SAMe for Prevention of Liver Cancer in MASLD-Related Cirrhosis

Patients with MASLD cirrhosis are at risk for progressive liver dysfunction and liver-related complications, and additional treatment strategies are needed. SAMe is a biologically relevant methyl donor with potential effects on liver metabolism, inflammation, and cellular injury pathways. In this study, eligible patients will be assigned to receive SAMe or placebo according to the study protocol. Investigators will evaluate safety, tolerability, study adherence, and changes in prespecified clinical and laboratory outcomes over the treatment period. Results from this study are intended to support the design of future trials and to clarify the potential role of SAMe in patients with MASLD cirrhosis.

• S-adenosyl-L-methionine (SAMe) (Drug): Oral S-adenosyl-L-methionine (SAMe) administered at 1,200 mg/day in two divided doses for 12 months. Each tablet provides 400 mg of SAMe (from 800 mg SAMe tosylate disulfate). Participants are instructed to take 2 tablets in the morning before breakfast and 1 tablet in the evening before dinner, approximately 30 minutes before meals.
• Placabo (Other): Matching placebo tablets for oral administration, administered on the same schedule as active SAMe for 12 months. Participants are instructed to take 2 tablets in the morning before breakfast and 1 tablet in the evening before dinner, approximately 30 minutes before meals. Placebo tablets are identical or similar to active SAMe tablets in size, color, shape, taste, and odor/appearance to maintain blinding.

Primary outcomes

• Change in Prognostic Liver Secretome signature (PLSec) score [Baseline to Month 12]: Prognostic Liver Secretome signature (PLSec) is a continuous serum biomarker score used to assess hepatocellular carcinoma risk. Higher PLSec scores indicate higher hepatocellular carcinoma risk, and lower PLSec scores indicate lower hepatocellular carcinoma risk. The primary analysis compares change from baseline to Month 12 between the SAMe and placebo groups. The protocol does not specify a fixed theoretical minimum or maximum PLSec score.

Secondary outcomes

• Incidence of adverse events and serious adverse events [Day 0 through 30 days after the last dose of study intervention]: Safety and tolerability of SAMe will be assessed by collection of adverse events and serious adverse events, graded and monitored per protocol and NCI CTCAE version 5.0.

Other outcomes

• Change in tumor-promoting extracellular vesicle microRNA levels [Baseline, Month 6, and Month 12]: Quantitative PCR assessment of tumor-promoting EV miRNAs in serum samples.
• Change in Fibrosis-4 (FIB-4) index [Baseline, Month 6, and Month 12]: Fibrosis-4 (FIB-4) index is a calculated score derived from routine clinical laboratory data and is used to assess the likelihood of liver fibrosis. Higher FIB-4 values indicate worse fibrosis risk. The protocol specifies assessment at baseline, Month 6, and Month 12. The protocol does not specify a fixed theoretical minimum or maximum value for FIB-4.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

1. individuals 18 years old or above.
2. Understand the study procedures and able to provide informed consent.
3. Clinical diagnosis of MASLD per American Association for the Study of Liver Diseases (AASLD) guideline: Patients with hepatic steatosis identified by imaging or biopsy, AND have at least one of five cardiometabolic risk factors:

   (i) BMI ≥25 kg/m2 (23 kg/m2 for Asian) OR waist circumference >94 cm for male or >80 cm for female.

   (ii) Fasting serum glucose ≥5.6 mmol/L (100 mg/dL) OR 2-hour post-load glucose levels ≥7.8 mmol/L (140 mg/dL) OR HbA1c ≥5.7% (39 mg/dL) OR type 2 diabetes OR treatment for type 2 diabetes (iii) Blood pressure ≥130/85 mmHg OR specific antihypertensive drug treatment. (iv) Plasma triglycerides ≥1.7 mmol/L (150 mg/dL) OR lipid lowering treatment (v) Plasma HDL-cholesterol ≤1.0 mmol/L (40 mg/dL) for male or ≤1.3 mmol/L (50 mg/dL) for female OR lipid lowering treatment.
4. Current weekly intake of alcohol <210 g (7.41 oz) for male or weekly intake of alcohol <140 g (4.76 oz) for female, \[1 oz/30 mL of alcohol is present in one 12 oz/360 mL beer, 4 oz/120 mL glass of wine, and a 1oz/30 mL measure of 40 proof (20%) alcohol\]
5. Diagnosis of cirrhosis confirmed via histopathology OR at least two of the following measures:

   (i) Transient elastography (FibroScan® ≥ 12 kPa) (ii) Computed tomography (iii) MRI including MR elastography (stiffness ≥ 4.71 kPa) (iv) Abdominal Ultrasound
6. Patient had imaging for HCC screening (Ultrasound or MRI or CT) within 3 months prior to screening.

Exclusion Criteria:

1. Confirmed diagnosis of HCC prior to screening, any suspicious nodules identified prior or during screening must be followed with documentation of HCC negative confirmed prior to randomization.
2. History of other causes of liver disease, including but not limited to alcoholic liver disease, hepatitis B, hepatitis C, autoimmune disorders (primary biliary cholangitis, primary sclerosing cholangitis, or autoimmune hepatitis), drug-induced hepatotoxicity, Wilson's disease, iron overload, or alpha-1-antitrypsin deficiency.
3. Most recent serum creatinine >1.5 mg/dl within 3 months prior to screening.
4. Active infection with positive urine culture, blood culture, or pneumonia at screening.
5. History of gastrointestinal bleeding within the prior 28 days
6. History of liver transplantation.
7. Women who are pregnant or nursing at screening.
8. Significant systemic illness including chronic obstructive pulmonary disease, congestive heart failure, and renal failure that in the opinion of the investigator would preclude the patient from participating in the study or poses a significant risk of mortality during the study period, such as conditions that are interfering with the absorption, distribution, metabolism, or excretion of S-adenosyl-L-methionine (SAMe) such as those with gastric bypass surgery.
9. HIV infection or patients who are immunocompromised.
10. Participation in another investigational drug, biologic, or medical device trial within 30 days prior to screening.
11. Systemic antibiotic use or use of rifaximin for 10 days or more within the last 2 months prior to screening.
12. Actively taking investigational or over-the-counter SAMe within 28 days prior to screening.
13. Subjects with psychiatric illnesses such as bipolar disorders and Parkinson's disease as SAMe may interfere with the levels of anti-psychotic drugs and might interact with drugs and dietary supplements that increase levels of serotonin (a chemical produced by nerve cells), such as antidepressants, L-tryptophan, and St. John's wort.
14. Members from the same family of study participant.