Peginterferon-alfa2a plus ribavirin for 48 versus 72 weeks in patients with detectable hepatitis C virus RNA at week 4 of treatment

Meta-analysis shows extended therapy improves response of patients with chronic hepatitis C virus genotype 1 infection

BACKGROUND & AIMS

Clinical trials provided conflicting results about whether extended duration of treatment with pegylated interferon-alfa (pegIFN-alfa) and ribavirin (more than 48 weeks) improves rates of sustained virologic response (SVR) in patients infected with hepatitis C virus (HCV) genotype 1 and slow virologic response. We performed a meta-analysis to determine the overall impact of extended treatment, compared with standard treatment, on virologic response rates in these patients.

METHODS

We performed a literature search to identify randomized controlled trials (RCTs) that included monoinfected, treatment-naive patients infected with HCV genotype 1; data were compared between slow responding patients treated with pegIFN-alfa-2a/b plus ribavirin for 48 weeks and those that received extended treatment (as much as 72 weeks). End points included SVR rates, end-of-treatment (EOT) response and relapse rates; they were calculated according to the DerSimonian-Laird estimate.

RESULTS

Six RCTs assessed the benefits of extended treatment with pegIFN-alfa-2a/b and ribavirin in treatment-naive patients with HCV genotype 1 that were slow responders (n = 669). The extended treatment significantly improved SVR rates in slow responders, compared with the standard of care (14.7% increase in overall SVR; 95% confidence interval, 4%-25.5%; P = .0072). Rates of viral relapse were significantly reduced by extended treatment, but EOT response rates were similar. The frequency of voluntary treatment discontinuation, but not of serious adverse events, was significantly increased by extended therapy.

CONCLUSIONS

Extending the duration of treatment with pegIFN-alfa-2a/b and ribavirin in patients with HCV genotype 1 and a slow response to therapy improves the rate of SVR.

Low virological response and high relapse rates in hepatitis C genotype 1 patients with advanced fibrosis despite adequate therapeutic dosing

BACKGROUND & AIMS

The impact of fibrosis stage on chronic hepatitis C virus (HCV) treatment response was explored in CHARIOT, a study of high dose peginterferon alfa-2a (PEG-IFNalpha-2a) induction therapy in treatment naïve genotype 1 infection.

METHODS

Eight hundred and ninety-six patients were randomised 1:1 to 360 microg (n=448) or 180 microg (n=448) PEG-IFNalpha-2a weekly with RBV 1000-1200 mg/day for 12 weeks followed by 36 weeks of 180 microg PEG-IFNalpha-2a weekly plus RBV 1000-1200 mg/day. Virological responses were assessed at week 4, 8, 12, 24, 48 (end of therapy), and 24 weeks following therapy (sustained virological response, SVR). As previously reported, there was no significant difference in SVR in the induction (53%) and standard (50%) arms, therefore the pooled study population was used for analysis of SVR and relapse.

RESULTS

A marked step-wise decline in SVR was evident by fibrosis stage: F0 (70%); F1 (60%); F2 (51%); F3 (31%); F4 (10%) (p<0.0001). Early virological responses were lower among F3/4 patients, including rapid virological response (RVR) (21% vs. 34% for F3/4 and F0-2, respectively) (p=0.0072), and the RVR positive predictive value was also lower (63% vs. 80%). Virological relapse rates were similar in early disease stages (F0, 16%; F1, 23%; F2, 26%), but increased markedly in advanced fibrosis (F3, 50%; F4, 80%) (p<0.0001). Cumulative PEG-IFNalpha-2a and ribavirin doses were similar among patients with F3/4 and F0-2 within treatment arms through week 4, 8, 12, and week 24.

CONCLUSIONS

Low virological response in hepatitis C genotype 1 patients with advanced fibrosis is not explained by inadequate cumulative PEG-IFN and ribavirin doses.

Antiviral treatment of chronic hepatitis C in clinical routine

OBJECTIVE

Pegylated interferon plus ribavirin is the standard treatment for chronic hepatitis C. Sustained virological response (SVR) rates of up to 60% are reported in randomized controlled trials, but it is unclear whether the results from such trials are reproducible in the clinical routine setting. We investigated consecutive treatment-naïve chronic hepatitis C patients at our center to examine the efficacy of treatment with pegylated interferon plus ribavirin in clinical routine.

MATERIALS AND METHODS

Between 2000 and 2006 we treated a total of 219 patients with pegylated interferon alpha (2a or 2b) and ribavirin (800-1200 mg/d). Among them, 34.8% of patients infected with HCV genotypes 1/4/6 and 18.4% of those with genotypes 2/3 had advanced fibrosis or cirrhosis (F3-F4). For analysis of outcome we subdivided our series into two groups of patients: those who fulfilled standard inclusion criteria in randomized controlled trials and those who did not.

RESULTS

The overall SVR rate was 44.3%. In patients with F0-F2 an SVR was achieved in 52.5%; in those with F3-F4 the SVR rate was 20.8%. In patients infected with genotypes 1/4/6 the SVR rate was 35.4% (SVR: F0-F2 47.7%; F3-F4 19.6%); in those with genotypes 2/3 the rate was 67.8%. The SVR rate in patients with unfavorable baseline factors was significantly lower (32.4% vs. 50%; P = 0.017) and they were more likely to be non-responders (30.9% vs. 13.8%).

CONCLUSION

In everyday clinical practice, up to one-third of patients show unfavorable baseline factors for antiviral therapy, resulting in worse therapeutic outcome. Differences in therapeutic outcome are influenced by patient selection and by the proportion and severity of the underlying liver disease.

Predictors of virological response to a combination therapy with pegylated interferon plus ribavirin including virus and host factors

A combination therapy with pegylated interferon (PEG-IFN) plus ribavirin (RBV) has made it possible to achieve a sustained virological response (SVR) of 50% in refractory cases with genotype 1b and high levels of plasma HCVRNA. Several factors including virus mutation and host factors such as age, gender, fibrosis of the liver, lipid metabolism, innate immunity, and single nucleotide polymorphism (SNPs) are reported to be correlated to therapeutic effects. However, it is difficult to determine which factor is the most important predictor for an individual patient. Data mining analysis is useful for combining all these together to predict the therapeutic effects. It is important to analyze blood tests and to predict therapeutic effects prior to initiating treatment. Since new anti-HCV agents are under development, it will be necessary in the future to select the patients who have a high possibility of achieving SVR if treatment is performed with standard regimen.

Meta-analysis: reduced incidence of hepatocellular carcinoma in patients not responding to interferon therapy of chronic hepatitis C

Interferon treatment for chronic hepatitis C reduces the incidence of hepatocellular carcinoma (HCC) in sustained responders. However, estimation of the effect of interferon treatment on HCC development in nonresponders is yet to be fully implemented. We conducted a meta-analysis of 3 randomized controlled trials and 6 prospective cohort studies, including 3,246 patients (1,922 patients received interferon treatment) to estimate the effect of single-course interferon treatment on HCC development in patients with chronic hepatitis C. Single-course interferon treatment prevented HCC development (RR 0.45; 95% CI 0.31-0.65). This preventive effect was shown even in nonresponders (RR 0.48; 95% CI 0.25-0.90). By subgroup analyses, single-course interferon treatment reduced HCC incidence in cirrhotic patients (RR 0.49; 95% CI 0.29-0.84), patients with annual HCC incidence less than 3% in control group (RR 0.42; 95% CI 0.26-0.66) and patients with annual HCC incidence of 3% or more in control group (RR 0.46; 95% CI 0.26-0.83). Furthermore, HCC incidence was reduced in 3 studies with follow-up period less than 5 years (RR 0.38; 95% CI 0.21-0.66) and in 6 studies with follow-up period of 5 years or more (RR 0.46; 95% CI 0.28-0.76). In conclusion, single-course interferon treatment was shown to prevent HCC development in chronic hepatitis C, even in nonresponders. This preventive effect may be speculated to be due to anti-inflammatory effect on persistent necro-inflammation and blocking progression of fibrosis in liver. Even if sustained virological response is not achieved, interferon may be worth administering in order to reduce HCC incidence in patients with chronic hepatitis C.

Pegylated-interferon plus ribavirin therapy in the treatment of CHC: individualization of treatment duration according to on-treatment virologic response

BACKGROUND

Standard treatment of chronic hepatitis C (CHC) is peginterferon alfa (PEG-IFN alfa) plus ribavirin (RBV) for 48 weeks in patients infected with genotype 1, and 24 weeks for those infected with genotype 2 or 3. However, recent studies have shown that on-treatment markers of virologic response can be used to tailor treatment duration according to each patient's response to therapy.

AIM

To discuss the rationale for assessing on-treatment markers of virologic response to PEG-IFN alfa plus RBV.

METHODS

A literature search was conducted using MEDLINE and conference proceedings for clinical studies of reduced and extended treatment durations in the treatment of CHC.

FINDINGS

Patients infected with genotype 1 and low baseline viral load who have undetectable HCV RNA by week 4 can be effectively treated for 24 weeks without any decline in efficacy. Extended treatment duration of 72 weeks has been studied in various selected patient groups with genotype 1 infection who are slow to respond to treatment; however, data are conflicting regarding the patient subgroup that may benefit most from this strategy. Finally, selected HCV genotype 2 or 3 patients with undetectable HCV RNA at week 4 and other favorable prognostic features may be effectively managed with shorter (12 to 16 weeks) treatment duration. Further work is required to determine how the findings of this review relate to patients who do not fit with the enrollment criteria of randomized clinical trials or who require dose adjustment based on adverse tolerability. Care should also be exercised when comparing data between studies because of differences in design and patient populations.

CONCLUSION

Evaluation of on-treatment markers of virologic response has revolutionized the treatment of CHC: implementation of these assessments in clinical practice is strongly supported by data from recent clinical studies, even in advance of formal recognition in treatment guidelines.

Individualisation of antiviral therapy for chronic hepatitis C

The combination of pegylated-interferon (PEG-IFN)/ribavirin is currently the standard of care antiviral treatment for chronic hepatitis C (CHC), but optimal results require an individual approach. Key issues are to deliver doses that confer optimal antiviral efficacy against hepatitis C virus (HCV) for a time sufficient to minimise relapse. Viral monitoring during therapy guides the subsequent treatment course, particularly HCV RNA results at 4 weeks (rapid viral response [RVR]) and 12 weeks (complete early viral response [cEVR]). There is strong evidence that for most patients with genotypes 2 or 3 HCV infection, RVR allows truncation of treatment to 16 weeks, provided ribavirin dose is weight-based. However, those patients with cirrhosis, insulin resistance/diabetes or older than 50 years need 6-12 months treatment. For "difficult-to-treat" CHC (genotypes 1 and 4), RVR is infrequent (approximately 15% in European studies), but allows treatment to be truncated from 48 to 24 weeks. Without RVR, there is some evidence that longer treatment (72 weeks) improves sustained viral response (SVR). However, "induction dosing" first 12 weeks of PEG-IFN clearly does not improve SVR. To prevent dose reductions and complete therapy, it is critical to detect and treat depression and other disabling side-effects, including judicious use of growth factors for severe anemia or neutropenia and possibly, thrombocytopenia. Another potentially important aspect may be attempts to counter central obesity and insulin resistance, which confer suboptimal antiviral response with any HCV genotype. Treatment partnerships with specialist nurses, psychological therapists and other healthcare workers are also essential for optimal individual management of patients with CHC.

Pegylated Interferon and Ribavirin Dosing Strategies to Enhance Sustained Virologic Response

Hepatitis C virus (HCV) affects about 170 million people worldwide and is the most common chronic blood borne infection in the United States. Since the advent of blood screening protocols in the early 1990s, injection drug use has become the leading cause of infection. Hepatitis C can have both hepatic and nonhepatic manifestations of infection. Hepatic manifestations include hepatic fibrosis, cirrhosis, liver cancer, and liver failure. The standard treatment for chronic HCV is combination therapy with pegylated interferon-α and ribavirin. Although pegylated interferon and ribavirin has been used against HCV for close to a decade, advances in therapy have centered on doses and treatment durations. There has been increasing interest in applying on-treatment response or viral kinetics to predict antiviral response rates and shape therapeutic intervention. Protease inhibitors are a promising adjuvant to combination therapy, but their efficacy and safety are still under investigation.

Definition of rapid virologic response with a highly sensitive real-time PCR-based HCV RNA assay in peginterferon alfa-2a plus ribavirin response-guided therapy

BACKGROUND & AIMS

Assessing hepatitis C virus (HCV)-RNA levels is integral to response-guided therapy. Rules for early discontinuation and determination of treatment duration were mainly established with HCV-RNA assays with a detection limit of 50IU/ml (COBAS Amplicor HCV [CA]). The currently used real-time PCR-based COBAS Ampliprep/COBAS-TaqMan HCV (CAP-CTM) test has a detection limit of approximately 10IU/ml. It is unknown whether shortening of treatment duration to 16/24 weeks in patients with rapid virological response at week 4 (RVR) and viral loads between 10 and 50IU/ml is possible.

METHODS

We reanalysed stored serum from two large, multinational, randomized trials in which patients were treated with peginterferon alfa-2a/ribavirin (n=962). Results of CAP-CTM with truly undetectable HCV RNA and those <15IU/ml, which includes patients with residual viraemia (<15), were compared with the originally obtained results using the CA assay.

RESULTS

RVR rates were comparable for CA (<50) and CAP-CTM (<15) with 32% and 32% for genotype (gt) 1 and 50% and 49% for gt2/3 patients, respectively. A significantly smaller number of samples really had truly undetectable HCV RNA by the CAP-CTM assay (24% for gt1, 37% for gt2/3). However, sustained virological response rates after shortened treatment (16/24weeks) were not significantly different in patients with a RVR <50, a RVR <15 and RVR undetectable (82%, 83%, 83% for 24weeks gt1 and 95%, 95%, 94% for 16weeks gt2/3).

CONCLUSIONS

Shortening the treatment duration to 16/24weeks can be performed on the basis of a RVR with HCV-RNA concentrations <15IU/ml by the CAP-CTM assay.

Review article: the role of rapid virological response in determining treatment duration for chronic hepatitis C

BACKGROUND

For patients with chronic hepatitis C, attaining rapid virological response (RVR) is highly predictive of attaining SVR.

AIM

To consider the predictive value of RVR in terms of SVR and relapse.

METHODS

Data were collected from published clinical trials to define the predictive value of RVR for SVR and evaluate the proposed continuum linking RVR to relapse.

RESULTS

These data support a 24-week regimen among genotype (G)1 patients who attain RVR with positive predictive values (PPVs) of 77.8% and 85.7% in patients with G1 infection treated for 24 and 48 weeks. Conversely, failure to attain RVR among G1 patients should not be viewed as a criterion for extending treatment duration beyond 48 weeks: negative predictive values (NPVs) were 60.9% and 52.7% in G1 patients without RVR treated for 48 and 72 weeks. Among G2/3 patients, RVR has a high PPV; however, the NPV varied with treatment duration indicating that a 24-week treatment regimen is warranted in G2/3 patients who fail to attain RVR.

CONCLUSIONS

The present analysis confirms RVR as a strong predictor of SVR that can be used to tailor treatment duration, but which also should be appreciated in the context of treatment duration and regimen.

Risk factors for relapse in chronic hepatitis C patients who have achieved end of treatment response

BACKGROUND AND AIM

Some patients with chronic hepatitis C experience virologic relapse even after achieving an end of treatment response. Prolonged therapy can be effective for helping such high-risk patients to avoid relapse. We aimed to identify factors predictive of virologic relapse in chronic hepatitis C patients who have achieved end of treatment response.

METHODS

We analyzed data from 242 chronic hepatitis C patients who achieved end of treatment response with peginterferon plus ribavirin therapy from 2003 to 2007.

RESULTS

Virologic relapse was identified in 32 patients (13.2%). We considered age, sex, body mass index, presence of diabetes, hemoglobin, platelet, alanine aminotransferase, stage of fibrosis, baseline hepatitis C virus RNA level, rapid virologic response, and adherence to drugs. For genotype 1 patients, older age (> or = 50 years) and higher baseline RNA level (> or = 2,000,000 IU/mL) were significantly correlated with occurrence of relapse. For genotypes 2 and 3, lower adherence to peginterferon (< 80%) was an independent risk factor for relapse.

CONCLUSIONS

In chronic hepatitis C patients who had achieved end of treatment response, risk factors for relapse were older age and higher baseline hepatitis C virus RNA level in genotype 1, and lower adherence to peginterferon in genotypes 2 and 3, which may be valuable to individualize duration of therapy.

Identifying HCV genotype 1 patients at risk of relapse

OBJECTIVE

The objective of this analysis was to identify predictors of relapse in genotype 1 patients after 48 weeks of treatment with peginterferon plus ribavirin.

METHODS

Retrospective analysis of data from treatment-naive genotype 1 patients with an end-of-treatment response after 48 weeks of treatment with peginterferon alpha-2a plus ribavirin 1000/1200 mg/day in the Canadian Pegasys Expanded Access Program.

RESULTS

Among treatment-naive genotype 1 patients with an end-of-treatment response (n = 432), the sustained virological response status was known for 405 individuals (sustained virological response n = 328, 81%; relapse n = 77, 19%). Early virological response rates at week 12 were similar in relapsers (98.7%) and sustained responders (98.5%). More relapsers (12 of 77, 15.6%) than sustained responders (15 of 328, 4.6%) had quantifiable hepatitis C virus (HCV) RNA (>or=600 IU/ml) at week 12 and, among these patients, mean and maximum HCV RNA levels were higher in relapsers, although the median values were similar. Factors significantly associated with relapse in the multiple logistic regression analysis include older age (odds ratio: 1.48 per decade, 95% confidence interval: 1.06-2.07; P = 0.023), Caucasian ethnicity (odds ratio: 3.23, confidence interval: 1.25-8.33; P = 0.016), higher baseline serum HCV RNA level (P = 0.005), the drop in HCV RNA between baseline and week 12 (P = 0.026), and the interaction between baseline HCV RNA level and the decrease in HCV RNA between baseline and week 12 (P = 0.032).

CONCLUSION

Older age, Caucasian ethnicity, and high baseline HCV RNA level, and a smaller decrease in HCV RNA between baseline and week 12 predict a relapse in genotype 1 patients.

Management of nonresponsive hepatitis C

More than 50% of hepatitis C virus (HCV)-infected patients do not respond to the classical pegylated interferon (PEG-IFN)/ribavirin combination therapy. However, failing to respond to one course of treatment is not synonymous of therapy failure and retreatment is often beneficial. Alternative retreatment strategies include repeating the classical standard of care with an optimized drug regimen and adherence, including ribavirin serum concentration adjustment, correcting, if at all possible, comorbidities, and the addition of new specific anti-HCV molecules to the backbone of pegylated interferon/ribavirin. Options of retreatment should include consensus and natural interferons. For patients with advanced disease exposed to a high risk of lethal complications, customized maintenance therapy could be an effective option since it may slow down complications in some patients. Since low-dose interferon monotherapy is not sufficient, such a maintenance therapy remains to be verified via clinical trials. New possibilities of noninvasive assessment of fibrosis and the use of genetic tests to predict fibrosis progression and responsiveness to interferon are major emerging opportunities that run parallel to the revolution of the pharmacologic armentarium.

Early identification of achieving a sustained virological response in chronic hepatitis C patients without a rapid virological response

BACKGROUND AND AIM

A number of hepatitis C virus (HCV) patients without a rapid virological response (RVR) achieved a sustained virological response (SVR) with peginterferon-alpha-2a/ribavirin. The aim of this study was to identify factors associated with SVR in non-RVR patients.

METHODS

Baseline and on-treatment factors were used to explore the prognostic factors for SVR in 113 HCV genotype-1 (HCV-1) and 20 HCV-2 non-RVR patients in two randomized trials.

RESULTS

The SVR rate in HCV-1 patients with a complete early virological response (cEVR) and partial early virological response was 91.9% versus 45% (P < 0.001) and 21.4% versus 10% (P = 0.62), respectively, after 48 and 24 weeks of treatment. The SVR rate in HCV-2 patients with a cEVR was 90.9% versus 57.1% (P = 0.25), respectively, after 24 and 16 weeks of treatment. Multivariate analysis showed that cEVR and standard regimen were independently associated with SVR. Viral kinetic study revealed that HCV viral loads < 10,000 IU/mL at week 4 were the best predictor of cEVR for both HCV-1 and HCV-2 non-RVR patients with the accuracy of 81% and 95%, respectively, and also of SVR with the accuracy of 78% and 92%, respectively, in patients receiving standard of care. The most important independent predictors for cEVR were HCV viral loads < 10(4) IU/mL at week 4, followed by increased ribavirin dose within 12 weeks of treatment.

CONCLUSIONS

Achieving a cEVR with standard of care is the most important predictor of SVR in non-RVR patients. Week 4 viral loads < 10,000 IU/mL could accurately predict cEVR early and following SVR in non-SVR patients.

Management of hepatitis C; Report of the Consensus Meeting at the 45th Annual Meeting of the Japan Society of Hepatology (2009)

The consensus meeting for the diagnosis, management and treatment for hepatitis C was held in 45(th) annual meeting for the Japan Society of Hepatology (JSH) in June 2009 where the recommendations and informative statements were discussed including organizers and presenters. The Several important informative statements and recommendations have been shown. This was the fourth JSH consensus meeting of hepatitis C, however, the recommendations have not been published in English previously. Thus, this is the first report of JSH consensus of hepatitis C. The rate of development of hepatocellular carcinoma (HCC) in HCV-infected patients in Japan is higher than in the USA, because the average age of the HCV-infected patients is greater and there are more patients with severe fibrosis of the liver than in the USA. In Japan, more than 60% of HCV-infected patients are genotype 1b infection, and they show lower response to perinterferon and ribavirin combination treatment. To improve the response rate is also an important issue in our country. To establish the original recommendations and informative statements to prevent the development of HCC is a very important issue in Japan.

Individualized treatment of chronic hepatitis C with pegylated interferon and ribavirin

Chronic infection with hepatitis C virus (HCV) is a major public health problem, with perhaps 180 million people infected worldwide. A significant proportion of these will eventually develop clinical complications, such as cirrhosis, liver decompensation and hepatocellular carcinoma. Sustained virological response (SVR) to antiviral therapy is associated with improvement in liver histology and survival free of liver-related complications. Great effort has been made to improve SVR rate by adapting the duration of therapy according to HCV genotype and to on-treatment response. Rapid virological response (RVR, undetectable HCV RNA at week 4) usually has a high positive predictive value for achieving SVR and early virological response (EVR, ≥ 2 log reduction or undetectable HCV RNA at week 12) exhibits a high negative predictive value for non-response. Individualized approach can improve cost-effectiveness of HCV antiviral therapy by reducing side effects and the costs of therapy associated with unnecessary exposure to treatment and through extending therapy for those with unfavorable features. This article summarizes recent data on strategies of individualized treatment in naïve patients with mono-infection by the different HCV genotypes. The management of common side effects, the impact of HCV infection on health-related quality of life and the potential applications of host genomics in HCV therapy are also briefly discussed.

[Antiviral therapy for chronic hepatitis C: current status and perspectives]

Antiviral therapy for chronic hepatitis C has advanced dramatically since the discovery of the hepatitis C virus and the introduction of interferon in early 1990's. An initial treatment regimen, 24 weeks of interferon monotherapy, achieved sustained virologic response, which is formally defined at 24 weeks after completion of the treatment, only for 5% of patients with genotype 1 high-viral load belonging to a difficult-to-treat group. Current standard therapy is a combination of pegylated interferon and ribavirin. Forty eight weeks of the combination therapy achieves successful viral eradication for 40-50% of genotype 1 patients while 24 weeks of that do so for 80% of genotype 2 patients. Early viral kinetics after the initiation of therapy is a useful predictor of the sustained virologic response for genotype 1 patients, serving as recommendation criteria for extended duration, 72 weeks, of combination therapy. New types of anti-HCV agents such as HCV protease and polymerase inhibitors are needed for patients that do not respond to combination therapy. Hepatitis C is not just an infectious disease, but a potentially serious liver disease progressing to end-stage liver cirrhosis and hepatocellular carcinoma. Antiviral therapy should be considered from the view point of suppressing liver-related death in hepatitis C virus-infected patients.

Treatment of hepatitis C in 2011: what can we expect?

Treatment for chronic hepatitis C virus (HCV) infection is the combination of a peginterferon and ribavirin. Although a fixed duration of treatment (24 weeks for patients with genotypes 2 and 3 and 48 weeks for patients with all other genotypes) has been advocated, the best results are likely to be achieved when the duration of therapy is adjusted based on the time to response. According to the principles of response-guided therapy, patients with rapid virologic response have a high rate of sustained virologic response (SVR) and a low rate of relapse, and can be treated for 24 weeks regardless of genotype. In contrast, patients who become HCV RNA undetectable at a slower rate need a longer duration of therapy. Direct-acting antiviral agents are currently being developed to treat patients with HCV genotype 1. These agents will significantly increase rapid virologic response when used with peginterferon and ribavirin; according to the concepts of response-guided therapy, such treatment will yield high rates of SVR with 24 to 28 weeks of treatment.

Practice guidelines for the treatment of hepatitis C: recommendations from an AISF/SIMIT/SIMAST Expert Opinion Meeting

It is increasingly clear that a tailored therapeutic approach to patients with hepatitis C virus infection is needed. Success rates in difficult to treat and low-responsive hepatitis C virus patients are not completely satisfactory, and there is the need to optimise treatment duration and intensity in patients with the highest likelihood of response. In addition, the management of special patient categories originally excluded from phase III registration trials needs to be critically re-evaluated. This article reports the recommendations for the treatment of hepatitis C virus infection on an individual basis, drafted by experts of three scientific societies.

Peginterferon alfa-2a/ribavirin for 48 or 72 weeks in hepatitis C genotypes 1 and 4 patients with slow virologic response

BACKGROUND & AIMS

This randomized multicenter trial evaluated individualization of treatment duration with peginterferon alfa-2a 180 microg/wk plus ribavirin 1000/1200 mg/day in patients with chronic hepatitis C genotype 1/4 based on the rapidity of virologic response (VR).

METHODS

Patients with a rapid VR (RVR; undetectable hepatitis C virus [HCV]-RNA level (<50 IU/mL at week 4) were treated for 24 weeks, those with an early VR (EVR; no RVR but undetectable HCV-RNA level or >or=2-log(10) decrease at week 12) were randomized to 48 (group A) or 72 weeks of treatment (group B; peginterferon alfa-2a was reduced to 135 microg/wk after week 48). Patients without an EVR continued treatment until week 72 if they had undetectable HCV-RNA levels at week 24. The primary end point was relapse; sustained VR (SVR; undetectable HCV-RNA level after 24 weeks of follow-up evaluation) was a secondary end point.

RESULTS

Of 551 genotype 1/4 patients starting treatment, 289 were randomized to group A (N = 139) or group B (N = 150). The relapse rate was 33.6% in group A (95% confidence interval [CI], 24.8%-43.4%) and 18.5% in group B (95% CI, 11.9%-27.6%; P = .0115 vs group A) and the SVR rate was 51.1% (95% CI, 42.5%-59.6%) and 58.6% (95% CI, 50.3%-66.6%; P > .1), respectively. The overall SVR rate was 50.4% (278 of 551; 95% CI, 46.2%-54.7%), including 115 of 150 patients with an RVR treated for 24 weeks and 4 of 78 patients without an EVR.

CONCLUSIONS

Extending therapy with peginterferon alfa-2a/ribavirin to 72 weeks decreases the probability of relapse in patients with an EVR. If they can be maintained on extended-duration therapy, SVR rates also may improve.

[Treatment optimization in chronic hepatitis C virus infection]

The treatment duration that obtains the optimal risk-benefit ratio in chronic hepatitis C infection is guided by viral kinetic data in weeks 4 and 12. Rapid virological response (RVR) and early virological response (EVR) have high positive and negative predictive value, respectively. Patients with genotype-1, RVR, without significant fibrosis and low baseline viral load (<600,000UI/ml) can receive treatment for 24 weeks without loss of efficacy, while the absence of EVR in these patients is a criterion for treatment interruption. Data on prolonging treatment to 72 weeks in patients with genotype 1 and a decrease of >2log in viremia without negativization of viremia in week 12 are contractictory. In patients with genotypes 2 and 3, 24-week treatment is superior to 16-week treatment, although 16-week treatment can be evaluated in patients with genotype 3 and RVR. In patients with genotype 2 and RVR, rates of RVR in 14-week treatment are similar to those in 24-week treatment, while in patients without RVR, treatment should be continued to 24 weeks. Key factors in treatment optimization are the weight-adjusted dose of ribavirin and therapeutic adherence.

On-treatment predictions of success in peg-interferon/ribavirin treatment using a novel formula

AIM: To predict treatment success using only simple clinical data from peg-interferon plus ribavirin therapy for chronic hepatitis C.

METHODS: We analyzed the clinical data of 176 patients with chronic hepatitis and hepatitis C virus genotype 1 who received 48 wk standard therapy, derived a predictive formula to assess a sustained virological response of the individual patient using a logistic regression model and confirmed the validity of this formula. The formula was constructed using data from the first 100 patients enrolled and validated using data from the remaining 76 patients.

RESULTS: Sustained virological response was obtained in 83 (47.2%) of the patients and we derived formulae to predict sustained virological response at pretreatment and weeks 4, 12 and 24. The likelihood of sustained virological response could be predicted effectively by the formulae at weeks 4, 12 and 24 (the area under the curve of the receiver operating characteristic: 0.821, 0.802, and 0.891, respectively), but not at baseline (0.570). The formula at week 48 was also constructed and validation by test data achieved good prediction with 0.871 of the area under the curve of the receiver operating characteristic. Prediction by this formula was always superior to that by viral kinetics.

CONCLUSION: These results suggested that our formula combined with viral kinetics provides a clear direction of therapy for each patient and enables the best tailored treatment.

Guidelines for the treatment of chronic hepatitis and cirrhosis due to hepatitis C virus infection for the fiscal year 2008 in Japan

In the 2008 guidelines for the treatment of patients with chronic hepatitis C, pegylated interferon (Peg-IFN) combined with ribavirin for 48 weeks are indicated for treatment-naive patients infected with hepatitis C virus (HCV) of genotype 1. Treatment is continued for an additional 24 weeks (72 weeks total) in the patients who have remained positive for HCV RNA detectable by the real-time polymerase chain reaction at 12 weeks after the start of treatment, but who turn negative for HCV RNA during 13-36 weeks on treatment. Re-treatment is aimed to either eradicate HCV or normalize transaminase levels for preventing the development of hepatocellular carcinoma (HCC). For patients with compensated cirrhosis, the clearance of HCV RNA is aimed toward improving histological damages and decreasing the development of HCC. The recommended therapeutic regimen is the initial daily dose of 6 million international units (MIU) IFN continued for 2-8 weeks that is extended to longer than 48 weeks, if possible. IFN dose is reduced to 3 MIU daily in patients who fail to clear HCV RNA by 12 weeks for preventing the development of HCC. Splenectomy or embolization of the splenic artery is recommended to patients with platelet counts of less than 50 x 103/mm(3) prior to the commencement of IFN treatment. When the prevention of HCC is at issue, not only IFN, but also liver supportive therapy such as stronger neo-minophagen C, ursodeoxycholic acid, phlebotomy, branched chain amino acids (BCAA), either alone or in combination, are given. In patients with decompensated cirrhosis, by contrast, reversal to compensation is attempted.

Management of chronic hepatitis C patients who have relapsed or not responded to pegylated interferon alfa plus ribavirin

Development of therapeutic strategies for patients with chronic hepatitis C who experience virological breakthrough, relapse or nonresponse lag behind those for treatment-naïve patients. The probability of a previously treated patient responding to re-treatment depends on the nature of the previous regimen, the magnitude of the response to previous treatment and the patient's characteristics. Relapsers have higher sustained virological response rates than nonresponders when re-treated with pegylated interferon plus ribavirin. Re-treatment of nonresponders to pegylated interferon plus ribavirin with the standard 48-week regimen resulted in an approximate 6% sustained response rate in the EPIC-3 program. In the REPEAT trial, the sustained response rate was significantly higher in nonresponders to pegylated interferon alfa-2b (12 kD) plus ribavirin randomized to 72 weeks of peginterferon alfa-2a (40 kD) plus ribavirin, compared with a 48-week regimen (16%vs 8%, P = 0.0006). Based on available data, extended treatment is the best option for these individuals. Undetectable viral RNA at week 12 is an important criterion for re-treatment in the REPEAT and EPIC studies. Maintenance therapy with pegylated interferon is generally ineffective in nonresponders and cannot be recommended. Directly acting antivirals may increase response rates and the burden of adverse events when combined with the standard of care, but will not be available for some years. In conclusion, after careful evaluation of an individual's benefit-risk ratio, a 72-week regimen is the preferred strategy for optimizing sustained response rates in patients who have not responded to the standard of care, provided that viral RNA is undetectable at week 12 of re-treatment.

Optimizing the treatment of chronic viral hepatitis C

Chronic hepatitis C is a major health concern. The current standard therapy is based on a combination of pegylated (PEG)-IFN-alpha and ribavirin (RBV). This treatment produces a sustained virological response (SVR) in approximately 55% of chronically infected patients. A number of virological factors (e.g., the hepatitis C virus [HCV] genotype and baseline titer of HCV RNA) may influence the treatment response. Indeed, the SVR rate is approximately 80% for patients infected with HCV genotypes 2 or 3, and approximately 45% for genotype 1 or 4 patients. Furthermore, the treatment duration can be modified as a function of the genotype. New drugs are being developed for the treatment of chronic hepatitis C but will probably be used in combination with the current standard therapy. This means that improvements in therapy based on a PEG-IFN-RBV combination will remain a true challenge in the coming years. Recent clinical trial results have demonstrated that the current therapy can be optimized. Modulation of the treatment duration and/or the RBV dose may increase the SVR rate. The present article reviews the current approaches to optimizing the treatment of chronic hepatitis C.

Effect of HCV RNA suppression during peginterferon alfa-2a maintenance therapy on clinical outcomes in the HALT-C trial

BACKGROUND & AIMS

The Hepatitis C Antiviral Long-term Treatment Against Cirrhosis (HALT-C) trial demonstrated that low-dose peginterferon maintenance therapy was ineffective in preventing clinical outcomes in patients with chronic hepatitis C, advanced fibrosis, and failure to achieve a sustained virologic response during lead-in phase treatment with standard dose peginterferon/ribavirin. This analysis was performed to determine whether suppressing HCV RNA during the trial was associated with a reduction in clinical outcomes.

METHODS

Seven hundred sixty-four patients treated during the lead-in phase of HALT-C trial were randomized to either peginterferon alfa-2a (90 microg/week) maintenance therapy or no treatment (control) for 3.5 years. Clinical outcomes included an increase in Child-Turcotte-Pugh score, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, variceal hemorrhage, hepatocellular carcinoma, and mortality.

RESULTS

During the lead-in, >or=4-log(10) decline in serum HCV RNA occurred in 178 patients; 82% of whom lost detectable HCV RNA and later broke through or relapsed. These patients had significantly (P = .003) fewer clinical outcomes whether randomized to maintenance therapy or control. Following randomization, serum HCV RNA increased significantly in all 90 control patients and in 58 of 88 receiving maintenance therapy. Only 30 patients had persistent suppression of HCV RNA by >or=4 log(10) during maintenance therapy. No significant reduction in clinical outcomes was observed in these patients.

CONCLUSIONS

Viral suppression by >or=4 log(10) with full-dose peginterferon/ribavirin is associated with a significant reduction in clinical outcomes. Continuing low-dose peginterferon maintenance therapy, even in patients with persistent viral suppression, does not lead to a further decline in clinical outcomes.

Viral hepatitis and HIV co-infection

Chronic hepatitis B virus (HBV) infection is overall recognised in 10% of HIV+ persons worldwide, with large differences according to geographical region. Chronic hepatitis C virus (HCV) infection affects 25% of HIV+ individuals, with greater rates ( approximately 75%) in intravenous drug users and persons infected through contaminated blood or blood products. HIV-hepatitis co-infected individuals show an accelerated course of liver disease, with faster progression to cirrhosis. The number of anti-HBV drugs has increased in the last few years, and some agents (e.g. lamivudine, emtricitabine, tenofovir) also exert significant activity against HIV. Emergence of drug resistance challenges the long-term benefit of anti-HBV monotherapy, mainly with lamivudine. The results using new more potent anti-HBV drugs (e.g. tenofovir) are very promising, with prospects for stopping or even revert HBV-related liver damage in most cases. With respect to chronic hepatitis C, the combination of pegylated interferon plus ribavirin given for 1 year permits to achieve sustained HCV clearance in no more than 40% of HIV-HCV co-infected patients. Thus, new direct anti-HCV drugs are eagerly awaited for this population. Although being a minority, HIV+ patients with delta hepatitis and those with multiple hepatitis show the worst prognosis. Appropriate diagnosis and monitoring of chronic viral hepatitis, including the use of non-invasive tools for assessing liver fibrosis and measurement of viral load, may allow to confront adequately chronic viral hepatitis in HIV+ patients, preventing the development of end-stage liver disease, for which the only option available is liver transplantation. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of antiretroviral drug discovery and development, Vol 85, issue 1, 2010.

APRI as a predictor of early viral response in chronic hepatitis C patients

AIM: To evaluate the aspartate aminotransferase (AST) to platelet ratio index (APRI) as a predictive factor of early viral response in chronic hepatitis C naive patients.

METHODS: We performed an ambispective case-control study. We enrolled chronic hepatitis C naive patients who were evaluated to start therapy with PEGylated interferon α-2b (1.5 μg/kg per week) and ribavirin (> 75 kg: 1200 mg and < 75 kg: 1000 mg). Patients were allocated into two groups, group 1: Hepatitis C patients with early viral response (EVR), group 2: Patients without EVR. Odds ratio (OR) and 95% confidence interval (CI) were calculated to assess the relationship between each risk factor and the EVR in both groups.

RESULTS: During the study, 80 patients were analyzed, 45 retrospectively and 35 prospectively. The mean ± SD age of our subjects was 42.9 ± 12 years; weight 70 kg (± 11.19), AST 64.6 IU/mL (± 48.74), alanine aminotransferase (ALT) 76.3 IU/mL (± 63.08) and platelets 209 000 mill/mm³ (± 84 429). Fifty-five (68.8%) were genotype 1 and 25 (31.3%) were genotype 2 or 3; the mean hepatitis C virus RNA viral load was 2 269 061 IU/mL (± 7 220 266). In the univariate analysis, APRI was not associated with EVR [OR 0.61 (95% CI 0.229-1.655, P = 0.33)], and the absence of EVR was only associated with genotype 1 [OR 0.28 (95% CI 0.08-0.94, P = 0.034)]. After adjustment in a logistic regression model, genotype 1 remains significant.

CONCLUSION: APRI was not a predictor of EVR in chronic hepatitis C; Genotype 1 was the only predictive factor associated with the absence of EVR in our patients.

Clinical performances of two real-time PCR assays and bDNA/TMA to early monitor treatment outcome in patients with chronic hepatitis C

BACKGROUND

Early viral monitoring is essential for the management of treatment outcome in patients with chronic hepatitis C. A variety of commercially available assays are now available to quantify HCV-RNA in routine clinical practice.

OBJECTIVES

Compare the clinical results of 3 commercially available assays to evaluate the positive predictive value (PPV) and the negative predictive value (NPV) of rapid virological response (RVR) at week 4 and early virological response (EVR) at week 12.

STUDY DESIGN

287 patients treated with standard care regimen combination therapy were studied. HCV-RNA values measured at baseline, week 4, week 12 with VERSANT HCV 3.0 Assay (bDNA), and VERSANT HCV-RNA Qualitative Assay (TMA) (bDNA/TMA); COBAS Ampliprep/COBAS/TaqMan (CAP/CTM) and Abbott m2000sp extraction/m2000rt amplification system (ART). RVR was defined as undetectable serum HCV-RNA and EVR as a > OR =2 log decline in baseline viral load (BLV).

RESULTS

Median (range) BVLs were: 5.585(2.585-6.816), 5.189(2.792-7.747) and 4.804(2.380-6.580) log(10)IU/ml, with bDNA/TMA, CAP/CTM and ART, respectively (p<0.01); RVR was observed in 22%, 30% and 27% of the patients and PPVs were 97%, 91% and 94% with bDNA/TMA, CAP/CTM and ART, respectively (p=0.317). EVR was observed in 76%, 73% and 67% of the patients and NPVs were 93%, 83% and 79% with bDNA/TMA, CAP/CTM and ART, respectively (p=0.09).

CONCLUSIONS

Treatment monitoring should include both detection of serum HCV-RNA at week 4 to predict SVR and at week 12 to predict non-SVR. The value of all 3 assays was similar for evaluating RVR or EVR. Because of viral load discrepancies the same assay should be used throughout patient treatment follow-up.

Predicting the probable outcome of treatment in HCV patients

Hepatitis C virus (HCV) is a major cause of chronic liver disease infecting more than 170 million people worldwide. HCV produces a wide gamut of manifestations varying from mild self-limiting disease to cirrhosis and hepatocellular carcinoma. A variety of viral, environmental and host genetic factors contribute to the clinical spectrum of patients infected with HCV and influence response to interferon (IFN) therapy. Predicting the probable outcome of treatment in patients with HCV infection has always been a challenging task. Treatment of HCV by pegylated interferon (peg-IFN) plus ribavirin eradicates the virus in approximately 60% of patients - HCV genotype 1 (42-51% response rates) and genotypes 2 and 3 (76-84% response rates); however, a significant number of patients do not respond to therapy or relapse following discontinuation of treatment or have significant side effects that preclude further treatment. Accurately predicting the patients who will respond to therapy is becoming increasingly important, both from the point of patient care and also with respect to the healthcare cost as clinicians need to continue treatment in patients who will respond and stop treatment in patients who are unlikely to respond. Viral RNA measurements and genotyping are used to optimize treatment as a low viral load and nongenotype 1 is more likely to be associated with sustained virological response (SVR). Rapid virological response (RVR) defined by undetectable HCV RNA at 4 weeks of treatment is increasingly being recognized as a powerful tool for predicting treatment response. A variety of host factors including single nuclear polymorphisms (SNPs) of IFN response genes, insulin resistance, obesity, ethnicity, human leukocyte antigens and difference in T-cell immune response has been found to modulate the response to antiviral treatment. The presence of severe fibrosis/cirrhosis on pretreatment liver biopsy predicts a poor response to treatment. Recent studies on gene expression profiling and characterization of the liver and serum proteome provide options to accurately predict the outcome of patients infected with HCV in the future. Future studies on the factors that predict treatment response and tailoring treatment based on this is required if we are to conquer this disease.

Chronic hepatitis B and C: update on therapy

Chronic infections with HBV and HCV are a major cause of liver-associated morbidity and mortality worldwide. An increased knowledge of HBV and HCV virology, natural history and predictors of virological response has led to the development of new strategies to improve treatment outcomes. The use of new antiviral agents with greater potency and a high genetic barrier to resistance, as well as on-treatment monitoring of virological response, may result in improved outcomes in HBV therapy. A greater understanding of predictors of virological response has led to the ability to individualize therapy in chronic HCV infection. Several new antiviral agents specifically targeting HCV are in development and should have a major impact on treatment response rates over the next few years.

Clinical trial: extended treatment duration of peginterferon-alpha2b plus ribavirin for 72 and 96 weeks in hepatitis C genotype 1-infected late responders

BACKGROUND

The benefits of prolonging peginterferon and ribavirin after 48 weeks of treatment to maximize sustained virological responses (SVR) in hepatitis C virus (HCV) genotype 1-infected patients remain to be understood.

AIM

To investigate whether extended treatment longer than 72 weeks may be superior to 72-week treatment.

METHODS

A total of 120 treatment-naïve or retreated patients with HCV genotype 1 were treated with peginterferon-alpha-2b (1.5 microg/kg/week) plus weight-based ribavirin. We had 34 late responders, in whom HCV RNA first became undetectable at week 12-48, and randomized them into three groups receiving standard-dose peginterferon-alpha-2b plus low-dose ribavirin (200 mg/day) for extended 24 weeks (group A), receiving low-dose peginterferon-alpha-2b (0.75 microg/kg/week) plus low-dose ribavirin for extended 48 weeks (group B) or no extended treatment (group C), and evaluated the outcome according to their virological response.

RESULTS

Multivariate analysis showed that the treatment for 96 weeks was identified as a significant, independent factor associated with SVR in HCV genotype 1-infected late responders in comparison with group A [odds ratio (OR), 10.002; P = 0.080] and group C (OR, 17.748; P = 0.025).

CONCLUSION

Extending the treatment duration from 48 weeks to 96 weeks improves SVR rates in genotype 1-infected patients with late virological response to peginterferon-alpha-2b and ribavirin.

Individualized treatment strategy according to early viral kinetics in hepatitis C virus type 1-infected patients

Individualized treatment on the basis of early viral kinetics has been discussed to optimize antiviral therapy in chronic hepatitis C virus (HCV) infection. Individually tailored reduction in treatment duration in HCV type 1-infected patients represents one possible strategy. Four hundred thirty-three patients were randomly assigned to receive either 1.5 microg/kg peginterferon alfa-2b weekly plus 800-1,400 mg ribavirin daily for 48 weeks (n = 225, group A) or an individually tailored treatment duration (18-48 weeks; n = 208, group B). In the latter group, treatment duration was calculated using the time required to induce HCV RNA negativity (branched DNA [bDNA] assay; sensitivity limit, 615 IU/mL) multiplied by the factor 6. All bDNA negative samples were retested with the more sensitive transcription-mediated amplification (TMA) assay (sensitivity limit, 5.3 IU/mL). Sustained virologic response (SVR) rates were significantly lower in group B (34.6% versus 48.0% [P = 0.005]) due to higher relapse rates (32.7% versus 14.2% [P< 0.0005]). Important predictors of response were the levels of baseline viremia as well as the time to TMA negativity on treatment. Taking the simultaneous presence of low baseline viral load (<800,000 IU/mL) and a negative TMA test within the first 4 weeks as predictors for treatment response, SVR rates were comparable between both treatment schedules with an SVR probability of >80% obtained in patients treated for only 18 or 24 weeks.

CONCLUSION

The individualized treatment strategy according to time to bDNA negativity failed to provide comparable efficacy compared with the standard of care. The inferiority of the individualized protocol may be explained by the use of a less sensitive HCV RNA assay, and also by underestimation of the importance of baseline viremia.

Ribavirin dose reduction raises relapse rate dose-dependently in genotype 1 patients with hepatitis C responding to pegylated interferon alpha-2b plus ribavirin

The impact of ribavirin exposure on virologic relapse remains controversial in combination therapy with pegylated interferon (Peg-IFN) and ribavirin for patients with chronic hepatitis C (CH-C) genotype 1. The present study was conducted to investigate this. Nine hundred and eighty-four patients with CH-C genotype 1 were enrolled. The drug exposure of each medication was calculated by averaging the dose actually taken. For the 472 patients who were HCV RNA negative at week 24 and week 48, multivariate logistic regression analysis showed that the degree of fibrosis (P = 0.002), the timing of HCV RNA negativiation (P < 0.001) and the mean doses of ribavirin (P < 0.001) were significantly associated with relapse, but those of Peg-IFN were not. Stepwise reduction of the ribavirin dose was associated with a stepwise increase in relapse rate from 11% to 60%. For patients with complete early virologic response (c-EVR) defined as HCV RNA negativity at week 12, only 4% relapse was found in patients given > or = 12 mg/kg/day of ribavirin and ribavirin exposure affected the relapse even after treatment week 12, while Peg-IFN could be reduced to 0.6 microg/kg/week after week 12 without the increase of relapse rate. Ribavirin showed dose-dependent correlation with the relapse. Maintaining as high a ribavirin dose as possible (> or = 12 mg/kg/day) during the full treatment period can lead to suppression of the relapse in HCV genotype 1 patients responding to Peg-IFN alpha-2b plus ribavirin, especially in c-EVR patients.

Short-term prolongation of pegylated interferon and ribavirin therapy for genotype 1b chronic hepatitis C patients with early viral response

AIM

We tailored extended treatments using pegylated interferon (PEG IFN) and ribavirin (RBV) to viral responses after initiation of therapy and investigated the efficacy and safety of its therapy for chronic hepatitis C (CHC) patients.

METHODS

Eighty-two genotype 1b CHC patients were enrolled in the present study. All patients received PEG IFN-alpha-2b and weight-based RBV therapy. We defined a viral response in which serum HCV-RNA is undetectable at week 4 as rapid viral response (RVR), detectable at week 4 and undetectable by week 12 as early viral response (EVR), and detectable at week 12 and undetectable by week 24 as late viral response (LVR). We set the treatment duration depending on viral response; 48 weeks for RVR patients and 72 weeks for LVR. Furthermore, EVR patients received a short-term extension of treatment duration to 52-60 weeks. We prospectively investigated sustained viral response (SVR) rates of these groups.

RESULTS

Overall SVR rate for the total patient group was 57.3%. SVR rates of the RVR, EVR and LVR patients were 100%, 80.5% and 40.0%, respectively. Nine patients could not complete this treatment protocol. Baseline platelet count and mutation in the interferon sensitivity-determining region of NS5A were significant independent predictors of SVR, and amino acid substitution of the core region was a significant independent predictor of non-viral response by multivariate logistic regression analyses.

CONCLUSION

The results indicate that short-treatment extension of PEG IFN plus RBV treatment protocols in EVR patients can improve overall SVR rates.

Psychiatric problems in patients infected with hepatitis C before and during antiviral treatment with interferon-alpha: a review

OBJECTIVE

Neuropsychiatric symptoms are common in patients with chronic hepatitis C (CHC) and can potentially be exacerbated by interferon-alpha treatment. Such symptoms can contribute to problems with treatment adherence, which can significantly compromise epidemiological virus control. This review summarizes current knowledge about the etiology, course, and management of neuropsychiatric symptoms in patients with CHC.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULTS

Psychopathological syndromes that occur during interferon-alpha treatment frequently have atypical features that may complicate their recognition using standard diagnostic criteria. In addition, prospective studies in this area often exclude patients with psychiatric disorders and have methodological disparities that make it difficult to develop guidelines for management of psychiatric side effects induced by interferon-alpha. Despite the high prevalence of chronic hepatitis C virus (HCV) infection in patients with psychiatric and substance use disorders, neuropsychiatric concerns often lead to the exclusion of such patients from interferon-alpha treatment, inappropriately depriving them of the potential benefits of this therapy.

CONCLUSION

Consultation-liaison psychiatrists should become familiar with the clinical spectrum of presentations associated with HCV infection as well as with related neuropsychiatric symptoms in order to promote the creation of multidisciplinary teams who specialize in the care of patients with HCV infections. More studies are needed to define neuropsychiatric syndromes that can be induced by interferon-alpha and to clarify best assessment and treatment procedures for these syndromes. It is also important to create and evaluate psychoeducational programs for all patients with chronic HCV infections, even those with low risk of complications, in order to promote adherence to therapy and optimize patients' quality of life.

Hepatitis C virus virology and new treatment targets

Hepatitis C virus (HCV) infection is the leading cause of chronic liver disease. An estimated 130 million people worldwide are persistently infected with HCV. Almost half of patients who have chronic HCV infection cannot be cured with the standard treatment consisting of pegylated IFN-alpha and ribavirin. For those patients who do not respond to this standard antiviral therapy, there is currently no approved treatment option available. Recent progress in structure determination of HCV proteins and development of a subgenomic replicon system enables the development of a specifically targeted antiviral therapy for hepatitis C. Many HCV-specific compounds are now under investigation in preclinical and clinical trials.

Peginterferon alfa-2a relapse rates depend on weight-based ribavirin dosage in HCV-infected patients with genotype 1: results of a retrospective evaluation

OBJECTIVE

The cumulative dosage of ribavirin per kilogram of body-weight prevents relapse and thus is a significant predictor of sustained virological response (SVR). Comparison of peginterferon (peg-IFN) alfa-2b/ribavirin and peg-IFN alfa-2a/ribavirin shows that the rates of SVR are similar, but the rates of relapse are significantly lower under the peg-IFN alfa-2b regimen. Depending on the weight-based ribavirin dose, patients with >105 kg reach a maximum of 13.2 mg/kg body-weight ribavirin in the peg-IFN alfa-2b regimen as opposed to only 11.3 mg/kg in the peg-IFN alfa-2a regimen. The aim of these investigations was to determine relapse rates in a retrospective analysis of 98 patients chronically infected with hepatitis C virus (HCV) genotype (GT) 1 in relation to the weight-based ribavirin dose.

MATERIAL AND METHODS

All patients completed treatment with peg-IFN alfa-2a/ribavirin (1000 mg/d or 1200 mg/d for patients weighing <75 kg or > or =75 kg) for 48 weeks. Classification of a low ribavirin dose with <13.2 mg/kg body-weight was used. Patients with a ribavirin dose > or =13.2 mg/kg were compared with those with a dose <13.2 mg/kg.

RESULTS

Patients with a ribavirin dose > or = 13.2 mg/kg (n=84) showed a relapse rate of 19.0% in contrast to 71.4% in patients with a ribavirin dose of <13.2 mg/kg (n=14) (p=0.0013). The SVR rate was significantly higher in the > or =13.2 mg/kg ribavirin dosed group (59.5% versus 28.6%).

CONCLUSIONS

Weight-adapted ribavirin dosing in combination with peg-IFN alfa-2a to avoid giving low doses of ribavirin should be evaluated. This will minimize relapse, especially in HCV GT 1 patients.

Effective prediction of outcome of combination therapy with pegylated interferon alpha 2b plus ribavirin in Japanese patients with genotype-1 chronic hepatitis C using early viral kinetics and new indices

BACKGROUND

The rates of sustained virologic response (SVR) and relapse with pegylated interferon alpha 2b (peginterferon) plus ribavirin in patients with genotype-1 chronic hepatitis C (CHC) are approximately 50 and 30%, respectively. We investigated whether SVR and transient response (TR) can be differentiated during treatment using new indices calculated from early viral kinetics and the timing of when hepatitis C virus (HCV)-RNA becomes undetectable.

METHODS

Peginterferon alpha 2b (1.5 microg/kg per week) plus weight-based ribavirin (600-1,000 mg/day) were administered to 141 patients with genotype-1 CHC for 48 weeks. The HCV-RNA loads were measured at baseline, 24 h, week 1, and week 2. The rebound index (RI, viral load at week 1 divided by viral load at 24 h) and the second rebound index (RI-2nd, viral load at week 2 divided by viral load at 24 h) were calculated.

RESULTS

With SVR, the viral load was reduced at 24 h, did not rise during week 1 (RI < or = 1.0), and was significantly reduced at week 2 (P < 0.05). Viral loads with TR and non-response increased at week 1. The SVR rate was 90% with RI < or = 1.0, 96% with rapid viral responders, and 93% with RI-2nd < 0.7 and week 8 early viral responders. The SVR rate with these 3 groups was 90% and administration for 48 weeks was recommended. With other groups, the SVR rate was 23% and the TR rate was 77%. Administration for 72 weeks was therefore recommended.

CONCLUSIONS

We distinguished SVR from TR during treatment using two indices (RI and RI-2nd) and the timing of HCV-RNA negativity.

Treatment of chronic hepatitis C in a slow responder: a case for extended therapy

BACKGROUND

A 49-year-old white man presented to his primary-care clinic with fatigue and poor concentration. He had an enlarged liver with a minimally tender edge and was subsequently referred to our liver clinic.

INVESTIGATIONS

Physical examination, laboratory investigations (including tests for HCV-RNA, antibodies to hepatitis B surface and core antigens, and HBV-DNA), and liver biopsy.

DIAGNOSIS

The patient had chronic hepatitis C infection and was a slow responder to treatment.

MANAGEMENT

Administration of pegylated interferon alpha2b plus ribavirin for 72 weeks. Escitalopram was given to manage his depression.