University of Groningen

Metabolic and mitogenic functions of fibroblast growth factor 1

Struik, Dicky

DOI:
10.33612/diss.133879075

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Struik, D. (2020). Metabolic and mitogenic functions of fibroblast growth factor 1. [Thesis fully internal (DIV),
University of Groningen]. University of Groningen. https://doi.org/10.33612/diss.133879075

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Chapter 1: Introduction
Dicky Struik

Section of Molecular Metabolism and Nutrition, Department of Pediatrics, University of

Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The
Netherlands.
Chapter 1

Abstract
Type 2 diabetes (T2D) and non-alcoholic fatty liver disease (NAFLD) are worldwide
health problems because they increase the risk of organ damage and mortality. Available
treatment options for these obesity-related diseases include lifestyle intervention,
pharmacological treatment, and bariatric surgery. Unfortunately, these treatment options are not
effective in all patients, signifying the need to identify new therapies that can improve metabolic
health. Fibroblast growth factor 1 (FGF1), a member of the fibroblast growth factor hormone
family, has been identified as an important physiological regulator of adipose tissue remodeling
and energy metabolism in mice. Remarkably, pharmacological administration of recombinant
FGF1 protein normalizes blood glucose levels and liver fat content in obese and diabetic animal
models, suggesting that FGF1 may have therapeutic potential in the treatment of T2D and
NAFLD. However, the metabolic pathways by which FGF1 improves blood glucose levels and
liver fat content remain largely unclear. In addition, FGF1 signaling is also linked to the
stimulation of cell growth, which is a highly unwanted effect with regard to its possible
therapeutic application. The development of a safe and effective FGF1-based drug thus requires
a better understanding of the relationship between FGF1’s metabolic and cell growth-promoting
functions. In this thesis, we report the results of preclinical studies aimed to provide details on
FGF1’s mechanism of action and safety. In this introductory chapter, we present background
information on the pathophysiology and treatment of T2D and NAFLD and describe how
several members of the fibroblast growth factors family, including FGF1, FGF15/19, and
FGF21 have been developed into new biologicals for the treatment of chronic metabolic
diseases. At the end of this chapter, the thesis outline will be presented.

8
 Introduction

Obesity
Obesity, a condition characterized by excessive body fat (Body Mass Index (BMI) >30
2
kg/m ), is a serious health problem because it accelerates the development of diseases that are
primarily associated with aging, such as T2D, NAFLD, cardiovascular disease (CVD), and
certain types of cancers1. According to the World Health Organization (WHO), about 13% of
the world’s adult population was obese in 20162. The prevalence of obesity is also increasing
among children, which has an estimated prevalence of 5-23% in European countries3. The
development of obesity is strongly dependent on a person’s genetic background. Twin studies
have shown heritability scores ranging from 40-70%4. Because monogenetic forms of obesity
are rare, it is assumed that the majority of obesity is of polygenic origin5,6. So far, genome-wide
association studies (GWAS) have identified over 300 genetic variants that potentially increase
the risk of obesity, with many of these variants being enriched in the regulation of appetite or
fat distribution6. Some well-known identified obesity-related gene variants include fat mass and
obesity-associated gene (FTO), pro-opiomelanocortin (POMC), melanocortin 4 receptor
(MC4R), and transmembrane protein 18 (TMEM18). How these gene variants contribute to
altered obesity risk is still largely unknown. In addition to genetic risk factors, various
environmental factors such as excessive food intake and a sedentary lifestyle, also known as
the obesogenic environment, further increase the risk of obesity4.

Insulin resistance and beta-cell failure

Obesity is often characterized by the gradual development of insulin resistance, a
condition in which muscle-, liver-, and fat cells fail to respond correctly to the pancreatic beta
cell-derived hormone insulin7. Although insulin resistance is usually associated with
compensatory insulin production, in some individuals, enhanced insulin secretion cannot be
maintained, which may result in beta cell failure8. How obesity contributes to the development
of insulin resistance and beta-cell failure is not entirely understood9. Factors that are believed
to play a role in the development of insulin resistance include genetic predisposition (e.g.,
polymorphisms in the transcription factor peroxisome proliferator-activated receptor gamma,
PPARγ), the elevation of certain lipid species (e.g., free fatty acids (FFA), diacylglycerols,
sphingolipids, and acylcarnitines), ectopic lipid accumulation, altered adipokine secretion (e.g.,
adiponectin and leptin), and chronic low-grade tissue inflammation7,9. Many of these factors
interfere with the insulin signaling pathways that regulate glucose and lipid metabolism. Very
similar pathological factors also appear to play a role in the development of beta-cell failure,
although other dysfunctional pathways have been identified as well, including endoplasmic
reticulum (ER) stress, amyloid plaque formation, and DNA damage10. Insulin resistance and
impaired beta-cell function profoundly change glucose and lipid levels in blood and tissues,
which contributes to the development of T2D, NAFLD, and CVD.

Pathophysiology of glucose metabolism in T2D

T2D affects around 500 million people worldwide and is a major cause of blindness,
kidney failure, heart attacks, stroke, and lower limb amputation11. Similar to obesity, genetic
factors also play an important role in the development of T2D. In monozygotic twins, when one
sibling develops T2D, between 60-90% of the other siblings will also develop the disease12.
Other factors that increase the risk of developing T2D include age (≥45 years), ethnicity (e.g.,
9
Chapter 1

African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Native
Hawaiian, or Pacific Islander), high blood pressure, dyslipidemia, history of gestational
diabetes, history of heart disease or stroke, and polycystic ovary syndrome13.
Biochemically, T2D is mainly characterized by chronically elevated blood glucose
levels, a condition also known as hyperglycemia9. Although temporary hyperglycemia may go
unnoticed, sustained hyperglycemia can lead to various symptoms such as excessive thirst,
frequent urination, irritability, blurred vision, or fatigue14. Sustained hyperglycemia enhances
the glycation of protein and lipid molecules, generating the so-called advanced glycation end-
products (AGE)15. AGE cause tissue damage and are linked to various diabetes complications
such as retinopathy, nephropathy, and neuropathy, which are collectively described as diabetic
microvascular complications15.
Diabetic retinopathy is a common complication of diabetes and has been held
responsible for around 10.000 new cases of blindness in the United States each year16. Diabetic
nephropathy is a leading cause of chronic kidney failure and is characterized by a gradual loss
of kidney function. Loss of kidney function can be examined by measuring microalbumin levels
in urine. Around 7% of T2D patients already show increased urine microalbumin levels at the
time of diagnosis, and the incidence of microalbuminuria increases by about 2% per year16.
Diabetic neuropathy is caused by nerve damage and can present itself as burning, pain, or
numbness. Neuropathy is considered to be the most common long-term complication of
diabetes as if it affects around 50% of the patients17.
Hyperglycemia in T2D arises because insulin resistance and beta-cell failure impair
normal glucose regulation in muscle, adipose, and liver9. The physiology of glucose metabolism
starts with the absorption of dietary glucose in the intestine. The absorption of glucose in the
intestine stimulates pancreatic insulin secretion, which raises plasma insulin levels. Insulin then
stimulates glucose uptake in muscle and adipose tissue. Because the brain and red blood cells
rely largely on glucose as an energy substrate, the body also can produce glucose endogenously.
Endogenous glucose production is mainly carried out by the liver. The rate of hepatic glucose
production is negatively controlled by insulin, although various other hormones play a role in
this as well. Thus, while dietary glucose is normally taken up into tissues, due to insulin
resistance and beta-cell failure, insulin-stimulated glucose uptake in muscle and adipose tissue
is reduced. At the same time, the ability of insulin to suppress hepatic glucose production is
also reduced. Collectively, these effects increase blood and interstitial glucose concentrations.
Whereas physiological blood glucose levels are generally around 5 mmol/L, in uncontrolled
T2D, glucose levels can easily increase up to 20 mmol/L18.
At a molecular level, insulin resistance in muscle and adipose tissue appears to be
mainly caused by reduced insulin-stimulated translocation of glucose transporter 4 (GLUT4) to
the myocyte and adipocyte plasma membrane19–21. GLUT4 is a member of a large family of
glucose transporters (GLUT1-14) that facilitate the transport of glucose across plasma
membranes. Under low insulin concentrations, most GLUT4 resides in intracellular vesicles22.
In response to glucose-stimulated insulin secretion, plasma insulin levels increase, resulting in
enhanced binding of insulin to the insulin receptor. Stimulation of the insulin receptor results
in the activation of the PI3K/AKT-AS160 pathway, which drives the fusion of GLUT4-
containing vesicles with the plasma membrane22. Membrane GLUT4 facilitates the uptake of
circulating glucose into cells, after which hexokinases rapidly phosphorylate glucose to produce
10
 Introduction

glucose-6-phosphate22. Intracellular glucose-6-phosphate then enters the glycolytic pathway, or

it can be stored as glycogen.
Currently, the classical view that muscle insulin resistance plays a key role in the
pathophysiology of T2D is somewhat changing. In clinical trials that examined the effects of
extreme weight loss through bariatric surgery or lifestyle intervention, it became apparent that
the reversal of T2D is associated with a rapid loss of fat from the pancreas and liver. This
reduction in ectopic lipid accumulation results in normalization of hepatic insulin sensitivity
and the first-phase insulin response, while muscle insulin sensitivity remains largely
unaffected23,24. These observations led to the formulation of the twin cycle hypothesis, which
states that muscle insulin resistance facilitates the development of fat accumulation in the liver,
which then impairs the ability of insulin to suppress hepatic glucose production23,24.

Figure 1. Regulation of hepatic glucose metabolism. GLUT2 is the principal transporter for the uptake of
glucose from the blood into the liver (1). Inside the hepatocytes, glucokinase (GCK) phosphorylates glucose,
generating glucose-6-phosphate (glucose-6-p) (2). Glycogen synthase (GS) then uses glucose-6-p in glycogen
formation (3). When energy demands increase, for example, during fasting, glucagon stimulates glycogen
phosphorylase (GP) activity to generate glucose-6-p (2). Glucose-6-p can then be dephosphorylated by the enzyme
glucose-6-phosphatase (G6PC) to produce glucose (4). Alternatively, glucose-6-p can be directed into the
glycolytic pathway generating pyruvate (5). Pyruvate can enter the tricarboxylic acid (TCA) cycle, and via its
conversion to oxaloacetate, this route allows the reformation of glucose-6-p, a process known as gluconeogenesis
(GNG) (6). Insulin regulates hepatic glucose metabolism at multiple levels, including elevation of GCK and GS
activity, and suppression of G6PC and gluconeogenesis.

Under physiological conditions, most glucose is taken up by skeletal muscle, brain, and
heart. However, a fraction of plasma glucose is taken up by the liver, where it can be used in a
variety of metabolic pathways. An overview of the regulation of hepatic glucose metabolism is
shown in Figure 1. The uptake of glucose from the blood into the liver is facilitated by GLUT2,

11
Chapter 1

another member of the GLUT family. In the hepatocytes, glucose is phosphorylated by

glucokinase, generating glucose-6-phosphate, a key intermediate that can enter various
metabolic routes. In the fed state, glucose-6-phosphate is largely stored as glycogen via the
actions of glycogen synthase25,26. When energy demands increase, stored glycogen can be
broken down to release glucose, a process known as glycogenolysis25,26. The pancreatic alpha
cell-derived hormone glucagon strongly regulates the breakdown of glycogen. Glucagon
stimulates glycogen phosphorylase activity, elevating intracellular glucose-6-phosphate
concentrations25. Glucose-6-phosphate can then be dephosphorylated by the enzyme glucose-
6-phosphatase to produce glucose26. In addition to generating glucose through glycogen
breakdown, the liver is also able to synthesize new glucose molecules from various precursor
molecules, including lactate, pyruvate, glycerol, and certain amino acids25. This de novo
glucose synthesis, also known as gluconeogenesis, further contributes to maintaining blood
glucose levels within narrow physiological ranges.
Next to glucagon, insulin is actively involved in controlling hepatic glucose fluxes at
multiple levels27. For example, insulin-dependent activation of glycogen synthase kinase-3β
increases glycogen synthase activity to promote glycogen storage28. Also, transcriptional
regulation through forkhead box ‘other’-1 (FOXO1) inhibits gluconeogenesis and glucose-6-
phosphatase expression29. Furthermore, sterol-regulatory-element-binding protein-1C
(SREBP1c)-dependent upregulation of glucokinase expression provides another way by which
insulin can control hepatic glucose production30. Hence, as insulin inhibits glucose production
and promotes glycogen storage, insulin resistance will increase net hepatic glucose production,
contributing to the development of hyperglycemia.

Pathophysiology of lipid metabolism in T2D

In addition to regulating glucose metabolism, insulin also controls various aspects of
lipid metabolism, causing many T2D patients to have altered lipid homeostasis as well31. An
overview of the main factors that contribute to the regulation of normal lipid homeostasis is
shown in Figure 2. The physiology of lipid metabolism starts with the absorption of dietary fat
in the intestine, a process that is facilitated by the postprandial release of pancreatic digestive
enzymes and bile acids32,33. In the enterocytes, triglycerides are incorporated into chylomicron
particles, which are part of the lipoprotein system that plays a crucial role in plasma lipid
transport32. In contrast to dietary glucose, dietary fat initially evades the liver as it enters the
plasma through the lymphatic system32. In the capillaries of muscle and heart, the triglyceride
content of the chylomicron particles is hydrolyzed by the enzyme lipoprotein lipase (LPL)34.
LPL-dependent hydrolysis of chylomicron-derived triglycerides liberates free fatty acids
(FFAs) that are oxidized in muscle and heart to generate energy-rich adenosine triphosphate
(ATP) molecules34 In adipose tissue, LPL-dependent hydrolysis of the triglyceride content also
liberates FFAs which, after uptake into the adipocytes, are immediately re-esterified and stored
as new triglycerides molecules35. Lipids stored in the form of triglycerides in adipose tissue
represent the body’s dominant fuel source and constitute over 90% of the total energy reserve36.
When energy demands increase, stored triglycerides can be broken down by adipose
tissue lipolysis, involving the sequential actions of adipose triglyceride lipase (ATGL),
hormone-sensitive lipase (HSL), and monoacylglycerol lipase (MGL)37. The activity of this
lipolytic pathway is inhibited by insulin, while stimulation is mainly achieved through
12
 Introduction

catecholamine-driven activation of beta-adrenergic receptors35. Activation of the lipolytic

pathway releases glycerol and FFA molecules. While glycerol can be used as a precursor in
hepatic gluconeogenesis, FFAs are oxidized in muscle and heart via beta-oxidation37. Adipose-
derived FFA can also be taken up by the liver, where they are re-esterified into new triglyceride
molecules. Glucose may provide an additional source of hepatic lipid formation, as it can be
converted into acetyl-CoA, which is a precursor in FFA and cholesterol synthesis38. This
process, in which dietary glucose is converted into lipids, is also called de novo lipogenesis
(DNL). Newly synthesized hepatic triglycerides can be stored inside hepatocytes, or they can
be packaged into another type of lipoprotein particle, called the very-low-density lipoprotein
particle (VLDL)39. The secretion of VLDL particles carries triglycerides from the liver to
peripheral tissues, including adipose, muscle, and heart39. Similar to chylomicron particles, the
hydrolysis of VLDL particles is dependent on LPL activity34.

Figure 2. Overview of the main factors that contribute to the regulation of lipid metabolism. Dietary lipids
are absorbed in the intestine and are then packaged into chylomicron particles that enter the bloodstream via the
lymphatic system (1). The liver also contributes to the production of lipid particles, which are called VLDL
particles. In the capillaries of muscle and heart, the triglyceride content of chylomicron and VLDL particles is
hydrolyzed by the enzyme LPL to generate FFAs that are used for energy production (2). The remnants of
chylomicron and VLDL particles generate IDL and LDL particles that are enriched in cholesterol and can
contribute to the development of atherosclerosis (3). In adipose tissue, LPL-dependent hydrolysis of the
triglyceride content also liberates FFAs, which are re-esterified and stored as new triglyceride molecules (4). The
breakdown of triglycerides in adipose tissue is controlled by lipolysis that involves the sequential actions of ATGL,
HSL, and MGL (5). The activity is of this pathway is strongly controlled by insulin and beta-adrenergic receptor
(ADRB) signaling. Adipose tissue lipolysis releases large amounts of FFAs that are used as an energy substrate
by muscle and heart (6). The oxidation of FFAs interferes with the uptake and oxidation of glucose in muscle, a
process known as the glucose-fatty acid cycle (7). FFAs are also taken up by the liver via the fatty acid transporter
CD36, after which they can be oxidized or incorporated into VLDL particles (8). The process of DNL, in which

13
Chapter 1

glucose is converted into acetyl-CoA, which is a precursor in FFA and cholesterol synthesis, provides an additional
source of hepatic lipids (8).

Altered lipid metabolism in T2D is primarily explained by the fact that insulin resistance
reduces the lipid storage promoting actions of insulin. Because lipid and glucose metabolism
are linked in many ways, altered lipid metabolism also contributes to changes in glucose
metabolism and vice versa40. For example, under physiological conditions, glucose-stimulated
insulin secretion increases LPL activity in adipose tissue, promoting triglyceride strorage34. In
insulin-resistant patients, due to reduced LPL activity, both chylomicron and VLDL triglyceride
particles accumulate in plasma, causing hyperlipidemia. As the remnants of these particles, that
is low-density lipoproteins (LDL), and intermediate-density lipoproteins (ILD) are highly
enriched in cholesterol, plasma cholesterol levels are also increasing, which elevates the risk of
atherosclerosis. Atherosclerosis is characterized by the narrowing of the arterial wall and
increases the risk of developing diabetic macrovascular complications such as cardiovascular
disease and stroke16. T2D patients have a two to four-fold increase in the risk of developing
coronary heart disease and ischemic stroke and a 1.5-3.6-fold increase in mortality41. As a result
of these diabetic complications, the life expectancy of patients with T2D can be reduced up to
5 years42,43.
Because insulin normally suppresses adipose tissue lipolysis, resistance to insulin also
increases plasma FFA and glycerol levels44. Increased plasma FFA levels are strongly
implicated in further promoting changes in glucose and lipid homeostasis45. The effect of FFA
on glucose metabolism is partly explained by the fact that FFA and related lipid species such
as long-chain fatty acyl CoAs, diacylglycerol, and ceramides interfere with insulin signaling
and glucose uptake and oxidation in both heart and muscle. Specifically, acetyl-Coa-derived
citrate production has been shown to impair GLUT4 translocation and glycolytic flux rates46.
Conversely, glucose can control fatty acid oxidation through malonyl-Coa-dependent inhibition
of carnitine palmitoyltransferase (CPT-1), an enzyme that controls FFA uptake into
mitochondria46. This bidirectional interaction between FFA and glucose oxidation is also
referred to as the glucose-fatty acid cycle or Randle cycle46. Another way by which elevated
FFA and glycerol levels may further contribute to dysregulated glucose homeostasis is by their
ability to stimulate hepatic gluconeogenesis47.
Apart from interfering with glucose metabolism in the heart, muscle, and liver, elevated
plasma fatty acid levels also drive hepatic lipid accumulation. Previous studies have shown that
around 60% of the total hepatic lipid content is derived from plasma FFAs coming from adipose
tissue 48. Increased hepatic lipid accumulation contributes to the development of NAFLD, a
condition that is closely linked to T2D39.

NAFLD
NAFLD is the most common chronic liver disorder worldwide and affects around 25%
of the world population49. The development of NAFLD is closely linked to obesity and insulin
resistance, and the prevalence of NAFLD among T2D patients is around 70%50. NAFLD
includes a spectrum of liver abnormalities ranging from simple steatosis (non-alcoholic fatty
liver, NAFL) to hepatic inflammation (non-alcoholic steatohepatitis, NASH) and cirrhosis51.
NAFL is histologically defined by the presence of lipids in more than 5% of the hepatocytes51.

14
 Introduction

However, around 25% of NAFLD patients also exhibit NASH, in which steatosis is
accompanied by histological signs of lobular inflammation and hepatocyte ballooning, with
or without fibrosis51,52. In a quarter of all NASH patients, there are also signs of liver fibrosis52.
Liver fibrosis or cirrhosis is the most unfavorable histological feature, as it is strongly
associated with the risk of developing end-stage liver disease, hepatocellular carcinomas, and
the need for liver transplantation52.
Although hepatic lipid accumulation is a normal physiological process, as it occurs
under both feeding and fasting conditions, in the context of over-nutrition and insulin resistance,
increased lipid accumulation can cause disturbed liver function53. Factors that determine hepatic
lipid content include FFA uptake, DNL, fatty acid oxidation, and VLDL secretion54. As
mentioned earlier, a significant fraction of hepatic triglyceride content is derived from FFA
uptake48. Studies using stably labeled isotopes have indicated that around 60% of hepatic
triglycerides in humans are derived from plasma FFAs, which themselves arise for more than
90% from adipose tissue stores48. Increased hepatic FFA uptake in NAFLD is suggested by the
upregulation of the FFA transporter CD36 in the liver of NAFLD patients54. Although the
contribution of DNL to hepatic lipid content is limited in healthy subjects, DNL appears to be
responsible for around 26% of the liver triglyceride content in NAFLD patients48. The
observation that insulin still promotes DNL despite insulin resistance is also known as selective
insulin resistance and may be explained by anatomical zonation of metabolic processes in the
liver55.
Studies on the role of FFA oxidation in NAFLD have yielded mixed results, with some
studies reporting decreased rates of hepatic ATP production, while increased FFA oxidation
rates have been observed as well54. Changes in VLDL production and secretion are also
expected to play a role in the development of NAFLD, as reflected by the fact that mutations in
apoB100, a large protein that stabilizes VLDL particles, cause hepatic steatosis56. Similarly,
mutations in the microsomal triglyceride transfer protein (MTP), a protein that is involved in
lipidation of VLDL particles, also cause steatosis54. In NAFLD patients, VLDL secretion rates
are increased; however, this cannot compensate for the increased hepatic triglyceride levels57.
Recent GWAS studies have shown that polymorphisms in patatin-like phospholipase
domain-containing 3 (PNPLA3) and transmembrane 6 superfamily, member 2 (TM6SF2) also
strongly contribute to increased hepatic lipid accumulation, although the underlying
mechanisms remain the be determined58,59.
Regarding the pathogenesis of NAFL to NASH, a ‘two-hit’ hypothesis was posited in
which steatosis (first hit) and an additional pathological factor, such as oxidative damage
(second hit), were required to develop NASH60. However, given that many pathological factors
appear to be involved in the progression of NAFL to NASH, including genetic predisposition,
mitochondrial dysfunction, ER stress, and even the gut microbiome, a multiple hit model was
recently proposed61. Furthermore, it has also been suggested that NASH might not always be
preceded by NAFL and that NAFL and NASH may represent distinct diseases62. Nevertheless,
the treatment of NASH is considered necessary to prevent fibrosis progression.

Treatment options for T2D

Treatment options for T2D include lifestyle intervention, pharmacological treatment,
and bariatric surgery, all of which are aimed at reducing hyperglycemia and dyslipidemia and
15
Chapter 1

the occurrence of micro- and macrovascular complications63. Because lifestyle factors such as
excessive food consumption, reduced physical activity, and smoking play an important role in
the development and progression of T2D, lifestyle changes form the basis of treatment. Patients
are strongly advised to stop smoking, as this is an independent risk factor for the development
of T2D and also increases the risk of cardiovascular complications64. Patients are also
recommended to increase physical activity, which can improve glycemic regulation
independent of weight loss65. In overweight (BMI>25 kg/m2 )or obese (BMI>30 kg/m2)
patients, weight loss is highly recommended as even slight weight loss (5-10%) lowers plasma
glucose and lipid levels and blood pressure66. Intensive weight management can even lead to
remission of T2D. In the Counterpoint study, a study that included 11 people with T2D, strong
caloric restriction (600 kcal/day) led to normalization of fasting glucose levels within one
week67. Normalization of fasting glucose levels was associated with decreased fat accumulation
in the liver and pancreas67. In the DiRECT study, a study that recruited 306 individuals with
T2D, various amounts of weight loss led to diabetes remission for at least 12 months (HbA1C
<6,5%) in 46% of the patients68. After a two-year follow-up period, diabetes remission dropped
to 36%69. Whether these intense weight management programs also reduce the risk of micro-
and macrovascular complications and mortality rates should become clear from future follow-
up studies. Thus far, a post-hoc analysis of the Look AHEAD trial, a study that compared
intensive lifestyle intervention with regular diabetes care, indicated for those patients that lost
at least 10% of their body weight, there was a 21% lower risk of a composite outcome of death
from cardiovascular disease, non-fatal acute myocardial infarction, non-fatal stroke, or
admission to hospital for angina70.
Despite these successes of weight loss on the remission and complications of diabetes,
it is important to note that the implementation of lifestyle changes appears to be remarkably
difficult, especially when they have to be applied over more extended periods71. According to
the WHO, adherence to long-term therapy for chronic illness averages only 50%72. In larger
studies, adequate glycemic control (HbA1c <7%) by caloric restriction is only achieved in 10-
20% of newly diagnosed T2D patients73, indicating that glucose-lowering drugs are usually
needed as well. Finally, it is estimated that around 3,5-25% of T2D patients have a normal body
weight74–77, which makes diet-mediated weight reduction an unfeasible treatment strategy in
these patients.
If adequate glycemic control cannot be achieved through lifestyle intervention,
treatment with glucose-lowering drugs is needed. Table 1 gives an overview of currently
available antidiabetic drugs, their mode of action, side effects, and contraindications. A low
dose of metformin is generally prescribed as the first line of treatment78. The dose of metformin
is gradually increased to achieve proper glycemic control. If treatment with metformin does not
result in adequate glycemic control, a sulfonylurea is added, preferably gliclazide78. Lastly, the
glucose-lowering treatment regimen can be expended with daily long-acting insulin injections,
which may need to be intensified during disease progression78. It appears that around 50% of
people require insulin treatment after ten years of glucose-lowering therapy79. Dipeptidyl
peptidase 4 (DDP-4) inhibitors or glucagon-like peptide-1 (GLP-1)-receptor agonist may be
used as alternatives to insulin treatment, although the long-term safety of these drugs is still
unknown78. In case of insufficient glycemic control, pioglitazone or sodium-glucose co-
transporter 2 (SGLT-2) inhibitors can also be prescribed. Similar to DDP-4 inhibitors and
16
 Introduction

GLP1-receptor agonists, the long-term safety of SGLT-2 inhibitors is still unknown78. The use
of pioglitazone is preferably avoided because of its long-term adverse safety effects78.
Even though a relatively large number of antidiabetic drugs are available, adequate long-
term glycemic control is difficult to obtain80. Some studies showed that at least 45% of patients
fail to achieve proper glycemic control81. Insufficient long-term glycemic control is believed to
be partly caused by disease progression, causing glucose levels to increase over time despite
treatment with glucose-lowering drugs80. Ineffective management of blood glucose levels
requires treatment intensification, resulting in the need to take higher doses of drugs, or
combinations of different drugs, both of which increase the risk of developing adverse drug
reactions63. As shown in Table 1, all of the currently available antidiabetic drugs are associated
with various adverse drug effects, including gastrointestinal intolerance, hypoglycemia, weight
gain, and organ dysfunction63. Adverse drug effects have been shown to contribute to poor
medication adherence, which directly contributes to insufficient glycemic control82. Optimal
treatment of hyperglycemia is further limited by various drug-related contraindications (Table
1), meaning some drugs cannot be used in certain groups of patients.
Despite their ability to lower blood glucose levels, the efficacy of glucose-lowering
drugs to prevent micro- and macrovascular complications appears to be very moderate.
According to a meta-analysis of randomized controlled trials that examined the effect of
intensive glucose lowering treatment (HbA1c ≤7.0%) on diabetes-related complications, their
only appears to be a small benefit on the risk of developing microalbuminuria and non-fatal
myocardial infarction83. Intensive glucose-lowering treatment does not significantly affect all-
cause mortality or cardiovascular death83. It should also be noted that these treatment benefits
are associated with a highly increased risk of developing hypoglycemic events83. It is estimated
that over five years, 117-150 patients need to be treated to prevent one myocardial infarction,
whereas 32 to 142 patients need to be treated to prevent one episode of microalbuminuria83.
Worryingly, for every 15 to 52 treated patients with glucose-lowering drugs, one episode of
hypoglycemia occurs83. Given these limited benefits of the current arsenal of glucose-lowering
treatments and their associated adverse effects such as hypoglycemia, novel therapies are
urgently needed.

Table 1. Overview of currently available antidiabetic drugs, their mode of action, side effects, and
contraindications. Adapted from NHG-standard Diabetes mellitus type 2.
Drug Mode of action Side effects Contra-indications
Metformin Reduces Gastro-intestinal, Severe kidney, liver, and
gluconeogenesis. headache, insomnia, taste heart dysfunction, poor
disturbances, lactic nutritional status, alcohol
acidosis. abuse.
Sulfonylureas Improve insulin secretion Weight gain, Kidney and liver
hypoglycemia, gastro- dysfunction.
intestinal, skin rash,
disturbed liver function,
pancytopenia.
Insulin Stimulates glucose Weight gain, Hypoglycemia,
uptake and reduces hypoglycemia, skin rash hypersensitivity to
hepatic glucose at the injection site, insulin
production.

17
Chapter 1

lipodystrophy, initial
increase in retinopathy.
Dipeptidyl-peptidase-4 Stimulate insulin Weight gain, gastro- Severe kidney, liver, and
inhibitors secretion and inhibit intestinal, pancreatitis, heart dysfunction, history
glucagon secretion. kidney dysfunction, of pancreatitis.
interstitial lung disease.
Glucagon-peptide like-1 Stimulate insulin Gastro-intestinal, rash at History of pancreatitis or
receptor agonists secretion and inhibit the injection site. pancreatic cancer, severe
glucagon secretion. kidney, liver, and heart
dysfunction.
Sodium-glucose Inhibits glucose Genital infections. Severe kidney or liver
cotransporter 2 inhibitors reabsorption in the dysfunction.
kidney.
Pioglitazone Improves insulin Weight gain, edema, Risk of heart failure,
sensitivity. possibly increased risk of liver dysfunction.
bone fractures, heart
failure, and lung disease.

In obese patients in which all treatment options have failed to improve glycemic control,
surgical weight loss using bariatric surgery offers a final strategy to treat T2D. Bariatric surgery
was initially used in severely obese patients who were unable to achieve sufficient weight loss
through lifestyle intervention84. More recently, it has been shown that bariatric surgery is also
a highly effective treatment for T2D and can lead to disease remission in up to 70% of the
patients two years after surgery, making this treatment superior to lifestyle intervention and
pharmaceutical treatments85. However, 15 years after surgery, T2D remission rates drop to
30%, showing that long-term glycemic control is a very tenacious problem84. Although long-
term diabetes remission is only maintained in one-third of surgically treated patients, the
cumulative incidence of microvascular complications is reduced by about 50% compared to
patients that received regular diabetes care86. In addition, bariatric surgery also leads to a 30%
decrease in the cumulative incidence of macrovascular complications and a 20% decrease in
overall mortality86,87. Currently, patients are eligible for bariatric surgery if they are severely
obese (BMI >35 kg/m2) and if other treatment options have failed84. However, the use of
bariatric surgery is limited by several contraindications for undergoing surgery, such as heart
failure, unstable coronary artery disease, end-stage lung disease, and portal hypertension88.
A summary of the effects of lifestyle intervention, pharmacological treatment, and
bariatric surgery on diabetes remission rates and the percentage of risk reduction in
microvascular and macrovascular complications and overall mortality is shown in Table 2.

Table 2. Effect of currently available T2D treatment options on diabetes remission rates and the percentage
of risk reduction in microvascular and macrovascular complications and overall mortality.
Treatment Diabetes remission Microvascular Macrovascular Mortality
complications complications
Lifestyle 36% (HbA1c <6.5, unknown -21% (composite unknown
intervention 2 years follow-up) end point)
Antidiabetic drugs 3-16% (HbA1c -15% -15% (non-fatal No effect.
<6.5, 2 years (microalbuminuria) myocardial
follow-up) infarction)

18
 Introduction

Bariatric surgery 70% (glucose <6.1 -50% (composite -30% (composite -20%
mmol/L, 2 years end point) end point)
follow-up)

Treatment options for NAFLD

Unlike the many treatment modalities that are available for T2D, treatment options for
NAFLD are very limited. While lifestyle interventions and bariatric surgery are partly effective
in reducing hepatic fat content, inflammation, and fibrosis, there are currently no FDA-
approved drugs available for the treatment of NAFLD. Similar to the treatment of T2D,
treatment of NAFLD involves lifestyle modifications aimed at improving metabolic health and
increasing weight loss. Even a slight weight loss of 3-5% causes a significant reduction in
hepatic steatosis89. Higher percentages of weight loss, ranging from 7-10%, reduce hepatic
inflammation, hepatocyte damage, and fibrosis 51,89,90. As mentioned earlier, the
implementation of lifestyle changes appears to be remarkably difficult, especially when they
have to be applied over more extended periods. As a result, significant weight loss is only
achieved by about 50% of the patients89. Alternatively, pronounced weight loss can also be
obtained by performing bariatric surgery. Bariatric surgery can improve NASH in more than
70% of the patients, while significant improvements in fibrosis are also observed91. However,
it should be noted that similar to the situation in T2D, a considerable portion of NALFD patients
(7-19%) have a normal body weight92, making weight loss-based therapies like caloric
restriction and bariatric surgery unsuitable.
Because lifestyle interventions and bariatric surgery are not effective or feasible in all
NAFLD patients, there is a great interest in the development of new pharmacologic treatments
for NAFLD. At this moment, around 60 different drugs are being tested for their efficacy and
safety in phase 1-3 clinical trials. Drugs that are currently in phase 3 clinical trials for the
treatment of NAFLD are summarized in Table 3. Three of these phase 3 drugs, Ocaliva,
Elafibranor and Resmetirom, target members of the nuclear receptor family, which are ligand-
activated transcription factors that regulate gene expression in response to endogenous or
exogenous ligand activation. Ocaliva is a semi-synthetic analog of the bile acid
chenodeoxycholic acid (CDCA) and activates the farnesoid X receptor (FXR). Ocaliva-
mediated activation of FXR reduces liver fat accumulation and fibrosis in animal models93,94.
In patients with NAFLD and T2D, Ocaliva reduces liver damage and fibrosis markers and also
improves NASH histology in about 50% of the patients95. Elafibranor is a dual peroxisome
proliferator-activated receptor α/δ (PPARα/δ) agonist which demonstrates liver-protective
effects in preclinical models of NAFLD96. However, in clinical trials, Elafibranor only
moderately improves NASH histology97. Resmetirom targets the thyroid hormone receptor β
(THR- β) and improves dyslipidemia and reduces liver fat accumulation; however, the full study
results have not yet been published98.
Because a large number of pathophysiological processes are involved in the
development and progression of NAFLD, a variety of biological pathways, including
inflammation and fibrogenesis, can potentially be targeted to reduce disease activity.
Cenicriviroc (CVC) is a dual antagonist of the C-C chemokine receptor types 2 and 5 and has
been shown to have anti-inflammatory and antifibrotic properties in animal models, probably
by decreasing the recruitment of proinflammatory leukocytes at the site of liver damage99. In

19
Chapter 1

humans, CVC does not improve steatohepatitis, although it significantly reduces fibrosis100.
Belapectin is a drug that targets galactin-3, a protein implicated in fibrosis progression. In
preclinical studies, Belapectin reduces liver fibrosis, while it also reduces liver damage markers
in humans101. In a follow-up trial, however, 16 weeks of Belapectin treatment did not improve
surrogate markers of hepatic fibrosis101.

Table 3. Summary of phase 3 NAFLD/NASH drugs, their mode action, side effects, and contraindications.
Drug Mode of action Side effects Contra-indications

Ocaliva FXR agonist Pruritus, fatigue, gastro- Complete biliary

intestinal, increased obstruction
LDL-cholesterol

Elafibranor Dual PPARα/δ agonist A reversible increase in Not available.

serum creatinine

Cenicriviroc CCR2-CCR5 antagonist Gastro-intestinal, Not available.

headache, fatigue.

Resmetiron THR-β-agonist Not available. Not available.

Belapectin Galectin inhibitor Not available. Not available.

New hormone-based treatments for T2D and NAFLD

Because current treatment options for T2D and NAFLD are only partially effective and
associated with numerous adverse drug reactions and contraindications, there is a clear need to
identify new therapeutic targets that can improve metabolic health. According to the James-
Lind Alliance disease priority setting partnership, the need to develop improved drugs for T2D
and NAFLD has been identified as a research priority among patients and health care
professionals102,103. The view that there is an unmet therapeutic need for patients with T2D or
NALFD is also recognized by the major drug regulatory agencies including the European
Medicines Agency (EMA) and the U.S. Food and Drug Administration (FDA), as well as non-
profit diabetes research associations like the European Association for the Study of Diabetes
(EASD) and the American Diabetes Association (ADA)104–109.
After the success of insulin therapy, there is great interest in the development of novel
hormone-based therapies110. Thus far, GLP1-receptor agonists and fibroblast growth factors
(FGFs) have shown remarkable efficacy to improve metabolic health in preclinical models111.
GLP-1 is a hormone that is produced in the gut and signals to the brain and pancreas, resulting
in suppression of appetite and gastric emptying and the stimulation of insulin secretion112.
Treatment with GLP-1 analogs decreases body weight and improves glycemic control and can
currently be prescribed for the treatment of T2D as an alternative to insulin therapy. It has
recently been shown that GLP-1 analogs may also be useful in the treatment of NAFLD. In
humans, treatment with the GLP-1 analog Liraglutide results in NASH resolution and a
reduction in the progression of fibrosis113.

20
 Introduction

Another group of hormones that recently received much attention as potential new drugs
for the treatment of T2D and NAFLD is the FGF hormone family. Several members of the FGF
family (i.e., FGF1, FGF19, and FGF21) have been identified as endogenous regulators of
metabolic homeostasis114. Therapeutic administrations of recombinant FGF protein potently
lowers glucose levels, hepatic fat content, and cholesterol levels in preclinical models,
signifying that FGFs can act as potential novel drug candidates for the treatment of various
obesity-related disorders, including T2D, NALFD, and dyslipidemia115. Thus far, efforts to
translate these findings to the clinic have resulted in the development of several FGF21- and
FGF19-based drugs that have already been tested in various clinical trials. In contrast, FGF1-
based drugs are still in preclinical development116. The potential of FGF-based drugs in the
treatment of non-metabolic diseases, particularly cholestasis, has been shown as well117,118.

The FGF superfamily

The mammalian FGF superfamily is one of the largest growth factor families and plays
a role in controlling a wide variety of biological processes, including embryonic development,
tissue homeostasis, and metabolism119. The FGF family consists of 22 closely-related genes
that originated from several gene- and genome duplications events during early metazoan and
vertebrate evolution (Figure 3)119. Phylogenetic analysis has shown that the 22 FGF genes can
be further grouped into seven subfamilies, including FGF subfamily 1, 4, 7, 8, 9, 11, and 19120.
Functional classification of FGF polypeptides shows that members of FGF subfamily 1, 4, 7,
8, and 9 function as autocrine/paracrine hormones, while members of the FGF19 family (i.e.,
FGF19, 21 and 23) mainly act as endocrine hormones120. Although there is no FGF19 gene in
mice, it shows the strongest sequence similarity with the mouse FGF15 gene. Because their
biological functions are conserved, the mouse FGF15 gene is considered to be the orthologue
of the human FGF19 gene and is therefore also designated as FGF15/19119,120. Members of the
FGF11 subfamily remain intracellular and are classified as intracrine FGFs119. Although
members of the FGF11 family show substantial sequence similarity to other FGF members,
they are functionally are unrelated119.
Whereas the transcriptional regulation of most FGF is largely unexplored, it has been
shown that the expression of the metabolic FGFs, FGF1, FGF15/19, and FGF21, is partly
controlled by nutrient-sensitive nuclear receptors, including PPARγ, FXR, and PPARα 115.
Besides, both FGF1 and FGF2 mRNAs contain an internal ribosomal entry site, indicating that
these genes can also be transcribed during conditions of cellular stress121,122. This view is
corroborated by the finding that endoplasmic reticulum stress affects FGF expression and
secretion123.
Once secreted from cells, autocrine/paracrine FGFs bind to heparan sulfate
proteoglycans (HSPG), which limits their diffusion into the interstitial space and regulates their
activity119. Members of the endocrine FGF19 subfamily have lost their ability to bind HSPG
and can diffuse into the bloodstream119. Instead of binding to HSPG, endocrine FGFs evolved
to bind the transmembrane protein β-klotho (KLB)124. Binding of FGF to HSPG or KLB
facilitates their interaction with FGF receptors (FGFRs). In both humans and mice, four FGFR
genes (FGFR1-4) have been identified125. Alternative splicing of the FGFR1-3 transcripts
generates various splice variants with different FGF ligand binding specificities125. The binding
of FGF ligands to FGFRs results in receptor dimerization and receptor transphosphorylation,
21
Chapter 1

creating docking sites for the recruitment of various adapter proteins, particularly fibroblast
growth factor receptor substrate 2α (FRS2α)119. FRS2α is involved in generating a signaling
complex that results in downstream activation of at least four canonical receptor tyrosine kinase
signaling nodes, including the MEK-ERK, PI3K-AKT, PLCγ, and STAT3 signaling pathways
(Figure 4)119. While much is known about the pathways being activated in response to FGFR
stimulation, little is known about the mechanisms that inactivate FGFR activity119. Ultimately,
altered FGFR activity is linked to the modulation of a wide range of cellular responses,
including proliferation, differentiation, migration, and apoptosis119.

Figure 3. Phylogenetic tree of the fibroblast growth factor superfamily. This figure shows the evolutionary
relationship between FGF genes. Branch lengths are proportional to the evolutionary distance between each gene.
The figure also shows the functional classification of FGF polypeptides. FGF subfamily 1, 4, 7, 8, and 9 (grey) act
as autocrine or paracrine hormones and are also known as canonical FGFs. Members of the FGF19 subfamily (red)
are classified as endocrine FGFs. The FGF11 subfamily members (blue) reside intracellularly and are classified as
intracrine FGFs.

The designation fibroblast growth factor originated from the early observation that
FGFs can stimulate the growth of fibroblasts126. However, the generation of FGF knockout
(KO) mice and the discovery of human hereditary diseases caused by mutations in FGFRs
clearly showed that FGFs could also target many other cell types and can regulate numerous
other biological activities119. The characterization of FGF KO mice revealed that most FGFs
play a role in several stages of embryonic development. Interestingly, disruption of the genes
encoding FGF15, FGF21, and FGF1, demonstrated that these proteins are critical regulators of
metabolic homeostasis during adulthood127–129.

22
 Introduction

Figure 4. Overview of the major signaling pathways activated in response to the FGF-dependent FGFR
stimulation. HSPG (1) and KLB (2) are involved in the sequestration of FGF ligands and promote FGFR1-4
binding. The activation of FGFRs results in receptor dimerization and the activation of canonical RTK intracellular
signaling pathways, including MAPK (3), PI3K/AKT (4), PLCγ (5), and STAT3 (6). Collectively, these pathways
modulate various cellular responses (7).

FGF15/19
Although FGF15 KO mice usually die after postnatal day seven, some FGF15 KO mice
survive due to differences in gene penetrance127. These surviving FGF15 KO mice are
characterized by increased fecal bile acid excretion, indicating that FGF15 is a negative
regulator of bile acid synthesis127. There is now considerable evidence that FGF15 and its
human orthologue FGF19 play a crucial role in the regulation of bile acid homeostasis130.
FGF15/19 appears to be predominantly produced in the ileum in response to bile acid-
dependent FXR activation130. Secreted FGF15/19 then travels to the liver to where it binds the
KLB/FGFR4 complex to inhibit the expression of cholesterol 7 alpha-hydroxylase (CYP7A1),
the rate-limiting enzyme in the conversion of cholesterol to bile acids130. Interestingly, the
endogenous role of FGF15/19 in the suppression of bile acid production can be largely
mimicked by the pharmacological administration of recombinant FGF19131. Because elevated
bile acid levels can result in enterohepatic toxicity and are linked to organ damage in diseases
such as cholestasis and NASH, the ability of recombinant FGF19 to suppress bile acid-related
toxicity in these diseases is currently studied in several preclinical and clinical studies117,118,132.
In addition to its role in bile acid metabolism, FGF15/19 also plays a crucial role in
regulating hepatic glucose, lipid, and protein metabolism130. Overexpression of FGF19
increases energy expenditure and protects against diet-induced hepatic lipid accumulation133,134.
FGF19 appears to improve hepatic steatosis by increasing fatty acid oxidation and decreasing
23
Chapter 1

DNL133,134. FGF19 also stimulates hepatic protein synthesis135. In addition, pharmacological

administration of FGF19 also lowers blood glucose levels in diabetic mice136,137. FGF19
appears to lower blood glucose levels partly by promoting hepatic glycogen storage and
simultaneous inhibition of gluconeogenesis135,138. In contrast to insulin, which largely controls
hepatic glycogen metabolism in an AKT-dependent manner, FGF19 stimulates glycogen
storage by increasing hepatic MAPK activity135. However, more recent studies suggest that the
metabolic effects of FGF19 may also involve its ability to affect the activity of various neuronal
systems, including elevation of sympathetic nerve activity and reduction of AGRP/NPY and
HPA activity137,139,140.
The potent preclinical activity of FGF19 in various disease models resulted in the
development of an FGF19-based drug that could be used in the treatment of human diseases.
Because prolonged administration of high doses of wildtype FGF19 is associated with the
occurrence of hepatocellular carcinomas in mice, the mitogenic effect of FGF19 formed a
considerable obstacle in the development of a safe but still effective FGF19-based drug. In a
large-scale (>150 FGF19 mutants), unbiased, in vivo screen, NGM Biopharmaceuticals
discovered a non-mitogenic FGF19 analog (NGM282) that retained the ability to lower blood
glucose levels in db/db mice141. Multiple clinical trials are currently investigating the safety and
efficacy of NGM282 in the treatment of T2D, NASH, primary sclerosing cholangitis, and
primary biliary cholangitis142. Thus far, these studies have shown that NGM282 potently
reduces plasma levels of 7alpha-hydroxy-4-cholesten-3-one (C4), a surrogate marker of bile
acid synthesis, in healthy subjects and various disease states. These studies provided, for the
first time, direct evidence that FGF19 reduces bile acid synthesis in humans. In NASH patients,
NGM282 reduces liver fat content, liver inflammation, and liver- damage and fibrosis markers
in plasma142. However, the potent glucose-lowering effects of NGM282 that were seen in
rodents are not recapitulated in humans142. The main side effect of NGM282 treatment is an
increase in plasma LDL levels142.

FGF21
In contrast to FGF19 KO mice, FGF21 KO mice develop relatively normal, although
some strains develop mild obesity and impaired glucose homeostasis128. However, the full
phenotype of FGF21 KO mice is only revealed when these mice are metabolically stressed128.
For example, in response to a ketogenic diet, FGF21 KO mice display increased body weight
and liver fat accumulation, indicating defective hepatic lipid oxidation128. In addition,
prolonged fasting increases hepatic FGF21 expression by enhancing the transcriptional activity
of PPARα, a transcription factor that responds to energy deprivation128,143. The upregulation of
FGF21 expression is associated with changes in lipolysis, ketogenesis, growth, torpor, and
female reproduction; all responses related to the adaptive starvation response128,143–145. A role
for FGF21 in the physiology of fasting is also supported by the bidirectional interaction with
glucagon146,147. In contrast to fasting-induced FGF21 expression, several other metabolic
stressors, such as high-carbohydrate diets, fasting-refeeding regimens, and cold exposure can
also stimulate FGF21 expression in various tissue, although the physiological relevance of this
remains largely unclear148–151.
Similar to FGF19, the pharmacological administration of FGF21 has potent effects on
glucose and lipid metabolism. The pharmacological activity of FGF21 was initially discovered
24
 Introduction

in a cell-based screen in which it was shown to promote glucose uptake in adipocytes152. In

diabetic rodents, acute administration of FGF21 reduces plasma insulin, glucagon, glucose, and
triglyceride levels153,154. Besides, chronic FGF21 treatment or FGF21 overexpression protects
against diet-induced obesity and improves insulin sensitivity153–156. In diabetic rhesus monkeys,
the therapeutic administration of FGF21 decreases plasma glucose, insulin, TG, and LDL
levels, and increases plasma HDL levels157. The acute FGF21-dependent metabolic
improvements are mechanistically linked to activation of the FGFR1/KLB complex in adipose
tissue, which increases plasma levels of the adipokine adiponectin, ultimately enhancing insulin
sensitivity158–160. In contrast, the metabolic improvements that are observed after long-term
FGF21 treatment appear to be caused by binding of FGF21 to FGFR1/KLB in the brain, which
increases energy expenditure by enhancing sympathetic outflow to brown and white adipose
tissue.137,145,161–164
Like FGF19, the potent metabolic effects of FGF21 in rodents and primates ultimately
led to the development of several FGF21-based drugs, which have been recently tested in
several clinical trials for their safety and efficacy in the treatment of T2D, NAFLD, and
dyslipidemia165. More recently, we found that autocrine/paracrine FGF1 also plays a vital role
in regulating metabolic homeostasis129. Similar to the endocrine FGFs, pharmacological
administration of FGF1 potently lowers blood glucose levels and hepatic fat content in obese
and diabetic rodents116,166. Interestingly, prolonged FGF1 treatment is not associated with side
effects that are typically seen with other antidiabetic drugs, such as weight gain and
hypoglycemia166. In comparison with the endocrine FGFs, preclinical studies show that the
metabolic effects of FGF1 require lower dosing and are more long-lasting. Also, the metabolic
actions of FGF1 are KLB independent, which is predicted to increase its therapeutic
applicability beyond that of FGF19 and FGF21, mainly since KLB expression is restricted to
specific tissues, and its expression is downregulated by obesity and tissue inflammation167,168.
Moreover, in contrast to their potent antidiabetic effects in rodents and non-human primates,
FGF19- and FGF21-based drugs do not significantly affect human glucose metabolism in
clinical trials165. Hence, the development of novel FGF-based drugs may provide the ability to
target human glucose and lipid metabolism more effectively.

FGF1
The FGF1 protein was isolated from the bovine pituitary gland in 1984 and was initially
known for its ability to stimulate the growth of fibroblasts126. The FGF1 gene itself was cloned
several years later and is now known to give rise to at least four different FGF1 transcript
variants, designated FGF1A, FGF1B, FGF1C, and FGF1D (Figure 5)129,169. The different
transcript variants are believed to result from a combination of alternative promoter usage and
splicing events of different 5’ untranslated exons169. The expression of the different FGF1
transcript variants is controlled in a tissue- and stimulus-specific manner129. Interestingly, all of
the well-described FGF1 transcript variants (1A, 1B, 1C, and 1D) give rise to the same 155
amino acid long non-glycosylated protein. The N-terminal region of the FGF1 protein contains
a nuclear localization sequence (NLS)170. Although the physiological relevance of nuclear
FGF1 activity is still unclear, it has been implicated in FGF1-dependent regulation of
proliferation, differentiation, and apoptosis171,172. The C-terminal region of the FGF1 protein
contains the HSPG binding site, which is crucial for its interaction with FGFRs173. In contrast
25
Chapter 1

to most other FGFs, FGF1 lacks a secretion signal peptide and is released from cells in a stress-
dependent non-classical secretory pathway174

Figure 5. Simplified scheme of the genomic organization and expression of the human FGF1 gene. The
human FGF1 gene consists of 11 different exons, of which seven are shown in this scheme. Alternative splicing
and promoter usage generate at least four different FGF1 transcript variants (FGF1A-D) that differ in their 5’
untranslated exons. Each splice variant consists of a specific 5’ untranslated exon coupled to exon 2-4. The
expression of these FGF1 transcript variants is controlled in a stimulus- and tissue-dependent manner. Translation
of the FGF1 transcript variants yields identical FGF1 polypeptides.

Once outside the cell, FGF1 shows a strong affinity for HSPGs, which are assumed to
regulate the stability, availability, and activity of FGF1119. Besides, it was proposed that the
binding of FGF1 to integrin ανβ3 also plays a role in regulating FGF1 activity175,176. However,
this view has recently been challenged by showing that mutations in the integrin-binding site
strongly reduce FGF1 protein stability and hence its biological activity177. In addition to HSPG
and integrin ανβ3, various other cell surface FGF1 binding sites have recently been identified,
including CD44 and CSPG4 178. However, more research is needed to understand the functional
implications of these interactions. In vitro, the effect of HSPG can be mimicked by the addition
of exogenous heparin, which has been shown to potentiate FGF1-dependent proliferation173.
FGF1 is unique in its ability to bind to and activate all four FGF receptors and is therefore also
called the universal FGF ligand179. Similar to other FGFs, binding of FGF1 to the FGFR can
result in the activation of at least four different signal transduction pathways, including the
MEK-ERK, PI3K-AKT, PLCγ, and STAT pathways119. The FGF-dependent activation of these
pathways has been linked to various cellular functions, in particular, its ability to stimulated the
growth of fibroblasts126. The first hints towards a metabolic role came from studies that showed
that FGF1 controls the in vitro differentiation and proliferation of preadipocytes and that obesity

26
 Introduction

sharply increases FGF1 expression in human and mouse adipose tissue129,180–183. In adipocytes,
FGF1 expression is strongly regulated by the lipid-sensitive transcription factor PPARγ,
providing additional evidence for a metabolic link129. Interestingly, thiazolidinediones, which
is a class of the antidiabetic drugs that target PPARγ and improve insulin sensitivity, also
increase FGF1 expression184.
Subsequent studies showed that FGF1 KO mice were unable to properly expand their
adipose tissue during diet-induced obesity, which resulted in ectopic lipid accumulation in the
liver and disturbed glucose metabolism129. Although the exact mechanism through which FGF1
controls adipose tissue remodeling remains unclear, its previously identified function in the
proliferation and differentiation of pre-adipocytes could play a role180–182. Also, given that the
adipose vasculature is sharply reduced in FGF1 KO mice, a paracrine effect of FGF1 on the
behavior of endothelial cells might be relevant as well129,183. Finally, it has also been shown that
FGF1 can act in an autocrine manner on mature adipocytes; however, the physiological
relevance of this autocrine FGF1 loop is still unclear (Figure 6).

Figure 6. Possible endogenous functions of FGF1 in adipose tissue. A HFD (1) and TZDs (2) increase adipose
FGF1 expression in a PPARγ-dependent manner (3). Secreted FGF1 may act in a paracrine manner to stimulate
preadipocyte differentiation (4) or angiogenesis (5). FGF1 may also directly act on adipocytes via an autocrine
loop (6).

In addition to its endogenous function in adipose tissue homeostasis and whole-body

glucose regulation, pharmacological administration of recombinant FGF1 has been found to
acutely lower blood glucose levels in several diabetic mouse models116,166. Although the
mechanism of its acute anti-diabetic effects remains unclear, FGFR1 signaling in adipose tissue
appears to play a critical role166. Also, chronic FGF1 administration has been shown to result
27
Chapter 1

in sustained glucose-lowering and improved insulin sensitivity166. Besides its glucose-lowering

effects, chronic FGF1 treatment also reduces steatosis and inflammation in the liver, suggesting
that in addition to adipose tissue, FGF1 can also target the liver116,166. More recently, it was
revealed that the central administration of FGF1 resulted in a continuous lowering of blood
glucose levels in diabetic rodents140,185–187. In contrast to the adipose-dependent glucose-
lowering effects of peripheral FGF1 administration, the glucose-lowering effects of centrally
administrated FGF1 are linked to activation of hypothalamic tanycytes185. Recently it was
shown that peripheral FGF1 administration also leads to activation of hypothalamic tanycytes,
indicating that the underlying glucose-lowering mechanisms of peripherally and centrally
administered FGF1 may be partially overlapping. An overview of the main pharmacological
effects of FGF1 is shown in Figure 7.

Figure 7. Overview of the main pharmacological effects of FGF1. Peripherally administered FGF1 targets
adipose tissue, which results in glucose-lowering via a mechanism that has not yet been completely understood
(1). Chronic FGF1 treatment results in reduced liver steatosis and inflammation, while glycogen storage and
hepatocyte proliferation are increased (2). Recently, it has been shown that chronic FGF1 treatment is also
associated with increased beta-cell mass (3). The fact that peripheral FGF1 administration also lowers food intake
suggests that FGF1 can pass the blood-brain barrier to target the brain (4). The effects of peripheral FGF1
administration on glycemic control and food intake can be mimicked by central FGF1 administration in the third
ventricle (5). In T1D rats, central FGF1 administration is also associated with reduced activity of the HPA axis
(5). Recently, it has been shown that the effects of central FGF1 administration on glycemic control and food
intake are dependent on the altered activity of the hypothalamic arcuate nucleus (6).

28
 Introduction

Although the metabolic actions of FGF1 have been reproduced by several independent
research groups, the involved metabolic pathways by which FGF1 improves blood glucose
levels and liver fat content remain largely unclear. In addition, FGF1 signaling is also linked to
the stimulation of cell growth, which is a highly unwanted effect with regard to its possible
therapeutic application and requires a better understanding of the relationship between the
metabolic and cell growth-promoting functions of FGF1. Ultimately, FGF1’s metabolic and
mitogenic functions are a reflection of its ability to activate various cellular signal transduction
pathways. Full understanding of FGF1 activity, therefore, also requires more in-depth insight
into the molecular players that regulate FGF1 signaling. Finally, a growing amount of
preclinical evidence suggests that FGF1, but also FGF19 and FGF21, improve metabolic
homeostasis by acting on the hypothalamus, however, whether the required FGF receptor
system is also present in the hypothalamus of humans remains unclear.

Thesis outline
In this thesis, we report the results of preclinical studies aimed to provide details on
FGF1’s mechanism of action and safety. In chapters 1 and 2, we present background
information on the pathophysiology and treatment of T2D and NAFLD and describe how
several members of the fibroblast growth factors family, including FGF1, FGF15/19, and
FGF21 have been developed into new biologicals for the treatment of chronic metabolic
diseases. In chapter 3, we provide an in-depth discussion on the efficacy and safety of
Pegbelfermin, an FGF21 analog that is currently in clinical trials for the treatment of NAFLD.
In chapter 4 and chapter 5, we report the results of several preclinical studies aimed to identify
the underlying mechanisms by which recombinant FGF1 lowers hepatic lipid content. In
chapter 6 and chapter 7, we report the results of preclinical studies aimed to identify the
underlying mechanisms by which recombinant FGF1 regulates glucose metabolism. In chapter
8, we addressed the safety of recombinant FGF1 administration by examining to what extent
the metabolic and cell growth-promoting functions of FGF1 can be dissociated. In chapter 9,
we used peptide-based protein tyrosine kinase and phosphatase activity profiling methods to
study more fundamental biological aspects of FGF1 activity, in particular the regulation of
cellular FGF1 signaling. In chapter 10, we comprehensively analyzed FGF and FGFR gene
expression levels in the hypothalamus of lean and obese human subjects. Finally, in chapter
11, the key findings of this thesis will be discussed.

Acknowledgments

All figures were created with BioRender.com

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