Cited by 2,039Liver Disease Diagnosis and TreatmentDiabetes Treatment and ManagementLiver physiology and pathology

A Placebo-controlled trial of subcutaneous semaglutide in nonalcoholic steatohepatitis

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Newsome, Philip N., Buchholtz, Kristine, Cusi, Kenneth, Linder, Martin, Okanoue, Takeshi, Ratziu, Vlad, Sanyal, Arun J., Sejling, Anne-Sophie +1 more·2021·New England Journal of Medicine

Abstract

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is a common disease that is associated with increased morbidity and mortality, but treatment options are limited. The efficacy and safety of the glucagon-like peptide-1 receptor agonist semaglutide in patients with NASH is not known. METHODS: We conducted a 72-week, double-blind phase 2 trial involving patients with biopsy-confirmed NASH and liver fibrosis of stage F1, F2, or F3. Patients were randomly assigned, in a 3:3:3:1:1:1 ratio, to receive once-daily subcutaneous semaglutide at a dose of 0.1, 0.2, or 0.4 mg or corresponding placebo. The primary end point was resolution of NASH with no worsening of fibrosis. The confirmatory secondary end point was an improvement of at least one fibrosis stage with no worsening of NASH. The analyses of these end points were performed only in patients with stage F2 or F3 fibrosis; other analyses were performed in all the patients. RESULTS: In total, 320 patients (of whom 230 had stage F2 or F3 fibrosis) were randomly assigned to receive semaglutide at a dose of 0.1 mg (80 patients), 0.2 mg (78 patients), or 0.4 mg (82 patients) or to receive placebo (80 patients). The percentage of patients in whom NASH resolution was achieved with no worsening of fibrosis was 40% in the 0.1-mg group, 36% in the 0.2-mg group, 59% in the 0.4-mg group, and 17% in the placebo group (P<0.001 for semaglutide 0.4 mg vs. placebo). An improvement in fibrosis stage occurred in 43% of the patients in the 0.4-mg group and in 33% of the patients in the placebo group (P = 0.48). The mean percent weight loss was 13% in the 0.4-mg group and 1% in the placebo group. The incidence of nausea, constipation, and vomiting was higher in the 0.4-mg group than in the placebo group (nausea, 42% vs. 11%; constipation, 22% vs. 12%; and vomiting, 15% vs. 2%). Malignant neoplasms were reported in 3 patients who received semaglutide (1%) and in no patients who received placebo. Overall, neoplasms (benign, malignant, or unspecified) were reported in 15% of the patients in the semaglutide groups and in 8% in the placebo group; no pattern of occurrence in specific organs was observed. CONCLUSIONS: This phase 2 trial involving patients with NASH showed that treatment with semaglutide resulted in a significantly higher percentage of patients with NASH resolution than placebo. However, the trial did not show a significant between-group difference in the percentage of patients with an improvement in fibrosis stage. (Funded by Novo Nordisk; ClinicalTrials.gov number, NCT02970942.).

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Crossref · 10.1056/nejmoa2028395

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  • GLP-1 RAs are indicated for the treatment of type 2 diabetes (all) and obesity (liraglutide and semaglutide only) and have beneficial effects on patient-important outcomes such as weight loss, cardiovascular and kidney events, hepatic steatosis, and mortality.

    “Clinically, GLP-1 RAs are indicated for the treatment of type 2 diabetes (all) and obesity (liraglutide and semaglutide only) and have beneficial effects on patient-important outcomes such as weight loss, cardiovascular and kidney events, hepatic steatosis, and mortality.5,7–9,11,30”

    From Glucagon-Like Peptide-1 Receptor Agonists and Thyroid Cancer: A Narrative Review (2024) · cites this paper as [30]

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  • In studies of liraglutide, semaglutide, and tirzepatide for MASLD, the primary outcome was resolution of fatty liver disease without worsening of fibrosis, and significant improvements were noted.

    “The primary outcome for all three studies was resolution of fatty liver disease without worsening of fibrosis, and significant improvements were noted.”

    From GLP-1 receptor agonists and next-generation incretin-based medications: metabolic, cardiovascular, and renal benefits (2026) · cites this paper as [82]

    The Efficacy section (p. 5) identifies NASH resolution without worsening of fibrosis as this semaglutide trial’s primary end point and reports a significant improvement versus placebo. This paper does not establish that the liraglutide and tirzepatide studies had the same primary outcome or significant results. Its Results (p. 2) also distinguish the significant NASH-resolution result from the nonsignificant improvement in fibrosis stage. (LLM, conf=0.87)

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  • A 2020 clinical trial involving patients with nonalcoholic steatohepatitis revealed a 15% incidence of tumors (benign, malignant, or unspecified) (35/239) among those administered semaglutide, compared to 8% (6/80) in the control group.

    “Notably, a 2020 clinical trial involving patients with nonalcoholic steatohepatitis (NASH) revealed a 15% incidence of tumors (benign, malignant, or unspecified) (35/239) among those administered semaglutide, compared to 8% (6/80) in the control group [108].”

    From Exploring the Side Effects of GLP-1 Receptor Agonist: To Ensure Its Optimal Positioning (2025) · cites this paper as [108]

    The Safety section (p. 8) reports 35 neoplasms across the semaglutide groups (15%) and 6 in the placebo group (8%); the adverse-events table (p. 10) gives denominators of 239 and 80, respectively. The year is inaccurate: the publication is dated 2021 (p. 1), and the Patients section (p. 5) says enrollment occurred in 2017–2018, not 2020. (LLM, conf=0.88)

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  • In the same 72-week phase 2 RCT, fibrosis improvement with semaglutide (43% vs 33%) did not reach significance.

    “Fibrosis improvement (43% vs. 33%) did not reach significance, likely due to study duration.”

    From Precision obesity medicine: A phenotype-guided framework for pharmacologic therapy across the lifespan (2025) · cites this paper as [54]

    The Efficacy section (p. 5) reports fibrosis improvement in 43% of the semaglutide 0.4-mg group versus 33% of the placebo group after 72 weeks, a nonsignificant difference (P=0.48). The Discussion (p. 11) says insufficient study duration was possible, but also identifies inadequate statistical power as a possible explanation; it does not establish duration as the likely cause. (LLM, conf=0.86)

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  • In a 72-week phase 2 RCT of 1197 participants with biopsy-confirmed MASH and F2-F3 fibrosis, semaglutide 0.4 mg/day achieved significant MASH resolution in 59% vs 17% with placebo.

    “In a 72-week phase 2 RCT of 1197 participants with biopsy-confirmed MASH and F2–F3 fibrosis, semaglutide 0.4 mg/day achieved a significant MASH resolution in 59% vs. 17% with placebo [54].”

    From Precision obesity medicine: A phenotype-guided framework for pharmacologic therapy across the lifespan (2025) · cites this paper as [54]

    The Efficacy section (p. 5) reports significantly greater NASH resolution without worsening of fibrosis at 72 weeks with semaglutide 0.4 mg daily than with placebo (59% vs. 17%) among patients with F2–F3 fibrosis. However, the Results (p. 2) report 320 randomized participants, not 1197, and the Methods (p. 2) state that the trial also enrolled patients with F1 fibrosis; the F2–F3 restriction applied to the primary-endpoint analysis. (LLM, conf=0.90)

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Authors
Newsome, P. N., Buchholtz, K., Cusi, K., Linder, M., Okanoue, T., Ratziu, V., Sanyal, A. J., Sejling, A.-S., & Harrison, S. A.
Affiliations
University Hospitals Birmingham NHS Foundation Trust (GB)
Venue
New England Journal of Medicine
Published
2021-03-25
Volume
384
Issue
12
Pages
1113-1124
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
OpenAlex
W3102426258
Cited by
2,039
References
28
Citations by year
2026: 352 · 2025: 458 · 2024: 417 · 2023: 334 · 2022: 264 · 2021: 205 · 2020: 7 · 2014: 1
FWCI
145.04
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • HAL (submittedVersion)
  • Ghent University Academic Bibliography (Ghent University) (submittedVersion)
  • University of Birmingham Research Portal (University of Birmingham) (submittedVersion, other-oa)
Funders
Novo Nordisk A/S
Topics
  • Health Sciences › Medicine › Epidemiology › Liver Disease Diagnosis and Treatment
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Medicine › Hepatology › Liver physiology and pathology
Keywords
nonalcoholic steatohepatitis, semaglutide, GLP-1 receptor agonists, liver fibrosis, NASH resolution, weight loss, adverse events, nausea, constipation, vomiting, dose comparison, obesity-related liver disease, drug safety and efficacy, GIP/GLP-1 receptor agonist
MeSH terms
Semaglutide, Adolescent, Adult, Aged, Amylases, Biopsy, Diabetes Mellitus, Type 2, Dose-Response Relationship, Drug, Double-Blind Method, Glucagon-Like Peptides, Female, Humans, Injections, Subcutaneous, Lipase, Liver, Liver Cirrhosis, Male, Middle Aged, Young Adult, Non-alcoholic Fatty Liver Disease

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