Digoxin for NASH with stage 2–3 fibrosis

Clinical Trial of Oral Digoxin In NASH (CODIN)

This trial will see if taking once-daily digoxin helps clear NASH and reduce liver scarring in adults with biopsy-confirmed NASH and stage 2–3 fibrosis.

Quick facts

• Phase: PHASE2
• Study type: Interventional
• Enrollment: 144 (estimated)
• Ages: 18 Years to 75 Years
• Sex: All
• Sponsor: Yale University (other)
• Drugs / interventions: methotrexate
• Locations: 2 sites (New Haven, Connecticut and 1 other locations)
• Trial ID: NCT06588699 on ClinicalTrials.gov

What this trial studies

This single-center, randomized, double-blind, placebo-controlled Phase 2 trial at Yale compares once-daily oral digoxin (given by titration-based or weight-based dosing) to placebo in adults with biopsy-proven NASH and fibrosis stage 2–3. Participants will have a baseline liver biopsy if needed and a repeat biopsy at 24 weeks to measure histologic resolution of NASH, along with imaging and blood biomarker assessments. Safety and tolerability, including monitoring for cardiac effects of digoxin, will be followed throughout the study. The primary outcome is histologic resolution of NASH, with secondary endpoints covering imaging, biochemical changes, and adverse events.

Who should consider this trial

Good fit: Adults with biopsy-confirmed NASH (NAS ≥4 with each component ≥1), histologic fibrosis stage 2 or 3, stable weight, and willingness to undergo liver biopsies and site follow-up are ideal candidates.

Not a fit: Patients with cirrhosis, other chronic liver diseases, recent positive hepatitis markers, inability to undergo biopsy, or contraindications to digoxin are unlikely to benefit from this trial.

Why it matters

Potential benefit: If successful, digoxin could offer a repurposed, widely available oral option to reduce liver inflammation and scarring in people with NASH.

How similar studies have performed: Preclinical studies and some observational data indicate digoxin can protect the liver, but randomized clinical evidence in NASH is limited, so this repurposing approach remains relatively novel.

Eligibility criteria

Inclusion Criteria

* Stable body weight (≤ 5% self-reported change in body weight) in the 30 days prior to screening
* Biopsy-confirmed non-alcoholic steatohepatitis (NASH) as defined by the NASH clinical research network (NASH CRN) histological scoring system, with non-alcoholic fatty liver disease score (NAS) ≥4 and with a score ≥1 for each of the three components (steatosis, hepatocellular ballooning, and lobular inflammation) on a liver biopsy performed within 6 months of screening
* Histological fibrosis stage 2 or 3 based on pathologist evaluation of a liver biopsy performed up to 6 months before screening
* Agrees to have a liver biopsy performed to assess baseline histology if one has not been performed up to 6 months before screening, and at 24 weeks after randomization Exclusion Criteria

Liver-related:

* Documented causes of chronic liver disease other than NASH
* History or clinical evidence of cirrhosis or portal hypertension
* History of positive HBsAg, positive anti-HIV, positive HCV-RNA
* AST or ALT \> 5 times upper limit of normal (ULN) at screening
* Total bilirubin \> 1.5 mg/dL at screening unless conjugated bilirubin is \< 1.5 × ULN
* International normalized ratio (INR) \> 1.3 at screening
* Known or suspected alcohol use \> 20 g/day for women or \> 30 g/day for men
* Treatment initiation or dose adjustment of vitamin E, pioglitazone, GLP-1RA, or SGLT-2 inhibitors within 30 days of signing the informed consent or 30 days prior to liver biopsy
* Treatment initiation or anticipated treatment (\>14 consecutive days) with medications known to affect steatosis (e.g., systemic corticosteroids, tamoxifen, valproic acid, methotrexate, tetracycline or amiodarone) within 30 days of signing the informed consent or 30 days prior to liver biopsy

Cardiac related:

* Heart rate less than 60 bpm at screening (visit 1) or at baseline (visit 2)
* Current diagnosis of severe aortic valve disease
* History of Accessory arterio-ventricular pathway (e.g., Wolf-Parkinson-White syndrome)
* History of complete heart block or second degree arterio-ventricular block without pacemaker or implantable cardiac device
* Current diagnosis of permanent atrial fibrillation
* Any of the following within the previous 6 months of signing informed consent: myocardial infarction, percutaneous intervention, pacemaker/implantable cardiac device implantation, cardiac surgery, or stroke
* Current use of the following medications: inotropic drugs such as (dopamine, dobutamine, noradrenaline, milrinone), anti-arrhythmics (amiodarone, dofetilide, sotalol, dronedarone, digoxin), parathyroid hormone analog (teriparatide), sympathomimetics (epinephrine, norepinephrine, dopamine), neuromuscular blocking agents (succinylcholine), calcium supplement, nondihydropyridine calcium channel blockers, ivabradine, and disulfiram.

Obesity related:

* Treatment initiation (in the 30 days prior to signing the informed consent or 30 days prior to liver biopsy) with orlistat, zonisamide, topiramate, phentermine, bupropion, and naltrexone alone or in combination or any other medication that could promote weight loss in the opinion of the investigator
* Participation (in the 30 days prior to signing the informed consent or 30 days prior to liver biopsy) in an organized diet-based weight reduction program (e.g., WeightWatchers, Optifast)
* Recent surgical treatment (\<6 months of signing informed consent) for obesity

General safety related:

* Presence or history of malignant neoplasms (in the past 5 years prior to screening), except basal and squamous cell skin cancer and any carcinoma in-situ
* Surgery scheduled or anticipated during the trial period, except for minor surgical procedures, in the opinion of the investigator
* Language barrier, mental incapacity, unwillingness, or inability to adequately understand or comply with study procedures
* Known or suspected hypersensitivity to the trial product or related products including allergy to milk, egg, soy, peanuts, and sulfites
* Recent participation (within 90 days prior to signing the informed consent) in any clinical trial of an approved or non-approved investigational medicinal product
* Female who is pregnant, breast-feeding or intends to become pregnant or is of childbearing potential and not using an adequate contraceptive method
* Renal impairment measured as estimated Glomerular Filtration Rate (eGFR) value of eGFR \< 30 ml/min/1.73 m2
* TSH \> 6 mIU/L or \< 0.4 mIU/L at screening
* Current use of the following medications: calcium supplementation, parathyroid hormone analog (teriparatide), neuromuscular blocking agents (succinylcholine) and disulfiram.
* Claustrophobia to an extent that would prevent tolerance of MRI
* Metallic implant that would prevent MRI examination including, metallic foreign body, aneurysm clips, vascular grafts or cardiac implants, neural stimulator, cochlear implant, metallic contraceptive device, body piercing that cannot be removed, cochlear implant, or any other contraindication to MRI

Where this trial is running

New Haven, Connecticut and 1 other locations

• Yale New Haven Health — New Haven, Connecticut, United States (RECRUITING)
• Yale New Haven Hospital — New Haven, Connecticut, United States (RECRUITING)

Study contacts

• Principal investigator: Bubu A Banini, MD, PhD — Yale University
• Study coordinator: Bubu Banini, MD, PhD

Conditions: NASH, NAFLD, MASH - Metabolic Dysfunction-Associated Steatohepatitis, Mash, MASH With Fibrosis, MASLD, Fatty Liver Disease, Fatty Liver Disease, Nonalcoholic