There is a need for continued drug development for nonalcoholic steatohepatitis (NASH). Bergamot is a plant whose fruit juice is enriched with flavonoids and phenolic compounds which improves dyslipidemia and markers of systemic inflammation in patients with Metabolic Syndrome. The aim of this study was to perform a preclinical "proof of concept" study of Bergamot polyphenolic formulation (BPF99) for the treatment of NASH. A disease reversal study was performed in the diet-induced animal model of NAFLD (DIAMOND). Groups of 8 weeks old mice were randomly assigned to receive chow diet, high fat diet with sugar in drinking water (Western diet-WD). Mice on WD were further randomized to continue on WD gavaged with vehicle or continue on WD with additional gavage of BPF99 (50 mg/kg) after 16 weeks of diet. Mice were euthanized after 11 additional weeks. The primary endpoint was resolution of NASH. Secondary endpoints included changes in individual histological features, body weight, liver enzymes, dyslipidemia, markers of oxidative stress and molecular markers of disease activity and fibrosis. The results showed that BPF99 reduced ALT (mean 71.6 vs 44.6 IU/l, p < 0.01), triglycerides (38.8 vs 28.1 mg/dl, p < 0.05), LDL-C (39.2 vs 23.7 mg/dl, p < 0.001). It significantly improved NASH resolution (p < 0.001) and the SAF scores (p < 0.05) while the NAS improvement approached significance. BPF99 reduced markers of oxidative stress, along with reduced JNK and p38 MAP kinase activity. BPF99 did not reduce the number of mice with fibrosis but improved collagen proportional area (p < 0.04) and procollagen I and III expression. Collectively our results showed that BPF99 resolves NASH and ameliorates key histological and pathophysiological features of NASH along with improvement in ALT and dyslipidemia in the DIAMOND mice.

Bergamot (Citrus bergamia Risso et Poiteau) juice has a particularly high content and a unique composition of flavonoids. Neoeriocitrin, neohesperidin, naringin, melitidin and brutieridin represent more than 95% of Bergamot Polyphenol Fraction (BPF), while rhoifolin, diosmin, poncirin and others can be found in the remaining 5%. The brilliant performance of BPF in clinical practice against as a treatment for hyperlipidemia and moderate hyperglycemia in metabolic syndrome, awaits a plausible mechanistic explanation. Considering the overwhelming scientific evidence, it is likely that flavonoid components of BPF are responsible for majority of pharmacological effects. Here, we will review the scientific evidence showing that flavonoids, in particular citrus flavonoids present in bergamot fruits, influence lipid and sugar metabolism at the molecular level. Anti-diabetic and dyslipidemia-correcting effects of bergamot polyphenols may be explained by their ability to activate AMP kinase (AMPK), which is a central regulator of glucose and fatty acids metabolism and inhibit cAMP phosphodiesterases (PDE), involved in regulation of lipolysis in adipocytes and liver. Importantly, certain polyphenols can act as 3-hydroxy-3-methlglutaryl coenzyme A (HMG-CoA) reductase inhibitors, thereby mimicking statins action. In addition, flavonoids bind and act as natural inhibitors of quinone oxidoreductase 2 (QR2/NQO2) and other enzymes with potential roles in metabolic regulation. Finally, pleiotropic and possible synergistic effects may account for enhanced nutraceutical effects of natural flavonoid mixtures, such as BPF as compared to purified flavonoids.

BACKGROUND:Statins are the most commonly prescribed drugs to reduce cardiometabolic risk. Besides the well-known efficacy of such compounds in both preventing and treating cardiometabolic disorders, some patients experience statin-induced side effects. We hypothesize that the use of natural bergamot-derived polyphenols may allow patients undergoing statin treatment to reduce effective doses while achieving target lipid values. The aim of the present study is to investigate the occurrence of an enhanced effect of bergamot-derived polyphenolic fraction (BPF) on rosuvastatin-induced hypolipidemic and vasoprotective response in patients with mixed hyperlipidemia.METHODS:A prospective, open-label, parallel group, placebo-controlled study on 77 patients with elevated serum LDL-C and triglycerides was designed. Patients were randomly assigned to a control group receiving placebo (n=15), two groups receiving orally administered rosuvastatin (10 and 20mg/daily for 30 days; n=16 for each group), a group receiving BPF alone orally (1000 mg/daily for 30 days; n=15) and a group receiving BPF (1000 mg/daily given orally) plus rosuvastatin (10mg/daily for 30 days; n=15).RESULTS:Both doses of rosuvastatin and BPF reduced total cholesterol, LDL-C, the LDL-C/HDL-C ratio and urinary mevalonate in hyperlipidemic patients, compared to control group. The cholesterol lowering effect was accompanied by reductions of malondialdehyde, oxyLDL receptor LOX-1 and phosphoPKB, which are all biomarkers of oxidative vascular damage, in peripheral polymorphonuclear cells.CONCLUSIONS:Addition of BPF to rosuvastatin significantly enhanced rosuvastatin-induced effect on serum lipemic profile compared to rosuvastatin alone. This lipid-lowering effect was associated with significant reductions of biomarkers used for detecting oxidative vascular damage, suggesting a multi-action enhanced potential for BPF in patients on statin therapy.

The occurrence of Metabolic Syndrome (MS) represents an independent risk factor for developing cardiovascular disease states in patients suffering from type 2 diabetes mellitus.Moreover, both the size of LDL particles and liver dysfunction identified as non alcoholic fatty liver disease (NAFLD) represent important biomarkers for the development of cardiometabolic risk in patients with MS.Here we studied the effect of bergamot polyphenolic fraction (BPF) in patients with MS and NAFLD.107 patients were enrolled at the San Raffaele IRCCS (Rome).All of them showed ultrasonografic evidences of NAFLD and at least three out of five previous identified criteria for the diagnosis of MS.Patients were divided into two groups: one receiving placebo and the second receiving BPF 650 mg twice a day for 120 consecutive days.In the group receiving BPF 650 mg twice a day, a significant reduction of fasting plasma glucose, serum LDL cholesterol and triglycerides alongside with an increase of HDL cholesterol was found.This effect was accompanied by significant reduction of both ultrasonographic and metabolic biomarkers of NAFLD.Moreover, a significant reduction of small dense LDL particles, as detected via proton NMR Spectroscopy, was found * Corresponding author.after BPF treatment.In conclusion, our data confirm the beneficial effect of bergamot-extract in patients with MS an effect highlighted by significant reduction of small dense LDL particles and by improvement of NAFLD biomarkers.This suggests a potential preventive role of bergamot derivatives in reducing cardiometabolic risk.

Introduction: To determine whether bergamot polyphenolic fraction (BPF), a proprietary extract from a unique antioxidant-rich citrus fruit (bergamot) known to be beneficial in subjects with metabolic syndrome and dyslipidemias, could significantly improve hepatic structure and function in patients with both metabolic syndrome and non-alcoholic fatty liver disease (NAFLD). Methods: One hundred seven patients who met the NCEP-ATP III criteria for metabolic syndrome and had ultrasonic evidence of severe NAFLD (hepato-renal index 2.5-3.5) after exclusion of alcohol, viral, and immune disorders were admitted to the study. Before and after 120 days of BPF 650 mg twice a day, all patients had full lipid analysis including lipoprotein fractionation (NMR), fasting glucose, ALT, AST, steato test, γ-GT, TNF-α (ELISA), CRP, and ultrasonographic hepatorenal tests. Results: Hepatic tests include: steato test (baseline: 0.74 ± 0.12; after 120 days BPF: 0.44 ± 0.09), ALT (U/L) (baseline: 54 ± 5.4; after 120 days BPF: 36 ± 5.3), AST (U/L) (baseline: 52. ± 6.4; after 120 days BPF: 41 ± 5.2), γ-GT (IU/L) (baseline: 38 ± 5.2; after 120 days BPF: 29.33 ± 1.1), hepatorenal index (baseline: 2.8 ± 0.4; after 120 days BPF: 1.5 ± 0.5). Inflammatory tests include: Hs-CRP (mcg/dL) (baseline: 1.2 + 0.8; after 120 days BPF: 0.94 + 0.6) and TNF-α (pg/mL) (baseline: 14.4 ± 1.9; after 120 days BPF: 10.7 ± 1.7). Metabolic tests include: fasting glucose (mg/mL) (baseline: 118 ± 1.4; after 120 days BPF: 98 ± 0.8). All values p<0.05. Standard lipid levels (TC, LDL, HDL, TG, IDL, VLDL) were significantly improved as were the size, density and number of all atherogenic lipoprotein particles (e.g., small dense LDL, NMR, LDL particle number). Conclusion: Bergamot polyphenolic extract (BPF) derived from the Calabrian bergamot citrus fruit is a potent anti-oxidant, AMP kinase activator, and HMG-CoA reductase inhibitor that has been proven to address all components of the metabolic syndrome. In a group of 107 patients with confirmed NAFLD and metabolic syndrome, BPF given twice per day before meals significantly improved all measured biochemical and ultrasonographic characteristics of both NAFLD and metabolic syndrome in 120 days without reported side effects. There was a striking improvement in hepatic function (biochemical) and structure (echogenic visual loss of hepatic fat) accompanied by lower levels of inflammation. As there is a dearth of proven therapeutic options for NAFLD and metabolic syndrome, this study suggests that BPF may be a safe and important therapeutic option for these conditions. Disclosure - James E. Ehrlich--consultant for Nat Health Solutions, distributor of BergaMet. Ross Walker--consultant for Nat Health Solutions. Vincenzo Mollace--consultant for Nat Health Solutions.Figure 1

Bergamot (Citrus bergamia Risso et Poiteau) fruits are characterized by a particularly high content and a unique composition of flavonoids, such as neoeriocitrin, neohesperidin, naringin, melitidin and brutieridin. Bergamot juice and its concentrate, highly enriched in polyphenols—here referred to as Bergamot Polyphenol Fraction (BPF)—has been evaluated in experimental and clinical studies. Studies performed in Italy and Australia showed that BPF treatment leads to an important reduction in lipid parameters in the blood of patients with hyperlipidemia ranging from 15 up to 40% for total cholesterol and cholesterol-LDL. A striking reduction (mean 41.0±2.6%) was also observed for plasma triglyceride levels, accompanied by a significant decrease in blood glucose (22.3±1.0%) in a subgroup of patients with metabolic syndrome. Although BPF cannot be proposed as a substitute for statins in patients at high risk of cardiovascular events, it offers an excellent alternative for low-risk and for statin-intolerant patients. The robust performance of BPF in clinical practice against cardiometabolic risk factors can be explained in the light of scientific evidence showing that bergamot flavonoids influence lipid and sugar metabolism acting as 3-hydroxy-3-methlglutaryl coenzyme A (HMG-CoA) reductase inhibitors and AMP kinase (AMPK) activators.

Background: Statins have a strong evidence-base as part of the management of cardiovascular disease. Bergamot polyphenolic fraction (BPF), a juice extract from citrus bergamia, has been found to reduce significantly blood cholesterol, triglycerides and oxyLDL in animal models and patients with hyperlipidaemia. We report on the effect of BPF in patients suffering from combined dyslipidaemia either untreated or treated with rosuvastatin. Methods: A prospective, open-label, parallel group, controlled study of 77 patients with low-density lipoprotein cholesterol (LDL-C) levels of >4.1 mmol/L and triglycerides levels >2.54 mmol/L was performed. Patients were randomly assigned to five groups, all receiving low fat diet: a control group, two groups receiving rosuvastatin (10 and 20 mg/day for 30 days), a group receiving BPF alone (1000 mg/day for 30 days) and, finally, a group receiving BPF (1000 mg/day) plus rosuvastatin (10 mg/day) for 30 days. Results: Rosuvastatin doses reduced LDL-C by 42 + 4% and 56 + 5%, respectively. Similar effect was seen in total cholesterol and non-high-density lipoprotein cholesterol (non-HDL-C) levels. In BPF-treated group, a 31 + 3% reduction of LDL-C and a significant improvement on the lipid profile was seen, including a significant reduction by 37 + 3% of triglycerides. Addition of BPF (1000 mg/daily) to rosuvastatin (10 mg/day) significantly enhanced rosuvastatin effect on serum cholesterol compared to rosuvastatin 20 mg alone (LDL-C reduction was 52 + 4%), with further reduction in triglycerides and increases in HDL cholesterol. Conclusion: Our data has clearly demonstrated that bergamot derived antioxidant polyphenols synergise with rosuvastatin, suggesting a role in statin-intolerant patients.