Effect of alpha-lipoic acid and Silybum marianum supplementation with a Mediterranean diet on metabolic dysfunction-associated steatosis

Abstract

BACKGROUND

The treatment of metabolic dysfunction-associated steatotic liver disease (MASLD) has focused on the control of comorbidities. Silybum marianum (SM) and alpha-lipoic acid (ALA) have shown antioxidant and adjuvant effects on the control of metabolic disorders.

AIM

To evaluate whether the SM-ALA formulation (LUDLEV^®), in combination with the Mediterranean diet (MD), could improve MASLD-related liver injury.

METHODS

A randomized, double-blind clinical trial was conducted on patients with MASLD. Administration of SM-ALA plus MD (group A) vs placebo plus MD (group B) was compared for 24 weeks. At baseline and weeks 12 and 24, anthropometric measurements, metabolic parameters, and liver function were analyzed. Clinical effectiveness was evaluated through transient elastography.

RESULTS

Fifty patients aged 54 ± 10 years were included, and the majority (74%) were female. Reduced visceral fat and umbilical circumference were reported in both groups, with significance in group A (P = 0.045 and 0.003, respectively). The decrease in controlled attenuation parameter was gradual and maintained at 12 and 24 weeks in group A (P = 0.026), whereas in group B the decrease was greater at week 12 and remained unchanged at week 24 (^∆controlled attenuation parameter: -27 dB/m). Mild adverse effects were reported in 4 patients in group A (16%) and 4 patients in group B (16%), with no significant differences between groups (P = 0.641).

CONCLUSION

SM-ALA (LUDLEV^®) combined with the MD can promote the improvement of metabolic parameters, reducing visceral fat and hepatic steatosis in Mexican patients with MASLD.

Key Words: Steatotic liver disease; Silybum marianum; Alpha-lipoic acid; Mediterranean diet; Fatty liver

Core Tip: Administration of Silybum marianum and alpha-lipoic acid in conjunction with a Mediterranean-style diet demonstrated a decrease in hepatic steatosis as measured by controlled attenuation parameter, improved biochemical parameters, and a reduction in the percentage of visceral fat. In addition to these metabolic benefits, the combination of Silybum marianum and alpha-lipoic acid is considered safe and well-tolerated.

INTRODUCTION

Fatty liver associated with metabolic dysfunction, now called metabolic dysfunction-associated steatotic liver disease (MASLD) by international consensus, is currently the most frequent chronic liver disease worldwide. Presenting in 25%-30% of the general population, it is considered a global public health problem[1,2]. Pharmacologic treatment has focused on the control of comorbidities, and currently only one drug, not yet available in Mexico, has been approved by the United States Food and Drug Administration for the treatment of patients with MASLD and fibrosis.

The implementation of a low-calorie Mediterranean diet (MD), characterized by foods low in saturated fats and high in vegetable oils and green vegetables, fruits, cereals, nuts, legumes, fish, dairy products, and red wine, has been shown to improve fatty acid content and liver inflammation. This is reflected in a decrease in transaminases when a weight loss of 5% to 7% is achieved. Additionally, the MD enhances insulin sensitivity and lipid profiles, aids in the prevention of MASLD-related diseases (such as diabetes and high blood pressure), and improves fibrosis and inflammation when weight loss exceeds 10%, regardless of physical activity regimens[3,4].

Silybum marianum (SM), a milk thistle seed extract, has demonstrated antioxidant, anti-inflammatory, and antifibrotic effects and has been used for centuries for treating liver diseases. Its therapeutic actions are related to silymarin, the active component of the seeds. In preclinical trials, silybin, the main active constituent of silymarin, was found to inhibit oxidative stress in the endoplasmic reticulum of hepatocytes and the NLRP3 inflammasome assembly through the NAD+/SIRT2 pathway. It eliminates reactive oxygen species and increases glutathione production through the bioavailability of cysteine, thus exerting its antioxidant effect. At the same time, it lowers elevated glucose and hemoglobin A1c levels, which is why it has been considered for treating MASLD[5].

Alpha-lipoic acid (ALA) is a cofactor of mitochondrial enzymes and is considered an antioxidant because its reduced form, dihydrolipoate, reacts with reactive oxygen species, thus protecting the cell membrane[6]. The administration of ALA has shown beneficial effects on adipokine levels and metabolic disorders, such as diabetes and obesity, which are clinical entities found in patients with MASLD[7]. Given this evidence, in addition to the improvement of metabolic syndrome components, the combination of these compounds is posited to have positive effects for treating MASLD. The aim of the present clinical trial was to evaluate whether the SM-ALA formulation (LUDLEV^®) combined with the MD could improve liver injury related to MASLD in Mexican patients.

MATERIALS AND METHODS

A double-blind, randomized controlled clinical trial was conducted on patients above 18 years of age who had sonographic evidence of hepatic steatosis and met the criteria for MASLD. The study was carried out at the liver disease clinic of the Instituto de Investigaciones Médico-Biologicas of the Universidad Veracruzana within the time frame of June 2023 and June 2024. Patients with chronic kidney disease undergoing renal replacement therapy, patients unable to understand or follow the protocol, or patients who were sensitive to the formula components were excluded. Patients who did not meet the follow-up time or drug dose, did not tolerate or had severe adverse effects to the drug components, or did not undergo transient elastography due to technical limitations were eliminated from the trial.

Intervention and groups

The patients included in the study were randomized through 1:1 systematic sampling to receive SM-ALA (LUDLEV^® 300 mg/46.2 mg) twice a day in association with the MD vs placebo plus the MD for 24 weeks. The sample size was calculated based on the study by Martínez-Rodríguez et al[8], in which 40 patients with nonalcoholic fatty liver disease were randomized into two groups to receive metformin 1500 mg q.a.d. or metformin 1500 mg q.a.d. + (15 mcg)-methionine (3 mg)-ALA (200 mg) for 24 weeks. There was a 70% decrease in ultrasound-graded steatosis (P < 0.001) in the patients who received ALA vs a 15% decrease in the patients who did not receive ALA. Taking this difference in proportions into account and considering a power of 80%, alpha error of 20%, and a 95% confidence interval, 20 pairs (40 patients) were required. Estimating a 25% loss (n = 10), our total sample size was calculated at 50 patients.

Nutritional assessments and interventions

Medical and nutritional evaluations, biochemical testing, and transient liver elastography with FibroScan were carried out at baseline and at follow-up weeks 12 and 24. Medical evaluation included a complete clinical history, anthropometric measurements, adverse event documentation, and weekly follow-up via telephone to assess drug treatment adherence.

Biochemical testing included complete blood count, blood chemistry, liver function tests, lipid profile, C-reactive protein, and serum insulin. Dietary plans were established by nutritional clinic personnel according to nutritional diagnosis and sex (caloric plans of 1400, 1500, 1600, or 1700 kcal/day). Adherence was assessed through a test of adherence to the dietary plan. Risk of liver fibrosis was calculated using the FIB-4 score. High risk was a score ≥ 3.25, indeterminate risk was a score of 1.45-3.25, and no risk was a score ≤ 1.45[9-11]. The liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) were determined with the FibroScan 502 Touch device equipped with M and XL probes (Echosens, Paris, France) and performed by a single operator trained and certified by the manufacturer. Probe selection was carried out using the automatic selection and change suggestion tool integrated into the equipment software. The following LSM cutoff points were: F0, ≤ 6.4kPa; F1, 6.5 to 6.9 kPa; F2, 7 to 8.6kPa; F3, 8.7 to 10 kPa; F3-F4, 10.1 to 15 kPa; and F4, ≥ 15kPa. The CAP cutoff points were: S0, ≤ 247; S1, 248 to 267; S2, 268 to 279; and S3, ≥ 280. Ten representative valid measurements were considered with a success rate < 30%[12,13].

Statistical analysis

For the result analysis, the numerical variables were expressed as measures of central tendency and dispersion, according to their distribution. The categorical variables were expressed as frequency and percentage. Data distribution was evaluated through the Kolmogorov-Smirnov test, and the Levene’s test was applied to examine homogeneity of variance in the numerical variables. Numerical variable means were compared using the Student’s t-test or the Wilcoxon test, according to the nature of the data and their distribution. On the other hand, the categorical variables were compared using the χ² test or the Fisher’s exact test. Correlations were evaluated through the Pearson or Spearman coefficients, according to the nature of the variables and data distribution. Statistical significance was set at a P < 0.05. SPSS version 22.0 statistical software (IBM Corp., Armonk, NY, United States) was utilized to perform the statistical analysis and create the figures and tables.

Ethical considerations

The study was reviewed and authorized by the research and ethics committee of the Instituto de Investigaciones Médico-Biológicas of the Universidad Veracruzana, folio IIMB-010-2023. All participants signed letters of informed consent that explained the procedure, risks, and benefits of the study as well as the use and protection of their personal information. The study was carried out according to the ethics regulations established by the Declaration of Helsinki of the World Medical Association (64^th general assembly, Fortaleza, Brazil, October 2013) and the general health law: Fifth title; health research: Single chapter; the general health law in research: Second title; ethical aspects of research on humans: Chapter one; and articles 16 and 23 of the federal law for the protection of personal data. The study was registered as a clinical trial, identification number NCT05913986 (ClinicalTrials.gov).

RESULTS

Characteristics of the patients

Fifty patients with MASLD were included in the study. Their mean age was 54 ± 10 years, mean body mass index (BMI) was 33.0 ± 5.8 kg/m², and the majority of patients were female (74%). They were randomized 1:1, with 25 patients (50%) in group A (ALA and SM) and 25 patients (50%) in group B (placebo). There were no differences in sex, age, weight, BMI, or comorbidities between the two groups. Two patients (4%) were lost due to lack of treatment adherence or family problems at follow-up week 12 and 3 patients (6%) at week 24 (Figure 1). Table 1 describes the population characteristics.

Figure 1  Flow diagram of the study.

Table 1 Clinical characteristics of the patients with metabolic dysfunction-associated steatotic liver disease by group.

Parameter	Group A, n = 25	Group B, n = 25	P value
Sex			0.333
Male	5 (20)	8 (32)
Female	20 (80)	17 (68)
Age in years	54.7 + 10.5	54.3 + 11.5	0.229
Weight	82.2 + 16.4	82.1 + 14.2	0.473
BMI	32.8 + 6.9	33.3 + 4.7	0.394
Normal weight	-	-
Overweight	10 (40)	5 (20)
Obesity I	5 (20)	10 (40)
Obesity II	6 (24)	9 (36)
Obesity III	4 (16)	1 (4)
Comorbidities
Diabetes	6 (24)	6 (24)	0.629
High blood pressure	7 (28)	8 (32)	0.758
Hypercholesterolemia	8 (32)	5 (20)	0.333
Hypertriglyceridemia	6 (24)	4 (16)	0.480
Hypothyroidism	2 (8)	2 (8)	0.695
Others	-	-

Data are n (%). BMI: Body mass index.

SM-ALA plus MD

In group A, the mean age was 54.7 ± 10.5 years, the majority (80%) were female, weight was 82.2 ± 16.4 kg, and BMI was 32.8 ± 6.9 kg/m². The main comorbidities were dyslipidemia, which was present in 15 patients (56%), followed by high blood pressure (28%) and diabetes (24%). At 12 weeks of treatment, body weight and visceral fat tended to decrease (P = 0.256 and 0.125, respectively), achieving a statistically significant loss in the visceral fat percentage at week 24 (P = 0.045). The total fat percentage gradually decreased at weeks 12 and 24 but not significantly (P = 0.543 and 0.744, respectively), and muscle mass remained unchanged (P = 0.554). In general, change was achieved in body composition, with a decrease in visceral fat percentage, with an average loss of -0.95% at week 24 (Table 2). There were no statistically significant changes in transaminase levels (P = 0.201 and 0.267), and they were within the normal range in the baseline measurement. There was a significant decrease in gamma-glutamyl transferase and C-reactive protein at treatment weeks 12 and 24 (P = 0.033 and 0.035, respectively). The lipid profile showed a tendency to decrease, especially low-density lipoprotein cholesterol (LDL-C), but did not reach significance at week 24 (P = 0.056; Table 3).

Table 2 Somatometric characteristics at baseline and at weeks 12 and 24 in the intervention group with metabolic dysfunction-associated steatotic liver disease.

SM-ALA + MD	Baseline	12 weeks	24 weeks	P value
Somatometry
Weight in kg	82.2 + 16.4	80.1 + 16.2	78.8 + 16.7	0.393
∆weight	-	-1.7 + 2.9	-2.5 + 3.5	0.388
BMI	32.8 + 6.9	32.5 + 6.8	32.4 + 7.05	0.57
Visceral fat as %	12.4 + 3.4	11.9 + 3.3	11.5 + 3.5	0.045
∆visceral fat	-	-0.54 + 1.6	-0.95 + 2.1	0.268
Total fat as %	41.9 + 10.8	42.0 + 10.5	41.0 + 11.5	0.744
Muscle as %	25.5 + 5.4	26.5 + 22.5	26.6 + 8.6	0.554
Circumference in cm
Umbilical	101.8 + 14.7	95.4 + 22.5	97.4 + 14.5	0.003
Hip	112.8 + 16.2	110.2 + 14.0	109.9 + 14.4	0.248
Waist	99.9 + 15.2	96.3 + 13.4	95.9 + 15.0	0.117
Waist-to-hip ratio	0.88 + 0.8	0.87 + 0.06	0.87 + 0.06	0.206
Elastography
kPa1	6.2 + 2.6	5.9 + 2.3	5.4 + 2.03	0.083
∆kPa	-	-0.29 + 2.9	-0.71 + 1.89	0.33

¹Non-normal distribution. ALA: Alpha-lipoic acid; BMI: Body mass index; MD: Mediterranean diet; SM: Silybum marianum.

Table 3 Biochemical parameters at the baseline and at weeks 12 and 24 in the intervention group with metabolic dysfunction-associated steatotic liver disease.

Biochemical parameters	Baseline	12 weeks	24 weeks	P value
Leukocytes in thousands/μL1	7.1 (5.3-13.7)	5.7 (4.5-10)	7.0 (4.7-12)	0.876
Hb in g/dL2	13.4 + 1.3	13.1 + 1.3	13.3 + 1.2	0.101
Platelets in miles/μL2	278 + 52	259 + 59	256 + 57	0.014
TB in mg/dL2	0.54 + 0.24	0.60 + 0.18	0.72 + 0.20	0.002
AST in U/L1	27 (11-49)	25 (20-63)	24 (15-45)	0.201
ALT in U/L1	32 (4-102)	30 (17-81)	25 (17-69)	0.267
ALP in IU/L2	99 + 49	92 + 24	81 + 16	0.205
GGT in U/L1	51 (18-370)	25 (10-130)	28 (12-142)	0.033
TP in g/dL1	7.4 (6.4-8.3)	7.4 (6.6-8.1)	7.4 (7.0-8.3)	0.125
Albumin in g/dL2	4.3 + 0.56	4.3 + 0.28	4.4 + 0.3	0.443
Cholesterol in mg/dL2	202 + 45	191 + 52	184 + 49	0.073
HDL in mg/dL1	44 (23-66)	40 (31-61)	46 (29-168)	0.850
LDL in mg/dL2	123 + 41	113 + 39	110 + 37	0.056
VLDL in mg/dL2	31 + 11	41 + 43	32 + 15	0.663
Triglycerides in mg/dL2	165 + 11	163 + 55	32 + 76	0.987
Glucose in mg/dL1	110 (69-316)	101 (83-200)	115 (91-242)	0.616
Creatinine in mg/dL2	0.77 + 0.16	0.67 + 0.14	0.66 + 0.25	0.223
CRP in mg/L1	4.60 (0.50-1.03)	3.90 (1.80-6.00)	0.51 (0.03-1.40)	0.035
Insulin in mg/L2	16.0 + 9.8	20.0 + 11.0	16.0 + 5.0	0.580
HOMA2	4.8 + 3.0	5.7 + 3.3	5.3 + 2.8	0.230

¹Non-normal distribution [median (range)];

²Normal distribution (mean standard deviation).

Data distribution was evaluated through the Kolmogorov-Smirnov test and homoscedasticity with the Levene’s test. Groups were compared using the Student’s t-test or Wilcoxon test for numerical values, and the χ² test or Fisher’s exact test for the categorical variables. ALP: Alkaline phosphatase; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CRP: C-reactive protein; GGT: Gamma-glutamyl transferase; Hb: Hemoglobin; HDL: High-density lipoprotein; HOMA: Homeostasis Model Assessment; LDL: Low-density lipoprotein; TB: Total bilirubin; TP: Prothrombin time; VLDL: Very low-density lipoprotein.

MD

In group B, the mean age was 54.3+11.5 years, the majority (68%) were female, weight was 82.1 ± 14.2 kg, and BMI was 33.3 ± 4.7 kg/m². The main comorbidities were dyslipidemia, which was present in 15 patients (36%), followed by high blood pressure (32%) and diabetes (24%). At treatment week 12, there was a statistically significant decrease in body weight (P = 0.053), averaging -1.6 kg, but at follow-up week 24 there was less total body weight loss compared with week 12 (-1.0 vs -1.6 kg) not achieving significant weight loss (P = 0.165). The percentages of total fat, visceral fat, and muscle mass had no significant changes at treatment weeks 12 and 24 (P = 0.873, 0.341, and 0.730, respectively; Table 4). There were no statistically significant changes in transaminase levels (P = 0.185 and 0.644) and their baseline measurements were within the normal range, as in group A. There was a significant decrease in alkaline phosphatase, very LDL-C, C-reactive protein, and insulin at treatment weeks 12 and 24 (P = 0.011, 0.041, 0.018, and 0.015, respectively). There were no significant differences in the remaining biochemical parameters (Table 5).

Table 4 Somatometric characteristics at baseline and weeks 12 and 24 in the control group with metabolic dysfunction-associated steatotic liver disease.

Placebo + MD	Baseline	12 weeks	24 weeks	P value
Somatometry
Weight in kg	82.1 + 14.1	79.3 + 12.6	79.2 + 13.3	0.165
∆weight	-	-1.6 + 3.7	-1.0 + 4.6	0.206
BMI	33.3 + 4.7	32.1 + 4.3	32.2 + 5.0	0.16
Visceral fat as %	11.8 + 2.9	12.1 + 2.9	12.8 + 4.3	0.341
∆visceral fat	-	0.33 + 1.6	0.05 + 1.6	0.624
Total fat as %	44.5 + 7.3	43.0 + 9.6	43.7 + 9.1	0.873
Muscle as %	23.9 + 4.2	25.0 + 6.2	24.0 + 4.1	0.73
Circumference in cm
Umbilical	101.2 + 13.2	98.8 + 11.8	94.1 + 18.7	0.07
Hip	113.0 + 11.3	110.3 + 10.2	109.3 + 11.3	0.182
Waist	98.4 + 12.6	96.4 + 11.8	95.7 + 12.3	0.056
Waist-to-hip ratio	0.87 + 0.7	0.87 + 0.08	0.87 + 0.08	0.876
Elastography
kPa	6.9 + 2.3	6.5 + 2.8	5.9 + 3.1	0.132
∆kPa	-	-0.27 + 2.8	1.13 + 3.4	0.032

BMI: Body mass index; MD: Mediterranean diet.

Table 5 Biochemical parameters at baseline and at weeks 12 and 24 in the control group with metabolic dysfunction-associated steatotic liver disease.

Biochemical parameters	Baseline	12 weeks	24 weeks	P value
Leukocytes in thousands/μL1	6.6 (4.1-9.5)	6.3 (4-9.6)	7.7 (4.2-9.9)	0.050
Hb in g/dL2	13.1 + 1.4	13.0 + 1.3	12.9 + 2.3	0.071
Platelets in miles/μL2	278 + 73	254 + 59	251 + 50	0.107
TB in mg/dL2	0.52 + 0.32	0.65 + 0.40	0.72 + 0.33	0.001
AST in U/L1	24 (12-148)	29 (18-110)	25 (17-75)	0.185
ALT in U/L1	30 (10-137)	30 (15-97)	28 (18-86)	0.644
ALP in IU/L2	101 + 41	86 + 30	38 + 18	0.011
GGT in U/L1	36 (19-198)	26 (11-152)	72 (28-98)	0.160
TP in g/dL1	7.3 (6.3-8.8)	7.4 (6.6-8.8)	7.7 (6.7-8.9)	0.661
Albumin in g/dL2	4.00 + 0.57	4.20 + 0.59	7.50 + 0.52	0.056
Cholesterol in mg/dL2	195 + 51	203 + 39	185 + 39	0.457
HDL in mg/dL1	44 (23-66)	44 (32-70)	48 (27-95)	0.213
LDL in mg/dL2	125 + 53	128 + 37	110 + 35	0.425
VLDL in mg/dL2	31.0 + 14.0	29.0 + 10.0	27.0 + 9.6	0.041
Triglycerides in mg/dL2	151 + 67	145 + 51	138 + 48	0.116
Glucose in mg/dL1	104 (71-175)	91 (81-148)	108 (90-177)	0.332
Creatinine in mg/dL2	0.76 + 0.21	0.66 + 0.13	0.69 + 0.20	0.233
CRP in mg/L1	2.70 (0.40-1.45)	0.80 (0.70-0.90)	0.27 (0.03-3.10)	0.018
Insulin in mg/L2	8.8 + 6.7	20.0 + 10.0	15.9 + 6.2	0.015
HOMA2	5.6 + 4.6	5.1 + 3.0	4.1 + 1.9	0.497

¹Non-normal distribution [median (range)];

²Normal distribution (mean standard deviation).

Data distribution was evaluated through the Kolmogorov-Smirnov test and homoscedasticity with the Levene’s test. Groups were compared using the Student’s t-test or Wilcoxon test for numerical values, and the χ² test or Fisher’s exact test for the categorical variables, correspondingly. Data distribution was evaluated through the Kolmogorov-Smirnov test and homoscedasticity with the Levene’s test. Groups were compared using the Student’s t-test or Wilcoxon test for numerical values, and the χ² test or Fisher’s exact test for the categorical variables, correspondingly. ALP: Alkaline phosphatase; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CRP: C-reactive protein; GGT: Gamma-glutamyl transferase; Hb: Hemoglobin; HDL: High-density lipoprotein; HOMA: Homeostasis Model Assessment; LDL: Low-density lipoprotein; TB: Total bilirubin; TP: Prothrombin time; VLDL: Very low-density lipoprotein.

SM-ALA vs MD

Even though there was no statistically significant decrease in body weight or BMI at treatment weeks 12 and 24 in the two groups, there were greater changes in body composition in the group A patients, with a decrease in the percentage of visceral fat (^∆-0.95 kg) and umbilical circumference. The two groups showed a significant decrease in the mean CAP values. In group A, the decrease was gradual and maintained at weeks 12 and 24 (P = 0.026), whereas a greater decrease was seen in group B at 12 weeks and remained unchanged at 24 weeks (^∆CAP -27 dB/m). In group A, steatosis determined through CAP was decreased in 17 patients (73.9%) and increased in 6 patients (26.1%) (P = 0.001). Improvement expressed as delta or change compared with the baseline measurement was ^∆-9.5 ± 41.0 dL/m and -22.0 ± 45.0 dL/m at weeks 12 and 24 (P = 0.224). In group B, measurement by CAP was decreased in 14 patients (56%), increased in 7 patients (30.4%), and unchanged in 2 patients (8%). Improvement expressed as delta or change compared with the baseline measurement was ^∆-27 ± 50 dL/m and -27 ± 44 dL/m at weeks 12 and 24 (P = 0.836; Figure 2). Regarding LSM changes, our patients had no statistically significant fibrosis data, but there was a decrease in the mean overall LSM value (^∆-1.13 kPa). In group A, the initial mean was 6.2 ± 2.6 kPa, with a decrease at 24 weeks to 5.4 ± 2.0 kPa (P = 0.330). In group B (placebo) the initial mean was 6.9 + 2.3 kPa and decreased to 5.9 + 3.1 kPa (P = 0.132) at week 24.

Figure 2 Mean controlled attenuation parameter at baseline and weeks 12 and 24 in the intervention and control groups with metabolic dysfunction-associated steatotic liver disease. P values are from repeated measures analysis of variance. CAP: Controlled attenuation parameter. Group A: Silybum marianum and alpha-lipoic acid + Mediterranean diet; Group B: Placebo + Mediterranean diet.

Adverse effects

Mild adverse effects were reported in 4 patients (16%) in group A and 4 patients (16%) in group B, with no significant differences between the groups (P = 0.641). The most frequently reported symptom was heartburn (3 patients, 6%), followed by nausea, constipation, and diarrhea. No patient suspended treatment, and no severe adverse effects were reported during the follow-up period.

DISCUSSION

Our results showed that the SM-ALA formulation (LUDLEV^®) reduced liver steatosis demonstrated by CAP and improved body composition after 24 weeks of treatment, together with a Mediterranean-style dietary regimen. The implementation of the Mediterranean-style diet and physical activity was the therapeutic intervention demonstrating that the greatest benefit in improving MASLD was weight loss through lifestyle change. The MD has been shown to reduce insulin levels and the Homeostasis Model Assessment of Insulin Resistance index while maintaining body weight stability. Despite these positive results, there are a limited number of studies validating its efficacy, and they point out variations due to geographical regions that may limit its effectiveness[14].

Nehmi-Filho et al[15] evaluated the response to silymarin, without a nutritional intervention or changes in physical activity for 180 days in 133 patients with obesity (BMI ≤ 34.9 kg/m²). They demonstrated a trend toward reduced waist circumference and waist-to-hip ratio in the silymarin group, with no changes in transaminases or the lipid profile. This was similar to results in our patients, in which the group with SM-ALA achieved a decrease in hip and waist circumference, with no statistical significance.

Regarding body composition, a decrease in the percentage of visceral fat was significant but not in the group with placebo. Chiurazzi et al[16] analyzed patients with obesity and MASLD that received a low-calorie MD plus nutraceutical supplementation (vitamin E, L-glutathione, and silymarin) compared with a low-calorie MD and placebo for 3 months. Nutraceutical supplementation significantly improved the anthropometric parameters (weight, waist and hip circumference) compared with the placebo group. Federico et al[17] evaluated the effect at 6 months from having administered the combination of silybin and vitamin D and E in patients with MASLD, showing improvement in the metabolic parameters, oxidative stress markers, and endothelial dysfunction in the treatment group vs the placebo group. Additionally, the benefit was greater in patients who had more than one metabolic syndrome criterion.

Biochemical parameters showed a trend toward reduced transaminases, total cholesterol, LDL-C, and triglycerides. Changes in metabolic parameters resulting from the administration of SM-ALA have been shown in preclinical trials, especially with silymarin supplements. In our patients, there was a decrease in total cholesterol, LDL-C, and triglycerides at follow-up weeks 12 and 24[18,19].

Transaminases [aspartate aminotransferase and alanine aminotransferase (ALT)], gamma-glutamyl transpeptidase, and alkaline phosphatase are serum markers for liver injury, the most specific of which is ALT[20]. Despite the fact that baseline transaminase levels were within normal parameters, there was a trend toward a decrease in ALT in the SM-ALA group of patients. These results show the hepatoprotective effects of SM-ALA as well as their contribution to improving the biochemical parameters of patients with MASLD.

Reinforcing the hepatoprotective role of silymarin, Moezian et al[21] showed that oral silymarin in patients with nonmetastatic breast cancer significantly reduced liver involvement after chemotherapy with the doxorubicin/cyclophosphamide-paclitaxel regimen. However, there were no differences with the placebo in liver elastography and liver function tests. The benefits to the liver of ALA were described by Tutunchi et al[22] in their comparison of the metabolic effects of ALA, myoinositol, and propolis in obese patients with MASLD. Their clinical trial showed that ALA could improve anthropometric measurements and serum levels of cholesterol, LDLs, triglycerides, and aminotransferases after 8 weeks of use.

No severe adverse effects were reported during the follow-up period. The adverse events that were reported were minimal and mild, and the supplement did not need to be suspended. Thus, the combination of SM and ALA is considered safe and well tolerated.

Of our study’s limitations, the first was that the evaluation of steatosis and fibrosis was carried out using noninvasive methods, although the gold standard is the evaluation of histologic improvement. Liver biopsy was not performed because it is an invasive procedure with complication risks. Second, is the fact that the majority of the patients had normal levels of aspartate aminotransferase and ALT, meaning that the response in steatohepatitis could not be evaluated. Importantly, our study excluded patients with cirrhosis of the liver because they did not have the typical clinical progression of steatosis and presented with other complications characteristic of portal hypertension. Therefore, the results could not be generalized to that population.

CONCLUSION

In conclusion, the SM-ALA formulation (LUDLEV^®) combined with the MD may favor the improvement of metabolic parameters as well as the decrease in visceral fat and hepatic steatosis in Mexican patients with MASLD. These data represent an initial study; more studies with larger sample sizes are needed for our results to be generalizable.

ACKNOWLEDGEMENTS

The authors kindly acknowledge Productos Medix SA de CV for the investigational drug provided for this study.