Bull. Pharm. Sci., Assiut University, Vol. 46, Issue 1, 2023, pp. 347-360.

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Bulletin of Pharmaceutical Sciences
Assiut University
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THE EFFECT OF MELATONIN, METFORMIN AND

URSODEOXYCHOLIC ACID ON NON-ALCOHOLIC FATTY LIVER
DISEASE: A RANDOMIZED, DOUBLE-BLINDED CONTROLLED
TRIAL
Kourosh Mojtahedi, Farahnaz Joukar, Seyyed Hossein Seyyed Nezhad Fahim, Sara Yeganeh,
Mehrnaz Asgharnezhad, Afshin Shafaghi, Saba Fakhrieh Asl and Fariborz Mansour-Ghanaei*

Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences,
Rasht, Iran

Objective: This study was to investigate and compare the effect of melatonin, metformin,
and ursodeoxycholic acid (UDCA) on non-alcoholic fatty liver disease(NAFLD). Methods: In
this randomized double-blinded clinical trial, 120 patients with NAFLD who had been referred
to Gastrointestinal and Liver Diseases Research Center, Rasht, Iran, between September 2015
and January 2016. Patients were randomly assigned to 4 groups. Each group received
melatonin, metformin, UDCA, or placebo in addition to a weight loss diet for 3 months.
Results: A significant reduction was observed in levels of steatosis, alanine aminotransferase,
alkaline phosphatase, body weight, BMI, waist circumstance and triacylglycerol among
participants in groups with metformin or melatonin administration. In addition a significant
decrease in fasting plasma glucose, and total cholesterol concentration was detected following
metformin and UDCA administration, respectively. Conclusions: The present study suggests
that the addition of metformin or melatonin to a low-caloric diet may be effective in the
treatment of patients with NAFLD.
Keywords: Melatonin, Metformin, Ursodeoxycholic acid, Non-alcoholic fatty liver disease

INTRODUCTION If NAFLD is not diagnosed expediently,

and subsequently appropriately managed, it can
Non-alcoholic fatty liver disease progress to chronic liver damage, such as
(NAFLD) is one of the most common hepatic cirrhosis of the liver and hepatocellular
disorders worldwide, which affects populations carcinoma (HCC)8 . Several agents have been
in both developed and developing countries1-3 proposed for the treatment of NAFLD,
.NAFLD is defined as evidence of hepatic however, no consensus on effective medical
steatosis without evidence of hepatocellular therapy has been established. Notwithstanding,
injury, and ranges from simple steatosis to non- although lifestyle modification is suggested as
alcoholic steatohepatitis (NASH), with or a first step in the management of NAFLD, its
without fibrosis4. The prevalence of NAFLD compliance is often low, and most patients fail
has proliferated in recent years, attributed to to follow recommended guidance9-11. For these
urbanization and changes in lifestyle, and has reasons, it is of contemporary interest and
thus become the third most likely cause of liver clinical importance that effective medical
[Link] a cohort study in the north treatments of NAFLD be established; to that
Iran, the prevalence of NAFLD was 44.2 % and end, several drugs such as metformin,
44.2 % and 40.1 % in women, and men gemfibrozil, UDCA, and melatonin have been
respectively6. Based on a study in the south of proposed as a potentially efficacious
Iran, the prevalence of NAFLD was 21.5 %7. treatments11-14.

‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Received in 27/11/2022 & Accepted in 23/1/2023

*Corresponding author: Fariborz Mansour-Ghanaei, E-mail: fmansourghanaei@[Link]

 Kourosh Mojtahedi, et al.

As insulin resistance plays an important Study participants

role in NAFLD pathogenesis15&16, agents that This study was a double-blinded
possess insulin resistive activity may be of randomized controlled trial in which 120
therapeutic value17. Metformin (1, 1- subjects aged 18-70 with NAFLD diagnosed
dimethylbiguanide hydrochloride), an agent of and mild to moderate steatosis were included.
the biguanide class, is an oral Subjects were recruited from the patients who
anti‐hyperglycemic agent that has, historically, had been referred to Razi hospital or
been used in patients with diabetes mellitus to gastrointestinal clinics, Guilan, Iran, between
decrease blood glucose levels18 .Moreover, it September 2015 and January 2016. NAFLD
acts as an insulin-sensitizing agent against was diagnosed and confirmed by (assessment
peripheral insulin resistance and reduces of transient elastography) fibroScan and
endogenous and exogenous insulin elevated levels of ALT serum concentrations.
requirements, as well as attenuating hepatic The sample size was calculated, a priori, using
glucose production19&20 Concomitant to insulin a type one error of (α) =0.05 and power =80%.
resistance, oxidative stress also plays a critical After considering 20% dropout, 30 subjects
were calculated as necessary for each group.
role in the onset and progress of NAFLD21. In
Patients were excluded if they had a history of
this regard, several antioxidant agents have
chronic disease, including cardiovascular
been suggested as viable in the treatment of
disease, pulmonary coronary disease,
NAFLD22 Melatonin (N-acetyl-5-
inflammatory systemic diseases, diabetes,
methoxytryptamine) is a serotonin-derived
metabolic syndrome or chronic kidney disease
neurohormone that is produced by the pineal
or hepatitis, alcohol consumption, cirrhosis,
gland, and has numerous biological functions23, hereditary hemochromatosis, Wilson’s disease
influencing the immune system, and possesses Cushing’s syndrome, antioxidant
free radicals scavenging, antioxidative, anti- supplementation, drug toxicity, and
inflammatory and anti-apoptotic properties24. gastrointestinal surgery, or were
Ursodeoxycholic acid is another agent which pregnant/lactating.
has been proposed for the treatment of
NAFLD, primarily due to its capability to Study design
decrease concentrations of hydrophobic bile First, all eligible participants, according to
acid in biliary and serum, reduce tumor inclusion and exclusion criteria, commenced a
necrosis factor-α levels, and suppress oxidative 2-weeks run-in period and were requested to
stress25-27. Several animal studies have complete a written informed consent. Next,
investigated the aforementioned medications subjects were randomly assigned into 4 groups
about NAFLD and reported promising findings. by block-randomization ([Link] ratio),
However, there is a distinct dearth of empirical adjusting for age, gender, and level of steatosis.
evidence from human studies. Therefore, the The randomization allocation sequence was
present study aimed to investigate and compare performed by a research assistant who was not
the effect of melatonin, metformin, and UDCA involved in the study, therefore, researchers
on NAFLD. were concealed to randomization and
allocation, as well as the participants, until
MATERIAL AND METHODS final analysis was completed. All participants
were instructed to self-administer metformin
The present study was performed based on (500 mg, twice a day)28, melatonin (10 mg,
the CONSORT statement recommendation and once a day)29&30, UDCA (300 mg, twice a
registered at IRCT (IRCT201407201155N21). day)31, or placebo along with a standardized
Also, the experimental protocol was abided by weight loss diet for 3-months. Drug therapies
the principles set out in the Declaration of and placeboes were pre-packaged and encoded
Helsinki. Also, the present study was approved by trained staff. The packages were
by Ethics Committee of Guilan University of indistinguishable, and blinding of researcher
Medical Sciences (1930231612). and participants were guaranteed. The weight
loss diet was (500 kcal less than individual
estimated energy requirement) specialized for

348
each patient and prescribed at the first of each processes and interpretation were performed by
month for the following month. Patients were a hepatologist who was masked to treatment
also asked not to take any supplements and not assignment.
to change their usual lifestyle. The subject’s
adherence was monitored by phone and Primary and secondary outcome
monthly face-to-face interviews, in addition to The primary outcome was a decrease in
assessments of un-consumed drugs. fibrosis and steatosis grade as well as
reductions in ALT, AST, and ALP serum
Anthropometric and biochemical concentration. Secondary outcome measures
measurements included changes in anthropometric, FPG,
Weight, height, and waist circumstances HbA1C, and lipid profile among participants.
were determined pre and post-intervention,
with the participant in a fasted status, with Statistical analysis
minimal clothes and unshod. The All analyses were performed using
measurements were performed by a trained Statistical Package for the Social Sciences
kinanthropometrist. (SPSS) software version 21. Kolmogorov-
A 10 mL overnight fasting blood sample Smirnov test was applied to verify the
was taken from each participant at baseline and normality of data distribution. To determine the
after 12-weeks to determine liver enzymes, difference between the 4 groups at baseline,
serum lipids, fasting plasma glucose (FPG), analysis of variance (ANOVA) was used. The
and HbA1C concentrations. All samples were mean change of each variable was calculated
stored at -70 C before analysis. To determine by subtracting the endpoint from baseline
the level of alanine aminotransferase (ALT), values. Descriptive data were analyzed in the
aspartate aminotransferase (AST), alkaline form of frequency and percentage for
phosphatase (ALP), triacylglycerol (TG), total qualitative variables and mean ± standard
cholesterol (TC), low-density lipoprotein deviation for quantitative variables. Analysis of
(LDL), high-density lipoprotein (HDL), FPG covariance (ANCOVA) was conducted to
and HbA1C, routine enzymatic assays were compare the change of variables. Furthermore,
applied by using commercially available kits the Chi-square test or Fisher Exact Test was
(Pars Azmoon, Tehran, Iran). also used for comparing categorical data
between groups. Statistical significance was
Histopathology defined as P < 0.05.
Liver stiffness was assessed by using
FibroScan (502 touch, Echosense, France)32, RESULTS AND DISCUSSION
while participants were in the supine position,
and the probe was placed on the right lobe of Results
liver in the intercostal position. The results of Our results showed that 120 NAFLD
the liver stiffness were presented as absent of patients were recruited and randomly divided
fibrosis (F0) and perisinusoidal or portal into one of four groups. There were no
fibrosis (F1), perisinusoidal and portal or incidences of drop-out, all participant’s data
periportal fibrosis (F2), septal and bridging was used for statistical analysis (Figure 1).
fibrosis (F3), and cirrhosis (F4). Cutoff levels The baseline demographic characteristics
of 7.1, 9.5, and 14.5 kPa were set as levels of each group are presented in Table 1. No
higher than F2, F3, and F4, respectively. significant difference was observed regarding
Furthermore, steatosis severity was evaluated age, anthropometric measures, lipid profile,
by controlled attenuation parameter method factors related to glycemic status, as well as
using the Fibroscan device. The steatosis was liver metabolic and pathological markers at the
determined according to the extent of fat in the beginning of the study. No serious adverse
liver as the absence of steatosis (S0); fat effects were observed or reported among
droplets in <33% hepatocytes (S1); fat droplets participants throughout the trial.
in 33-66% hepatocytes (S2) and fat droplets in
> 66% hepatocytes (S3). All screening

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 Kourosh Mojtahedi, et al.

Fig. 1: Participant’s flow diagram.

Table 1: General characteristics of NAFLD patients in 4 treatment groups.

Variables Melatonin Metformin Ursocholic Placebo P-value*
(N=30) (N=30) acid (N=30)
(N=30)
Age (year) 43.66±11.01 42.85±10.55 44.72±11.07 43.12±10.87 0.91
Sex (Male/Female) 12/18 11/19 12/18 12/18 0.93
Weight (Kg) 88.54±15.06 91.96±16.81 90.10±13.16 93.05±10.33 0.59
BMI 31.39±2.82 32.26±3.12 31.83±2.79 32.57±2.55 0.39
Waist circumstance (cm) 99.83±7.43 104.57±11.44 103.58±9.77 105.02±10.17 0.16
ALT (IU/L) 76.13±32.23 70.71±34.82 67.75±32.41 73.88±28.16 0.75
AST(IU/L) 47.10±27.69 44.67±25.04 42.44±24.63 38.11±24.31 0.57
ALP(IU/L) 79.26±18.36 87.31±25.83 89.62±37.40 87.46±32.08 0.53
Bilirubin Total (mg/dL) 0.90±0.24 0.95±0.32 0.96±0.27 0.95±0.30 0.84
Bilirubin Direct (mg/dL) 0.23±0.06 0.27±0.10 0.26±0.09 0.26±0.08 0.82
PTT 31.63±1.88 31.03±4.28 31.65±1.91 31.50±2.76 0.82
INR 1.07±0.07 1.05±0.05 1.06±0.06 1.05±0.06 0.52
Albumin (g/dL) 4.35±0.37 4.41±0.31 4.43±0.36 4.38±0.45 0.85
TG (mg/dl) 199.32±74.21 182.58±91.33 218.85±98.61 202.61±85.47 0.46
TC (mg/dl) 185.70±26.53 190.14±28.58 201.89±27.91 191.22±25.93 0.13
HDL (mg/dl) 40.03±5.83 38.78±5.71 37.86±4.98 39.91±5.63 0.38
LDL (mg/dl) 107.63±21.24 120.51±27.55 121.79±25.89 118.44±23.18 0.10
FPG (mg/dl) 97.26±28.60 100.85±27.82 96.01±26.00 95.31±33.89 0.88
HbA1C (%) 4.44±0.53 4.54±0.42 4.51±0.46 4.40±0.48 0.65
Steatosis score (CAP) 294.7±21.9 288.4±30.2 283.6±32.4 303.2±28.1 0.14
<33% (S1) 11 10 8 11 0.94**
33-66% (S2) 17 19 21 18
>66% (S3) 2 1 1 1
Fibrosis score (Kpa) 6.91±2.44 6.76±2.21 7.01±2.38 6.84±2.25 0.97
Absent 6 4 2 4 0.66**
Perisinusoidal/pericellular 16 18 20 17
Periportal 7 6 8 6
Bridging 1 2 - 3
Cirrhosis - - - -

Data are presented as mean ± SD; * P-Value was obtained from ANOVA. ** P-value was calculated by Chi-
square test.
Abbreviations: ALT: alanine aminotransferase; AST: aspartate aminotransferase; ALP: alkaline phosphatase;
TG: triacylglycerol; TC: total-cholesterol; LDL: Low-density lipoprotein; HDL: High-density lipoprotein;
FPG: Fasting plasma glucose; BMI: Body mass index.

350
 Primary outcomes The change in Fibrosis (melatonin: -0.86±1.39;
The result of present study demonstrated a metformin: -1.03±1.38; UDCA: -0.54±1.38;
significant improvement in the level of placebo: -0.52±1.34; P=0.39) or AST
steatosis (melatonin: -47.92±20.92; metformin: (melatonin: -14.40±23.59; metformin: -
-55.14±25.78; UDCA: -21.06±28.64; placebo: - 15.14±18.46; UDCA: -10.82±21.33; placebo: -
17.85±27.53; P=0.001), ALT (melatonin: - 8.66±17.37; P=0.57) levels was not significant
19.73±18.81; metformin: -25.96±19.97; between the 4 groups. Moreover, we did not
UDCA: -11.02±27.12; placebo: -10.50±18.02; detect any meaningful change in the
P=0.01) and ALP (melatonin: -17.83±13.02; aforementioned parameters after UDCA
metformin: -18.59±13.19; UDCA: -9.58±19.61; administration in comparison with the control
placebo: -9.13±17.93; P=0.03) among group (Figure 2 & Table 2).
metformin or melatonin participants in
comparison to the control or UDCA acid group.

Figure 2. The effect of melatonin on levels of steatosis and score of fibrosis among patients with
Fig. 2: NAFLD.
The effectData
of melatonin
expressedon
as levels
mean of steatosis
± SE. and score
* P-value <0.05of
in fibrosis
compare among patients with
to placebo.
NAFLD. Data expressed as mean ± SE. * P-value <0.05 in compare to placebo.

351
 Kourosh Mojtahedi, et al.

Table 2: Change from baseline to post 3 months treatment in anthropometrics, serum lipids, glycemic,
and liver biochemical parameters by treatment groups.
Variables Melatonin Metformin Ursocholic Placebo P-
acid value
ALT Pre 76.13±32.23 70.71±34.82 67.75±32.41 73.88±28.16
Post 56.40±30.66 44.75±31.93 56.73±30.78 63.38±29.81
Change -19.73±18.81 -25.96±19.97 -11.02±27.12 -10.50±18.02 0.01
AST Pre 47.10±27.69 44.67±25.04 42.44±24.63 38.11±24.31
Post 32.70±28.08 29.53±27.36 31.62±24.73 29.45±26.14
Change -14.40±23.59 -15.14±18.46 -10.82±21.33 -8.66±17.37 0.57
ALP Pre 79.26±18.36 87.31±25.83 89.62±37.40 87.46±32.08
Post 61.43±16.26 68.72±22.71 80.04±32.12 78.33±28.43
Change -17.83±13.02 -18.59±13.19 -9.58±19.61 -9.13±17.93 0.03
Weight Pre 88.54±15.06 91.96±16.81 90.10±13.16 93.05±10.33
Post 82.32±12.44 86.20±12.86 86.98±13.20 89.50±11.10
Change -6.23±4.27 -6.76±3.26 -3.12±3.90 -3.55±3.12 0.001
BMI Pre 31.39±2.82 32.26±3.12 31.83±2.79 32.57±2.55
Post 29.19±2.14 30.24±2.64 30.74±2.16 31.33±2.63
Change -2.20±1.09 -2.02±1.93 -1.09±1.11 -1.24±1.01 0.002
Waist Pre 99.83±7.43 104.57±8.44 103.58±9.77 105.02±10.17
circumstance
Post 97.13±6.30 101.56±8.63 102.17±8.69 106.22±9.02
Change -2.70±2.02 -3.00±2.48 -1.41±2.25 -1.2±2.11 0.002
TG Pre 199.32±74.21 182.58±91.33 218.85±98.61 202.61±85.47
Post 176.60±52.36 156.30±71.35 208.39±81.11 193.40±74.13
Change -22.72±17.63 -26.28±18.20 -10.46±21.72 -9.21±21.42 0.001
TC Pre 185.70±26.53 190.14±28.58 201.89±27.91 191.22±25.93
Post 162.59±25.76 165.65±26.18 165.65±28.6 173.03±24.82
Change -23.11±21.26 -24.49±23.21 -36.24±20.92 -18.19±22.21 0.01
HDL Pre 40.03±5.83 38.78±5.71 37.86±4.98 39.91±5.63
Post 39.91±5.69 39.80±5.47 38.48±5.20 41.11±4.98
Change -0.12±4.52 1.02±4.87 0.62±4.52 1.2±4.09 0.79
LDL Pre 107.63±21.24 120.50±27.55 121.79±25.89 118.44±23.18
Post 100.32±18.34 108.80±20.51 105.93±21.28 111.06±21.29
Change -7.31±13.25 -11.70±19.90 -15.86±17.25 -7.38±16.74 0.16
FPG Pre 97.26±28.60 100.85±27.82 96.01±26.00 95.31±33.89
Post 91.77±20.28 89.99±17.62 92.15±16.34 92.23±22.15
Change -5.49±10.25 -10.86±9.42 -3.85±10.77 -3.08±12.52 0.02
HbA1C Pre 4.44±0.53 4.54±0.42 4.51±0.46 4.40±0.48
Post 4.35±0.46 4.42±0.43 4.59±0.52 4.46±0.54
Change -0.09±0.44 -0.12±0.38 0.08±0.41 0.06±0.45 0.15
Data was presented as mean ± SD; P value was obtained by ANCOVA
adjusted for age, sex and baseline BMI.

352
Secondary outcomes therapy in NAFLD treatment. In concordance
Compared to the control group, a with the present study, several investigations
significant reduction in body weight have shown favorable effects following
(melatonin: -6.23±4.27; metformin: -6.76±3.26; metformin administration in improving
UDCA: -3.12±3.90; placebo: -3.55±3.12; NAFLD. Lin et al36 showed that metformin can
P=0.001), BMI (melatonin: -2.20±1.09; reduce hepatomegaly and hepatic steatosis, and
metformin: -2.02±1.93; UDCA: -1.09±1.11; reverse fatty liver disease in ob/ob mice. A 48-
placebo: -1.24±1.01; P=0.002), WC week clinical trial, in which 28 patients with
(melatonin: -2.70±2.02; metformin: -3.00±2.48; non-alcoholic steatohepatitis were treated with
UDCA: -1.41±2.25; placebo: -1.2±2.11; 2000 mg/day metformin, indicated an
P=0.002), TG (melatonin: -22.72±17.63; improvement in liver histology, decreases in
metformin: -26.28±18.20; UDCA: - ALT levels among 30% of patients. Also, an
10.46±21.72; placebo: -9.21±21.42; P=0.001) intervention consisting of metformin, plus
was observed in both metformin and melatonin dietary restriction of lipids and complex
groups. In addition, FPG concentrations carbohydrates, was compared with dietary
(melatonin: -5.49±10.25; metformin: - restrictions alone, and highlighted a
10.86±9.42; UDCA: -3.85±10.77; placebo: - preferential improvement in ALT levels,
3.08±12.52; P=0.02) was significantly decrease insulin resistance, and severity of
in metformin group in compared to control. We 37
steatohepatitis .
did not find a significant change in any Several mechanisms have been putatively
variable, except TC (melatonin: -23.11±21.26; suggested regarding the functionality of
metformin: -24.49±23.21; UDCA: - metformin. It seems that metformin can
36.24±20.92; placebo: -18.19±22.21; P=0.01), influence metabolism through activation of
following UDCA treatment when compared adenosine monophosphate (AMP)-activated
with the placebo group. No significant protein kinase in both the liver and muscles38.
difference was detected in HbA1C, TC, LDL The activation of AMP kinase acts to reduce
and HDL between all 4 groups (Table 2). lipogenesis and gluconeogenesis along with
enhancing glucose and fatty acid uptake by
Discussion hepatic and peripheral tissue, either directly or
The present study indicates that treatment indirectly through serine–threonine kinase
with metformin or melatonin, in addition to a known as LKB139. By improving insulin
low-caloric diet, for 3 months among NAFLD actions, metformin can also exhibit a weight-
patients may have a beneficial effect on hepatic lowering effect40&41. In a study conducted by
steatosis, ALT, ALP, TG, and weight loss, as
Loomba et al, patients following a metformin
compared with UDCA plus low-caloric diet or
treatment regimen reported that they could
low-caloric diet alone. In addition,
better control their appetite, as compared to no
administration of UDCA and metformin
treatment; the author further suggested that it
resulted in improved TC and FPG
might be due to fact that AMP kinase is also
concentrations, respectively. However, no
present in the hypothalamus and may regulate
significant difference was detected in liver
food intake, appetite, and satiety39.
fibrosis score, AST, HbA1C, LDL, and HDL
The results of the present studies indicated
between groups.
that administration of melatonin plus weight-
Attributed to the ever-increasing global
loss diet is efficacious in the treatment of
prevalence of diabetes, metabolic syndrome,
NAFLD. In line with our study, several animal
and obesity, the incidence of NAFLD is
and human study have reported the positive
inexorably rising33&34 NAFLD is well reported
influence of this agent. A study on mice with
to be an independent risk factor for fatal and
NAFLD, induced by high fat diet,
non-fatal cardiovascular disease events35, demonstrated that administration of melatonin
further demonstrating that NAFLD treatment for 12 weeks significantly reduces body
prevention remain a strong, the contemporary weight, FPG, ALT and, LDL. In addition, liver
focus for clinical care, globally. The present steatosis and inflammation markers in NAFLD
study demonstrated that metformin in addition mice was decreased after melatonin
to a low-caloric diet may be an efficacious treatment42. In a study conducted by Gonciarz

353
 Kourosh Mojtahedi, et al.

et al, patients with non-alcoholic steatohepatitis melatonin regulates body weight and improves
that followed a 24-week melatonin glucose hemostasis. However, it appears that
administration had significant attenuation in melatonin does not alter insulin sensitivity and
elevated liver enzymes43. Further, Celinski et al glucose metabolism, only acting when a
conducted a study in which patients with metabolic disturbance occurs45.
NAFLD consumed melatonin 10 mg/day for 14 The results of the present study did not
months; in this study, participants in the demonstrate any significant effect of UDCA on
melatonin group experienced a reduction in NAFLD in comparison with the control group.
pro-inflammatory cytokines and improvement Although a favorable impact of this agent has
in some parameters of fat metabolism. been shown on liver histology and functions by
However, no significant reduction in liver smaller open-label clinical studies58&59, a
enzymes was reported44. double-blinded trial with 2-years follow-up and
Although animal studies have shown that 166 participants did not find any significant
melatonin significantly attenuates weight gain improvement in liver histology or laboratory
and reduces body weight and visceral data by UDCA treatment at doses ranging from
adiposity45-47, clinical trials in humans have not 13 to 15 mg/kg60. Furthermore, high dose
indicated any change in anthropometric therapy with UDCA (23-28 mg/kg/day) on non-
measures manifest from melatonin alcoholic steatohepatitis for 18-months failed
48&49 to improve overall histology and laboratory
administration . The maximum dosage of
melatonin which has been investigated on data, except gamma-glutamyl transferase61. In
weight loss in human studies is 6 mg/day50; this case, is apparent that ursodeoxycholic acid
however, this amount of melatonin is small in should not be prioritised in the treatment of
comparison with those used in animal models NAFLD, in comparison with other options.
(4-10 mg/kg body weight)45-47. In the present study, no serious adverse
The exact hepatoprotective mechanism of effects related to the intervention groups were
melatonin is not well-understood; tentatively, it observed among participants. However,
has been suggested that the main role of antecedents evidence has demonstrated some
melatonin in NAFLD treatment is attributable undesirable effects attributed to drug
to decreases in oxidative stress, which is one of administration, and, thus, should be considered
the main pathophysiological mechanisms of when prescribed in clinical practice. Common
NAFLD51. It has been suggested that melatonin adverse effects among patients with metformin
can decrease oxidative stress by improving treatment is gastrointestinal complaints such as
SOD and GSH-Px activities, and can improve diarrhea, nausea, and abdominal cramping, in
hepatic steatosis, inflammation and elevated addition to lactic acidosis62&63. Furthermore, a
liver enzymes51&52. On the other hand, obesity mild vitamin B12 malabsorbtion might occur
and insulin resistance are considered to be among patients with long-term metformin
important risk factors in the onset and treatment64. Human and animal studies have
development of NAFLD. Contemporary documented that melatonin is generally safe
evidence suggests that melatonin has a role in during short-term intake and only mild
body weight, and metabolism regulation53. unfavorable side effects, including; headache,
Melatonin can regulate the metabolism of dizziness, nausea, and sleepiness have been
carbohydrates and retain brown adipocytes, as reported65. Furthermore, clinical studies have
well as elevate its metabolic activity54. shown the long-term use of melatonin also
Melatonin has receptors (MT1 and MT2) in the causes only mild adverse-effects65&66.
islets of Langerhans which indicates the insulin Although empirical evidence has indicated
production and secretion partially controlled by exogenous melatonin can be considered as a
melatonin55. Studies have suggested that safe agent, there is a dearth of evidence on
melatonin administration may lead to interactions with breast-feeding and pregnancy,
suppression in insulin secretion and enhance and thus should be carefully considered67&68.
insulin sensitivity in the peripheral tissue56 and Several rare reactions resulting from
central nervous system57; moreover, these ursodeoxycholic acid intake including diarrhea,
effects on metabolism could explain why decompensation of liver cirrhosis in end‐stage
primary biliary cirrhosis case, and recurrent

354
right upper quadrant abdominal pain has been Funding
reported in small subsets of patients69-71. The This study was supported by the
ursodeoxycholic acid absorption has an Gastrointestinal and Liver diseases Research
interaction with ciclosporin, nitrendipine, Center of Guilan University of Medical
dapsone, and cytochrome P4503A substrates, Sciences.
and its absorption is reduced by concurrent
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