This randomized, double-blind, placebo-controlled superiority trial will investigate the efficacy and safety of JPHX granule as a treatment for NAFLD. A flow diagram of this trial is shown in Figure. 1. This study will be conducted in Shuguang Hospital Affiliated with Shanghai University of Traditional Chinese Medicine.
Five visits including one follow-up were designed in this trial: week 6, 12, 18, 24 after enrolment and week 36 for follow-up. Each time point has five-day time flexibility. The study schedule is shown in Figure.2.
The diagnosis of NAFLD according to the “Guidelines of prevention and treatment for nonalcoholic fatty liver disease” updated in 2018 by the National Workshop on Fatty Liver and Alcoholic Liver Disease CSoH, Chinese Medical Association, Fatty Liver Expert Committee CMDA.(29). The diagnosis of TCM syndromes is based on the ‘Diagnostics of Traditional Chinese Medicine’(30) and the ‘Consensus opinion on diagnosis and treatment of nonalcoholic fatty liver disease with integrated traditional Chinese and Western Medicine’(31).
(1) Met the diagnostic criteria of NAFLD or NASH with spleen deficiency and blood stasis syndrome;
(3) MRI-PDFF fat fraction ≥ 5% ;
(4) BMI < 35 kg/m2;
(5) Willing and able to follow the scheduled visit plan, diet and exercise guidance, laboratory tests, and other research procedures;
(6) Serum alanine aminotransferase (ALT) < 5 times the upper normal limit;
(7) Signed informed consent of participants.
Exclusion criteria
(1) Participants who regularly used other hepatoprotective drugs in the past 1 month before screening;
(2) History of taking drugs that may affect lipid metabolism in 3 months before screening, such as tamoxifen, amiodarone, sodium valproate, methotrexate, and glucocorticoid;
(3) The patients combined with special conditions that may lead to fatty liver, such as total parenteral nutrition, inflammatory bowel disease, celiac disease, hypothyroidism, Cushing's syndrome, β-lipoprotein deficiency, lipoatrophic diabetes, and Mauriac syndrome;
(4) Patients with alcoholic fatty liver disease (male alcohol intake > 30g/d, female alcohol intake > 20g/d), liver cirrhosis, liver decompensation, and other chronic liver diseases, such as hepatitis B, hepatitis C, autoimmune liver diseases;
(5) Type 2 diabetes patients with unstable control (HbA1c ≥ 9.5% before enrolment);
(6) Patients with high risk or extremely high risk of arteriosclerotic cardiovascular disease (ASCVD);
(7) Those who have had bariatric surgery in the past year or who have taken weight-loss drugs in the past three months have lost more than 10% of their weight;
(8) Participants with a history of drug or narcotic abuse;
(9) Pregnant women, lactating women, and participants with major primary diseases or malignant tumors.
Randomization and concealment
Allocation
A researcher in an independent data center will conduct the design of the randomization sequence with SPSS Ver 24.0 software. Enrolled participants will be randomly assigned to the JPHX group or the placebo-controlled group in a 1:1 ratio. The sequence will be sealed as confidential documents in opaque envelopes and kept independently.
Blinding
All patients and researchers will be blinded to the treatment assignments until the study is completed. Personnel unrelated to this clinical trial will complete the preparation of drug blinding and emergency letters. Duplicate blinding is adopted in this study. All the data will enter into the database in double copies, and the final statistical plan is confirmed by question answering, verification, and blind review, the database will be locked. After that, the first unblinding will be carried out and the results of the undefined group information corresponding to random numbers for necessary statistical analysis can be obtained. After the analysis, the main researcher will perform the second unblinding with the identification of two groups. All the unblinding processes will be recorded. In case of emergency, the reason, time, and place of blindness breaking will be recorded, and the cases are treated as missing cases.
Recruitment
The potential participants will get the basic information of this trial from outpatient physicians or through the advertisements located in the hospital, and communicated with the researchers through the contact information. Trained researchers will conduct the investigation. Participants will be informed of the detailed process of this trial, collection of laboratory and imaging evaluation, storage of biological specimens, and be shown the informed consent form with an oral explanation of the probable benefits and potential risks to assure that participation is entirely voluntary. Participants will be offered a choice to proceed after they have signed the informed consent form. During the enrolment, the biological and imaging examinations will be conducted, and the results with other needed information of participants will be confidentially recorded in the case report form (CRF).
Withdrawal, dropout, and discontinuation
Participants are free to withdraw at any time and will be investigated the reason for withdrawal. The reason and its connection with this trial will be recorded after investigation. If severe adverse events occur, or participants do not meet the requirements of this trial, such as gestation or take forbidden drugs concomitantly, participants will be advised to discontinue the participation. If moderate or severe adverse reactions judged to be related to the clinical trial occur in more than 25% of the total participants, or if the required number of participants has not been fully enrolled within the schedule, this clinical trial may be terminated early.
Interventions
Participants in the JPHX group will receive JPHX granule, while JPHX simulated granule as placebo will be applied in the control group. Both groups of participants will receive regular health education, including diet control, exercise, and behavior modification. ①diet adjustment: low sugar, low fat, and high vitamin diet are recommended. The fat content is less than 30%, protein content accounts for 15%-18%, and carbohydrate accounts for 52%-55% of the daily total energy; ②Strengthen physical exercise: exercise for more than 30 minutes each time, 4 times a week; ③Adjust emotion and keep a good mood; ④During the experimental period, other traditional Chinese medicine and Western medicine with lipid-lowering or fatty liver treatment as the main treatment are prohibited.
The JPHX granule is compounded of 8 Chinese herbs, whose ingredients are equivalent to Atractylodes Macrocephala Koidz. (Bai Zhu), Radix Salviae. (Dan Shen), Aurantii Fructus. (Zhi Ke), Paeoniae Radix Alba. (Bai Shao), Radix Puerariae. (Ge Gen), Alisma Orientale. (Sam.) Juz. (Ze Xie), Schisandrae Chinensis Fructus. (Wu Wei Zi), Curcumaelongae Rhizoma (Jiang Huang, and packaged at a unit of 6.39 g. The placebo will have a similar appearance, weight, and taste compared to the JPHX. Both JPHX and placebos will be produced by Jiangyin Tianjiang Pharm Co. Ltd, Jiangsu, China, and will be packaged follow the randomization sequence. Granules will be instructed to take 2 packs two times per day for 24 weeks. Participants will receive the drug for 6 weeks at each visit and give back the drugs left over from the previous visit. Other medications and their doses during this period will also be recorded in CRF. Any questions raised by participants will be answered to facilitate completion. Participants will be advised to get more medical advice in the clinic after the trial. The detailed study schedule is shown in Figure. 2.
Outcomes
The primary outcome is the percentage change of liver fat content tested by MRI-PDFF, MRI-PDFF correlates with histology-determined steatosis grade in adults with NAFLD and is more accurate than conventional dual-phase imaging in classifying steatosis grade in patients with NAFLD(32, 33). The secondary outcomes are body weight, body mass index (BMI), waist circumference, waist-to-hip ratio (WHR), serum liver function including ALT, aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), total bilirubin (TBIL), direct bilirubin (DBIL), indirect bilirubin (IDBIL), alkaline phosphatase (34), albumin (35), pre-albumin (Pre-ALB), and total bile acid (TBA); fasting serum TC, TG, HDL-C, LDL-C; fasting plasma glucose (FPG), fasting insulin (FINS), Homeostasis model assessment - insulin resistance (HOMA-IR). All mentioned serum biochemical which will be measured at baseline, 12 and 24 weeks after randomization. The life quality will be measured by Medical Outcomes Study item short-form health survey (SF-36), the changes in the syndromes of Traditional Chinese Medicine (TCM) for participants will be measured using four TCM diagnostic methods and the Scores of TCM Syndrome Scale. The blood and urine routine examination, blood urea nitrogen, creatinine, and uric acid will be examined as safety outcomes in this trial.
Ethical consideration
The clinical trial protocol was jointly agreed upon by the main researcher and the sponsor and was approved by the Ethics Committee before implementation. If the protocol is revised in the process of this trial, it needs reapproval from the ethics committee before implementation. The process of this trial will be monitored by the IRB of Shuguang Hospital affiliated with Shanghai University of TCM and the Science and Technology Commission of Shanghai Municipality.
Data management
All collected data will be managed with an electronic data capture system program compiled by the statistical department in Shuguang hospital. The data will be input and proofread independently by two data administrators. For the questions that occurred in the proofread, the data administrator will generate a concentrator data ready queue (DRQ) and send questions to the researchers through the clinical supervisor. The researchers should deal with it and return it as a final version in time. The data administrator will confirm and input the final version according to the researchers, and issue DRQ again if necessary. The data will be locked by the principal investigator after double-checked. The locked data file will not be changed. The problems found after data locking will be corrected in the statistical analysis status after confirmation. All data collected will be kept confidential in this trial.
Statistical analysis
Statistical analysis will be performed by an independent researcher using SAS 9.1 statistical analysis software. The efficacy evaluation will be conducted in the full analysis set(36) according to the intention-to-treatment Principle. Cases that meet the trial protocol, have good compliance (80%-120%), did not take banned drugs during the trial, and completed the contents of the CRF regulations will be defined as the Per-Protocol Set.
For continuous data, the measurement of each visit between groups will be analyzed using the independent t-test or Wilcoxon rank-sum test according to the distribution of the data. Paired t-test or Wilcoxon signed-rank test will be applied to compare the changes before and after treatment. The categorical data of each visit in different will be described by frequency and constituent ratio. Chi-square test / Fisher exact probability method will be adopted for comparison. All statistical analysis will be conducted by bilateral test, and the P-value less than or equal to 0.05 will be considered to be statistically significant. Subgroup analyses will be conducted with a list of variables based on information collected to explore the source of potential high heterogeneity.