Exploration of Medicine

Open Access Meta-Analysis

GLP-1 receptor agonists for NAFLD treatment in patients with and

without type 2 diabetes: an updated meta-analysis
Alessandro Mantovani* , Giorgia Beatrice, Graziana Petracca, Filippo Pampagnin, Damiano Sandri,
Giovanni Targher*
Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria
Integrata of Verona, 37126 Verona, Italy

*Correspondence: Alessandro Mantovani, Section of Endocrinology, Diabetes and Metabolism, Department of Medicine,
University and Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy. alessandro.mantovani@
univr.it; Giovanni Targher, Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda
Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy. [email protected]
Academic Editor: Amedeo Lonardo, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, Italy
Received: March 30, 2020 Accepted: May 2, 2020 Published: June 29, 2020

Cite this article: Mantovani A, Beatrice G, Petracca G, Pampagnin F, Sandri D, Targher G. GLP-1 receptor agonists for NAFLD
treatment in patients with and without type 2 diabetes: an updated meta-analysis. Explor Med. 2020:1:108-23. https://doi.
org/10.37349/emed.2020.00008

Abstract
Aim: Recent randomized controlled trials (RCTs) have tested the efficacy of glucagon-like peptide-1
receptor agonists (GLP-1 RA) to specifically treat non-alcoholic fatty liver disease (NAFLD). We performed
a meta-analysis of RCTs to investigate the efficacy of GLP-1 RAs for treatment of NAFLD or non-alcoholic
steatohepatitis (NASH).
Methods: We systematically searched PubMed and ClinicalTrials.Gov databases utilizing specific terms to
identify placebo-controlled or head-to-head RCTs (last research on March 1, 2020) involving NAFLD patients
with the aim of evaluating the efficacy of GLP-1 RAs to treat NAFLD/NASH. Primary outcomes were changes
in serum liver enzymes, liver fat content, or histologic resolution of NASH. Weighted mean differences (WMD)
were used to test the differences between the treatment arms.
Results: Overall, we found 7 placebo-controlled or head-to-head RCTs involving 472 middle-aged individuals
(66% men; 77% with established diabetes) followed for a median of 16 weeks that have used liraglutide or
exenatide to treat NAFLD on imaging (n = 6) or biopsy (n = 1). Compared to placebo or reference therapy,
treatment with GLP-1 RAs decreased serum alanine aminotransferase [n = 7 studies; WMD: -8.77 IU/L,
95% confidence intervals (CI) -17.69 to 0.14 IU/L; I2 = 87.3%], gamma-glutamyltransferase levels (n = 4
studies; WMD: -10.17 IU/L, 95% CI -14.27 IU/L to -6.07 IU/L; I2 = 0%) and imaging-defined liver fat content
(n = 4 studies; WMD: -6.23%, 95% CI -8.95% to -3.51%; I2 = 85.9%). In one RCT involving 55 patients with
biopsy-proven NASH, a 48-week treatment with liraglutide also led to a greater histological resolution of
NASH than placebo.
Conclusions: GLP-1 RAs (mostly liraglutide) seem to be a promising treatment option for NAFLD or NASH.

© The Author(s) 2020. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International
License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing, adaptation, distribution
and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Explor Med. 2020:1:108-23 | https://doi.org/10.37349/emed.2020.00008 Page 108

Keywords
Glucagon-like peptide-1 receptor agonists, type 2 diabetes, non-alcoholic fatty liver disease, non-alcoholic
steatohepatitis

Introduction
Non-alcoholic fatty liver disease (NAFLD) is a metabolic liver disease that includes a variety of progressive
pathologic conditions, spanning from simple steatosis to steatohepatitis (NASH), advanced fibrosis and, lastly,
cirrhosis [1, 2]. To date, NAFLD is an increasingly recognized public health problem worldwide, affecting
roughly a quarter of the general population and up to 70-90% of patients who are obese or have type 2
diabetes mellitus (T2DM) [1-3]. The burden of NAFLD is influenced by the epidemics of obesity and T2DM,
and the prevalence of these pathologic conditions is also expected to increase in the future.
Over the last decade, it has become evident that NAFLD (principally its more severe histologic forms) is
not only related to increased liver-related morbidity and mortality [1, 2], but also increased risk of relevant
extra-hepatic diseases, such as cardiovascular disease (the principal cause of mortality in patients with
NAFLD), cancers and chronic kidney disease [2-6].
Although the pathogenesis of NAFLD is multifactorial, it is important to underline that this burdensome
liver disease is linked with insulin resistance, abdominal obesity, and T2DM [1, 2, 5, 7]. Indeed, strong
evidence indicates that abdominal obesity, T2DM and metabolic syndrome can synergistically contribute to
the development and the progression of NAFLD [1, 2, 5]. As with other chronic liver diseases, the severity of
liver fibrosis is the principal histological feature of long-term adverse clinical outcomes in NAFLD [2, 8-10].
Moreover, on the other hand, NAFLD is related to increased risk of T2DM and metabolic syndrome [11, 12].
To date, specific pharmacological treatments for NAFLD are not available. The mainstay of NAFLD
management is lifestyle modification to prompt weight loss through diet and physical exercise [2, 13, 14].
However, based on the strong link existing between NAFLD and insulin resistance or T2DM, many non-
randomized interventional studies and randomized controlled trials (RCTs) have investigated the role of
“older” hypoglycaemic agents (i.e. metformin and pioglitazone) and other newer anti-hyperglycemic drugs
in NAFLD patients, irrespective of the presence of T2DM [5, 13-15]. The most reliable data regarding the
efficacy of various hypoglycaemic agents in patients with biopsy-proven NASH concern pioglitazone [13-15].
However, long-term safety concerns have limited its use. Among the newer anti-hyperglycaemic agents,
glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are a class of glucose-lowering drugs that are also
able to induce significant weight loss and improve insulin resistance [16]. In addition, in people with T2DM,
GLP-1 RAs strongly decrease the adverse cardiovascular and renal outcomes [17], suggesting that this class
of anti-hyperglycaemic drugs may be a reasonable option to treat NAFLD in patients with and without
diabetes mellitus.
For these reasons, we have carried out a comprehensive systematic review and meta-analysis of
placebo-controlled or head-to-head RCTs that have assessed the GLP-1 RAs in the treatment of NAFLD.

Methods
Search strategy and study selection
We conducted a systematic review and meta-analysis following with the preferred reporting items for
systematic reviews and meta-analyses (PRISMA) guidelines. For the present study, we have included
placebo-controlled or head-to-head RCTs conducted in adults (age > 18 years) with NAFLD in which GLP-1
RAs were used for the treatment of NAFLD. We have included RCTs with at least 20 patients per arms.
Eligible studies [18-26] were obtained by searching PubMed and ClinicalTrials.Gov databases until
March 1, 2020 (date of the last research), using the following keywords: “non‐alcoholic fatty liver disease”
(OR “NAFLD” OR “non‐alcoholic steatohepatitis” OR “NASH”) AND “glucagon-like peptide-1 receptor agonists”
OR “GLP-1 RA” OR “liraglutide” OR “exenatide” OR “dulaglutide” OR “albiglutide” OR “semaglutide”. Searches

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were confined to placebo-controlled or head-to-head RCTs in which the diagnosis of NAFLD was made by liver
biopsy or imaging techniques (i.e. ultrasonography, computed tomography, magnetic resonance imaging, and/
or spectroscopy). Studies that included patients with significant alcohol consumption and secondary causes
of chronic liver disease were excluded. In addition, non-English-language articles, editorials, commentaries
and abstracts, unpublished studies or non-randomized studies were excluded. One investigator screened
citations, whereas a second one assessed the excluded citations. Two investigators (AM and GT) judged full-
text articles by using the inclusion criteria. Disagreements were then resolved by consensus.

Data extraction and quality evaluation

For eligible RCTs [18-24], we obtained data on the main characteristics of participants, type of intervention,
methods used for the diagnosis NAFLD, as well as information on primary outcomes. Specifically, the primary
outcomes were alterations in serum liver enzyme levels [i.e. alanine aminotransferase (ALT), aspartate
aminotransferase (AST) and gamma-glutamyltransferase (GGT)], liver fat content on imaging techniques, as
well as alterations in the histologic scores of NAFLD or histologic resolution of NASH in the two treatment
arms. We also obtained data on weight loss and changes in the levels of hemoglobin A1c and, whenever
available, information on visceral adipose tissue (as assessed by imaging methods) and adverse events.
Two investigators evaluated the risk of bias independently. For this purpose, we used the Cochrane
Collaboration’s tool [27]. It is important to remember that this tool evaluates 7 potential sources of bias:
random sequence generation, allocation concealment, blinding of participants and personnel, blinding of
outcome assessment, incomplete outcome data, selective reporting, and other bias [27]. For each domain, we
categorized RCTs into three categories: low, unclear, and high risk of bias [27].

Data synthesis and analysis

The effect sizes were displayed as weighted mean difference (WMD) and 95% confidence intervals (CI) for
RCTs describing primary outcome measures between patients with and without NAFLD. The overall estimate
of the effect size was computed using a random-effects model [28]. When requested, we also calculated mean
difference for continuous outcomes both at baseline and at the end of the trial by using specific statistical
methods [28, 29].
Visual inspection of the forest plots was used to estimate the heterogeneity. The heterogeneity among
studies was also tested by the I2-statistics. Specifically, the interpretation of the I2-statistics is as follows:
I2 values of roughly 25% show low heterogeneity, I2 values of roughly 50% show medium heterogeneity,
whereas I2 values of roughly 75% show high heterogeneity [30].
In order to test the sources of heterogeneity among the RCTs, we also conducted subgroup analyses
by study country (Asia vs. Europe), methods used for the diagnosis of NAFLD (imaging vs. biopsy), median
duration of the trial or different GLP-1 RA drug used (liraglutide vs. exenatide). Further sensitivity analyses
were also made by omitting one study at a time (data not reported).
Since the number of the eligible RCTs included in the meta-analysis was less than 10, we performed
neither meta-regression analyses nor funnel plots for assessing potential publication bias [28].
All statistical tests were two sided and used a significance level of P < 0.05. All statistical analyses were
performed using the software STATA® 14.2 (Stata, College Station, TX).

Results
The flow diagram of the study selection is reported in Figure S1. As reported, we identified 9 potentially RCTs
from publication databases until March 1, 2020 [18-26]. After assessing the full text of such 9 publications,
we further excluded two studies [25, 26] for specific reasons (Figure S2).
In total, seven placebo-controlled (n = 3 studies) or head-to-head (n = 4 studies) RCTs were considered
eligible for our meta-analysis and were therefore tested for quality [18-24]. Table 1 reports the main
characteristics of 7 RCTs are described in. Overall, there were 472 middle-aged obese individuals [66% men;
mean age 47 ± 3 years; mean (± SD) body mass index 32 ± 3 kg/m2; mean AST 49 ± 37 UI/L; mean ALT

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66 ± 50 UI/L; prevalence of diabetes 77%] with NAFLD or NASH, who were followed for a median period
of 16 weeks (inter-quartile range: 12-24 weeks). Of 472 individuals, 253 were randomly assigned to the
placebo or reference therapy group, whereas 219 were randomly allocated to either exenatide (n = 3 RCTs) or
liraglutide (n = 4 RCTs) in order to treat NAFLD or NASH specifically. As shown in Table 1, five RCTs included
exclusively patients with T2DM [18, 20, 21, 23, 24], one RCT was conducted in both patients with and without
T2DM [19], whilst one RCT included non-diabetic women with polycystic ovary syndrome [22]. Four RCTs
were performed in China [15, 18, 20, 21] and three [16, 17, 19] in Europe (i.e. United Kingdom, France, and
Denmark). The diagnosis of NAFLD was made by liver biopsy in one RCT, i.e. the liraglutide efficacy and
action in NASH (LEAN) study that included adults with biopsy-proven NASH [19]. By contrast, the detection
of NAFLD was based on liver ultrasonography in two RCTs [18, 21], whereas in the remaining four RCTs,
the diagnosis of NAFLD was based on magnetic resonance imaging-proton density fat fraction or magnetic
resonance spectroscopy [20, 22-24].
In eligible RCTs, GLP-1 RAs had a similar adverse event profile to either placebo or reference therapy,
except for a slight increase of the frequency of gastro-intestinal symptoms, such as nausea, diarrhea, and loss
of appetite. However, it is important to highlight that these adverse events were mostly temporary and mild
in severity across the RCTs.
As shown in Figures 1, 2 and 3, when compared to placebo or reference therapy, GLP-1 RAs decreased
the circulating levels of both ALT (n = 7 studies; pooled WMD: -8.77 IU/L, 95% CI -17.69 IU/L to 0.14 IU/L)
or GGT (n = 4 studies; pooled WMD: -10.17 IU/L, 95% CI -14.27 IU/L to -6.07 IU/L) and tended to decrease
serum AST levels (n = 6 studies; pooled WMD: -3.41 IU/L, 95% CI -11.49 IU/L to 4.68 IU/L).
Table 1. Placebo-controlled or active-controlled RCTs of GLP-1 RAs for treatment of NAFLD or NASH (ordered by publication year)
Author, Study Interventions Efficacy and/or effectiveness Major Cochrane RCT’s quality
year, characteristics (n), trial outcomes A vs. B (or vs. C) adverse scale
country length effects
(Ref) (weeks)
Shao et Patients with A. Exenatide Reversal rate of NAFLD on Not reported Random sequence generation
al. 2014; T2DM and + glargine (n ultrasound (A vs. B): 93% vs. (selection bias): unclear
China [18] NAFLD on = 30) 67%, P < 0.01
Allocation concealment
ultrasound
B. Intensive Differences in body weight (selection bias): unclear
Mean age: 43 insulin: insulin change post-treatment vs. pre-
Blinding of participants and
years; male sex: aspart + treatment: -7.8 kg vs. 3.3 kg, P
researchers (performance
48%; BMI 30 insulin glargine < 0.001
bias): unclear
kg/m2; HbA1c (n = 30)
No difference in changes in
7.6%; ALT 166 Blinding of outcome
Length: 12 HbA1c between the groups
IU/L; AST 123 assessment (detection bias):
weeks
IU/L unclear
Incomplete outcome data
(attrition bias): unclear
Selective reporting (reporting
bias): unclear
Other bias: unclear
Armstrong Patients with A. Liraglutide Histologic resolution of NASH: Gastro- Random sequence generation
et al. 2016; biopsy-proven 1.8 mg (n = 39% vs. 9%, P = 0.019 intestinal (selection bias): low
UK [19] NASH (i.e. 26) disorders
Change in histologic NAS Allocation concealment
LEAN trial) in the
B. Placebo (n score: -1.3 vs. -0.8, P = 0.24 (selection bias): low
liraglutide
Mean age: 51 = 26)
Change in fibrosis stage: -0.2 vs. placebo: Blinding of participants and
years; male
Length: 48 vs. 0.2, P = 0.11 81% vs. researchers (performance
sex: 60%; BMI
weeks 65% bias): low
36 kg/m2; ALT Fibrosis improvement: 26% vs.
71 IU/L; AST 14%, P = 0.46 Blinding of outcome
51 IU/L; fibrosis assessment (detection bias):
Fibrosis worsening: 9% vs.
F3-F4 (on low
36%, P = 0.04
histology) 52%; Incomplete outcome data
pre-existing Change in serum ALT: -26.6
(attrition bias): low
diabetes: 33% UI/L vs. -10.2 UI/L, P = 0.16
Selective reporting (reporting
Change in serum AST: -27 UI/L
bias): low
vs. +9 IU/L, P = 0.02
Other bias: low

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Table 1. Placebo-controlled or active-controlled RCTs of GLP-1 RAs for treatment of NAFLD or NASH (ordered by publication
year) (continued)
Author, Study Interventions Efficacy and/or effectiveness Major Cochrane RCT’s quality
year, characteristics (n), trial outcomes A vs. B (or vs. C) adverse scale
country length effects
(Ref) (weeks)
Dutour et Patients with A: Exenatide Exenatide and reference Not reported Random sequence generation
al. 2016; T2DM, 95% 5-10 mcg bid treatment had a similar (selection bias): unclear
France of whom had (n = 22) improvement in terms of
Allocation concealment
[20] NAFLD on MR HbA1c values (−0.7 ± 0.3% vs.
B: Placebo (n (selection bias): unclear
spectroscopy −0.7 ± 0.4%; P = 0.29)
= 22)
Blinding of participants and
Mean age: 52 Significant weight loss was
Length: 26 researchers (performance
years; male sex: observed in the exenatide
weeks bias): unclear
48%; BMI 36 group (-5.5 ± 1.2 kg vs. -0.2 ±
kg/m ; HbA1c
2
0.8 kg, P = 0.001 for difference Blinding of outcome
7.5%; ALT 29 between groups) assessment (detection bias):
IU/L; AST 22 unclear
When compared with the
IU/L Incomplete outcome data
reference therapy, exenatide
induced a significant reduction (attrition bias): unclear
in liver fat content (-23.8 ± Selective reporting (reporting
9.5% vs. 12.5 ± 9.6%, P = bias): unclear
0.007)
Other bias: unclear
Feng et Patients with A. Liraglutide Liver fat content decreased Not reported Random sequence generation
al. 2017; T2DM and up to 1.8 mg/d in all groups as follows: from (selection bias): unclear
China [21] NAFLD on (n = 31) 36.7 ± 3.6% to 13.1 ± 1.8% in
Allocation concealment
ultrasound the liraglutide group; from 33.0
B. Metformin (selection bias): unclear
± 3.5% to 19.6 ± 2.1% in the
Mean age: 47 up to 2000
gliclazide group, and from 35.1 Blinding of participants and
years; male sex: mg/d (n = 31)
± 2.3% to 18.4 ± 2.2% in the researchers (performance
75%; BMI 28
C. Gliclazide metformin group (P < 0.001 for bias): unclear
kg/m2; HbA1c
60-120 mg/d all treatment groups, final vs.
9.1%; ALT 49 Blinding of outcome
(n = 31) baseline)
IU/mL; AST 31 assessment (detection bias):
IU/L Length: 24 Reduction in liver fat content unclear
weeks following liraglutide treatment Incomplete outcome data
was greater when compared (attrition bias): unclear
to that following gliclazide
treatment (P = 0.001) Selective reporting (reporting
bias): unclear
Both liraglutide and metformin
treatments reduced body Other bias: unclear
weight and improved serum
liver enzymes
HbA1c levels were lower in
the liraglutide and metformin
groups than in the gliclazide
group

Frøssing Women with A. Liraglutide Liraglutide treatment reduced Nausea and Random sequence generation
et al. 2017; polycystic ovary 1.8 mg/d (n body weight by 5.2 kg (-5.6% constipation (selection bias): unclear
Denmark syndrome and = 48) from baseline), liver fat content in the
Allocation concealment
[22] NAFLD on MR by 44% (on MR spectroscopy) liraglutide
B. Placebo (n (selection bias): unclear
spectroscopy as well as NAFLD prevalence group
= 24)
by roughly two-thirds (P < 0.01 Blinding of participants and
Mean age: 47
Length: 26 for all) researchers (performance
years; female
weeks bias): unclear
sex: 100%; BMI Liraglutide treatment reduced
33 kg/m2 fasting plasma glucose Blinding of outcome
and HbA1c [liraglutide vs. assessment (detection bias):
placebo, mean between-group unclear
difference (95% CI), -0.24 Incomplete outcome data
(-0.44 to -0.04) mmol/L; mean (attrition bias): unclear
HbA1c (95% CI), -1.38 (-2.48
to -0.28) mmol/mol] Selective reporting (reporting
bias): unclear
Other bias: unclear

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Table 1. Placebo-controlled or active-controlled RCTs of GLP-1 RAs for treatment of NAFLD or NASH (ordered by publication
year) (continued)
Author, Study Interventions Efficacy and/or effectiveness Major Cochrane RCT’s quality
year, characteristics (n), trial outcomes A vs. B (or vs. C) adverse scale
country length effects
(Ref) (weeks)
Yan et Patients with A. Liraglutide In the liraglutide and sitagliptin Not reported Random sequence generation
al. 2019; T2DM and 1.8 mg/d (n groups, liver fat content (selection bias): unclear
China [23] NAFLD on MRI- = 24) decreased from baseline to
Allocation concealment
PDFF week 26 (in particular, in the
B. Insulin (selection bias): unclear
liraglutide group the reduction
Mean age: 44 glargine 0.2
ranged from 15.4 ± 5.6% to Blinding of participants and
years; male sex: IU/kg/d (n =
12.5 ± 6.4%, P < 0.001, while researchers (performance
69%; BMI 29.8 24)
in the sitagliptin group the bias): unclear
kg/m2; HbA1c
C. Sitagliptin reduction ranged from 15.5
7.7%; ALT 43 Blinding of outcome
100 mg/d (n ± 5.6% to 11.7 ± 5.0%, P =
IU/L; AST 33 assessment (detection bias):
= 27) 0.001)
IU/L unclear
Length: 26 HbA1c levels decreased in all Incomplete outcome data
weeks treatment groups (in particular, (attrition bias): unclear
in the liraglutide group the
reduction ranged from 7.8 ± Selective reporting (reporting
1.4% to 6.8 ± 1.7%, P < 0.001; bias): unclear
in the sitagliptin group from Other bias: unclear
7.6 ± 0.9% to 6.6 ± 1.1%, P =
0.016; and in the insulin group
from 7.7 ± 0.9% to 6.9% ±
1.1%, P = 0.013)
Body weight decreased in the
liraglutide and in the sitagliptin
groups, but not in the insulin
glargine group
Liu et al. Patients with A. Exenatide Liver fat content was reduced Adverse Random sequence generation
2020; T2DM and 1.8 mg/d (n after exenatide treatment events were (selection bias): unclear
China [24] NAFLD on MRI- = 38) (Δ liver fat -17.6 ± 12.9%). comparable
Allocation concealment
PDFF Exenatide treatment also led between the
B. Insulin (selection bias): unclear
to a greater reduction in the two groups
Mean age: 48 glargine 0.2
visceral adipose tissue (ΔVAT Blinding of participants and
years; male sex: IU/kg/d (n =
-43.6 ± 68.2 cm2), serum researchers (performance
50%; BMI 28 38)
ALT, AST, GGT levels, BMI bias): unclear
kg/m2; HbA1c
Length: 24 and waist circumference than
8.3%; ALT 38 Blinding of outcome
weeks insulin glargine
IU/L; AST 28 assessment (detection bias):
IU/L unclear
Incomplete outcome data
(attrition bias): unclear
Selective reporting (reporting
bias): unclear
Other bias: unclear
BMI: body mass index; HbA1c: hemoglobin A1c; MR: magnetic resonance; MRI-PDFF: magnetic resonance imaging-proton
density fat fraction; VAT: visceral adipose tissue

Figure 4 reports the forest plot and pooled estimates of the effect of GLP-1 RAs on changes in liver
fat content in the eligible RCTs using imaging methods for measuring it (notably, the LEAN study was not
included in the figure as this trial used liver biopsy). When compared to placebo or reference therapy, GLP-1
RAs significantly improved liver fat content (n = 4 studies; pooled WMD: -6.23%, 95% CI -8.95% to -3.51%).
It should be noted that, the LEAN trial [19], using liver biopsy for investigating the effect of liraglutide in
patients with NASH, documented that 40% of patients, who received liraglutide had histological resolution of
NASH with no worsening of fibrosis when compared with 9% of patients in the placebo group (P < 0.05). In
addition, in that study, fewer patients in the liraglutide group had progression of fibrosis when compared to the
placebo group and a greater proportion of patients in the liraglutide group had also significant improvements
in steatosis and hepatocyte ballooning. No difference was seen in lobular inflammation and NAFLD activity
score between the two treatment arms. Patients in the liraglutide group also had a statistically significant
reduction in body weight and serum liver enzyme levels.

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 Page 114
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Figure 1. Forest plot and pooled estimates of the effect of GLP-1 RAs on changes in serum alanine aminotransferase (ALT) levels in the eligible placebo-controlled or head-to-head RCTs (n = 7).
The effect size was expressed as WMD and 95% CIs
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Figure 2. Forest plot and pooled estimates of the effect of GLP-1 RAs on changes in serum aspartate aminotransferase (AST) levels of in the eligible RCTs (n = 6). The effect size was expressed
as WMD and 95% CIs
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Figure 3. Forest plot and pooled estimates of the effect of GLP-1 RAs on changes in serum gamma-glutamyltransferase (GGT) levels in the eligible placebo-controlled or head-to-head RCTs (n =
4). The effect size was expressed as WMD and 95% CIs
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Figure 4. Forest plot and pooled estimates of the effect of GLP-1 RAs on changes in liver fat content as detected by imaging methods in the eligible placebo-controlled or head-to-head RCTs (n =
4). The effect size was expressed as WMD and 95% CIs
 As shown in Table 2, we did subgroup analyses to test the sources of heterogeneity among the eligible
RCTs. After stratifying the RCTs for study country, diagnostic methods of NAFLD, length of the trial or single
GLP-1 RA drug tested, the positive effects of GLP-1 RAs on serum liver enzymes and liver fat content were
substantially consistent across all subgroups.

Table 2. Effects of GLP-1 RAs on changes in serum liver enzyme levels and liver fat content (assessed by imaging methods)
in the eligible RCTs, stratified by study country, methods used for the diagnosis of NAFLD, individual GLP-1 RA drug used and
duration of the trial
ALT (IU/L) AST (IU/L) GGT (IU/L) Liver fat content (%)
Study Country
Asia WMD -11.1 WMD -4.3 WMD -10.1 WMD -4.9
(95% CI -25.7 to 3.6) (95% CI -14.2 to 5.6) (95% CI -14.3 to 5.9) (95% CI -7.8 to -2.0)
I = 93%
2
I = 92%
2
I = 0%
2
I2 = 57%
n = 4 studies n = 4 studies n = 2 studies n = 3 studies
Europe WMD -4.6 WMD -1.0 WMD -12.1 WMD -9.0
(95% CI -17.4 to 8.3) (95% CI -14.6 to 12.5) (95% CI -31.8 to 7.6) (95% CI -10.2 to -7.8)
I2 = 58% I2 = 37% I2 = 0% I2 = 0%
n = 3 studies n = 2 studies n = 2 studies n = 1 study
Diagnosis of NAFLD
Ultrasonography WMD -14.7 WMD -4.5 WMD -9.8 WMD -6.0
(95% CI -44.9 to 15.4) (95% CI -22.3 to 13.3) (95% CI -14.1 to -5.5) (95% CI -7.2 to -4.8)
I = 97%
2
I = 96%
2
I = 0%
2
I2 = 0%
n = 2 studies n = 2 studies n = 1 study n = 1 study
Biopsy WMD -22.0 WMD -7.0 WMD -38.0 Not available on imaging
methods
(95% CI -42.8 to -1.3) (95% CI -20.4 to 6.4) (95% CI -109 to 33.9)
I = 0%
2
I = 0%
2
I2 = 0%
n = 1 study n = 1 studies n = 1 study
MRI-PDFF or WMD -3.6 WMD -2.2 WMD -13.6 WMD -6.1
spectroscopy
(95% CI -11.4 to 4.3) (95% CI -11.8 to 7.4) (95% CI -28.8 to 1.6) (95% CI -11.2 to -0.9)
I = 54%
2
I = 64%
2
I = 0%
2
I2 = 85%
n = 4 studies n = 3 studies n = 2 studies n = 3 studies
Individual GLP-1 RA drug used
Exenatide WMD -16.3 WMD -8.6 WMD -10.1 WMD -8.9
(95% CI -31.8 to -0.87) (95% CI -16.8 to -0.38) (95% CI -14.2 to -5.9) (95% CI -10.1 to -7.8)
I = 81%
2
I = 60%
2
I = 0%
2
I2 = 0%
n = 3 studies n = 3 studies n = 3 studies n = 2 studies
Liraglutide WMD -0.43 WMD 2.5 WMD -38.0 WMD -4.4
(95% CI -4.9 to 4.1) (95% CI -2.2 to 7.2) (95% CI -109 to 33.9) (95% CI -8.2 to -0.5)
I = 37%
2
I = 35%
2
I = 0%
2
I2 = 77%
n = 4 studies n = 3 studies n = 1 study n = 2 studies
Median length of trial
Length ≤ 24 weeks WMD -13.9 WMD -6.1 WMD -10.1 WMD -6.0
(95% CI -32.8 to 4.8) (95% CI -18.8 to 6.7) (95% CI -14.2 to -5.9) (95% CI -7.2 to -4.9)
I = 95%
2
I = 95%
2
I = 0%
2
I2 = 0%
n = 3 studies n = 3 studies n = 2 studies n = 2 studies
Length > 24 weeks WMD -2.5 WMD 0.8 WMD -12.1 WMD -5.7
(95% CI (-10.5 to 5.6) (95% CI -6.7 to 6.8) (95% CI -31.8 to 7.6) (95% CI -12.6 to -1.1)
I = 37%
2
I = 0%
2
I = 0%
2
I2 = 92%
n = 4 studies n = 3 studies n = 2 studies n = 2 studies
MRI-PDFF: magnetic resonance imaging-proton density fat fraction

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 As shown in Figures S2, S3 and S4, when compared to placebo or reference therapy, GLP-1 RAs also
improved anthropometric parameters, mostly intra-abdominal visceral adipose tissue (n = 4 studies; pooled
WMD: -27.43, 95% CI -42.66 cm2 to -12.2 cm2), and slightly reduced hemoglobin A1c levels (n = 6 studies;
pooled WMD: -0.13, 95% CI -0.47% to 0.21%).

Discussion
Our updated systematic review and meta-analysis involved seven placebo-controlled or head-to-head RCTs
(published until March 1, 2020) testing the efficacy of either exenatide (n = 3 studies) or liraglutide (n = 4
studies) to treat NAFLD for a median period of 16 weeks with a total of 472 middle-aged individuals with
and without T2DM. Overall, the results of our meta-analysis support the capability of GLP-1 RAs (especially
liraglutide) to reduce serum liver enzyme levels (mostly serum GGT concentrations) and to improve NAFLD.
The improvement of NAFLD by liraglutide and other GLP-1 RAs is, in all likelihood, multifactorial and
may be mainly thought as a direct consequence of the cumulative effect of these glucose-lowering agents on
weight loss, insulin resistance and liver. In fact, the GLP-1 RAs are efficacious for treatment of T2DM and are
also able to improve insulin resistance and promote weight loss (on average ~3-4 kg after 24 weeks) [16].
Moreover, it is important to mark that GLP-1 receptors are also highly expressed in human hepatocytes
and that GLP-1 RAs may decrease hepatic fat content by reducing de novo lipogenesis, enhancing fatty acid
oxidation and improving hepatic insulin signaling both in the hepatocytes [31-33].
From this study, however, it comes to light that a relevant problem in this specific topic is the lack of
high-quality RCTs with important hepatic endpoints (i.e. liver histologic data). Indeed, no robust data are
currently available in the literature with liver histological endpoint as a primary outcome in order to support
the efficacy of GLP-1 RAs as a specific treatment for NAFLD. This is an important and relevant aspect to be
taken into consideration when we interpret the results of the present meta-analysis. In fact, we believe that
RCTs of pharmacologic treatments designed for improving the liver disease severity in NAFLD patients should
constantly include patients with biopsy‐proven NASH or advanced fibrosis, that is strongly associated with
unfavorable outcomes [2, 8-10, 13, 14]. In addition, although magnetic resonance imaging-estimated proton
density fat fraction or proton magnetic resonance spectroscopy can be used to quantify the liver fat content,
the capacity of these techniques for detecting NASH and fibrosis is relatively limited [1, 34]. Therefore, on
the basis of these considerations, the majority of eligible RCTs included in the present study have obtained a
fair quality according to the Cochrane Collaboration’s tool (Table 1). To date, notably, only the LEAN trial has
used the liver biopsy for diagnosing and staging NAFLD [19]. In this multicenter phase 2 RCT involving 55
UK obese adults with NASH, it has been documented that patients who were randomly assigned to liraglutide
had a greater histological resolution of NASH and significant improvements in individual histologic scores
of NASH (except for liver fibrosis regression) when compared to those receiving placebo [19]. The authors
of this trial also suggested that the beneficial effects of liraglutide on the histological liver endpoints were
presumably owing to its direct hepatic effect and weight loss. The beneficial effect of liraglutide on body
weight and, especially, on intra-abdominal visceral adipose tissue has been also documented by the results
of our meta-analysis. It should be noted that, in our meta-analysis, we did not include the study of Armstrong
et al. [25], [Liraglutide effect and action in diabetes (LEAD) & LEAD-2 trials] and that of Gluud et al. [26], for
unsatisfactory inclusion criteria and/or unsatisfactory study design. However, it should be noted that the
findings of these two studies were substantially consistent with those of the eligible RCTs included in the
present meta-analysis.
Several RCTs with a long duration of follow-up have clearly demonstrated that liraglutide and other long-
acting GLP-1 RAs are also able to reduce the risk of developing cardiovascular and renal diseases in patients
with T2DM [35-39]. For instance, in a meta-analysis involving many of these RCTs (for a total of nearly 56,
000 T2DM individuals followed for approximately 3 years), Kristensen et al. [17], confirmed that GLP-1
RAs reduced major adverse cardiovascular events by 12% (hazard ratio 0.88, 95% CI 0.82-0.94), hospital
admission for heart failure by 9% (hazard ratio 0.91, 95% CI 0.83-0.99) and chronic kidney disease by 17%
(hazard ratio 0.83, 95% CI 0.78-0.89).

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 Based on these aspects, we strongly believe that if larger phase 3 RCTs will confirm the interesting
findings of the LEAN trial [19], it is reasonable to suppose that liraglutide and other long-acting GLP-1 RAs
will become a suitable treatment option in NAFLD patients.
Our meta-analysis has some limitations. First, it includes a relatively low number of placebo-controlled
and head-to-head RCTs with a small sample size and a short follow-up. Second, the eligible RCTs used only
liraglutide or exenatide because at present the data on the efficacy and safety of other long-acting GLP-1 RAs
(e.g., dulaglutide and semaglutide) in patients with NAFLD are not available. Third, data with liver histological
endpoint as a primary outcome were accessible only for the LEAN trial. Therefore, these findings are not
conclusive and further investigation is also required.
In conclusion, the results of our updated meta-analysis of placebo-controlled or head-to-head RCTs
suggest that, when compared to placebo or reference therapy, GLP-1 RAs (especially liraglutide) show
favorable results on reductions in serum liver enzymes, liver fat content and histological resolution of NASH.
However, these findings warrant further evaluation in larger, randomized controlled phase 3 trials.

Abbreviations
ALT: alanine aminotransferase
AST: aspartate aminotransferase
CI: confidence interval
GGT: gamma-glutamyltransferase
GLP1 RA: glucagon-like peptide-1 receptor agonists
LEAD: liraglutide effect and action in diabetes
LEAN: liraglutide efficacy and action in NASH
NAFLD: non-alcoholic fatty liver disease
NASH: non-alcoholic steatohepatitis
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
RCTs: randomized controlled trials
T2DM: type 2 diabetes mellitus
WMD: Weighted mean difference

Supplementary materials
The supplementary materials for this article are available at: https://www.explorationpub.com/uploads/
Article/file/10018_sup_1.pdf.

Declarations
Author contributions
AM and GT contributed to study concept and design, acquisition of data, and drafting of the manuscript.
AM and GT contributed to statistical analysis of data. AM, GB, GP, FP, DS, and GT contributed to analysis and
interpretation of data. GB, GP, FP, and DS contributed to critical revision of the manuscript for important
intellectual content. AM and GT are the guarantor of this work and, as such, had full access to all the data in
the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflicts of interest
The authors declare that they have no conflicts of interest.

Ethical approval
Not applicable.

Explor Med. 2020:1:108-23 | https://doi.org/10.37349/emed.2020.00008 Page 120

Consent to participate
Not applicable.

Consent to publication
Not applicable.

Availability of data and materials

Not applicable.

Funding
Not applicable.

Copyright
© The Author(s) 2020.

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