of the follow-up, with only six (5%) patients being lost for the survival analysis. This percentage of patients is relatively low for a long-term study including alcoholic patients and is within the range tolerated in clinical studies in which the final outcome is death (40).

Methionine metabolism is impaired in human cirrhosis. Cirrhotic patients have a normal or even higher basal concentration of methionine and a reduced plasma clearance, suggesting that in these patients there is an inactivation of methionine adenosyltransferase which hinders the synthesis of AdoMet, leading to

a depletion of hepatic glutathione (13,41). We postu- late that in patients with alcoholic cirrhosis exogenous administration of AdoMet for a long period of time normalizes methionine metabolism and restores hepatic glutathione concentration which inhibits, in part, lipid peroxidation and, as a consequence, disminishes the liver injury This mechanism is supported by experimental data in the baboon model of alcohol-induced liver injury, in which chronic ethanol consumption was associated with a significant depletion of Ad- oMet, and AdoMet supplementation attenuated liver injury as shown by a less marked glutathione depletion and by lesser increases in plasma AST and glutamate- dehydrogenase (30). Thus, by diminishing liver injury, AdoMet could delay or prevent the occurrence of hepatic failure, and this fact could explain why the beneficial effects of this treatment are more patent in patients with less advanced liver disease, Child’s A and B patients, who still have relatively preserved liver function.

Until now, AdoMet has mainly been used in the treatment of intrahepatic cholestasis. Meta-analysis of the different controlled trials demonstrated that Ad- oMet given orally or parenterally was able to improve both the pruritus and the biochemical parameters of cholestasis such as serum bilirubin, alkaline phosphatase and y-glutamyl transferase (34). Oral administration of 1200 mg/day of AdoMet for 6 months resulted in a significant increase of hepatic glutathione in both patients with alcoholic and in those with nonalcoholic liver disease (14). However, in these studies only the short-term effects of AdoMet were investigated; the present study is the first long-term clinical study including a large number of patients with alcoholic cirrhosis. As well as the effects on prognosis, this study also shows that AdoMet given for 2 years is a safe and well-tolerated drug with no important adverse effects. In fact, only a few patients voluntarily discontinued the treatment because of mild digestive symptoms such as nausea, pyrosis or diarrhea.

In the last decade, different therapeutic approaches have been proposed in the treatment of alcoholic cirrhosis, but none have demonstrated a clear beneficial effect (42). The results of the present study suggest that AdoMet is a promising drug in the treatment of alcoholic cirrhosis, especially in patients with Child A and B classification. However, these encouraging data should be confirmed with a clinical trial including a larger and more homogeneous series of patients.

Acknowledgements Supported by the Laboratories Europharma, S.A. grupo Boehringer Ingelheim Espafia, S.A., Madrid, Spain;

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Laboratories Knoll Farmaceutici Spa, L&ate, Milan, Italy; grant from the Comision Asesora de Investiga- cion Cientifica y Tecnica (SAF 96/0108), and (SAF98/ 0 132), Ministerio de Education y Ciencia, Spain; grant from the Fondo de Investigaciones Sanitarias (FIS 94/ 0231), Spain. We are indebted to Dr. Carlo di Padova (Knoll Farmaceutici Spa, Liscate, Milan, Italy) for ex- pert review of the manuscript and Mrs. Rosa Martinez for secretarial support.

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