Michael Schilsky, MD, is a professor of medicine and medical director of adult liver transplant at Yale-New Haven Transplantation Center.

Michael Schilsky, MD

A novel once-daily formulation of trientine tetrahydrochloride (TETA 4HCl) achieved systemic drug exposure comparable to the approved twice-daily formulation, according to phase 1 TRIUMPH-3 data presented by Michael Schilsky, MD, at The Liver Meeting 2026 in Denver, Colorado.

The findings target a persistent challenge in Wilson disease: lifelong therapy that depends on adherence. Current anticopper drugs require at least twice-daily dosing timed away from meals, and missed doses often cause no immediate symptoms, Schilsky, professor of medicine at Yale School of Medicine, told HCPLive.

Once-Daily Trientine for Wilson Disease: TRIUMPH-3 Data

Once-Daily Trientine Matches Twice-Daily Exposure in Wilson Disease

“Any time you increase beyond once a day, the amount of non-adherence, non-compliance goes up very dramatically,” he said.

In the randomized, open-label, crossover study, 26 participants received a total daily dose of 900 mg trientine base, either as a new 300-mg formulation once daily or as the EU-approved 150-mg formulation in 2 divided doses 8 hours apart. Peak plasma concentration roughly doubled with once-daily dosing (geometric mean, 3436 vs 1567 ng/mL), but total exposure was comparable, with a geometric mean ratio of 1.155 for AUC

. Concentrations at 48 hours were also similar, suggesting excretion is independent of dosing frequency. Five participants experienced 8 adverse events, 7 of them mild.

Schilsky notes that the formulation itself was the key hurdle. His group’s 2015 pilot study found once-daily trientine effective in 8 patients with stable disease, but existing tablets created a high pill burden.

 The new formulation fits double the drug into nearly the same tablet size.

Because once-daily dosing produces a higher peak, studies must still show that the greater initial exposure is well tolerated by the liver. Separate patient-reported data presented at the meeting suggest once-daily dosing may improve convenience and adherence.

Watch the full interview to hear Schilsky discuss what needs to be shown before once-daily trientine reaches practice and how a planned head-to-head trial with D-penicillamine could support its use as first-line therapy.

Schilsky M, Weiss KH, Ashdown T, et al. Can a novel instant release trientine tetrahydrochloride formulation be effective when administered once daily? Results of the TRIUMPH-3 pharmacokinetic study. Presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, CO.

Ala A, Aliu E, Schilsky ML. Prospective pilot study of a single daily dosage of trientine for the treatment of Wilson disease. 

. 2015;60(5):1433-1439. doi:10.1007/s10620-014-3495-6

Tsochatzis E, Kamlin CO, Hurt C, et al. Understanding the drivers of treatment experience and adherence in Wilson disease: what do patient interviews and reported outcomes from a phase 2 study evaluating a new trientine tetrahydrochloride formulation tell us? Presented at: The Liver Meeting 2026; November 5-9, 2026; Denver, CO.

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TRIUMPH-3 pharmacokinetic data show once-daily trientine tetrahydrochloride achieved exposure comparable to twice-daily dosing for Wilson disease.

Early Treatment May Protect Cognitive Function in Wilson Disease, With Michael Schilsky, MD

New 5-year data from the Wilson Disease Registry indicate patients without severe neurologic involvement can show meaningful cognitive gains after early detection and therapy.

Michael Schilsky, MD, a professor of medicine and medical director of adult liver transplant at Yale-New Haven Transplantation Center, presented the findings at the 

American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025

, and reported patients with abnormal baseline cognition saw significant MoCA improvement over time when treated early in the disease course.

WD is a rare inherited multisystem disorder affecting approximately 1 in 30,000 individuals worldwide. The disease primarily impacts hepatic and neurological function and stems from pathogenic mutations in the ATP7B gene, which impairs the liver’s ability to excrete excess copper. Copper accumulation damages the liver and brain, and without daily treatment, the disease is fatal.

In patients, early signs of excess copper may present as neurologic (40-45%), hepatic (50-60%), or psychiatric (10-20%) symptoms. Although the liver is affected first, neurological symptoms are the initial presentation in about 40% of patients. Before diagnosis, 20% of patients have already seen a psychiatrist, and some report psychological or behavioral changes such as depression, anxiety, impulsivity, and aggression.

“When you see patients with severe neurologic impairment or other mental health concerns, the key questions become: How intact are they, and what is the effect of therapy?”

“It was important to examine this prospectively. Using a multinational, multicenter registry that collected detailed data, we evaluated cognition, quality of life, neurologic function, and liver function to understand baseline cognition and how it changes over time.”

The study conducted a cross-sectional and longitudinal analysis using the Montreal Cognitive Assessment (MoCA) and the Unified Wilson’s Disease Rating Scale (UWDRS), a disease-specific tool evaluating neurologic symptoms. With a possible score of 30, a MoCA score of ≥ 26 is considered normal and <26 is considered abnormal, indicating cognitive impairment. Participants were classified by phenotype at diagnosis: asymptomatic (21%), hepatic (30%), or neurologic (37%).

The cohort included 138 patients with a mean baseline MoCA score of 26.3. A total of 44 patients (32%) had MoCA scores <26 (mean 22.9, 3), distributed as 21% asymptomatic, 30% hepatic, and 37% neurologic.

Investigators found a negative correlation between MoCA and UWDRS at baseline (r = -0.47, 

 = <.001, Pearson), and patients with MoCA <26 had significantly higher UWDRS scores (

Over 2-3 years, investigators observed an average 1-point increase in MoCA (

= .001), suggesting cognitive improvement with treatment. In a longitudinal follow-up at 2, 3, 4, and 5 years (

< .01), only patients with baseline MoCA <26 showed significant improvements in cognitive function. Phenotype-adjusted analysis revealed the hepatic group experienced a 0.6-1.8 MoCa increase from baseline.

Patients with less severe neurologic disease showed less Central Nervous System injury at baseline, which was associated with a greater likelihood of cognitive improvement over time.

“Overall, cognition is preserved in most patients and remains stable with treatment,” said Schilsky. “And importantly, with treatment, patients without severe neurologic impairment are likely to improve.”

Schilsky, M, Ulcay A, Maras H, et al. Cognitive function in patients with Wilson disease: prospective analysis from the Wilson Disease Registry study. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.

Disease W. Wilson Disease - Wilson Disease Association. Wilson Disease Association. Published August 13, 2021. Accessed November 14, 2025. 

https://wilsondisease.org/do-i-have-wilson-disease/?gad_source=1&gad_campaignid=16684019432&gbraid=0AAAAADN9hfNH0Qklo1N7KKX3qO0womQLJ&gclid=CjwKCAiAw9vIBhBBEiwAraSATuJdNxoP57_7zjL0DUUF0B9EceR3whBrdSIFmutmQSsj2E3BL4nQkhoC-xwQAvD_BwE

Data presented at AASLD 2025 show patients without severe neurologic involvement can achieve cognitive improvement with early detection and therapy.


Challenges and Innovations in Wilson Disease, with Michael Schilsky, MD

, also known as hepatolenticular degeneration, is a genetic disorder of copper metabolism that leads to the accumulation of copper in the liver and other tissues, including the brain.

With an estimated prevalence of 1 case per 30,000 live births in most populations, Wilson disease is rare but serious, with gradual damage from copper accumulation resulting in hepatic, neurologic, and 

 manifestations. With the availability of effective treatment options, early detection and intervention are critical for preventing disease progression, mitigating symptoms, and maintaining quality of life.

, Michael Schilsky, MD, a professor of medicine and medical director of adult liver transplant at Yale-New Haven Transplantation Center, discusses the biggest challenges in Wilson disease and recent innovations that have helped to address some of the field’s largest unmet needs.

Schilsky begins by highlighting the need for tools to effectively monitor patients, citing shortcomings in the historical approach of examining urinary copper excretion. He references novel approaches with better sensitivity, also describing advances in diagnostics that have the potential to be implemented universally and catch the disease during infancy.

However, Schilsky notes that detecting Wilson disease so early introduces questions about when to start treatment. He says the current understanding is that it is relatively safe to wait 2 to 3 years while monitoring copper and diet before slowly initiating therapy.

“Whenever you deal with a rare disorder, and Wilson's disease is typically present in about 1 in 30,000 individuals, the key is really recognizing the disease,” Schilsky said. “If we can have newborn screening, we’ll capture a lot and that would be wonderful. If we don't, we have to continue to raise awareness so that we can identify patients at a younger age before they develop more severe symptoms.”

Schilsky goes on to commend his colleagues working in pediatrics for moving the needle and helping identify more patients at a younger age. He additionally recognizes the work being done by patient organizations that are providing advocacy and support for patients and families.

Considerations for Effectively Managing Wilson Disease, with Michael Schilsky, MD

Editors’ note: Schilsky has relevant disclosures with Vivet Therapeutics, Orphalan, Alexion, Wilson Disease Association, National Institute of Health, DepYmed, and Arbomed.

UpToDate. Wilson disease: Epidemiology and pathogenesis. Jun 19, 2024. Accessed March 24, 2025. 

https://www.uptodate.com/contents/wilson-disease-epidemiology-and-pathogenesis

Schilsky describes lingering challenges and unmet needs in Wilson disease and highlights recent innovations in monitoring and diagnosis.

With an estimated prevalence of 1 case per 30,000 live births in most populations, Wilson disease is rare but serious, with gradual damage from the accumulation of copper resulting in hepatic, neurologic, and 

 manifestations. With effective treatment options available, early detection and intervention are critical for preventing disease progression, mitigating symptoms, and maintaining quality of life.

, Michael Schilsky, MD, a professor of medicine and medical director of adult liver transplant at Yale-New Haven Transplantation Center, explains the hepatic manifestations of Wilson disease caused by defective copper transport and subsequent excessive copper accumulation in the liver, which, if untreated, can lead to progressive liver damage, cirrhosis, and acute liver failure, as well as neurological deterioration and psychiatric complications.

Schilsky notes that Wilson disease is highly treatable with long-standing established therapies. Specifically, he highlights the role of chelating agents, such as trientine and penicillamine, which accelerate copper excretion, and zinc salts, which reduce intestinal copper absorption.

For patients who are already presenting with symptoms, Schilsky says the goal is to stop these symptoms from progressing and hopefully cause them to regress and improve over time. For those who are diagnosed at an early stage and have not yet developed symptoms, he says with appropriate treatment, these patients may be able to avoid symptoms altogether.

Schilsky emphasizes that the management of Wilson disease extends beyond copper removal, calling attention to the need for ongoing monitoring, dietary modifications, and addressing complications of liver disease such as portal hypertension and hepatocellular carcinoma risk. For patients with neurological symptoms, supportive therapies targeting tremors, dystonia, or psychiatric conditions may be necessary.

While lifelong medical therapy is effective for most patients, Schilsky notes about 5% present with a more severe form of the disease, causing acute liver failure requiring urgent liver transplantation. Ultimately, he stresses that early diagnosis is crucial, as Wilson disease is highly manageable for most patients when detected in its early stages.

UpToDate. Wilson disease: Epidemiology and pathogenesis. Jun 19, 2024. Accessed March 20, 2025. 

Schilsky provides an overview of Wilson disease and describes optimal management strategies, highlighting the importance of early detection and intervention.

Michael Schilsky, MD

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