Well, you also mentioned in one of your reviews, there are strategies 'drug the bug', and also 'bugs as drugs' to treat non-alcoholic fatty liver disease and NASH. That's right. So it could be transplanting bacteria that have a more healthy profile, effectively 'the bug becomes a drug'. And this, along with effectively trying to change the endogenous microbiome, either by manipulating with probiotics or perhaps selective antibiotics, also can ultimately transform the microbiome and hopefully change the nature of NASH. I think the microbiome becomes particularly compelling as a driver in those patients with Lean NASH. I mean, after all, they don't have excess fat in the liver and obesity, and yet, they have NASH. And to me that, along with genetic factors, ethnic risks, it speaks to the idea that those NASH patients could have an unusual microbiome or unusual components of their microbiome that are leading to NAFLD, even though they are lean. Again, it's early days, really, but I'm confident we'll continue to make progress. Dr. Anton Titov, MD.: What about strategies of using sort of small molecules or natural substances such as butyrate, curcumin was mentioned, to decrease pro-inflammatory cytokines, including NF kappa B? The current approach from the pharmaceutical and biotech industry is to identify drug targets either in the intestine or in the liver that can regulate and therefore can lead to resolution or improvement in NASH. Butyrate, not so much. You know, there's a slightly cynical perspective on this. The natural compounds and chemicals that might be available to us over the counter, supplements are not of great interest to the pharmaceutical industry because they can't be patented, and they cannot yield commercial success. And so I think we need to acknowledge that there may be treatments out there, even existing drugs that could be repurposed. Dr. Scott Friedman, MD.: But they are not being adequately pursued because there's no commercial incentive. There's no company that's going to benefit commercially from that drug. And so it becomes a little hard to test things like butyrate, in part because there's no commercial interest in developing those kinds of therapies. That is a place where I think foundations and government agencies can fill an important gap in trying to use either natural compounds that are well-characterized and safe or even repurposed drugs that are already off their patent life but could be very well tolerated. And we've done a couple of studies in my laboratory, showing that drugs that have already been tried for other diseases, to our surprise, have a benefit in NASH as well. Unfortunately, we've not been able to engage the commercial sponsors that hold the patents to actually repurpose those drugs and invest in a clinical NASH therapy program. So there are some real-world considerations about how drugs are developed beyond just whether they're effective and safe. I wish it weren't so, but that's just the way the system works.
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