A pilot study of vitamin E versus vitamin E and pioglitazone for the treatment of nonalcoholic steatohepatitis

Clin Gastroenterol Hepatol. 2004 Dec;2(12):1107-15. doi: 10.1016/s1542-3565(04)00457-4.


Background & aims: Insulin resistance and oxidative stress contribute to the pathogenesis of nonalcoholic steatohepatitis (NASH). We conducted a pilot study for the following reasons: (1) to test the hypothesis that a combination of an antioxidant (vitamin E) and an insulin sensitizer (pioglitazone) would be superior to vitamin E alone for the treatment of NASH, and (2) to define the effects of these interventions on insulin-sensitive metabolic functions and correlate the effects with changes in liver histology.

Methods: A randomized prospective trial was performed to compare the efficacy and safety of vitamin E alone (400 IU/day) vs. vitamin E (400 IU/day) and pioglitazone (30 mg/day) in nondiabetic, noncirrhotic subjects with NASH. Metabolic functions were assessed by a 2-step, hyperinsulinemic (10 and 40 mU/m2/min) euglycemic clamp.

Results: A total of 10 patients were randomized to each arm. Two patients on combination therapy discontinued treatment; one because of pregnancy and the other because of hepatotoxicity. Treatment with vitamin E only produced a significant decrease in steatosis (mean grade, 2.2 vs. 1.4; P < .02). Compared with baseline, combination therapy produced a significant decrease in steatosis (mean, 2.3 vs. 1; P < .002), cytologic ballooning (1.3 vs. 0.2; P < .01), Mallory's hyaline (0.7 vs. 0.2; P < .04), and pericellular fibrosis (1.2 vs. 0.6; P < .03). Although vitamin E had no significant effects, combination therapy produced a significant increase in metabolic clearance of glucose and a decrease in fasting free fatty acid (FFA) and insulin. The decrease in fasting FFA and insulin independently predicted improvement in hepatic steatosis and cytologic ballooning.

Conclusions: A combination of vitamin E and pioglitazone produces a greater improvement in NASH histology. The improvement in steatosis and cytologic ballooning are related to treatment-associated decreases in fasting FFA and insulin levels.

Publication types

  • Clinical Trial
  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • 3-Hydroxybutyric Acid / analysis
  • Alanine Transaminase / analysis
  • Antioxidants / therapeutic use*
  • Drug Therapy, Combination
  • Fatty Acids, Nonesterified / metabolism
  • Fatty Liver / drug therapy*
  • Fatty Liver / metabolism
  • Fatty Liver / pathology
  • Female
  • Glucose / metabolism
  • Humans
  • Hypoglycemic Agents / therapeutic use*
  • Insulin / metabolism
  • Insulin Resistance / physiology
  • Logistic Models
  • Male
  • Middle Aged
  • Pilot Projects
  • Pioglitazone
  • Prospective Studies
  • Thiazolidinediones / therapeutic use*
  • Treatment Outcome
  • Vitamin E / therapeutic use*


  • Antioxidants
  • Fatty Acids, Nonesterified
  • Hypoglycemic Agents
  • Insulin
  • Thiazolidinediones
  • Vitamin E
  • Alanine Transaminase
  • Glucose
  • 3-Hydroxybutyric Acid
  • Pioglitazone