I just returned from the EASL meeting in Vienna. It is one of the two most important gatherings of liver researchers and industry conferences focused on liver disease. For many years this was a modest affair. There have always been plenty of ways for the liver to be harmed but there was not much that could be done so, like the liver, the event cooked along in the background. When the cures for Hep C and HIV were developed everything changed. When it became clear that liver disease could be cured and that something could be done about the very large disease load peculating through our generations the spotlight turned squarely toward liver function.
Our epidemiological studies have, for years, been showing the burden of disease building in society with our steadily advancing obesity and comorbid problems. Most of the attention has been focused on diabetes, cancer, and heart disease because we had ways to at least try to deal with these health threats. The liver, which is a comorbid participant in a wide variety of diseases, was largely ignored because there was nothing medicine could do about the typical liver diseases of NAFLD and NASH. Even though a stage 4 NASH is 7 times more likely to kill you than diabetes, it remained mostly out of sight because of its lack of symptoms.
However, today the times they are achangin!
EASL 2019 showcased the opening act in what will eventually become real therapy for NAFLD and NASH. Intercept released the results of its phase 3 trial of obetacholic acid which became the first drug to show enough benefit to warrant consideration for approval by the FDA.
This is a very big step as the first drug with an ability to reduce disease enough to be considered as therapy, but it is important to understand what that means. It is not a cure for our disease. It provides a modest benefit and does have some possible side effects, like increased itching for some that are a challenge, but it proves that the complex chemistry of the liver can be treated. By killing the historical advice of "you have cirrhosis and I'm sorry but we have no treatment", we create instead the affirmative of let's see if we have something that can help. The hopelessness of a cirrhosis diagnosis can just die now.
That is the best side of this coin. The hard part is that we still have a very long way to go. This is one small step to actually being able to deal with the reality of fibrotic liver disease. We should be greatly encouraged because many other drugs are being tested and with this proof in hand we can be confident that very useful therapies will develop that have far more effective results. We must not assume that it will be a short journey, however, and our hope must be tempered by that reality.
This truly is the dawning of a new day for liver patients, but our road ahead is still a long one. The singular result of the EASL meeting is the message that help is on the way but the rescue party carries a heavy burden and the path for them is difficult. Many of the rescuers will be lost or take a wrong road and fail in the end, but we do know that a proper path exists. As we wait, the mantra must for now and always be lifestyle and exercise. Treat yourself kindly and always remember that food is medicine.
More broadly, EASL was a tour de force of the spectacular science being done on our behalf. The amount and the quality of research that is being deployed to deal with liver disease is really quite amazing. The liver does an estimated 500 jobs simultaneously and I believe there are researchers who are working to understand every nuance, every jot and tittle, of what makes the liver the indispensable leader of the biochemistry that allows us to think of ourselves as independent beings.
When I think about how miraculous we are and how amazing it is that we can be alive at all, I like to remember our family tree and how this complexity came to be. When the first single cell life began to join together as cooperative groups, they found great advantage in the ability to find food and the associations grew more and more complex. Metabolism, the processing of food into energy, always has by products that are harmful. Beyond some critical size a developing organism requires a way to manage those toxins. This was the birth of the liver and it remains today the most important organ allowing the complex creatures that we are to actually function over time. So as you think about your food as medicine remember that fundamentally you are the oddly shaped transport mechanism that your bowels, supported by its liver, built to find food for itself. So best to do a good job of finding that food.
