601
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Entecavir treatment in patients with severe acute exacerbation of chronic hepatitis B. J Hepatol 2011; 54:236-42. [PMID: 21030105 DOI: 10.1016/j.jhep.2010.06.043] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 06/28/2010] [Accepted: 06/29/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Severe acute exacerbation of chronic hepatitis B is a unique clinical presentation with significant morbidity and mortality. Lamivudine was used in most previous studies, but the drug was limited by the development of resistance. Our objective is to study the safety and efficacy of entecavir in patients with severe acute exacerbation. METHODS Consecutive patients with severe acute exacerbation of chronic hepatitis B were recruited from 1998 to 2009. All patients had serum alanine aminotransferase and bilirubin increased beyond 10 and 3 times the upper limit of normal, respectively. The primary endpoint was overall mortality at week 48. Virological and biochemical responses were also studied. RESULTS Thirty-six patients and 117 patients were treated with entecavir and lamivudine, respectively. By week 48, 7 (19%) patients in the entecavir group and 5 (4%) patients in the lamivudine group died (adjusted hazard ratio 5.1, 95% confidence interval 1.5-17.2, p=0.010). Similarly, the entecavir group had higher liver-related mortality (adjusted hazard ratio 4.0, 95% confidence interval 1.0-15.7, p=0.044). Despite a lower prevalence of cirrhosis, more patients in the entecavir group developed prolonged jaundice, hepatic encephalopathy, and ascites. Entecavir resulted in more rapid and complete viral suppression, with 71% of patients achieving undetectable hepatitis B virus (HBV) DNA at week 48, compared to 40% in the lamivudine group (p=0.007). However, rapid HBV DNA reduction at week 4 was associated with prolonged jaundice. CONCLUSIONS Entecavir treatment is associated with increased short-term mortality in patients with severe acute exacerbation of chronic hepatitis B but achieves better virological response in the long run.
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602
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Fung J, Seto WK, Lai CL, Yuen J, Wong DKH, Yuen MF. Profiles of HBV DNA in a large population of Chinese patients with chronic hepatitis B: implications for antiviral therapy. J Hepatol 2011; 54:195-200. [PMID: 21056499 DOI: 10.1016/j.jhep.2010.06.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 06/06/2010] [Accepted: 06/30/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS We determined the virological profile in Chinese chronic hepatitis B (CHB) subjects and its implications regarding current treatment guidelines. METHODS A total of 1400 treatment-naïve CHB patients had their HBV DNA levels determined using the Cobas Taqman assay. Patient demographics, HBeAg status, and liver biochemistry were also recorded. RESULTS The subjects were predominantly male (62%), had a median age of 45 years, and 301 (22%) were HBeAg-positive. In subjects aged ≤ 25, 26-35, 36-45, 46-55, and >55 years, there was a decreasing trend of HBV DNA levels of 9.9, 9.3, 8.2, 7.4, and 7.3 log copies/ml, respectively (p<0.001), in HBeAg-positive subjects, while the pattern was reversed with HBV DNA levels of 3.7, 4.4, 4.7, 4.9, and 5.2 log copies/ml, respectively, in HBeAg-negative subjects (p<0.001). In HBeAg-negative subjects, the proportion of patients with elevated ALT compared to those with normal ALT was significantly higher in older age groups (p<0.001). In our study population, by applying the AASLD, EASL, and APASL guidelines, 64%, 99%, and 64% would be eligible for antiviral therapy, respectively, in HBeAg-positive patients (with elevated ALT), and 38%, 72%, and 43%, respectively, in HBeAg-negative patients (with elevated ALT). Up to 54% of patients over the age of 40 years would be recommended for liver biopsy to determine further eligibility for treatment. CONCLUSIONS For HBeAg-negative CHB, more patients had elevated ALT and a higher viral load with increasing age. Close monitoring is recommended in this group so that treatment may be considered. By applying the current treatment guidelines, a wide discrepancy can be observed in the proportion of patients eligible for treatment in the absence of histological data.
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Affiliation(s)
- James Fung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, Hong Kong
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603
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Ryu HJ, Lee JM, Ahn SH, Kim DY, Lee MH, Han KH, Chon CY, Park JY. Efficacy of adefovir add-on lamivudine rescue therapy compared with switching to entecavir monotherapy in patients with lamivudine-resistant chronic hepatitis B. J Med Virol 2011; 82:1835-42. [PMID: 20872709 DOI: 10.1002/jmv.21898] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
No study has reported on the comparative effect of adefovir (ADV) add-on lamivudine (LAM) versus switching to entecavir (ETV) in LAM-resistant patients with chronic hepatitis B. From October 2007 to September 2008, 92 consecutive LAM-resistant patients were enrolled (47 LAM+ADV and 45 ETV 1 mg). All patients were followed for at least 12 months. The parameters assessed included normalization of ALT, HBeAg seroconversion, undetectable HBV DNA, reduction of HBV DNA, and predictors of virologic response. In the LAM+ADV and ETV groups, the baseline DNA levels were 7.61 (5.19-9.49) and 7.10 (5.43-9.74)log(10)copies/ml, respectively. At month 12, a virologic response occurred in 18/47 (38.3%) and 11/45 (24.4%; P=0.182) patients; ALT normalization, in 39/41 (95.1%) and 36/40 (90.0%; P=0.432); HBeAg seroconversion, in 5.1% and 2.4% (P=0.606); and virologic breakthrough, in 2.1% and 11.1% (P=0.107), respectively. The mean reduction from the baseline HBV DNA level was greater in the LAM+ADV group at month 12 (3.80 ± 1.12 vs. 2.7 ± 1.32 log(10)copies/ml; P<0.001). In the multivariate analysis, the independent parameters related to a virologic response at month 12 were baseline ALT (OR=1.003, 95% CI=1.000-1.006, P=0.026) and baseline HBV DNA (OR=0.495, 95% CI=0.298-0.823, P=0.007). Compared with switching to ETV monotherapy, ADV add-on LAM therapy was more effective at reducing the viral load in patients with LAM resistance, and the baseline HBV DNA and ALT levels were independent predictors of the virologic response. However, ADV add-on therapy had limitations in patients with a higher baseline HBV DNA in LAM rescue therapy.
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Affiliation(s)
- Han Jak Ryu
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
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604
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Yu LH, Li N, Cheng SQ. The Role of Antiviral Therapy for HBV-Related Hepatocellular Carcinoma. Int J Hepatol 2011; 2011:416459. [PMID: 21994855 PMCID: PMC3170809 DOI: 10.4061/2011/416459] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Revised: 03/15/2011] [Accepted: 04/08/2011] [Indexed: 12/18/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a highly prevalent and lethal cancer worldwide; despite the curative treatment for HCC, the rate of tumor recurrence after hepatectomy remains high. Tumor recurrence can occur early (<2 years) or late (>2 years) as metastases or de novo tumors. Several tumor factors were associated with HCC recurrence; high hepatitis B virus (HBV) load is the major risk factor for late recurrence of HCC after resection. Preoperative antiviral therapy improves liver function, and postoperative reduce HCC recurrence. In this paper, we focus on antiviral treatment to improve the liver function, prevent recurrence, and lengthen the overall survival for HBV-related HCC.
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Affiliation(s)
- Liang-He Yu
- Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai 200438, China
| | - Nan Li
- Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai 200438, China
| | - Shu-Qun Cheng
- Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai 200438, China,Tumor Comprehensive Treatment Department, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, 225 Changhai Road, Shanghai 200438, China,*Shu-Qun Cheng:
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605
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Liaw YF, Sheen IS, Lee CM, Akarca US, Papatheodoridis GV, Suet-Hing Wong F, Chang TT, Horban A, Wang C, Kwan P, Buti M, Prieto M, Berg T, Kitrinos K, Peschell K, Mondou E, Frederick D, Rousseau F, Schiff ER. Tenofovir disoproxil fumarate (TDF), emtricitabine/TDF, and entecavir in patients with decompensated chronic hepatitis B liver disease. Hepatology 2011; 53:62-72. [PMID: 21254162 DOI: 10.1002/hep.23952] [Citation(s) in RCA: 252] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 08/19/2010] [Indexed: 12/12/2022]
Abstract
UNLABELLED Data are limited on the safety and effectiveness of oral antivirals other than lamivudine and adefovir dipivoxil for treatment of chronic hepatitis B (CHB) in patients with decompensated liver disease. This Phase 2, double-blind study randomized 112 patients with CHB and decompensated liver disease to receive either tenofovir disoproxil fumarate (TDF; n = 45), emtricitabine (FTC)/TDF (fixed-dose combination; n = 45), or entecavir (ETV; n = 22). The primary endpoint was safety; more specifically, tolerability failure (adverse events resulting in permanent treatment discontinuation) and confirmed serum creatinine increase ≥ 0.5 mg/dL from baseline or confirmed serum phosphorus <2 mg/dL. Patients with insufficient viral suppression (e.g., confirmed HBV DNA ≥ 400 copies/mL at week 8 or 24) could begin open-label FTC/TDF but were considered failures in this interim week 48 analysis for efficacy endpoints. Tolerability failure was infrequent across arms: 6.7% TDF, 4.4% FTC/TDF, and 9.1% ETV (P = 0.622) as were confirmed renal parameters meeting threshold 8.9%, 6.7%, and 4.5% (P = 1.000), respectively. Six patients died (none considered related to study drug) and six received liver transplants (none had HBV recurrence). The adverse event and laboratory profiles were consistent with advanced liver disease and complications, with no unexpected safety signals. At week 48, HBV DNA was <400 copies/mL (69 IU/mL) in 70.5% (TDF), 87.8% (FTC/TDF), and 72.7% (ETV) of patients. Proportions with normal alanine aminotransferase were: 57% (TDF), 76% (FTC/TDF), and 55% (ETV). Hepatitis B e antigen (HBeAg) loss/seroconversion occurred in 21%/21% (TDF), 27%/13% (FTC/TDF), and 0%/0% (ETV). Child-Turcotte-Pugh and Modification for End-stage Liver Disease scores improved in all groups. CONCLUSION All treatments were well tolerated in patients with decompensated liver disease due to CHB with improvement in virologic, biochemical, and clinical parameters.
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Affiliation(s)
- Yun-Fan Liaw
- Liver Research unit, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
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606
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Ni YH. Natural history of hepatitis B virus infection: pediatric perspective. J Gastroenterol 2011; 46:1-8. [PMID: 20812021 DOI: 10.1007/s00535-010-0304-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 07/30/2010] [Indexed: 02/07/2023]
Abstract
Hepatitis B virus (HBV) infection is an important disease globally. Chronic HBV infection may result in serious complications. Its transmission may be either perinatal or horizontal. Perinatal transmission is particularly important after the implementation of a universal vaccination program. Through either route, chronic carrier status is usually established in early childhood. The course of the disease course is determined by the host-virus interaction. The host's immune system initially tolerates the virus, and then gradually attempts to clear it. The virus, on the other hand, tries to avoid host immune system attack by a strategy involving targeted epitope mutations. By generating mutants, the virus can survive attacks from the host's immune system, enabling the infection to persist. Different individuals have different responses to HBV infection; genetic polymorphisms in cytokines, hormones, and other immune modulators may affect the final outcome of chronic HBV infection. Due to the implementation of a universal infant HBV vaccination program, HBV infection is now under control. Unfortunately, there still are some cases of vaccination failure. Very high maternal viremia, in utero infection, or escape mutants are possible reasons for vaccination failure. Immunocompromised hosts also risk vaccination failure. Blood or organ donors with occult HBV infection are possible sources for immunocompromised hosts. These victims of vaccination failure may exhibit a different disease course due to chronic HBV infection from those who acquired the infection before the universal vaccination era. The achievement of our ultimate goal of HBV elimination depends on a globally effective universal vaccination program, as well as the application of some novel successful medications to control those who are already infected.
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Affiliation(s)
- Yen-Hsuan Ni
- Department of Pediatrics, College of Medicine and Children's Hospital, National Taiwan University, 8 Chung-Shan South Road, Taipei, Taiwan.
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607
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Abstract
There has been a recent paradigm shift in the indications and endpoints of treatment for chronic hepatitis B (CHB). Hepatitis B e antigen (HBeAg)-negative disease is being increasingly recognized. Antiviral treatment for both HBeAg-positive and HBeAg-negative patients should aim at long-term suppression of HBV DNA, with the ultimate ideal endpoint of hepatitis B surface antigen (HBsAg) seroconversion. Conventional interferon alpha (IFN-α), the only agent licensed in 1991, has been superseded by pegylated IFN-α. HBeAg seroconversion using pegylated IFN-α is 33%, with only 25% of HBeAg-positive patients achieving undetectable HBV DNA by polymerase chain reaction (PCR) assay. Five nucleoside/nucleotide analogues have been licensed since 1998. Lamivudine, an L-nucleoside, is limited by the development of resistance in 76% of patients after 5 years of therapy. Telbivudine, another L-nucleoside, is more potent than lamivudine but resistance still develops in 25% of HBeAg-positive and 11% HBeAg-negative patients after 2 years. Adefovir, an acyclic phosphonate, is relatively weak, but is effective against lamivudine- and telbivudine- resistant mutations, for which it should be used in combination (add-on therapy) rather than substituted. Resistance to adefovir develops slowly, rising to 29% for HBeAg-negative patients by year 5, but more rapidly when used alone for lamivudine-resistant HBV. Currently the two first line nucleoside/nucleotides are entecavir and tenofovir. Entecavir, a cyclopentane (D-nucleoside), is very potent, with 94% of patients having undetectable HBV DNA after 5 years. Resistance develops in only 1.2% of treatment-naïve patients. Tenofovir, another acyclic nucleotide, is more potent with less renal toxicity compared to adefovir. It is effective against lamivudine-resistant mutations when used alone. No resistance to tenofovir has been described after its use for 3 years or longer, often for patients with human immunodeficiency virus/HBV co-infection. With these current, potent antiviral agents associated with very low rates of resistance, long-term HBV DNA suppression and possibly even reversal of cirrhosis can now be achieved in a proportion of patients. In addition, long-term treatment with these antiviral agents is associated with a reduced risk of development of hepatocellular carcinoma.
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Affiliation(s)
- Man-Fung Yuen
- Department of Medicine, the University of Hong Kong, Queen Mary Hospital, China.
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608
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Abstract
Outcomes of chronic hepatitis B virus (HBV) infection are heterogeneous. Estimates of annual incidence of cirrhosis and hepatocellular carcinoma (HCC) are 2-10% and 1-3%, respectively. Several viral factors, including HBV genotype, viral load and specific viral mutations, have been associated with disease progression. Among these, HBV genotype is not only predictive of clinical outcomes but has also been associated with response to interferon treatment. Currently, at least 10 HBV genotypes and several subtypes have been identified; they have distinct geographic distribution. Acute infection with genotypes A and D results in higher rates of chronicity than genotypes B and C. Compared to genotype A and B cases, patients with genotypes C and D have lower rates of spontaneous hepatitis B e antigen (HBeAg) seroconversion; when this occurs, it tends to be delayed. HBV genotype C has a higher frequency of basal core promoter (BCP) A1762T/G1764A mutation, pre-S deletion and is associated with higher viral load than genotype B. Similarly, genotype D has a higher prevalence of BCP A1762T/G1764A mutation than genotype A. These observations suggest important pathogenic differences between HBV genotypes. These may contribute to more severe liver disease, including cirrhosis and HCC with genotypes C and D HBV infection. In addition, genotype A and B patients have better responses to interferon-based therapy than genotypes C and D, but there are few consistent differences for direct HBV antivirals. In conclusion, genotyping of chronic HBV infections can help practicing physicians identify those at risk of disease progression and determine optimal anti-viral therapy.
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Affiliation(s)
- Chih-Lin Lin
- Department of Gastroenterology, Taipei City Hospital, Taiwan
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609
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A comparison of treatment with adefovir and entecavir for chronic hepatitis B in China: The 2-year results of a prospective study: Adefovir versus Entercavir for Chronic Hepatitis B. HEPATITIS MONTHLY 2011; 11:27-31. [PMID: 22087113 PMCID: PMC3206656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 09/27/2010] [Accepted: 10/01/2010] [Indexed: 11/12/2022]
Abstract
BACKGROUND The reduction of hepatitis B virus replication to minimal levels is emerging as key therapeutic goal in chronic hepatitis B (CHB). OBJECTIVES This study aimed to evaluate and compare the efficacies of adefovir (ADV) and entecavir (ETV) in CHB. PATIENTS AND METHODS In this prospective study, 100 naïve patients were assigned to treatment with ADV (33 HBeAg-positive and 19 HBeAg-negative patients) or ETV (32 HBeAg-positive and 16 HBeAg-negative patients). The primary efficacy outcome was ALT normalization, reduction in HBV DNA, and seroconversion of HBeAg. Second efficacy outcomes included resistance and safety. Comparisons of quantitative and qualitative variables between groups were analyzed by student t-test and chi-square test (or Fisher's exact test), respectively. RESULTS Among HBeAg-positive patients, ETV was superior to ADV with respect to mean reduction in HBV DNA (-7.5 versus -6.3, respectively, at Month 24, p = 0.003) and the percentage of those with HBV DNA < 103 copies/mL at Month 24 [96.9% (31/32) vs. 69.7% (23/33), respectively, p = 0.002] and < 300 copies/mL at Month 24 [84.4% (27/32) vs. 54.5% (18/33), respectively, p = 0.004]. But, the rates of ALT normalization and HBeAg seroconversion between the groups were similar [87.9% (29/33) vs. 96.9% (31/32), respectively, p=0.355; and 24.2% (8/33) vs. 25.0% (8/32), respectively, p = 0.943]. In HBeAg-negative patients who received ETV or ADV, the reduction in HBV DNA (-6.8 versus -5.9, respectively, p = 0.192), percentage of ALT normalization [100% (16/16) vs. 78.9% (15/19), respectively, p=0.109], HBV DNA < 103 copies/mL [100% (16/16) vs. 89.5% (17/19), respectively, p = 0.489], and HBV DNA < 300 copies/mL [100% (16/16) vs. 84.2% (16/19), respectively, p = 0.234] were similar. No ETV- or ADV-associated mutations were observed, and both agents were well tolerated. CONCLUSIONS ETV and ADV are effective therapies for CHB. In HBeAg-positive patients, the efficacy of ETV is significantly superior to that of ADV, and in HBeAg-negative patients, the agents effect similar biochemical and virological responses.
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610
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Abstract
Chronic hepatitis B virus (HBV) infection is a major health problem in the Asia-Pacific region. In the past decade, much progress has been made in the understanding and management of this disease. The introduction of universal vaccination has significantly reduced the incidence of perinatal infection in most Asia-Pacific countries. As the majority of the adult population have not been immunized at birth, we are still facing a large population of young HBV-infected patients in the coming two decades. The study of long-term longitudinal databases has provided deeper insight into the clinical significance of HBV DNA suppression, hepatitis B e antigen (HBeAg) seroconversion and hepatitis B surface antigen (HBsAg) seroclearance in chronic hepatitis B. With a better understanding on the natural history of HBV infection, one can now stratify the risk of chronic hepatitis B patients for adverse clinical outcomes and use this to individualize management. The introduction of non-invasive assessment of liver fibrosis can potentially reduce the necessity of liver biopsy. There have also been great advances in the development of antiviral therapy in the past decade. However, the high cost of HBV antiviral drugs poses major challenges to health authorities in many Asia-Pacific countries. Properly performed cost-effective analysis and understanding on the best timing of stopping antiviral drugs will be important to facilitate the most appropriate allocation of resources.
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Affiliation(s)
- Henry Lik-Yuen Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, China.
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611
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Nahar N, Nahar Rahman AJE, Habib S. Histopathological Assessment of Liver
Biopsy Specimen in the Context of HBV
DNA and HBeAg in Patients with
Chronic Hepatitis B. Euroasian J Hepatogastroenterol 2011. [DOI: 10.5005/jp-journals-10018-1018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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612
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Abstract
Chronic hepatitis B virus (HBV) infections remain a major public health problem worldwide. According to World Health Organization estimates, more than 300 million people are chronically infected and exposed to the risk of developing severe complications including cirrhosis and hepatocellular carcinoma (HCC). Major progress in the treatment of chronic hepatitis B (CHB) has been made during the last decade with the development of antivirals that inhibit viral polymerase activity. Antiviral drug resistance is an important factor in determining the success of long-term therapy for CHB. The development of resistance to nucleoside analogues (NUCs) has been associated with exacerbations of liver disease. Sequential therapy increases the risk of the emergence of multidrug resistance. The selection of a potent antiviral with a high barrier to resistance as a first-line therapy provides the best chance of achieving long-term treatment goals and should be used whenever possible. This has led to a significant decrease in drug resistance in countries where this strategy is affordable. However, the barrier to resistance of a given antiviral agent is influenced by the genetic barrier, drug potency, patient adherence, pharmacological barrier, viral fitness, the drug mechanisms of action and cross resistance. Furthermore, because of specific viral kinetics, prolonged treatment with NUCs does not result in the clearance of the viral genome from the infected liver. It is therefore important to continue research to identify new viral and immune targets and develop novel antiviral strategies for controlling viral replication as well as preventing drug resistance and its complications in the long term.
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Affiliation(s)
- Fabien Zoulim
- INSERM, U871, Lyon, France Université de Lyon, 69001 Lyon, France.
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613
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Abstract
Telbivudine (Sebivo®; Tyzeka®) is a synthetic nucleoside analogue that inhibits replication of hepatitis B virus (HBV). It is used in the treatment of adults with chronic hepatitis B (CHB) with evidence of viral replication and persistently elevated serum ALT and/or AST levels, and/or histological evidence of active disease. Telbivudine is a potent antiviral that provides effective and sustained viral suppression in patients with compensated CHB. In clinical trials, treatment outcomes were improved significantly more with telbivudine 600 mg once daily than with lamivudine 100 mg or adefovir 10 mg once daily, and telbivudine-treated patients had significantly less viral resistance than lamivudine-treated patients. Increasing rates of hepatitis B e antigen (HBeAg) seroconversion were achieved in HBeAg-positive patients during periods of up to 4 years continuous telbivudine treatment, and seroconversion was durable in most patients throughout a 2-year, off-treatment follow-up, indicating the potential for a finite treatment period in this group of patients. Telbivudine is associated with a medium genetic barrier to resistance and, as patients with undetectable HBV DNA levels have significantly improved outcomes, it is recommended that HBV DNA levels are monitored at week 24 (and 6 monthly thereafter), with the addition of a nucleoside/nucleotide analogue without cross resistance (such as adefovir dipivoxil) if viraemia is present to reduce the risk of resistance (Roadmap concept). Telbivudine was generally well tolerated in clinical trials for periods of up to 4 years, and has a similar tolerability profile to that of lamivudine. A minority of telbivudine-treated patients experience creatinine kinase elevation, usually transient, and myopathy occurs rarely. In modelled cost effectiveness studies in several Asian countries, treatment with telbivudine Roadmap was cost effective in HBeAg-positive patients. Thus, telbivudine provides a valuable treatment option in CHB, particularly when administered using the Roadmap concept in HbeAg-positive patients.
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614
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Wang S, Han Q, Zhang G, Zhang N, Li Z, Chen J, Lv Y, Li N, Xing F, Tian N, Zhu Q, Liu Z. CpG oligodeoxynucleotide-adjuvanted fusion peptide derived from HBcAg epitope and HIV-Tat may elicit favorable immune response in PBMCs from patients with chronic HBV infection in the immunotolerant phase. Int Immunopharmacol 2010; 11:406-11. [PMID: 21182997 DOI: 10.1016/j.intimp.2010.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 12/05/2010] [Accepted: 12/06/2010] [Indexed: 12/22/2022]
Abstract
The absence or insufficiency of specific immune response results in chronic hepatitis B virus (HBV) infection and immunotolerance. Therapeutic fusion peptide containing hepatitis B core antigen (HBcAg)(18-27) CTL epitope and human immunodeficiency virus (HIV)-Tat(49-57) peptide was synthesized and the activity when adjuvanted with CpG oligodeoxynucleotide (CpG ODN) was evaluated in PBMCs from patients with chronic HBV infection in the immunotolerant phase in this study. Results showed that the fusion peptide when adjuvanted with CpG ODN could induce significantly higher levels of IFN-γ and IL-4 in the PBMCs compared with fusion peptide or CpG ODN alone. The magnitude of augmentation to IFN-γ by the fusion peptide plus CpG ODN was much higher than that to IL-4. Cytotoxicity assay showed that the percentage of target cell lysis by effector cells stimulated by fusion peptide plus CpG ODN was higher than that in fusion peptide or CpG ODN alone at most of the E/T ratios tested. The magnitude augmented to IFN-γ by fusion peptide plus CpG ODN was also much higher than that to the percentage of target cell lysis. It is concluded that HBcAg(18-27) and HIV-Tat(49-57) fusion peptide when adjuvanted with CpG ODN may have much higher potency to induce IFN-γ than to induce IL-4 and cytotoxicity, suggesting the favorable immune response towards noncytolytic inactivation of the virus mediated by IFN-γ and the potential to break the tolerant state in chronic HBV infection.
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MESH Headings
- Adjuvants, Immunologic/adverse effects
- Adjuvants, Immunologic/chemical synthesis
- Adjuvants, Immunologic/pharmacology
- Adult
- Apoptosis Regulatory Proteins/adverse effects
- Apoptosis Regulatory Proteins/chemistry
- Apoptosis Regulatory Proteins/pharmacology
- Cell Culture Techniques
- Cell Survival/drug effects
- Chromatography, High Pressure Liquid
- DNA/chemistry
- DNA/pharmacology
- Enzyme-Linked Immunosorbent Assay
- Epitopes/chemistry
- Female
- Hep G2 Cells
- Hepatitis B Surface Antigens/chemistry
- Hepatitis B, Chronic/blood
- Hepatitis B, Chronic/immunology
- Humans
- Immune Tolerance
- Interferon-gamma/immunology
- Interferon-gamma/metabolism
- Interleukin-4/immunology
- Leukocytes, Mononuclear/drug effects
- Leukocytes, Mononuclear/immunology
- Male
- Middle Aged
- Oligodeoxyribonucleotides
- Peptide Fragments/chemistry
- Recombinant Fusion Proteins/adverse effects
- Recombinant Fusion Proteins/chemistry
- Recombinant Fusion Proteins/pharmacology
- Survivin
- Th1 Cells/drug effects
- Th1 Cells/immunology
- Th2 Cells/drug effects
- Th2 Cells/immunology
- Young Adult
- tat Gene Products, Human Immunodeficiency Virus/adverse effects
- tat Gene Products, Human Immunodeficiency Virus/chemistry
- tat Gene Products, Human Immunodeficiency Virus/pharmacology
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Affiliation(s)
- Suna Wang
- Department of Infectious Diseases, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an 710061, Shaanxi Province, The People's Republic of China
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615
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Shin SR, Koh KC, Gwak GY, Choi MS, Lee JH, Paik SW, Yoo BC. A low viral load predicts a higher initial virologic response to adefovir in patients with Lamivudine-resistant chronic hepatitis B. Gut Liver 2010; 4:530-6. [PMID: 21253304 DOI: 10.5009/gnl.2010.4.4.530] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2009] [Accepted: 07/28/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND/AIMS Adefovir (ADV) is the preferred drug for treating lamivudine (LAM)-resistant hepatitis B. However, not all patients who face virologic breakthrough during LAM treatment respond to ADV. The aim of this study was to determine the factors associated with efficacy of ADV in LAM-resistant hepatitis B patients. METHODS The medical records of 231 patients who received ADV due to LAM-resistance were reviewed. Efficacy was assessed by the initial virologic response (IVR), defined as hepatitis B virus (HBV) DNA not being undetectable by real-time PCR at 6 months of ADV treatment. RESULTS Seventy patients (30%) achieved IVR. While 'add-on' modality, hepatitis B e antigen (HBeAg) negativity, and low baseline HBV DNA levels were associated with IVR in univariate analysis, multivariate analysis revealed HBeAg status and the DNA level to be the significant factors. The probability of IVR achievement increased sharply per each log(10) copies/mL decrement in the baseline viral load, which was 133 times in patients who had HBV DNA <10(5) copies/mL compared with those who had ≥10(8) copies/mL. CONCLUSIONS Factors associated with the IVR were HBeAg negativity and a low baseline viral load. Therefore, when virologic breakthrough with genotypic resistance emerges during LAM therapy, ADV treatment should be considered immediately before further increases in viral load. Additional long-term follow-up data are warranted.
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Affiliation(s)
- Su Rin Shin
- Department of Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
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616
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Zhang FK, Liu DG, Jia JD. Antiviral therapy for hepatitis B in special populations. Antivir Ther 2010; 15:1067-75. [PMID: 21149913 DOI: 10.3851/imp1663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
There has been much progress in antiviral therapy for chronic hepatitis B; however, antiviral therapy for hepatitis B in special populations is still very challenging. Here, we review antiviral therapy for hepatitis B in special populations, including children and pregnant patients, patients with hepatitis-B-related cirrhosis, patients with acute hepatitis B and chronic hepatitis B surface antigen carriers who receive immunosuppressive or cytotoxic therapy. Major advances have been made in antiviral therapy for hepatitis B in these special populations because of recent increasing availability of oral nucleoside/nucleotide analogues that are well-tolerated and highly effective; however, the findings are mostly based on small uncontrolled short-term studies. More well-designed clinical studies on antiviral therapy for hepatitis B in these special populations are urgently needed to obtain more evidence-based high-quality data.
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Affiliation(s)
- Fu-Kui Zhang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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617
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Yu SJ, Lee JH, Chung GE, Lee CH, Cho EJ, Jang ES, Kwak MS, Kim YJ, Yoon JH, Jang JJ, Lee HS. Validation of P2/MS for reflecting hepatic fibrosis in patients with hepatocellular carcinoma. THE KOREAN JOURNAL OF HEPATOLOGY 2010; 16:389-96. [PMID: 21415583 PMCID: PMC3304609 DOI: 10.3350/kjhep.2010.16.4.389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 11/20/2010] [Accepted: 11/30/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS P2/MS is known as a simple, accurate, and noninvasive marker for determination of the degree of hepatic fibrosis in patients with viral hepatitis. We aimed to validate P2/MS in patients with HCC. METHODS Consecutive HCC patients who underwent surgical resection between June 2007 and March 2009 at Seoul National University Hospital were enrolled. Fibrosis stage was reviewed and assessed according to METAVIR scoring. P2/MS values [platelet count (10(9)/L)](2)/[monocyte fraction (%)(x)segmented neutrophil fraction (%)] and other noninvasive fibrosis scoring systems were calculated. RESULTS A total of 171 patients were included; seven patients with METAVIR F1, 31 with F2, 41 with F3, and 92 with F4. The area under the receiver-operating characteristic curve of P2/MS was 0.804 [95% confidence interval (CI), 0.681~0.927] for detection of significant fibrosis (F2-F4) and 0.769 (95% CI, 0.698~0.839) for detection of histological cirrhosis (F4). At a value < 62, P2/MS detected significant fibrosis with a specificity of 85.7% (95% CI, 42.0~99.2) and a positive likelihood ratio of 4.268 (95% CI, 0.692~26.309); and at a value > 115, P2/MS ruled out significant fibrosis with a sensitivity of 90.2% (95% CI, 84.4~94.1) and a negative likelihood ratio of 0.34 (95% CI, 0.106~0.095). P2/MS had a superior efficacy for detection of hepatic fibrosis in patients with HCC compared to the other noninvasive panels. CONCLUSIONS P2/MS can accurately detect fibrosis in patients with HCC. Thus, P2/MS might be utilized as a noninvasive index reflecting the degree of hepatic fibrosis in HCC patients.
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Affiliation(s)
- Su Jong Yu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Goh Eun Chung
- Department of Internal Medicine and Healthcare Research Institute, Seoul National University Hospital, Healthcare System Gangnam Center, Seoul, Korea
| | - Chang-Hoon Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul Municipal Boramae Hospital, Seoul, Korea
| | - Eun Ju Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Sun Jang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Min-Sun Kwak
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ja-June Jang
- Department Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Suk Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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618
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Chan HLY, Wong VWS, Chim AML, Chan HY, Wong GLH, Sung JJY. Serum HBsAg quantification to predict response to peginterferon therapy of e antigen positive chronic hepatitis B. Aliment Pharmacol Ther 2010; 32:1323-31. [PMID: 21050234 DOI: 10.1111/j.1365-2036.2010.04474.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND On-treatment predictors of response to peginterferon can guide individualization of therapy in chronic hepatitis B virus infection. AIM To investigate the use of serum hepatitis B surface antigen quantification to predict sustained response. METHODS Hepatitis B e antigen-positive chronic hepatitis B patients who received peginterferon for 32-48 weeks with or without lamivudine combination were studied. Sustained response was defined as hepatitis B e antigen seroconversion and chronic hepatitis B virus DNA <10 000 copies/mL until 12 months post-treatment. RESULTS Twenty-one of 92 (23%) patients achieved sustained response. At month 6, the area under receiver operating characteristics curve for hepatitis B surface antigen to predict sustained response was 0.77 (95% confidence interval 0.65-0.89, P < 0.001). An hepatitis B surface antigen cutoff at 300 IU/mL at month 6 could give the maximum combination of sensitivity (62%) and specificity (89%) to predict sustained response. Nine of 21 (43%) sustained responders vs. 9 of 71 (13%) nonsustained responders had >1 log hepatitis B surface antigen reduction at month 6 (P < 0.001). Combined hepatitis B surface antigen ≤ 300 IU/mL and >1 log reduction at month 6 had sensitivity, specificity, positive and negative predictive values of 43%, 96%, 75% and 85% to predict sustained response, respectively. CONCLUSION On-treatment serum hepatitis B surface antigen can predict response to peginterferon therapy in chronic hepatitis B.
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Affiliation(s)
- H L-Y Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong SAR.
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619
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Jonas MM, Block JM, Haber BA, Karpen SJ, London WT, Murray KF, Narkewicz MR, Rosenthal P, Schwarz KB, McMahon BJ. Treatment of children with chronic hepatitis B virus infection in the United States: patient selection and therapeutic options. Hepatology 2010; 52:2192-205. [PMID: 20890947 DOI: 10.1002/hep.23934] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 08/16/2010] [Indexed: 12/15/2022]
Abstract
Chronic hepatitis B virus (HBV) infection in children presents a therapeutic challenge for the practitioner. Decisions regarding selection of patients who may benefit from treatment, appropriate timing of treatment, and the choice of antiviral therapy are complex and are compounded by the limited number of drugs that have been studied in children. An expert panel of nationally recognized pediatric liver specialists was convened by the Hepatitis B Foundation on August 11, 2009, to consider clinical practice relative to the therapeutic options available for children. A detailed account of these discussions is provided, and the opinions expressed are based on consensus of the experts, as well as on published evidence when available. The panel concludes that, at this time, there is no established benefit of treatment of children in the immune tolerant phase, and there is a very high risk of development of drug resistance. In addition, there is no indication for treatment of children in the inactive carrier state. For children in the immune active or reactivation phases, liver histology can help guide treatment decisions, and family history of liver disease, especially hepatocellular carcinoma, may argue for early treatment in some cases. Outside of clinical trials, interferon is the agent of choice in most cases. Nucleos(t)ide analogues are secondary therapies, and children who receive these agents require careful monitoring for development of resistance. There are a few situations when treatment is indicated regardless of HBV DNA or alanine aminotransferase levels. There is still much to be elucidated about the appropriate use of HBV therapy in children. Until more clinical data and therapeutic options are available, a conservative approach is warranted.
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Affiliation(s)
- Maureen M Jonas
- Division of Gastroenterology, Children's Hospital Boston, Boston, MA 02115, USA.
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620
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Lin LY, Wong VWS, Zhou HJ, Chan HY, Gui HL, Guo SM, Wang H, Huang L, Bao SS, Xie Q, Chan HLY. Relationship between serum hepatitis B virus DNA and surface antigen with covalently closed circular DNA in HBeAg-negative patients. J Med Virol 2010; 82:1494-500. [PMID: 20648602 DOI: 10.1002/jmv.21863] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hepatitis B virus (HBV) covalently closed circular DNA (cccDNA) is responsible for viral persistence. This study aimed to investigate the serum surrogate markers for cccDNA and to evaluate the intrahepatic viral events associated with disease activity in HBeAg-negative chronic hepatitis B patients. Thirty-three treatment-naïve patients with a negative HBeAg who had a liver biopsy were studied. Active disease was defined as a serum alanine aminotransferase >40 IU/L and a serum HBV DNA >10,000 copies/ml. This study showed significant correlation between serum HBV DNA and both log cccDNA (r = 0.41, P = 0.018) and log total intrahepatic HBV DNA (r = 0.71, P < 0.0001). No significant correlation was observed between serum HBsAg and log cccDNA (P = 0.15) or log total intrahepatic HBV DNA (P = 0.97). Fourteen and 19 patients had inactive and active disease, respectively. The median log cccDNA and log total intrahepatic HBV DNA (copies/10(6) cells) were significantly higher in patients with active disease compared with those with inactive disease (4.11 vs. 3.53, P = 0.03 and 5.46 vs. 4.64, P < 0.001, respectively). The HBV replicative efficiency, defined as the ratio of serum HBV DNA to cccDNA, was approximately 20% higher in patients with active disease. No significant difference was observed in the HBsAg levels and the ratio of serum HBsAg to cccDNA between the two groups. In conclusion, serum HBV DNA, but not HBsAg, reflects the amount of cccDNA and the replication efficiency of HBV in patients with HBeAg-negative chronic hepatitis B.
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Affiliation(s)
- L Y Lin
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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621
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Zhou YL, Duan ZJ. Viral versus alcoholic cirrhosis: clinical characteristics, prophylaxis and treatment. Shijie Huaren Xiaohua Zazhi 2010; 18:3313-3319. [DOI: 10.11569/wcjd.v18.i31.3313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the clinical characteristics, prophylaxis and treatment between viral and alcoholic cirrhosis.
METHODS: The clinical data for 952 cirrhotic patients who were treated at the First Affiliated Hospital of Dalian Medical University form April 2004 to May 2009 were collected. These patients were divided into three groups: viral cirrhosis (VC) group, alcoholic cirrhosis (AC) group, and VC plus AC group. Sex, age, medical history, clinical manifestations, liver function, complications, and the main cause of death were compared among the three groups of patients.
RESULTS: Of all cases, 63.66% had VC. In the VC plus AC group, two-thirds of patients had alcoholic hepatitis and hepatitis B. Male patients were more commonly seen in the three groups, especially in the AC group (M∶F = 48.5∶1). Compared to the AC group, the VC group and VC plus AC group had a high prevalence of splenomegaly. Upper gastrointestinal bleeding was the most common complication in all the groups. The prevalence of hepatocellular carcinoma in the VC group was higher than that in the AC group, and the prevalence of spontaneous bacterial peritonitis in the AC group was higher than that in the VC group (13.1% vs 5.2%, P < 0.01). Hepatic encephalopathy was the common death cause in both the VC and AC groups, followed by upper gastrointestinal bleeding and hepatocellular carcinoma. The most common cause of death in the AC plus VC group was hepatocellular carcinoma.
CONCLUSION: Prophylaxis and treatment of upper gastrointestinal bleeding and hepatic encephalopathy are important for patients with AC or VC. Prophylaxis of intestinal infection is important for AC patients. Prophylaxis of hepatocellular carcinoma is important for patients with both AC and VC.
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622
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Guirgis BS, Abbas RO, Azzazy HM. Hepatitis B virus genotyping: current methods and clinical implications. Int J Infect Dis 2010; 14:e941-53. [DOI: 10.1016/j.ijid.2010.03.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2008] [Revised: 03/10/2010] [Accepted: 03/11/2010] [Indexed: 02/06/2023] Open
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623
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Sun X, Qin W, Zhou R, Wang L, Li Y, Zhao L. Effect of conventional interferon-α in patients with HBeAg-positive chronic hepatitis B: a systematic review and meta-analysis. J Evid Based Med 2010; 3:220-5. [PMID: 21349073 DOI: 10.1111/j.1756-5391.2010.01100.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although a few studies have tested the effect of interferon-α on chronic hepatitis B, its treatment effect remains uncertain, and the association of treatment effect with intervention characteristics has not been thoroughly explored. This study examined the effect of IFN-α in patients with HBeAg-positive chronic hepatitis B, and investigated the characteristics associated with treatment effect. METHODS We searched MEDLINE, Scientific Citation Index, Current Content Connect, Cochrane Controlled Trial Register, and Chinese Biomedical Database, all up to 15 September 2009. We included randomized trials comparing IFN-α to placebo, no treatment, or standard care (SC) in patients with HBeAg-positive chronic hepatitis B. Two reviewers assessed the risk of bias and extracted data, independently and in duplicate. We conducted meta-analyses of the included studies, and subgroup analyses to examine the association of pre-specified characteristics (eg, dose, treatment duration) with treatment effect. RESULTS A total of 31 randomized controlled trials, involving 2164 patients, were included. The risk of bias varied across studies. Compared with placebo, no treatment, or SC, IFN-α improved loss of HBeAg (OR 2.36, 95% CI 1.83 to 3.04), HBV DNA undetectability (OR 2.04, 95% CI 1.28 to 3.32), HBeAg seroconversion (OR 1.82, 95% CI 1.26 to 2.62), ALT normalization (OR 1.24, 95% CI 1.01 to 1.56), and loss of HBsAg (OR 2.45, 95% CI 1.22 to 4.91). Treatment effects differed in high versus low dose, and long versus short duration of IFN-α. The effect of high dose IFN-α (OR 3.28, 95% CI 2.31 to 4.66) is statistically larger than that of low dose IFN-α (OR 1.58, 95% CI 1.10 to 2.28) on loss of HBeAg (interaction P = 0.017), and longer IFN-α treatment durations produce greater effects (OR 3.28, 95% CI 2.16 to 5.00) than do shorter durations (OR 1.94, 95% CI 0.42 to 2.66, interaction P = 0.038). High dose IFN-α had a significant effect on HBV DNA undetectability (OR 2.80, 95% CI 2.03 to 3.86), while low dose IFN-α did not (OR 0.93, 95% CI 0.61 to 1.41, interaction P = 0.01); longer treatments significantly improved HBV DNA undetectability (OR 2.58, 95% CI 1.62 to 4.12), but shorter durations did not (OR 1.28, 95% CI 0.83 to 1.97, interaction P = 0.024). CONCLUSIONS IFN-α can improve serological, biomedical, and virological response. Higher doses and prolonged treatments appear to have larger treatment benefits than lower doses and shorter treatments. However, the increased adverse reactions and costs associated with higher doses and prolonged treatment warrant caution in applying these results.
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Affiliation(s)
- Xin Sun
- Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China.
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624
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Wursthorn K, Jung M, Riva A, Goodman ZD, Lopez P, Bao W, Manns MP, Wedemeyer H, Naoumov NV. Kinetics of hepatitis B surface antigen decline during 3 years of telbivudine treatment in hepatitis B e antigen-positive patients. Hepatology 2010; 52:1611-20. [PMID: 20931556 DOI: 10.1002/hep.23905] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED The impact of prolonged direct antiviral therapy on hepatitis B surface antigen (HBsAg) levels in patients with chronic hepatitis B is poorly understood. We quantitatively assessed serum HBsAg levels during 3 years of telbivudine treatment, as well as their relationship with virologic and biochemical characteristics in 162 hepatitis B e antigen-positive patients who maintained undetectable serum hepatitis B virus (HBV) DNA long-term. Telbivudine treatment progressively reduced serum HBsAg levels (mean ± SD) from baseline (3.8 ± 0.6 log₁₀ IU/mL) to treatment week 24 (3.4 ± 0.7 log₁₀ IU/mL), treatment year 1 (3.3 ± 0.8 log₁₀ IU/mL), and treatment year 3 (3.0 ± 1.4 log₁₀ IU/mL) (P <0.0001). In this patient population, HBsAg loss was observed in nine (6%) of 162 patients through year 3. During the first year of treatment, three patterns of HBsAg decline were observed: rapid (≥ 1 log₁₀ IU/mL) in 32 patients, slow (0-1 log₁₀ IU/mL) in 74 patients, and steady levels in 56 patients. These findings were associated with different likelihoods of HBsAg loss during long-term telbivudine therapy. Eight of 32 patients with rapid HBsAg decline versus none of 56 patients with steady HBsAg levels achieved HBsAg loss at year 3 (P = 0.0024). HBV genotype was a significant determinant for HBsAg kinetics, with the fastest decline in genotype A patients. In patients with subsequent HBsAg loss, viral antigens were already undetectable in liver biopsy samples after 1 year of treatment. This was associated with markedly enhanced antiviral T cell reactivity. CONCLUSION In patients who have effective suppression of viral replication during telbivudine treatment, a rapid decline in serum HBsAg levels during the first year may identify those with a greater likelihood of achieving HBsAg clearance.
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Affiliation(s)
- Karsten Wursthorn
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany.
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625
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Sung JJY, Amarapurkar D, Chan HLY, Cheng J, Kao JH, Han KH, Piratvisuth T. Treatment of chronic hepatitis B in Asia-Pacific countries: is the Asia-Pacific consensus statement being followed? Antivir Ther 2010; 15:607-16. [PMID: 20587854 DOI: 10.3851/imp1561] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The Asia-Pacific consensus guidelines for the management of chronic hepatitis B state that the principal indicators for starting therapy are increased HBV DNA levels (> or =20,000 IU/ml for hepatitis B e antigen [HBeAg]-positive status and >2,000 IU/ml for HBeAg-negative status) and alanine aminotransferase (ALT) levels >2x the upper limit of normal. We aimed to determine whether clinicians in the Asia-Pacific region are treating patients with chronic hepatitis B according to the Asia-Pacific consensus statement on the management of chronic hepatitis B. METHODS An online survey of chronic hepatitis B treatment practices was prepared, consisting of 14 questions grouped into seven categories: patient statistics, treatment statistics, treatment decision, first-choice treatment, treatment duration, future directions and patient preference. RESULTS In total, 124 respondents from 12 countries completed the survey. Most respondents indicated that detectable HBV DNA was either the first or second most important factor when deciding whether to initiate therapy. Many physicians were unsure about initiation of treatment in patients >40 years of age when ALT levels were within the normal range. Oral antiviral drugs were the most frequently used medication because of their effectiveness, safety and ability to provide sustained viral suppression. Conversely, the most important reasons for selecting interferon therapy were effectiveness, fixed duration of treatment and lack of drug resistance. Criteria for stopping treatment generally followed the recommendations included in the guidelines. CONCLUSIONS These data suggest that clinicians from the Asia-Pacific region use criteria beyond those advocated in treatment guidelines when deciding whether to initiate treatment in HBV-infected patients.
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Affiliation(s)
- Joseph J Y Sung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
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626
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Lim LG, Aung MO, Seet BL, Tan C, Dan YY, Lee YM, Sutedja DS, Fernandes M, Lee GH, Koay E, Lim SG. Alanine aminotransferase is an inadequate surrogate marker for detecting lamivudine resistance. World J Gastroenterol 2010; 16:4691-6. [PMID: 20872970 PMCID: PMC2951520 DOI: 10.3748/wjg.v16.i37.4691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2010] [Revised: 04/24/2010] [Accepted: 05/01/2010] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the accuracy of serum alanine aminotransferase (ALT) in diagnosing lamivudine resistance and factors that contributed to abnormal serum ALT. METHODS This was a retrospective study of chronic hepatitis B patients on lamivudine therapy who were followed for 3-mo with liver function tests and hepatitis B virus (HBV) DNA measurement. Lamivudine resistance was defined as HBV DNA ≥ 1 log from nadir on at least 2 occasions, confirmed by genotyping. Serum ALT levels in patients with lamivudine resistance were compared to serum ALT levels in those without lamivudine resistance. RESULTS There were 111 patients with and 117 without lamivudine resistance. The area under the receiver operating characteristic of serum ALT to diagnose lamivudine resistance was 0.645 ± 0.037. Serum ALT > 42.5 U/L gave the best diagnostic accuracy with sensitivity = 61%, specificity = 60%, positive predictive value = 60%, negative predictive value = 61%, positive likelihood ratio = 1.53 and negative likelihood ratio = 0.65 for predicting lamivudine resistance, missing 39% of resistant patients. Using other serum ALT cutoffs, diagnostic accuracy was lower. By multivariate analysis, baseline abnormal serum ALT was associated with abnormal ALT during resistance (OR = 5.98, P = 0.003), and males were associated with serum ALT flares during resistance (OR = 8.9, P = 0.016). CONCLUSION Serum ALT is inadequate for diagnosing lamivudine resistance and has implications where viral resistance testing is suboptimal and for reimbursement of rescue therapy.
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627
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Abstract
The goal of hepatitis B treatment is to prevent the development of cirrhosis, liver failure, and hepatocellular carcinoma. Ideally, clinical studies should demonstrate that hepatitis B therapies can prevent liver-related complications; however, these clinical endpoints evolve over years or decades. Therefore, clinical trials have relied on intermediate endpoints to evaluate the efficacy of treatment and to determine when treatment can be stopped. Intermediate endpoints that have been used include biochemical, histological, virological, and serological endpoints. This review will discuss the validity of these intermediate endpoints as surrogates of clinical endpoints, and the rates at which these intermediate endpoints can be achieved with currently available therapies.
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Affiliation(s)
- W Chotiyaputta
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA
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628
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Hepatitis B e antigen seroconversion: a critical event in chronic hepatitis B virus infection. Dig Dis Sci 2010; 55:2727-34. [PMID: 20238245 DOI: 10.1007/s10620-010-1179-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 02/22/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Replication of hepatitis B virus (HBV) is the primary driver of disease progression and clinical outcomes in patients with chronic hepatitis B (CHB), but other factors, such as hepatitis B e antigen (HBeAg) status, also influence disease course. The importance of HBeAg seroconversion is underscored by current CHB treatment guidelines that recommend limiting the duration of antiviral therapy in HBeAg-positive patients who achieve seroconversion. AIMS A 2-day meeting of leading hepatologists with extensive experience managing patients with CHB in the Asia-Pacific region was held with the overall goals of reviewing and evaluating (1) available data on the relationship between HBeAg seroconversion and clinical outcomes for patients with HBeAg-positive CHB, and (2) the ways in which seroconversion should influence patient management. CONCLUSIONS It was agreed that HBeAg seroconversion is an important serologic end point for patients with CHB and that achieving this goal should be an important consideration in treatment selection. Patients with HBeAg-positive CHB should consider pegylated interferon if they are aged < 40 years (especially women), have lower HBV DNA levels, can afford this treatment, and have a lifestyle that would support adherence to injection therapy. Alternatively, nucleos(t)ide analogs are recommended in patients with alanine aminotransferase levels ≥ 2 × the upper limit of normal, HBV DNA levels < 9 log(10) IU/ml, and compensated CHB. Entecavir, telbivudine, and tenofovir may be used as first-line therapy; they can be administered as a finite therapeutic course in HBeAg-positive patients who seroconvert. Telbivudine and tenofovir should be considered in women of child-bearing potential.
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Chang TT, Liaw YF, Wu SS, Schiff E, Han KH, Lai CL, Safadi R, Lee SS, Halota W, Goodman Z, Chi YC, Zhang H, Hindes R, Iloeje U, Beebe S, Kreter B. Long-term entecavir therapy results in the reversal of fibrosis/cirrhosis and continued histological improvement in patients with chronic hepatitis B. Hepatology 2010; 52:886-93. [PMID: 20683932 DOI: 10.1002/hep.23785] [Citation(s) in RCA: 730] [Impact Index Per Article: 52.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED One year of treatment with entecavir (0.5 mg daily) in nucleoside-naive patients with hepatitis B e antigen (HBeAg)-positive or HBeAg-negative chronic hepatitis B (CHB) resulted in significantly improved liver histology and virological and biochemical endpoints in comparison with lamivudine. Patients who received at least 3 years of cumulative entecavir therapy in phase 3 studies and a long-term rollover study and underwent long-term liver biopsy were evaluated for improvements in histological appearance. Sixty-nine patients [50 HBeAg-positive and 19 HBeAg-negative] receiving entecavir therapy underwent long-term liver biopsy (median time of biopsy = 6 years, range = 3-7 years). Histological improvement was analyzed for 57 patients who had adequate baseline biopsy samples, baseline Knodell necroinflammatory scores > or =2, and adequate long-term biopsy samples. At the time of long-term biopsy, all patients in the cohort had a hepatitis B virus DNA level <300 copies/mL, and 86% had a normalized alanine aminotransferase level. Histological improvement (> or =2-point decrease in the Knodell necroinflammatory score and no worsening of the Knodell fibrosis score) was observed in 96% of patients, and a > or =1-point improvement in the Ishak fibrosis score was found in 88% of patients, including all 10 patients with advanced fibrosis or cirrhosis at the phase 3 baseline. CONCLUSION The majority of nucleoside-naive patients with CHB who were treated with entecavir in this long-term cohort achieved substantial histological improvement and regression of fibrosis or cirrhosis.
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Affiliation(s)
- Ting-Tsung Chang
- Department of Internal Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
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630
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Enomoto M, Mori M, Ogawa T, Fujii H, Kobayashi S, Iwai S, Morikawa H, Tamori A, Sakaguchi H, Sawada A, Takeda S, Habu D, Shiomi S, Kawada N. Usefulness of transient elastography for assessment of liver fibrosis in chronic hepatitis B: Regression of liver stiffness during entecavir therapy. Hepatol Res 2010; 40:853-61. [PMID: 20887589 DOI: 10.1111/j.1872-034x.2010.00687.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM The usefulness of transient elastography remains to be validated in chronic hepatitis B, particularly as a tool for monitoring the degree of liver fibrosis during treatment. METHODS The subjects were 50 patients with chronic hepatitis B virus infection. Liver biopsy was performed in 38 patients, and in 12 patients with platelet counts of 50 × 10(9)/L or less, cirrhosis was clinically diagnosed on the basis of specific signs of portal hypertension. Liver stiffness was measured by transient elastography at baseline and after 12 months of treatment in 20 nucleos(t)ide-naïve patients who started entecavir within 3 months after study entry. RESULTS Twenty (40%) patients were classified as F1, 10 (20%) as F2, 5 (10%) as F3, and 15 (30%) as F4 (cirrhosis). Median liver stiffness (interquartile range) was 7.0 kPa (5.6-9.4), 9.8 kPa (5.6-14.7), 9.8 kPa (7.6-12.9), and 17.3 kPa (8.2-27.6) in fibrosis stages F1 to F4, respectively. Liver stiffness significantly correlated with fibrosis stage (r = 0.46; P = 0.0014). Of the patients who started entecavir, median liver stiffness significantly decreased from 11.2 kPa (7.0-15.2) to 7.8 kPa (5.1-11.9; P = 0.0090) during 12 months of treatment. Median levels of amino-terminal peptide of type III procollagen and type IV collagen 7S domain in serum significantly decreased from 0.9 (0.6-1.3) to 0.6 (0.5-0.7) U/mL (P = 0.0010) and from 5.0 (4.4-6.7) to 3.9 (3.2-4.4) ng/mL (P = 0.015), respectively. CONCLUSION Liver stiffness measurement can be useful for monitoring regression of liver fibrosis during entecavir treatment in patients with chronic hepatitis B virus infection.
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Affiliation(s)
- Masaru Enomoto
- Department of Hepatology, Osaka City University Graduate School of Medicine, Osaka, Japan
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631
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Abstract
Many studies have attested that not only does HBV genotype influence the outcome of the disease but it also influences the outcome of therapy with interferons and pegylated interferons, with genotype A doing better than genotype D in Caucasians and genotype B better than genotype C in Asians. However, the guidelines from three regional bodies - AASLD, APASL and EASL - all stop short of recommending genotyping as part of the management of chronic hepatitis B. The recommendations, however, from several national organizations as well as from individual reviewers suggest that genotyping is essential to detect patients in whom the use of pegylated interferon will give a high likelihood of response with a finite course of therapy and avoid the disadvantages of nucleoside analogues with their viral resistance. It is concluded that determination of HBV genotype should form part of the management in treating chronic hepatitis B.
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Affiliation(s)
- W G E Cooksley
- Discipline of Medicine, University of Queensland, Royal Brisbane Hospital, Brisbane, QLD, Australia.
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632
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Response predictors to treatment with pegylated interferon in chronic hepatitis B. Braz J Infect Dis 2010. [DOI: 10.1016/s1413-8670(10)70104-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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633
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Berg T, Benhamou Y, Calleja JL, Levrero M, Johnson W, Ellis N. A survey of chronic hepatitis B patient management practices in the European Union. J Viral Hepat 2010; 17:624-30. [PMID: 20487257 DOI: 10.1111/j.1365-2893.2010.01318.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The current study sought to evaluate the characteristics of chronic hepatitis B virus (HBV) infection and current management practices in the European Union by surveying physician and patient records. A detailed survey of physician practices and management of patients with CHB was conducted between July and October 2006 in France, Germany, Italy and Spain. A total of 200 physicians participated in the survey, and data were collected from 2023 patients with chronic HBV infection. Most patients were men (69%), who had hepatitis B e antigen (HBeAg)-negative disease (64%), and demonstrated evidence of significant disease [53%; moderate fibrosis (35%), compensated cirrhosis (14%), or decompensated cirrhosis (4%)]. Among the 1665 HBV-monoinfected patients surveyed, 1184 (71%) were currently receiving treatment for chronic HBV infection. At treatment initiation, 70% of HBeAg-positive patients had both pretreatment serum HBV DNA levels <or=9 log(10) copies/mL and alanine aminotransferase (ALT) levels >or=2 x the upper limit of normal (ULN), and 81% of HBeAg-negative patients had HBV DNA levels of <or=7 log(10) copies/mL. Among untreated patients, HBV DNA levels <or=5 log(10,) ALT levels <2 x ULN, and mild or no liver fibrosis were present in 48% and 84% of HBeAg-positive and HBeAg-negative patients, respectively. In conclusion, the majority of European patients with CHB surveyed were HBeAg negative, Caucasian, men, and presented with significant histologic liver disease. At treatment initiation, most HBeAg-positive patients had pretreatment serum HBV DNA levels <or=9 log(10) copies/mL and ALT levels >or=2 x ULN, while the HBeAg-negative patients had HBV DNA levels <or=7 log(10) copies/mL.
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Affiliation(s)
- T Berg
- Sektion Hepatologie, Klinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Leipzig, Germany.
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634
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Lv GC, Ma WJ, Ying LJ, Jin X, Zheng L, Yang YD. Efficacy of telbivudine in HBeAg-positive chronic hepatitis B patients with high baseline ALT levels. World J Gastroenterol 2010; 16:4095-9. [PMID: 20731026 PMCID: PMC2928466 DOI: 10.3748/wjg.v16.i32.4095] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of telbivudine (LDT) in hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) patients who have high baseline alanine aminotransferase (ALT) levels between 10 and 20 times the upper limit of normal.
METHODS: Forty HBeAg-positive CHB patients with high baseline ALT levels between 10 and 20 times the upper limit of normal were enrolled and received LDT monotherapy for 52 wk. Another forty patients with baseline ALT levels between 2 and 10 times the upper limit of normal were included as controls. We compared the virological, biochemical, serological and side effect profiles between the two groups at 52 wk.
RESULTS: By week 52, the mean decrease in hepatitis B virus (HBV) DNA level compared with baseline was 7.03 log10 copies/mL in the high baseline ALT group and 6.17 log10 copies/mL in the control group, respectively (P < 0.05). The proportion of patients in whom serum HBV DNA levels were undetectable by polymerase chain reaction assay was 72.5% in the high baseline ALT group and 60% in the control group, respectively (P < 0.05). In addition, 45.0% of patients in the high baseline ALT group and 27.5% of controls became HBeAg-negative, and 37.5% of those in the high baseline group and 22.5% of controls, respectively, had HBeAg seroconversion (P < 0.05) at week 52. Moreover, in the high baseline group, 4 out of 40 patients (10%) became hepatitis B surface antigen (HBsAg)-negative and 3 (7.5%) of them seroconverted (became HBsAg-positive). Only 1 patient in the control group became HBsAg-negative, but had no seroconversion. The ALT normalization rate, viral breakthrough, genotypic resistance to LDT, and elevations in creatine kinase levels were similar in the two groups over the 52 wk.
CONCLUSION: High baseline ALT level is a strong predictor for optimal results during LDT treatment.
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635
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Abstract
The incidence of hepatitis B virus (HBV) infection in dialysis populations has declined over recent decades, largely because of improvements in infection control and widespread implementation of HBV vaccination. Regardless, outbreaks of infection continue to occur in dialysis units, and prevalence rates remain unacceptably high. For a variety of reasons, dialysis patients are at increased risk of acquiring HBV. They also demonstrate different disease manifestations compared with healthy individuals and are more likely to progress to chronic carriage. This paper will review the epidemiology, modes of transmission and diagnosis of HBV in this population. Prevention and treatment will be discussed, with a specific focus on strategies to improve vaccination response, new therapeutic options and selection of patients for therapy.
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Affiliation(s)
- Matthew Edey
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
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636
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Duarte-Rojo A, Feld JJ. Hepatitis B Biomarkers: Clinical Significance of the Old and the New. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s11901-010-0053-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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637
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Thedja MD, Roni M, Harahap AR, Siregar NC, Ie SI, Muljono DH. Occult hepatitis B in blood donors in Indonesia: altered antigenicity of the hepatitis B virus surface protein. Hepatol Int 2010; 4:608-14. [PMID: 21063484 DOI: 10.1007/s12072-010-9203-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Accepted: 07/13/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Occult hepatitis B virus infection (OBI) poses a challenge to the safety of blood donation. The prevalence of OBI is not well documented in Indonesia, although this information in such an endemic country is needed. This study was aimed to evaluate the prevalence of occult hepatitis B in blood donors from two cities of Indonesia, and to study the genetic variation and its effect on the predicted antigenicity of HBsAg. METHODS Serum samples of 309 regular blood donors negative for HBsAg were tested for anti-HBs and anti-HBc. Hepatitis B virus (HBV) DNA isolated from anti-HBc-positive samples were analyzed by polymerase chain reaction, cloned and sequenced. Antigenic properties of identified HBsAg mutants were predicted by calculation of the antigenic index. RESULTS Of the 309 HBsAg-negative samples, anti-HBc was positive in 134 (43.4%) and HBV DNA was detected in 25 (8.1%). Seven of the viremic samples had nucleotide substitutions (A521G, A551T, C582T, and A562G) in the S gene, causing amino acid mutations (T123A, M133L, and T143M) in the 'a' determinant of HBsAg that resulted in changes in the predicted antigenicity. CONCLUSIONS OBI was detected in blood donors' samples in Indonesia. Anti-HBc was shown to be a better screening parameter than HBsAg, however, it might result in the loss of donors particularly in endemic countries. HBsAg detection failure in this study might be due to mutations altering the protein antigenicity and/or the low-level carriage of HBV.
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638
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Affiliation(s)
- Anna S F Lok
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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639
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Abstract
There have been major advances in the field of hepatitis B (HBV) over the last few decades. These advances have resulted in the understanding of the natural history of chronic HBV infection, effective vaccines against the virus, sensitive assays for screening and monitoring of treatment, and effective treatments for viral suppression, all leading to improved outcomes. Debates and controversies remain, however, over the ideal management strategies of patients with chronic hepatitis B. To eradicate HBV, the global community needs to improve current preventive, screening, and treatment strategies.
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Affiliation(s)
- Michelle Lai
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA.
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640
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Dienstag JL. Peginterferon therapy for HBeAg-negative chronic hepatitis B: less than meets the eye. Am J Gastroenterol 2010; 105:1770-2. [PMID: 20686463 DOI: 10.1038/ajg.2010.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pegylated interferon (PEG IFN) has been recommended as a first-line therapy for hepatitis B e antigen (HBeAg)-negative chronic hepatitis B; however, data supporting this recommendation are derived from a single randomized controlled trial. In this issue of the Journal, Rijckborst et al. report the results of a second randomized controlled PEG IFN trial in 138 HBeAg-negative patients. The trial was undertaken to test the efficacy of adding ribavirin to PEG IFN; however, the results were unequivocal in concluding that adding ribavirin was not effective. Moreover, the efficacy of PEG IFN for these HBeAg-negative subjects was disappointing; only 7.5% of the study cohort had undetectable hepatitis B virus DNA (<400 copies/ml) 24 weeks after a 48-week course of therapy, and none lost hepatitis B surface antigen. This study challenges the value and limits the appeal of PEG IFN therapy for HBeAg-negative chronic hepatitis B.
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641
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642
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Wu B, Li T, Chen H, Shen J. Cost-effectiveness of nucleoside analog therapy for hepatitis B in China: a Markov analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:592-600. [PMID: 20561341 DOI: 10.1111/j.1524-4733.2010.00733.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the economic consequences of nucleoside analog therapy for hepatitis B treatment in China. METHODS A cost-utility analysis of treatments for HBeAg-positive and HBeAg-negative chronic hepatitis B (CHB) was conducted using a Markov model, in which patients' yearly transitions between different health states were tracked. Patients were tracked as they moved between the following health states: CHB, HBeAg seroconversion (HBeAg-positive CHB patients can have this special health state), virologic resistance, virologic response, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplantation, and death. The transition parameters were derived either from systematic reviews of the literature or from previous economic studies. Cost and utility data came from studies based on a Chinese CHB cohort. One-way sensitivity analyses as well as second-order Monte Carlo and probabilistic sensitivity analyses were performed. RESULTS The entecavir strategy yielded the most quality-adjusted life years (QALYs) for both HBeAg-positive and HBeAg-negative patients when compared with the "no treatment," the lamivudine, the adefovir, and the telbivudine strategies. The risks of complications and mortality also decreased. In the economic analysis, the "no treatment" strategy was the least effective, whereas the entecavir strategy was both the least expensive and the most cost-effective option, followed by telbivudine and lamivudine. The probabilistic sensitivity analysis showed that the entecavir strategy would result in improved cost-effectiveness in >90% of cases at a threshold of $20,000 per QALY. In a one-way sensitivity analysis, the most influential parameters impacting the model's robustness were the utilities of the CHB and virologic response health states. CONCLUSIONS In China, when treating both HBeAg-positive and HBeAg-negative CHB populations, entecavir is the most cost-effective option when compared with lamivudine, adefovir, and telbivudine.
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Affiliation(s)
- Bin Wu
- Department of Pharmacy, Renji Hospital, Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
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643
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Abstract
The goal of antiviral therapy for chronic hepatitis B is to prevent the development of cirrhosis and hepatocellular carcinoma. End points, including viral suppression, alanine aminotransferase normalization, hepatitis B e antigen loss, hepatitis B surface antigen loss, and improvement in liver histology, are used to determine treatment success. Treatment is based on hepatitis B virus (HBV) replication status and stage of liver disease, modulated by the age of the patient, hepatitis B e antigen (HBeAg) status and patient preference. Seven therapies are approved, including two formulations of interferon and five orally administered nucleos(t)ide analogs. These therapies are effective in suppressing HBV replication and have also been shown to prevent disease progression.
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644
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Abstract
Providing appropriate treatment and follow-up to hepatitis B virus (HBV)-infected mothers and their newborns is critical in preventing HBV mother-to-child transmission (MTCT) and eradicating HBV infection. Although highly effective in preventing MTCT, standard passive-active immunoprophylaxis with hepatitis B immunoglobulin and the hepatitis B vaccine may have a failure rate as high as 10% to 15%. Antiviral treatment has been used during pregnancy and may decrease MTCT. Several issues must be addressed in future clinical studies before universal recommendations for antiviral therapy for pregnant women can be made.
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Affiliation(s)
- Corinne Buchanan
- Cedars-Sinai Medical Center, Geffen UCLA School of Medicine, Los Angeles, CA 90048, USA
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645
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Rijckborst V, ter Borg MJ, Cakaloglu Y, Ferenci P, Tabak F, Akdogan M, Simon K, Raptopoulou-Gigi M, Ormeci N, Zondervan PE, Verhey E, van Vuuren AJ, Hansen BE, Janssen HLA. A randomized trial of peginterferon alpha-2a with or without ribavirin for HBeAg-negative chronic hepatitis B. Am J Gastroenterol 2010; 105:1762-9. [PMID: 20461068 DOI: 10.1038/ajg.2010.186] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Hepatitis B e antigen (HBeAg)-negative chronic hepatitis B patients are at high risk of treatment relapse after any antiviral therapy. Combining peginterferon alpha-2a with ribavirin might improve sustained response rates. METHODS Overall, 138 HBeAg-negative chronic hepatitis B patients were randomized to receive monotherapy (peginterferon alpha-2a 180 microg weekly plus placebo) or combination therapy (peginterferon alpha-2a weekly plus ribavirin 1,000 or 1,200 mg daily, depending on body weight) for 48 weeks. Post-treatment follow-up lasted 24 weeks. Analyses were based on the modified intention-to-treat population after exclusion of five patients. RESULTS At the end of follow-up, 14 (20%) of 69 patients assigned to monotherapy and 10 (16%) of 64 assigned to combination therapy had a combined response (hepatitis B virus (HBV) DNA <10,000 copies/ml (<1,714 IU/ml) and a normal alanine aminotransferase level, P=0.49). At the end of treatment, more patients had a combined response (25 (36%) vs. 26 (41%) in the monotherapy and combination therapy group, respectively, P=0.60), but subsequently relapsed during follow-up. Serum HBV DNA and hepatitis B surface antigen (HBsAg) levels decreased during treatment (mean change at week 48 compared with baseline -3.9 vs. -2.6 log copies/ml, P<0.001 and -0.56 vs. -0.34 log IU/ml, P=0.23, respectively). HBV DNA levels relapsed after treatment discontinuation; HBsAg remained at end-of-treatment levels. In general, combination therapy was well tolerated, although it was associated with a higher risk of anemia and neutropenia. CONCLUSIONS Treatment with peginterferon alpha-2a resulted in a limited sustained response rate in HBeAg-negative chronic hepatitis B patients. Addition of ribavirin did not improve response to therapy.
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Affiliation(s)
- Vincent Rijckborst
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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646
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Rijckborst V, Hansen BE, Cakaloglu Y, Ferenci P, Tabak F, Akdogan M, Simon K, Akarca US, Flisiak R, Verhey E, Van Vuuren AJ, Boucher CAB, ter Borg MJ, Janssen HLA. Early on-treatment prediction of response to peginterferon alfa-2a for HBeAg-negative chronic hepatitis B using HBsAg and HBV DNA levels. Hepatology 2010; 52:454-61. [PMID: 20683945 DOI: 10.1002/hep.23722] [Citation(s) in RCA: 179] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED Peginterferon alfa-2a results in a sustained response (SR) in a minority of patients with hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB). This study investigated the role of early on-treatment serum hepatitis B surface antigen (HBsAg) levels in the prediction of SR in HBeAg-negative patients receiving peginterferon alfa-2a. HBsAg (Architect from Abbott) was quantified at the baseline and during treatment (weeks 4, 8, 12, 24, 36, and 48) and follow-up (weeks 60 and 72) in the sera from 107 patients who participated in an international multicenter trial (peginterferon alfa-2a, n = 53, versus peginterferon alfa-2a and ribavirin, n = 54). Overall, 24 patients (22%) achieved SR [serum hepatitis B virus (HBV) DNA level < 10,000 copies/mL and normal alanine aminotransferase levels at week 72]. Baseline characteristics were comparable between sustained responders and nonresponders. From week 8 onward, serum HBsAg levels markedly decreased in sustained responders, whereas only a modest decline was observed in nonresponders. However, HBsAg declines alone were of limited value in the prediction of SR [area under the receiver operating characteristic curve (AUC) at weeks 4, 8, and 12 = 0.59, 0.56, and 0.69, respectively]. Combining the declines in HBsAg and HBV DNA allowed the best prediction of SR (AUC at week 12 = 0.74). None of the 20 patients (20% of the study population) in whom a decrease in serum HBsAg levels was absent and whose HBV DNA levels declined less than 2 log copies/mL exhibited an SR (negative predictive value = 100%). CONCLUSION At week 12 of peginterferon alfa-2a treatment for HBeAg-negative CHB, a solid stopping rule was established with a combination of declines in serum HBV DNA and HBsAg levels from the baseline. Quantitative serum HBsAg in combination with HBV DNA enables on-treatment adjustments of peginterferon therapy for HBeAg-negative CHB.
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Affiliation(s)
- Vincent Rijckborst
- Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
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647
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648
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Mao QG, Pan JS, Fang KN, Zhang RM, Hong QY, Song MN, Zhu JP, Huang WQ, Chen LM, Hong MZ. Precise prediction model and simplified scoring system for sustained combined response to interferon-α. World J Gastroenterol 2010; 16:3465-71. [PMID: 20632453 PMCID: PMC2904897 DOI: 10.3748/wjg.v16.i27.3465] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To establish a predictive algorithm which may serve for selecting optimal candidates for interferon-α (IFN-α) treatment.
METHODS: A total of 474 IFN-α treated hepatitis B virus e antigen (HBeAg)-positive patients were enrolled in the present study. The patients’ baseline characteristics, such as age, gender, blood tests, activity grading (G) of intrahepatic inflammation, score (S) of liver fibrosis, hepatitis B virus (HBV) DNA and genotype were evaluated; therapy duration and response of each patient at the 24th wk after cessation of IFN-α treatment were also recorded. A predictive algorithm and scoring system for a sustained combined response (CR) to IFN-α therapy were established. About 10% of the patients were randomly drawn as the test set. Responses to IFN-α therapy were divided into CR, partial response (PR) and non-response (NR). The mixed set of PR and NR was recorded as PR+NR.
RESULTS: Stratified by therapy duration, the most significant baseline predictive factors were alanine aminotransferase (ALT), HBV DNA level, aspartate aminotransferase (AST), HBV genotype, S, G, age and gender. According to the established model, the accuracies for sustained CR and PR+NR, respectively, were 86.4% and 93.0% for the training set, 81.5% and 91.0% for the test set. For the scoring system, the sensitivity and specificity were 78.8% and 80.6%, respectively. There were positive correlations between ALT and AST, and G and S, respectively.
CONCLUSION: With these models, practitioners may be able to propose individualized decisions that have an integrated foundation on both evidence-based medicine and personal characteristics.
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649
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Lui YYN, Tsoi KKF, Wong VWS, Kao JH, Hou JL, Teo EK, Mohamed R, Piratvisuth T, Han KH, Mihm U, Wong GLH, Chan HLY. Cost-effectiveness analysis of roadmap models in chronic hepatitis B using tenofovir as the rescue therapy. Antivir Ther 2010; 15:145-55. [PMID: 20386069 DOI: 10.3851/imp1496] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The roadmap approach is recommended to guide chronic hepatitis B treatment. We evaluated the cost-effectiveness of various treatment strategies in the global market. METHODS Lamivudine and telbivudine were tested in roadmap models with switch-to tenofovir if HBV was detectable at week 24 or add-on tenofovir if resistance developed at year 1. Tenofovir and entecavir were tested as continuous monotherapy. In the reference arm, lamivudine was used with add-on tenofovir if resistance developed at year 1. The primary measure of effectiveness was undetectable HBV DNA at year 2. Cost-effectiveness was measured by incremental cost-effectiveness ratio (ICER) in US dollars against the reference arm. RESULTS In the US and Germany, costs of the reference arms were US $14,486 and US $9,998 for hepatitis B e antigen (HBeAg)-positive and US $11,398 and US $7,531 for HBeAg-negative patients, respectively. In HBeAg-positive patients, the lamivudine roadmap was most cost-effective (ICER US $15,260 in the US and US $29,113 in Germany) with comparable effectiveness (75.1%) to other strategies. In HBeAg-negative patients, tenofovir and entecavir monotherapies were most effective (91-96%) and cost-effective (ICER US $31,297-43,387 in the US and US $53,976-59,822 in Germany). In Asia, where telbivudine cost was lower, both telbivudine and lamivudine roadmaps were cost-effective in HBeAg-positive patients. Tenofovir would be most cost-effective in HBeAg-negative patients if its cost equaled that of telbivudine in Asia. CONCLUSIONS In HBeAg-positive patients, lamivudine roadmap was most cost-effective; in Asia, telbivudine roadmap had comparable cost-effectiveness to lamivudine roadmap because of the relatively low price of telbivudine. In HBeAg-negative patients, entecavir and tenofovir monotherapies were more cost-effective than the roadmap models.
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Affiliation(s)
- Yanni Yan-Ni Lui
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Terrritories, Hong Kong
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Ide T, Sata M, Chayama K, Shindo M, Toyota J, Mochida S, Tomita E, Kumada H, Yamada G, Yatsuhashi H, Hayashi N, Ishikawa H, Seriu T, Omata M. Evaluation of long-term entecavir treatment in stable chronic hepatitis B patients switched from lamivudine therapy. Hepatol Int 2010; 4:594-600. [PMID: 21063482 PMCID: PMC2939999 DOI: 10.1007/s12072-010-9185-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 06/25/2010] [Indexed: 01/04/2023]
Abstract
PURPOSE Current Japanese guidelines recommend that patients should be switched from lamivudine to entecavir when they meet certain criteria. This analysis examines the efficacy and safety of long-term entecavir therapy in patients who were switched to entecavir after 24 weeks' lamivudine therapy in Japanese studies ETV-047 and ETV-060. METHODS The Phase II Japanese study ETV-047 assessed the efficacy of different entecavir doses when compared with lamivudine. A total of 33 Japanese patients who received lamivudine 100 mg daily in ETV-047 entered the open-label rollover study ETV-060 and subsequently received treatment with entecavir 0.5 mg daily. Hepatitis B virus (HBV) DNA suppression, alanine aminotransferase (ALT) normalization, hepatitis B e antigen (HBeAg) seroconversion, and resistance were evaluated among patients with available samples for up to 96 weeks. Safety was assessed throughout the treatment period. RESULTS After 96 weeks of entecavir therapy in ETV-060, 90% of patients achieved HBV DNA <400 copies/mL as compared to 21% of patients who completed 24 weeks of lamivudine therapy in ETV-047. Increasing proportions of patients achieved ALT normalization and HBeAg seroconversion following long-term entecavir treatment. No patients experienced virologic breakthrough, and substitutions associated with entecavir resistance were not observed in patients with detectable HBV DNA. Entecavir was well tolerated during long-term treatment. CONCLUSIONS Switching lamivudine-treated patients with chronic hepatitis B to entecavir results in increased virologic suppression with no evidence of resistance through 2 years of entecavir therapy. These findings support recommendations in the current Japanese treatment guidelines that stable lamivudine patients should be switched to entecavir.
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Affiliation(s)
- Tatsuya Ide
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Michio Sata
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Kazuaki Chayama
- Department of Medicine and Molecular Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Michiko Shindo
- Division of Liver Disease, Department of Internal Medicine, Akashi Municipal Hospital, Akashi, Hyogo Japan
| | - Joji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Hokkaido, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Saitama Medical University, Saitama, Japan
| | - Eiichi Tomita
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | | | - Gotaro Yamada
- Department of Internal Medicine, Center for Liver Diseases, Kawasaki Medical School, Kawasaki Hospital, Okayama, Japan
| | - Hiroshi Yatsuhashi
- Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Norio Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Taku Seriu
- Research and Development, Bristol-Myers K.K, Tokyo, Japan
| | - Masao Omata
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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