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Abstract
The development of direct-acting antivirals (DAA) has revolutionized the treatment of chronic hepatitis C, enabling cure of hepatitis C virus (HCV) infection in more than 95% of cases. There are essentially no contraindications, so almost any patient can now be successfully treated. The result is the prevention or amelioration of cirrhosis, hepatocellular carcinoma (HCC), and extrahepatic manifestations. Consequently, the 2020 Nobel Prize in Medicine and Physiology was awarded for the discovery of HCV. Due to the high efficacy of therapy, even global HCV elimination is conceivable even without a vaccine. Here, we would like to venture a SWOT analysis of current HCV therapies aimed at HCV elimination.
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Affiliation(s)
- Markus Cornberg
- Department of Gastroenterology, Hepatology, and Endocrinology, 9177Hannover Medical School Hannover, Hannover, Germany.,Centre for Individualised Infection Medicine (CiiM), a joint venture of Helmholtz Centre for Infection Research and Hannover Medical School, Hannover, Germany.,German Center for Infection Research (DZIF), Partner-Site Hannover-Braunschweig, Hannover, Germany
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2
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Binka M, Janjua NZ, Grebely J, Estes C, Schanzer D, Kwon JA, Shoukry NH, Kwong JC, Razavi H, Feld JJ, Krajden M. Assessment of Treatment Strategies to Achieve Hepatitis C Elimination in Canada Using a Validated Model. JAMA Netw Open 2020; 3:e204192. [PMID: 32374397 PMCID: PMC7203608 DOI: 10.1001/jamanetworkopen.2020.4192] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/04/2020] [Indexed: 12/19/2022] Open
Abstract
Importance Achievement of the World Health Organization (WHO) target of eliminating hepatitis C virus (HCV) by 2030 will require an increase in key services, including harm reduction, HCV screening, and HCV treatment initiatives in member countries. These data are not available for Canada but are important for informing a national HCV elimination strategy. Objective To use a decision analytical model to explore the association of different treatment strategies with HCV epidemiology and HCV-associated mortality in Canada and to assess the levels of service increase needed to meet the WHO elimination targets by 2030. Design, Setting, and Participants Study participants in this decision analytical model included individuals with hepatitis C virus infection in Canada. Five HCV treatment scenarios (optimistic, very aggressive, aggressive, gradual decrease, and rapid decrease) were applied using a previously validated Markov-type mathematical model. The optimistic and very aggressive treatment scenarios modeled a sustained annual treatment of 10 200 persons and 14 000 persons, respectively, from 2018 to 2030. The aggressive, gradual decrease, and rapid decrease scenarios assessed decreases in treatment uptake from 14 000 persons to 10 000 persons per year, 12 000 persons to 8500 persons per year, and 12 000 persons to 4500 persons per year, respectively, between 2018 and 2030. Main Outcomes and Measures Hepatitis C virus prevalence and HCV-associated health outcomes were assessed for each of the 5 treatment scenarios with the goal of identifying strategies to achieve HCV elimination by 2030. Results An estimated mean 180 142 persons (95% CI, 122 786-196 862 persons) in Canada had chronic HCV infection at the end of 2017. The optimistic and gradual decrease scenarios estimated a decrease in HCV prevalence from 180 142 persons to 37 246 persons and 37 721 persons, respectively, by 2030. Relative to 2015, this decrease in HCV prevalence was associated with 74%, 69%, and 69% reductions in the prevalence of decompensated cirrhosis, hepatocellular carcinoma, and liver-associated mortality, respectively, leading to HCV elimination by 2030. More aggressive treatment uptake (very aggressive scenario) could result in goal achievement up to 3 years earlier than 2030, although a rapid decrease in the initiation of treatment (rapid decrease scenario) would preclude Canada from reaching the HCV elimination goal by 2030. Conclusions and Relevance The study findings suggest that Canada could meet the WHO goals for HCV elimination by 2030 by sustaining the current national HCV treatment rate during the next decade. This target will not be achieved if treatment uptake is allowed to decrease rapidly.
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Affiliation(s)
- Mawuena Binka
- British Columbia Centre for Disease Control, Vancouver, Canada
| | - Naveed Z. Janjua
- British Columbia Centre for Disease Control, Vancouver, Canada
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- University of British Columbia, Vancouver, Canada
| | - Jason Grebely
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Chris Estes
- Center for Disease Analysis, Lafayette, Colorado
| | - Dena Schanzer
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
| | - Jisoo A. Kwon
- Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Naglaa H. Shoukry
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Centre de Recherche du Centre Hospitalier de l’Universite de Montreal, Montreal, Quebec, Canada
| | - Jeffrey C. Kwong
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- ICES, Toronto, Ontario, Canada
| | - Homie Razavi
- Center for Disease Analysis, Lafayette, Colorado
| | - Jordan J. Feld
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, Canada
- Canadian Network on Hepatitis C, Montreal, Quebec, Canada
- University of British Columbia, Vancouver, Canada
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HCV genotype profile in Brazil of mono-infected and HIV co-infected individuals: A survey representative of an entire country. PLoS One 2020; 15:e0227082. [PMID: 31905224 PMCID: PMC6944355 DOI: 10.1371/journal.pone.0227082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION To be eligible for government-provided treatment in Brazil, all HCV-infected individuals are required to be genotyped shortly after diagnosis. We describe the HCV genotype (G) profiles by geographic region, gender, age and HIV co-infection. METHODS We assessed 29,071 genotypes collected from HCV-infected individuals from March 2016 to March 2018 (Abbott Real-Time HCV Genotype). We randomly selected 12,336 samples for HIV co-infection testing using an EIA rapid test kit (TR DPP HIV 1/2 Bio-Manguinhos). Descriptive statistical analyses were performed using R. RESULTS Overall, HCV genotype distribution was 40.9% G1A, 30.2% G1B, 23.8% G3, 3.8% G2, 0.7% G4, 0.1% G5 and 0.6% with multiples genotypes. G1A prevalence was 44.4% among males and 35.8% among females. G1B and G2 were more prevalent in older individuals than G1A and G3. G3 was more prevalent in the South region. Of samples tested for HIV co-infection, 15% were HIV+. Median age among HCV/HIV co-infected individuals was 50 years old compared to 57 years old among mono-infected individuals. Distinct HCV genotype prevalence between HCV/HIV co-infected and HCV mono-infected individuals were respectively: G1A 60.6% versus 37.8%, G1B 15.2% versus 32.9%, and G3 18.9% versus 24.7%. G4 was detected among co-infected young men (3.5% versus 0.2% among mono-infected). CONCLUSION The increasing prevalence of G3, as inferred by the younger ages of the HCV-infected individuals, poses an extra challenge with regards to disease progression. Distinct genotypical profiles between HCV mono-infection and HCV/HIV co-infection warrant future research in order to better understand and help mitigate HCV chains of transmission.
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Fraňková S, Urbánek P, Husa P, Němeček V, Razavi H, Razavi-Shearer D, Chlíbek R, Šperl J. Chronic hepatitis C in the Czech Republic: Forecasting the disease burden. Cent Eur J Public Health 2019; 27:93-98. [PMID: 31241282 DOI: 10.21101/cejph.a5350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 04/25/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Chronic HCV infection is associated with cirrhosis of the liver, hepatocellular carcinoma (HCC), and liver transplantation. HCV disease burden and the impact of new potent direct acting antivirals (DAAs) in the Czech Republic are unknown. METHODS Using a modelling framework, HCV disease progression in the Czech Republic was predicted to 2030 under the current standard of care treatment structure. In addition, two strategies to reduce the future burden of HCV infection were modelled: an incremental increase in treatment annually and WHO targets. RESULTS The number of viremic infected individuals in the Czech Republic is estimated to peak in 2026 (n = 55,130) and to decline by 0.5% by 2030 (n = 54,840). The number of individuals with compensated cirrhosis (n = 1,400), decompensated cirrhosis (n = 80), HCC (n = 70), and liver-related deaths (n = 60) is estimated to more than double by 2030. Through aggressive increases in diagnosis and treatment, HCV related mortality may decrease by 70% by 2030. CONCLUSIONS Disease burden associated with chronic HCV infection is projected to peak in the Czech Republic in 30-40 years. Assuming that the current portion of DAAs used remains constant, a significant reduction in HCV disease burden is possible through increased diagnosis and treatment through 2030. This analysis provides evidence in order to facilitate the development of national strategies for HCV care and management in the Czech Republic.
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Affiliation(s)
- Soňa Fraňková
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petr Urbánek
- Department of Internal Medicine, First Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic
| | - Petr Husa
- Clinic of Infectious Diseases, University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Vratislav Němeček
- National Reference Laboratory for Hepatitis, National Institute of Public Health, Prague, Czech Republic
| | - Homie Razavi
- Center for Disease Analysis, Lafayette, Colorado, USA
| | | | - Roman Chlíbek
- Department of Epidemiology, Vaccination Centre, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Jan Šperl
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Sharafi H, Ghalamkari S, Hassanshahi A, Alavian SM. Pooled Prevalence of NS5A Resistance-Associated Substitutions in Chronic HCV Genotype 3 Infection: A Study Based on Deposited Sequences in GenBank. Microb Drug Resist 2019; 25:1072-1079. [PMID: 31021305 DOI: 10.1089/mdr.2018.0358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Using direct-acting antiviral agents (DAAs) against hepatitis C virus (HCV) infection results in a high treatment response rate. However, several factors can significantly alter this outcome such as resistance-associated substitutions (RASs) in HCV NS5A gene. This study aimed to evaluate the prevalence of naturally occurring RASs of NS5A in HCV genotype 3 (HCV-3) sequences isolated from individuals with chronic HCV-3 infection. All the registered sequences in the GenBank under "NS5A" AND "Hepacivirus C" query were evaluated and screened, those which followed our inclusion criteria were enrolled in our pooled analysis. The retrieved sequences of included studies were evaluated for substitutions, RASs, and RASs conferring >100 resistance fold change (RASs >100 × ) in NS5A amino acid positions 24, 28, 30, 31, 62, 92, and 93. From 7 enrolled studies, a total of 370 HCV-3a isolates were retrieved and investigated. Forty-eight (13.0%, 95% CI = 9.9-16.8%) isolates harbored NS5A RASs. Moreover, Y93H was the only NS5A RAS >100 × observed in 13 (3.5%, 95% CI = 2.0-5.9%) retrieved sequences. The low frequency of naturally occurring NS5A RASs, especially those with clinical relevance (RASs >100 × ), among individuals with HCV-3 infection and the high rate of treatment response to DAAs suggest not to investigate every individual with HCV-3 infection for NS5A RASs before treatment.
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Affiliation(s)
- Heidar Sharafi
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, the Islamic Republic of Iran.,Middle East Liver Diseases (MELD) Center, Tehran, the Islamic Republic of Iran
| | - Saman Ghalamkari
- Department of Biology, Islamic Azad University, Arsanjan Branch, Arsanjan, Iran
| | - Alireza Hassanshahi
- Department of Biology, Islamic Azad University, Shahrekord Branch, Shahrekord, Iran
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, the Islamic Republic of Iran.,Middle East Liver Diseases (MELD) Center, Tehran, the Islamic Republic of Iran
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Tamai H, Shingaki N, Mori Y, Moribata K, Kawashima A, Maeda Y, Niwa T, Deguchi H, Inoue I, Maekita T, Iguchi M, Kato J, Ichinose M. Low-Dose Pegylated Interferon α-2b Plus Ribavirin for Elderly and/or Cirrhotic Patients with Genotype 2 Hepatitis C Virus. Gut Liver 2017; 10:617-23. [PMID: 26601828 PMCID: PMC4933424 DOI: 10.5009/gnl15193] [Citation(s) in RCA: 4] [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] [Received: 04/23/2015] [Revised: 06/16/2015] [Accepted: 06/25/2015] [Indexed: 12/11/2022] Open
Abstract
Background/Aims This study aimed to predict sustained viral response (SVR) to low-dose pegylated interferon (PEG-IFN) plus ribavirin of elderly and/or cirrhotic patients with genotype 2 hepatitis C virus (HCV) using viral response within 2 weeks. Methods Low-dose PEG-IFN-α-2b plus ribavirin was administered to 50 elderly and/or cirrhotic patients with genotype 2 HCV for 24 weeks. The dynamics of HCV RNA and HCV core antigen levels within 2 weeks were measured. Results The patients’ median age was 66 years. There were 21 male and 29 female patients. The median baseline HCV RNA level was 5.7 log IU/mL. Rapid viral response was achieved in 17 patients (34%), SVR in 28 (56%), and two (4%) discontinued treatment. Univariate analysis of factors contributing to SVR showed significant differences for sex, baseline virus level, and response within 4 weeks. When 40 fmol/L was set as the cutoff value for the core antigen level at 1 week, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for predicting SVR were 93%, 75%, 84%, 88%, and 85%, respectively. Conclusions Low-dose PEG-IFN plus ribavirin was a safe and cost-effective treatment for elderly and/or cirrhotic patients with genotype 2 HCV, and the viral response within 2 weeks was a useful predictor of SVR.
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Affiliation(s)
- Hideyuki Tamai
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Naoki Shingaki
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yoshiyuki Mori
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Kosaku Moribata
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akira Kawashima
- Department of Internal Medicine, Naga Municipal Hospital, Wakayama, Japan
| | - Yoshimasa Maeda
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Toru Niwa
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hisanobu Deguchi
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Izumi Inoue
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takao Maekita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Mikitaka Iguchi
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Jun Kato
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masao Ichinose
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Abstract
Hepatitis C virus (HCV) represents a significant global disease burden, with an estimated 130-150 million people worldwide living with chronic HCV infection. Within the six major clinical HCV genotypes, genotype 3 represents 22-30% of all infection and is described as a unique entity with higher rates of steatosis, faster progression to cirrhosis, and higher rates of hepatocellular carcinoma. Hepatic steatosis in the setting of hepatitis C genotype 3 (HCV-3) is driven by viral influence on three major pathways: microsomal triglyceride transfer protein, sterol regulatory element-binding protein-1c, and peroxisome proliferator-associated receptor-α. Historically with direct-acting antivirals, the rates of cure for HCV-3 therapies lagged behind the other genotypes. As current therapies for HCV-3 continue to close this gap, it is important to be cognizant of common drug interactions such as acid-suppressing medication and amiodarone. In this review, we discuss the rates of steatosis in HCV-3, the mechanisms behind HCV-3-specific steatosis, and current and future therapies.
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Affiliation(s)
- Austin Chan
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Infectious Diseases Research, Duke Clinical Research Institute, Durham, NC, USA
| | - Keyur Patel
- Toronto Center for Liver Disease, University of Toronto, Toronto, ON, Canada
| | - Susanna Naggie
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Infectious Diseases Research, Duke Clinical Research Institute, Durham, NC, USA.
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Predictors of sustained virological response in patients with hepatitis C virus genotype 3 infection. Clin Exp Hepatol 2016; 2:117-124. [PMID: 28856274 PMCID: PMC5497420 DOI: 10.5114/ceh.2016.62526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/01/2016] [Indexed: 12/15/2022] Open
Abstract
Aim of the study To assess predictors of sustained virological response (SVR) in patients with chronic hepatitis C virus (HCV) genotype 3 treated with standard therapy. Material and methods We retrospectively investigated data of 116 consecutive treatment-naïve patients chronically infected with HCV genotype 3, treated with pegylated interferon alpha (PegIFNα) and ribavirin (RBV) for 24 weeks. HCV RNA at week 4 (rapid virological response – RVR) and week 12 (early virological response – EVR) were measured in 85 and 105 patients respectively. Liver biopsy data were available for 103 patients. The variables were compared between patients with an SVR and those without. Results Overall 70.7% of patients achieved an SVR. Pretreatment factors including younger age, mild liver fibrosis as well as normal values of gamma-glutamyl transferase (GGT) and platelet count were significantly associated with higher SVR rate in univariate analysis. In the multivariate analysis only baseline platelet count > 140 000/µl and normal GGT activity were correlated with higher SVR rate. At weeks 4 and 12 HCV RNA was undetectable in 34.1% and 84.8% of patients respectively. The SVR rate was significantly higher in patients with an RVR compared to those without (p = 0.002). Only 2 patients with a rapid and early virological response did not achieve an SVR; both had negative pretreatment prognostic factors. Conclusions In treatment-naïve patients with genotype 3 HCV infection, low baseline platelet count and elevated GGT activity were significantly associated with poor response to PegIFNα and RBV. Achieving a rapid and early virological response was associated with higher likelihood of an SVR.
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Marotta P, Bailey R, Elkashab M, Farley J, Feinman SV, Peltekian K, Poliquin M, Witt-Sullivan H, Rampakakis E, Drolet M, Cooper C. Real-world effectiveness of peginterferon α-2b plus ribavirin in a Canadian cohort of treatment-naïve chronic hepatitis C patients with genotypes 2 or 3: results of the PoWer and RediPEN studies. Eur J Clin Microbiol Infect Dis 2016; 35:597-609. [PMID: 26851949 PMCID: PMC4819461 DOI: 10.1007/s10096-016-2576-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 01/04/2016] [Indexed: 01/02/2023]
Abstract
The purpose of this investigation was to assess the real-life effectiveness of pegylated interferon (peg-IFN) α-2b with ribavirin (RBV) in a cohort of treatment-naïve patients with chronic genotypes 2 (G2) or 3 (G3) hepatitis C virus (HCV) infection. A post-hoc pooled analysis of two Canadian multicenter, observational studies, RediPEN and PoWer, was carried out. A total of 1242 G2- or G3-infected patients were included. The primary outcome was sustained virologic response (SVR). Secondary endpoints included early virologic response (EVR), end-of-treatment (EOT) response, and relapse. Multivariate logistic regression was used to identify independent predictors of treatment response. SVR in G2 and G3 was 74.4 % and 63.6 %, respectively. Relapse occurred in 12.7 % and 19.1 % of G2- and G3-infected patients achieving EOT response, respectively. Overall, G3 was found to independently predict reduced SVR [odds ratio (OR) = 0.20; p = 0.007] and increased relapse (OR = 6.84; p = 0.022). Among G3-infected patients, increasing fibrosis score was the most important factor predicting reduced SVR [F2 vs. F0/F1 (OR = 0.41; p = 0.009); F3 vs. F0/F1 (OR = 0.72; p = 0.338); F4 vs. F0/F1 (OR = 0.27; p = 0.001)]. Male gender (OR = 13.16; p = 0.020) and higher fibrosis score [F2 vs. F0/F1 (OR = 9.72; p = 0.016); F3/F4 vs. F0/F1 (OR = 4.23; p = 0.113)] were associated with increased relapse in G3 patients. These results support the real-life effectiveness of peg-IFN α-2b plus ribavirin in HCV G2- and G3-infected patients. Overall, genotype was identified as the most significant predictor of treatment outcome. Fibrosis score and gender were key outcome predictors in the G3-infected population. In clinical settings, peg-INF/RBV offers an alternative for patients without access to all oral direct-acting antivirals.
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Affiliation(s)
- P Marotta
- London Health Sciences Center, London, ON, Canada
| | - R Bailey
- University of Alberta, Edmonton, AB, Canada
| | - M Elkashab
- Toronto Liver Centre, Toronto, ON, Canada
| | - J Farley
- Dr. John Farley Inc., Vancouver, BC, Canada
| | | | - K Peltekian
- Atlantic Hepatology Services, Halifax, NS, Canada
| | - M Poliquin
- Clinique Médicale L'Actuel, Montreal, QC, Canada
| | | | - E Rampakakis
- JSS Medical Research Inc., St-Laurent, QC, Canada.
| | - M Drolet
- Merck Canada Inc., Kirkland, QC, Canada
| | - C Cooper
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Broglio KR, Daar ES, Quintana M, Yuan Y, Kalsekar A, Spellberg B, Lewis RJ, Akker DVD, Detry MA, Le T, Berry SM. A meta-analysis platform methodology for determining the comparative effectiveness of antihepatitis C virus regimens. J Comp Eff Res 2016; 4:101-14. [PMID: 25825840 DOI: 10.2217/cer.14.69] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Many hepatitis C virus regimens are unlikely to be compared head to head. In more difficult to treat populations where there is no standard of care, trials are single arm. We describe a flexible meta-analysis platform in this setting. METHODS Our meta-analysis is literature based. We illustrate our methodology and show how inference can be extended to single-arm trials. RESULTS As an example, in the single arm setting, a regimen with response rates of 84, 72 and 54% in genotype 1a across treatment naive, previous partial responders and previous null responders, respectively, would have 95% probability of superiority to IFN-α + RBV + TPV. CONCLUSION This is a rigorous approach to comparative effectiveness that accounts for varying patient populations and plans for the incorporation of emerging treatments.
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Yeh ML, Hsieh MY, Huang CI, Huang CF, Hsieh MH, Liang PC, Lin YH, Hou NJ, Lin ZY, Chen SC, Huang JF, Dai CY, Chuang WL, Yu ML. Personalized Therapy of Chronic Hepatitis C and B Dually Infected Patients With Pegylated Interferon Plus Ribavirin: A Randomized Study. Medicine (Baltimore) 2015; 94:e1837. [PMID: 26496327 PMCID: PMC4620800 DOI: 10.1097/md.0000000000001837] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/19/2015] [Accepted: 09/23/2015] [Indexed: 12/18/2022] Open
Abstract
We aimed to investigate whether response-guided therapy (RGT) with peginterferon-alpha plus ribavirin by using hepatitis C virus (HCV) genotype, pretreatment HCV RNA levels, and rapid virological response (RVR, undetectable HCV RNA at treatment week 4) could be applied for active HCV/hepatitis B virus (HBV) dually infected patients, without compromised the treatment efficacy.A total of 203 patients, seropositive of HCV antibody, HCV RNA and HBV surface antigen (HBsAg), and seronegative for HBV e antigen for >6 months, were randomized to receive peginterferon-alpha/ribavirin by either genotype-guided therapy (GGT, n = 102: HCV genotype 1 [HCV-1], 48 weeks; HCV-2/3, 24 weeks) or RGT (n = 101: HCV-1, 48 or 24 weeks if patients with baseline VL <400,000 IU/mL and RVR; HCV-2/3, 24 or 16 weeks if patients with RVR). The primary endpoint was HCV-sustained virological response (SVR).The HCV SVR rate was comparable between the GGT (77.5%, 79/102) and RGT groups (70.3%, 71/101, P = 0.267), either among HCV-1/HBV (69.4% [43/62] vs 63.5% [40/63], P = 0.571) or among HCV-2/3/HBV (90.0% [36/40] vs 81.6% [31/38], P = 0.342) dually infected patients based on intention-to-treat analysis. In HCV-1/HBV dually infected patients, RVR (odds ratio [OR]: 6.05; 95% confidence intervals [CI]: 2.148-17.025, P = 0.001) and lower pretreatment blood glucose levels (OR: 0.97; CI: 0.944-0.989, P = 0.003) were independent predictors of HCV SVR. Although RVR (OR: 10.68; CI: 1.948-58.514, P = 0.006) was the only significant factor associated with HCV SVR in HCV-2/3/HBV dually infected patients. HBsAg loss at 1 year posttreatment was observed in 17 of 185 (9.2%) patients. The rates of discontinuation and adverse events were similar between the 2 groups.RGT with peginterferon-alpha/RBV may be considered for HBeAg-negative HBV/HCV dually infected patients.
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Affiliation(s)
- Ming-Lun Yeh
- From the Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital (M-LYeh, M-YH, C-FH, P-CL, Y-HL, Z-YL, S-CC, J-FH, C-YD, W-LC, M-LYu), Faculty of Internal Medicine, College of Medicine, and Graduate Institute of Clinical Medicine, and Center for Infectious Disease and Cancer Research, Kaohsiung Medical University (M-LYeh, C-FH, M-HH, Z-YL, S-CC, J-FH, C-YD, W-LC; M-LYu), Institute of Biomedical Sciences, National Sun Yat-Sen University (M-LYu), Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital (C-IH, N-JH), Department of Occupational Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University (C-FH), Department of Preventive Medicine, Kaohsiung Medical University Hospital (M-HH), Graduate Institute of Medicine, College of Medicine (M-LYeh, C-YD), Center for Infectious Disease and Cancer Research; and Center for Lipid Science and Aging Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C-YD, W-LC, M-LYu)
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Swallow E, Song J, Yuan Y, Kalsekar A, Kelley C, Mu F, Kim S, Noviello S, Signorovitch J. Daclatasvir + sofosbuvir versus standard of care for hepatitis C genotype 3: a matching-adjusted indirect comparison. J Comp Eff Res 2015; 5:129-39. [PMID: 26390233 DOI: 10.2217/cer.15.49] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIMS To compare the efficacy and tolerability of daclatasvir and sofosbuvir (DCV + SOF) versus SOF and ribavirin (SOF + R) and versus peginterferon-alfa plus ribavirin (A/R) in patients infected with hepatitis C genotype 3. PATIENTS & METHODS Clinical trials of SOF + R or A/R were identified in systematic literature reviews. The DCV+SOF population was adjusted via propensity score weighting to match average baseline characteristics to those reported for the comparator regimens. RESULTS The SVR12 rate was similar between DCV + SOF and SOF + R, and significantly higher with DCV + SOF than A/R. Rates of discontinuation due to AEs were similar or significantly lower in patients treated with DCV + SOF than SOF + R or A/R. CONCLUSION With its high efficacy and improved tolerability, DCV + SOF is an important treatment for hepatitis C genotype 3.
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Affiliation(s)
- Elyse Swallow
- Analysis Group, Inc., 111 Huntington Avenue, 10th Floor, Boston, MA 02199, USA
| | - Jinlin Song
- Analysis Group, Inc., 111 Huntington Avenue, 10th Floor, Boston, MA 02199, USA
| | - Yong Yuan
- Bristol-Myers Squibb, 100 Nassau Park Boulevard, Princeton, NJ 08540, USA
| | - Anupama Kalsekar
- Bristol-Myers Squibb, 100 Nassau Park Boulevard, Princeton, NJ 08540, USA
| | - Caroline Kelley
- Analysis Group, Inc., 111 Huntington Avenue, 10th Floor, Boston, MA 02199, USA
| | - Fan Mu
- Analysis Group, Inc., 111 Huntington Avenue, 10th Floor, Boston, MA 02199, USA
| | - Soomi Kim
- Analysis Group, Inc., 111 Huntington Avenue, 10th Floor, Boston, MA 02199, USA
| | - Stephanie Noviello
- Bristol-Myers Squibb, 100 Nassau Park Boulevard, Princeton, NJ 08540, USA
| | - James Signorovitch
- Analysis Group, Inc., 111 Huntington Avenue, 10th Floor, Boston, MA 02199, USA
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Hofmann WP, Mauss S, Lutz T, Schober A, Böker K, Moog G, Baumgarten A, Pfeiffer-Vornkahl H, Alshuth U, Hüppe D, Wedemeyer H, Manns MP, Schott E. Benefit of Treatment Individualization in Patients with Chronic Hepatitis C Receiving Peginterferon Alfa-2a and Ribavirin in a Large Noninterventional Cohort Study. PLoS One 2015; 10:e0134839. [PMID: 26230998 PMCID: PMC4521757 DOI: 10.1371/journal.pone.0134839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 07/14/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND AIMS Individualization of treatment with peginterferon alfa and ribavirin in patients with chronic hepatitis C showed benefit in controlled trials and was implemented in treatment guidelines to increase response rates and to reduce side effects and costs. However, it is unknown whether individualization was adopted in routine daily practice and whether it translated into improved outcomes. METHODS From a large noninterventional cohort study, clinical and virologic response data of 10,262 HCV patients who received peginterferon alfa-2a and ribavirin between 2003-2007 and 2008-2011 were analyzed. To account for treatment individualization, a matched-pair analysis (2,997 matched pairs) was performed. Variation in treatment duration and dosing of ribavirin were analyzed as indicators for individualization. RESULTS Sustained virological response (SVR) rates were similar between 2003-2007 and 2008-2011 (62.0% vs. 63.7%). Patients with comorbidities were more abundant in the later period, (44.3% vs. 57.1%). The subsequent matched-pair analysis demonstrated higher SVR rates in the 2008-2011 period (64.3%) than in the 2003-2007 period (61.2%, p=0.008). More patients received abbreviated or extended treatment regimens in the later than the earlier period as an indicator of treatment individualization. To the same end, ribavirin doses were higher in the later period (12.6 versus 11.6 mg/kg/day). Factors independently associated with SVR included HCV genotype, low baseline viral load, younger age, route of infection, absence of concomitant diseases, lower APRI score, normal gamma-GT, higher ribavirin doses, no substitution for drug abuse, treatment duration, and treatment in the 2008-2011 period. CONCLUSIONS Treatment individualization with peginterferon alfa and ribavirin was implemented in daily routine between 2003-2007 and 2008-2011, SVR rates improved in the same period. These findings may be most relevant in resource-limited settings.
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Affiliation(s)
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | | | | | | | - Gero Moog
- Practice of Gastroenterology, Kassel, Germany
| | | | | | | | | | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology, and Endocrinology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Eckart Schott
- Dept. of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
- * E-mail:
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Bourlière M, Benali S, Ansaldi C, Le Folgoc G, Riso A, Lecomte L. Optimal therapy of genotype-2 chronic hepatitis C: what's new? Liver Int 2015; 35 Suppl 1:21-6. [PMID: 25529084 DOI: 10.1111/liv.12711] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The standard of care (SOC) for the treatment of HCV genotype 2 (HCV-2) was pegylated interferon alpha plus ribavirin (PEG-IFN/RBV) at weight-based doses for a response-guided duration. The launches of sofosbuvir and daclatasvir in 2014 have resulted in new, better tolerated and shorter treatment. The combination of sofosbuvir and RBV for 12 weeks appears to be the new SOC in both European and American guidelines. The cost and therefore the access to this treatment remains a problem in many countries because of major economic constraints. For the few more difficult-to-treat patients, a combination of direct acting antivirals may be suitable and is being studied in ongoing trials. Because of rapidly changing treatment recommendations, the decision to treat HCV-2 patients with currently approved drugs or to wait until a better option is available in the future, must be made according to the stage of fibrosis.
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Affiliation(s)
- Marc Bourlière
- Department of Hepato-Gastroenterology, Hospital Saint Joseph, Marseilles, France
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Abstract
BACKGROUND AND AIMS Chronic hepatitis C virus infection is prevalent among 200,000 individuals in Poland; however, few are aware of their condition (30,000 diagnosed) and even fewer are treated (2490 in 2014). This analysis projected future disease burden and developed two treatment scenarios to control or eliminate hepatitis C virus-related disease in Poland. METHODS Using a modeling approach, the infected population and future disease progression were quantified. Baseline variables included viremic prevalence, age and sex, diagnosis rate, treatment rate, disease progression, and sustained virologic response rates. Data were collected from the literature and through expert interviews. RESULTS The number of prevalent hepatitis C virus infections is projected to decrease (5%) by 2030. However, the numbers of individuals with compensated and decompensated cirrhosis, and hepatocellular carcinoma are estimated to increase by 40, 55, and 60%, respectively. By increasing sustained virologic response rates to 95% from 2015 onward, and the number of treated cases (from 2490 to 5000), the number of individuals with cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma is projected to remain constant until 2030. A strategy to eliminate chronic hepatitis C virus infection was also considered. To reduce total infections by 90% and mortality by 80%, treatment was increased to 15,000 patients annually. This scenario required the diagnosis of 15,000 new cases (compared with 3000 today). CONCLUSION A marked reduction in hepatitis C virus-related disease burden is possible, with increased diagnosis and treatment. The results could inform the development of effective disease management in Poland.
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Heidrich B, Wiegand SB, Buggisch P, Hinrichsen H, Link R, Möller B, Böker KHW, Teuber G, Klinker H, Zehnter E, Naumann U, Busch HW, Maasoumy B, Baum U, Hardtke S, Manns MP, Wedemeyer H, Petersen J, Cornberg M. Treatment of naïve patients with chronic hepatitis C genotypes 2 and 3 with pegylated interferon alpha and ribavirin in a real world setting: relevance for the new era of DAA. PLoS One 2014; 9:e108751. [PMID: 25302676 PMCID: PMC4193764 DOI: 10.1371/journal.pone.0108751] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/26/2014] [Indexed: 01/21/2023] Open
Abstract
Evidence based clinical guidelines are implemented to treat patients efficiently that include efficacy, tolerability but also health economic considerations. This is of particular relevance to the new direct acting antiviral agents that have revolutionized treatment of chronic hepatitis C. For hepatitis C genotypes 2/3 interferon free treatment is already available with sofosbuvir plus ribavirin. However, treatment with sofosbuvir-based regimens is 10–20 times more expensive compared to pegylated interferon alfa and ribavirin (PegIFN/RBV). It has to be discussed if PegIFN/RBV is still an option for easy to treat patients. We assessed the treatment of patients with chronic hepatitis C genotypes 2/3 with PegIFN/RBV in a real world setting according to the latest German guidelines. Overall, 1006 patients were recruited into a prospective patient registry with 959 having started treatment. The intention-to-treat analysis showed poor SVR (GT2 61%, GT3 47%) while patients with adherence had excellent SVR in the per protocol analysis (GT2 96%, GT3 90%). According to guidelines, 283 patients were candidates for shorter treatment duration, namely a treatment of 16 weeks (baseline HCV-RNA <800.000 IU/mL, no cirrhosis and RVR). However, 65% of these easy to treat patients have been treated longer than recommended that resulted in higher costs but not higher SVR rates. In conclusion, treatment with PegIFN/RBV in a real world setting can be highly effective yet similar effective than PegIFN± sofosbuvir/RBV in well-selected naïve G2/3 patients. Full adherence to guidelines could be further improved, because it would be important in the new era with DAA, especially to safe resources.
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Affiliation(s)
- Benjamin Heidrich
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Liver Foundation, HepNet Study-House, Hannover, Germany, and German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Steffen B. Wiegand
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Liver Foundation, HepNet Study-House, Hannover, Germany, and German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Peter Buggisch
- IFI Institute for Interdisciplinary Medicine, Asklepios Klinik St Georg, Hamburg, Germany
| | - Holger Hinrichsen
- Gastroenterology, Gastroenterologische Schwerpunkt Praxis, Kiel, Germany
| | | | | | | | | | - Hartwig Klinker
- Dept. of Internal Medicine II, University of Würzburg, Würzburg, Germany
| | | | - Uwe Naumann
- Center for Addiction-Medicine, Hepatology and HIV, Praxiszentrum Kaiserdamm, Berlin, Germany
| | | | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Liver Foundation, HepNet Study-House, Hannover, Germany, and German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Undine Baum
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Liver Foundation, HepNet Study-House, Hannover, Germany, and German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Svenja Hardtke
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Liver Foundation, HepNet Study-House, Hannover, Germany, and German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Liver Foundation, HepNet Study-House, Hannover, Germany, and German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Liver Foundation, HepNet Study-House, Hannover, Germany, and German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
| | - Jörg Petersen
- IFI Institute for Interdisciplinary Medicine, Asklepios Klinik St Georg, Hamburg, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- German Liver Foundation, HepNet Study-House, Hannover, Germany, and German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Braunschweig, Germany
- * E-mail:
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Exploratory trial of ombitasvir and ABT-450/r with or without ribavirin for HCV genotype 1, 2, and 3 infection. J Infect 2014; 70:197-205. [PMID: 25246359 DOI: 10.1016/j.jinf.2014.09.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/08/2014] [Accepted: 09/15/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To examine the safety and efficacy of ombitasvir and ABT-450 with ritonavir (ABT-450/r) ± ribavirin (RBV) in treatment-naïve, non-cirrhotic adults with chronic HCV genotype 1-3 infection. METHODS Patients in this open-label, exploratory, phase 2, multicenter study received ombitasvir (25 mg QD) and ABT-450/r (200/100 mg QD) ± RBV for 12 weeks. Primary efficacy endpoint was HCV RNA < lower limit of quantitation (LLOQ) from week 4 through 12. Sustained virologic response 12 weeks post-treatment (SVR12) was a secondary endpoint. RESULTS Sixty-one patients were enrolled. Among genotype 1-, 2-, and 3-infected patients, respectively, HCV RNA was<LLOQ from week 4 through 12 in 10 (100%; 95% CI 69-100), 9 (90%; 56-100), and 7 (70%; 35-93) receiving the RBV-containing regimen and 9 (90%; 56-100), 8 (80%; 44-97), and 2 (18%; 2-52) receiving the RBV-free regimen. Among genotype 1-, 2-, and 3-infected patients, respectively, SVR12 was achieved by 10 (100%), 8 (80%), and 5 (50%) receiving the RBV-containing regimen, and 6 (60%), 6 (60%), and 1 (9%) receiving the RBV-free regimen. The most common adverse events were fatigue, nausea, and headache. One patient discontinued due to an adverse event. CONCLUSIONS In this study, ombitasvir and ABT-450/r ± RBV regimens were generally well-tolerated. Sustained virologic response was achieved in most patients with HCV genotype 1 or 2 infection, but low SVR rates were observed in HCV genotype 3-infected patients.
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Rao PN, Koshy A, Philip J, Premaletha N, Varghese J, Narayanasamy K, Mohindra S, Pai NV, Agarwal MK, Konar A, Vora HB. Pegylated interferon alfa-2b plus ribavirin for treatment of chronic hepatitis C. World J Hepatol 2014; 6:520-526. [PMID: 25068004 PMCID: PMC4110544 DOI: 10.4254/wjh.v6.i7.520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 04/11/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the safety and efficacy of pegylated interferon alfa-2b, indigenously developed in India, plus ribavirin in treatment of hepatitis C virus (HCV).
METHODS: One-hundred HCV patients were enrolled in an open-label, multicenter trial. Patients were treated with pegylated interferon alfa-2b 1.5 μg/kg per week subcutaneously plus oral ribavirin 800 mg/d for patients with genotypes 2 and 3 for 24 wk. The same dose of peginterferon plus weight-based ribavirin (800 mg/d for ≤ 65 kg; 1000 mg/d for > 65-85 kg; 1200 mg/d for > 85-105 kg; 1400 mg/d for > 105 kg body weight) was administered for 48 wk for patients with genotypes 1 and 4. Serological and biochemical responses of patients were assessed.
RESULTS: Eighty-two patients (35 in genotypes 1 and 4 and 47 in 2 and 3), completed the study. In genotype 1, 25.9% of patients achieved rapid virologic response (RVR): while the figures were 74.1% for early virologic response (EVR) and 44.4% for sustained virologic response (SVR). For genotypes 2 and 3, all patients bar one belonged to genotype 3, and of those, 71.4%, 87.5%, and 64.3% achieved RVR, EVR, and SVR, respectively. In genotype 4, 58.8%, 88.2%, and 52.9% of patients achieved RVR, EVR, and SVR, respectively. The majority of patients attained normal levels of alanine aminotransferase by 4-12 wk of therapy. Most patients showed a good tolerance for the treatment, although mild-to-moderate adverse events were exhibited; only two patients discontinued the study medication due to serious adverse events (SAEs). Eleven SAEs were observed in nine patients; however, only four SAEs were related to study medication.
CONCLUSION: Peginterferon alfa-2b, which was developed in India, in combination with ribavirin, is a safe and effective drug in the treatment of HCV.
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Puri P, Anand AC, Saraswat VA, Acharya SK, Sarin SK, Dhiman RK, Aggarwal R, Singh SP, Amarapurkar D, Arora A, Chhabra M, Chetri K, Choudhuri G, Dixit VK, Duseja A, Jain AK, Kapoor D, Kar P, Koshy A, Kumar A, Madan K, Misra SP, Prasad MV, Nagral A, Puri AS, Jeyamani R, Saigal S, Shah S, Sharma PK, Sood A, Thareja S, Wadhawan M. Consensus Statement of HCV Task Force of the Indian National Association for Study of the Liver (INASL). Part II: INASL Recommendations for Management of HCV in India. J Clin Exp Hepatol 2014; 4:117-40. [PMID: 25755549 PMCID: PMC4116713 DOI: 10.1016/j.jceh.2014.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 06/04/2014] [Indexed: 12/12/2022] Open
Abstract
The estimated prevalence of hepatitis C virus (HCV) infection in India is between 0.5 and 1.5% with hotspots showing much higher prevalence in some areas of northeast India, in some tribal populations and in certain parts of Punjab. Genotype 3 is the most prevalent type of infection. Recent years have seen development of a large number of new molecules that are revolutionizing the treatment of hepatitis C. Some of the new directly acting agents (DAAs) like sofosbuvir have been called game-changers because they offer the prospect of interferon-free regimens for the treatment of HCV infection. These new drugs have not yet been approved in India and their cost and availability is uncertain at present. Till these drugs become available at an affordable cost, the treatment that was standard of care for the whole world before these newer drugs were approved should continue to be recommended. For India, cheaper options, which are as effective as the standard-of-care (SOC) in carefully selected patients, are also explored to bring treatment within reach of poorer patients. It may be prudent to withhold treatment at present for selected patients with genotype 1 or 4 infection and low levels of fibrosis (F1 or F2), and for patients who are non-responders to initial therapy, interferon intolerant, those with decompensated liver disease, and patients in special populations such as stable patients after liver and kidney transplantation, HIV co-infected patients and those with cirrhosis of liver.
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Key Words
- ALT, alanine amintraonsferase
- ANC, absolute neutrophil count
- AST, aspartate aminotransferase
- CH–C, Chronic Hepatitis C
- CKD, chronic kidney disease
- CTP, Child-Turcotte-Pugh
- EIA, enzyme immunoassay
- ETR, end-of-treatment response
- EVR, early virological response
- GRADE, Grading of Recommendations Assessment, Development and Evaluation
- HCV, hepatitis C virus
- HIV, Human immunodeficiency virus
- IFNa, interferon alfa
- INASL, Indian National Association for Study of the Liver
- PCR, polymerase chain reaction
- Peg-IFNa, pegylated interferon alfa
- RBV, Ribavirin
- RVR, rapid virological response
- SOC, standard of care
- SVR, sustained virological response
- ULN, upper limit of normal
- anti-HCV, antibody to HCV
- antiviral therapy
- chronic hepatitis
- hepatitis C virus
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Affiliation(s)
- Pankaj Puri
- Department of Gastroenterology, Army Hospital (R & R), New Delhi 110010, India
| | - Anil C. Anand
- Department of Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical, Sciences, Lucknow, Uttar Pradesh 221016, India
| | - Subrat K. Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi 110070, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and, Research, Chandigarh 160012, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical, Sciences, Lucknow, Uttar Pradesh 221016, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Odisha 753007, India
| | - Deepak Amarapurkar
- Department of Gastroenterology, Bombay Hospital, Mumbai, Maharashtra 400020, India
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi 110060, India
| | - Mohinish Chhabra
- Department of Gastroenterology, Fortis Hospital, Mohali, Punjab 160047, India
| | - Kamal Chetri
- Department of Gastroenterology, International Hospital, Guwahati, Assam 781005, India
| | - Gourdas Choudhuri
- Department of Gastroenterology, Fortis Hospital, Gurgaon, Haryana 122002, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and, Research, Chandigarh 160012, India
| | - Ajay K. Jain
- Department of Gastroenterology, Choithram Hospital & Research Centre, Indore, Madhya Pradesh 452014, India
| | - Dharmesh Kapoor
- Department of Gastroenterology, Global Hospital, Hyderabad, Andhra Pradesh 500004, India
| | - Premashis Kar
- Department of Gastroenterology, LNJP Hospital, and Maulana Azad Medical College, New Delhi 110002, India
| | - Abraham Koshy
- Department of Hepatology, Lakeshore Hospital, Cochin, Kerala 682304, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi 110060, India
| | - Kaushal Madan
- Department of Gastroenterology, Medanta Medicity, Gurgaon, Haryana 122001, India
| | - Sri P. Misra
- Department of Gastroenterology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh 211001 India
| | - Mohan V.G. Prasad
- Department of Gastroenterology, VGM Hospital, Coimbatore, Tamil Nadu 641005, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital, Mumbai, Maharashtra 400026, India
| | - Amarendra S. Puri
- Department of Gastroenterology, GB Pant Hospital, New Delhi 110002, India
| | - R. Jeyamani
- Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu 632004, India
| | - Sanjiv Saigal
- Department of Gastroenterology, Medanta Medicity, Gurgaon, Haryana 122001, India
| | - Samir Shah
- Department of Gastroenterology, Global Hospital, Mumbai, Maharashtra 400078, India
| | - Praveen K. Sharma
- Department of Medicine, Armed Forces Medical College, Pune, Maharashtra 411040, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, Punjab 141001, India
| | - Sandeep Thareja
- Department of Gastroenterology, Army Hospital (R & R), New Delhi 110010, India
| | - Manav Wadhawan
- Department of Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India
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22
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EASL Clinical Practice Guidelines: management of hepatitis C virus infection. J Hepatol 2014; 60:392-420. [PMID: 24331294 DOI: 10.1016/j.jhep.2013.11.003] [Citation(s) in RCA: 646] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023]
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Wada Y, Tamai H, Uno A, Kawashima A, Shingaki N, Mori Y, Moribata K, Miyata K, Higashi K, Deguchi H, Ueda K, Inoue I, Maekita T, Iguchi M, Kato J, Ichinose M. Prediction of efficacy to pegylated interferon-α-2b plus ribavirin in patients with genotype 2 hepatitis C virus using viral response within 2 weeks. Hepatol Res 2014; 44:179-86. [PMID: 23531032 DOI: 10.1111/hepr.12101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 12/28/2012] [Accepted: 02/18/2013] [Indexed: 12/26/2022]
Abstract
AIM Rapid virological response (RVR), defined as serum hepatitis C virus (HCV) RNA negativity at 4 weeks, is the most useful predictor of sustained virological response (SVR) to standard pegylated interferon (PEG IFN) plus ribavirin therapy for patients infected with genotype 2 HCV. The aim of the present study was to predict SVR using viral response within 2 weeks of therapy initiation. METHODS Of 64 HCV genotype 2 patients with a high viral load treated with standard PEG IFN-α-2b plus weight-based ribavirin for 24 weeks, 58 patients whose adherence was more than 67% were analyzed. RNA and core antigen levels were measured at four time points: the day of therapy initiation, the following day, and at 1 and 2 weeks. RESULTS SVR was achieved in 73% (47/64) of patients. Univariate analysis of SVR contributing factors showed significant differences with age, bodyweight, white blood cell count, platelet count, fibrosis marker levels, baseline core antigen level and viral response. The area under the receiver-operator curve (AUC) of the core antigen level at 1 week (AUC, 0.940) was the highest among the significant SVR predicting factors. Setting 100 fmol/L as the cut-off value for core antigen level at 1 week, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for predicting SVR were 100%, 86%, 96%, 100% and 97%, respectively, and for predicting RVR were 66%, 93%, 97%, 46% and 72%, respectively. CONCLUSION The HCV core antigen level at 1 week after therapy initiation is the most useful predictor for SVR.
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Affiliation(s)
- Yuki Wada
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Randomized clinical trial comparing high versus standard dose of ribavirin plus peginterferon alfa-2a in hepatitis C genotype 3 and high viral load. Dargen-3 study. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:1-8. [DOI: 10.1016/j.gastrohep.2013.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 10/01/2013] [Accepted: 10/08/2013] [Indexed: 01/17/2023]
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Zhu Y, Chen S. Antiviral treatment of hepatitis C virus infection and factors affecting efficacy. World J Gastroenterol 2013; 19:8963-8973. [PMID: 24379621 PMCID: PMC3870549 DOI: 10.3748/wjg.v19.i47.8963] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 11/19/2013] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) infection is the leading cause of chronic liver-related diseases, including cirrhosis, liver failure, and hepatocellular carcinoma. Currently, no effective vaccine is available for HCV infection. Polyethylene glycol interferon-α (PegIFN-α) in combination with ribavirin (RBV) is the standard of care (SOC) for chronic hepatitis C. However, the efficacy of PegIFN-α and RBV combination therapy is less than 50% for genotype 1 HCV, which is the dominant virus in humans. In addition, IFN and RBV have several severe side effects. Therefore, strategies to improve sustained virological response (SVR) rates have been an important focus for clinical physicians. The serine protease inhibitors telaprevir and boceprevir were approved by the United States Food and Drug Administration in 2011. The addition of HCV protease inhibitors to the SOC has significantly improved the efficacy of treatments for HCV infection. Several direct-acting antiviral drugs currently in late-stage clinical trials, both with and without peg-IFN and RBV, have several advantages over the previous SOC, including higher specificity and efficacy, fewer side effects, and the ability to be administered orally, and might be optimal regimens in the future. Factors affecting the efficacy of anti-HCV treatments based on IFN-α include the HCV genotype, baseline viral load, virological response during treatment, host IL28B gene polymorphisms and hepatic steatosis. However, determining the effect of the above factors on DAA therapy is necessary. In this review, we summarize the development of anti-HCV agents and assess the main factors affecting the efficacy of antiviral treatments.
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Tapper EB, Afdhal NH. Is 3 the new 1: perspectives on virology, natural history and treatment for hepatitis C genotype 3. J Viral Hepat 2013; 20:669-77. [PMID: 24010641 DOI: 10.1111/jvh.12168] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Affecting 2-3% of the world's population, hepatitis C is a common viral infection which is a significant cause of morbidity and mortality. Hepatitis C genotype 1 is the dominant viral genotype among Western patients. For the last 20 years, in the era of interferon-based therapy, it was far more difficult to treat relative to genotypes 2 and 3. Accordingly, a significant focus of research was on new antiviral agents for the dominant genotype 1 patient. Now, as promising specific treatments are being introduced for genotype 1, the attention of clinicians and researchers has turned back to the 50-70 million patients infected with a nongenotype 1 hepatitis C. Furthermore, after recent, larger randomized trials, we have realized that genotype 2 is truly interferon sensitive while genotype 3 patients are far less successful with therapy. In this fundamentally altered landscape, genotype 3 is now potentially the most difficult to treat genotype and an area of intense research for new drug development. Herein we review the virology, natural history and the treatment of genotype 3 hepatitis C.
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Affiliation(s)
- E B Tapper
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Selic Kurincic T, Lesnicar G, Poljak M, Meglic Volkar J, Rajter M, Prah J, Baklan Z, Kotar T, Maticic M. Impact of added fluvastatin to standard-of-care treatment on sustained virological response in naïve chronic hepatitis C Patients infected with genotypes 1 and 3. Intervirology 2013; 57:23-30. [PMID: 24080608 DOI: 10.1159/000354541] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/16/2013] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The combination of pegylated interferon-α and ribavirin is a standard-of-care (SOC) treatment for chronic hepatitis C (CHC), and it achieves a sustained virological response (SVR) in 41-52% of genotype 1 and in 73-79% of genotype 3 patients. In a few clinical trials, the combination of fluvastatin and SOC increased the SVR in genotype 1 patients. METHODS This prospective study enrolled 179 naïve CHC patients. In the fluvastatin group patients received the combination of SOC and fluvastatin 80 mg daily; historical controls matching the study group in genotype, age and gender were treated with the SOC treatment only. RESULTS On-treatment viral responses as well as the SVR did not differ significantly between the two groups, except for the genotype 1 patients with a high viral load presenting a significantly higher SVR rate in the fluvastatin group (75%) compared to the control group (41%; p = 0.024). Multivariate logistic regression identified hepatitis C virus (HCV) genotype 3 infection (p < 0.001), age ≤40 years (p < 0.001), liver steatosis <5% (p < 0.01) and low viral load (p < 0.001) as independent predictors of an SVR. CONCLUSION A combination of fluvastatin and SOC significantly improved the SVR in naïve CHC patients infected with HCV genotype 1 and high viral load, but it did not improve the SVR in patients infected with HCV genotype 3.
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Affiliation(s)
- Tanja Selic Kurincic
- Department of Infectious Diseases and Febrile Conditions, General Hospital Celje, Celje, Slovenia
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AlMalki WH. HCV infection: an enigma, recent advances and new paradigms for its treatment. Future Virol 2013. [DOI: 10.2217/fvl.13.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
HCV infection is a serious human liver health problem and has infected 200 million people worldwide. Persistent HCV infection can lead to chronic hepatitis C, which is a significant risk of serious hepatic diseases such as hepatic steatosis, hepatic fibrosis and hepatocellular carcinoma. The current standard-of-care options to treat HCV infection are limited, expensive and produce side effects in infected patients that often cause termination of the therapy. Recently, the approval of direct-acting antivirals represents a major breakthrough for the improvement of treatment strategies against chronic HCV infection. Similarly, the development of more effective, safe and well-tolerated interferon therapy is opening a new era in HCV therapeutics. Moreover, a new vaccine technology has been tested in mice for its therapeutic efficacy against the most conserved regions of the HCV genome. This review article will focus on the recent advances in HCV therapeutics and discuss new paradigms to develop the most convenient drugs and treatment strategies.
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Affiliation(s)
- Waleed Hassan AlMalki
- Department of Pharmacology & Toxicology, College of Pharmacy, Umm Al-Qura University, PO Box 13578, Makkah, Saudi Arabia
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Mangia A, Mottola L, Piazzolla V. Update on the treatment of patients with non-genotype 1 hepatitis C virus infection. Clin Infect Dis 2012; 56:1294-300. [PMID: 23271787 DOI: 10.1093/cid/cis1195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Current treatment for patients with non-genotype 1 hepatitis C virus infection consists of pegylated interferon plus ribavirin for 24 weeks, which leads to sustained virologic response (SVR) rates of 65%-80%. In the United States, the ribavirin dose for genotypes 2 and 3 is 800 mg/day. However, the use of weight-based ribavirin allows for the potential to shorten the duration of treatment from 24 to 12-14 weeks without reducing SVR rates in individuals who have undetectable viral loads at treatment week 4 and do not have severe liver disease. For patients who are still viremic at week 4, treatment durations even longer than 24 weeks are advised in Europe. In addition, accumulating evidence shows that for patients with unfavorable baseline characteristics, using weight-based ribavirin may increase SVR. In patients who do not achieve SVR with ribavirin 800 mg/day for 24 weeks, retreatment with weight-based ribavirin should be considered. The impact of new molecules in development will be discussed.
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Affiliation(s)
- Alessandra Mangia
- Liver Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy.
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Villa E, Cammà C, Di Leo A, Karampatou A, Enea M, Gitto S, Bernabucci V, Losi L, De Maria N, Lei B, Ferrari A, Vukotic R, Vignoli P, Rendina M, Francavilla A. Peginterferon-Α_2B plus ribavirin is more effective than peginterferon-Α_2A plus ribavirin in menopausal women with chronic hepatitis C. J Viral Hepat 2012; 19:640-9. [PMID: 22863268 DOI: 10.1111/j.1365-2893.2012.01593.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Under-enrolment of women to randomized clinical trials, including chronic hepatitis C, has long been recognized. The aim of this study was to identify factors predictive of sustained virological response (SVR) to PEG IFN/Ribavirin antiviral therapy in relation to gender and reproductive status of female patients involved. Seven hundred and forty-six treatment-naïve patients (431 men, 315 women) treated with Peg-IFNα-2a (180 μg/week) or Peg-IFNα-2b (1.5 μg/kg/week) plus ribavirin (800-1400 mg/day) for 24 or 48 weeks were studied between 2006 and 2010. Differences in SVR rate, overall and by gender were assessed after adjustment and propensity score matching. SVR was obtained in 44.2% of Peg-IFNα-2a-treated patients and in 51.2% of Peg-IFNα-2b-treated patients (intention-to-treat; P = 0.139). Age, fibrosis stage and genotype 2 and 3 were independently associated with SVR by multivariate analysis. Analysing by gender, the difference in SVR between PEG-IFNα types was not significant in men but highly significant in women (Peg-IFNα-2a:39.1%vs Peg-IFNα-2b:54.4%, P = 0.007). This was attributable to a higher SVR rate with Peg-IFNα-2b in the difficult postmenopausal population (26.9% Peg-IFNα-2a vs 46.0% Peg-IFNα-2b, P = 0.040). In women, absence of menopause, genotype 2 hepatitis C virus infection and use of Peg-IFNα-2b were independently associated with SVR. In conclusion, predictive factors for SVR are different in men and women. Factors differing between genders are menopause, severe steatosis and peg-interferon used. The higher SVR rate with Peg-IFNα-2b in menopausal women is likely attributable to more favourable pharmacokinetics that allows Peg-IFNα-2b to reach visceral fat and oppose the increased cytokine production and enhanced inflammatory status in menopause.
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Affiliation(s)
- E Villa
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria & University of Modena and Reggio Emilia, Modena, Italy.
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Lagging M, Duberg AS, Wejstål R, Weiland O, Lindh M, Aleman S, Josephson F. Treatment of hepatitis C virus infection in adults and children: updated Swedish consensus recommendations. ACTA ACUST UNITED AC 2012; 44:502-21. [PMID: 22506634 DOI: 10.3109/00365548.2012.669045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Swedish recommendations for the treatment of hepatitis C virus (HCV) infection were updated at a recent expert meeting. Therapy for acute HCV infection should be initiated if spontaneous resolution does not occur within 12 weeks. The recommended standard-of-care therapy for chronic HCV genotype 1 infection is an HCV protease inhibitor in combination with peginterferon (peg-IFN) and ribavirin. Treatment is strongly recommended in patients with bridging fibrosis and cirrhosis, whereas in patients with less advanced fibrosis, deferring therapy may be preferential in light of likely therapeutic improvements in the near future. Patients with chronic genotype 2/3 infection should generally be treated with peg-IFN and ribavirin for 24 weeks. In patients with a very rapid viral response (i.e. HCV RNA below 1000 IU/ml on day 7), or favourable baseline characteristics and undetectable HCV RNA week 4, treatment can be shortened to 12-16 weeks, provided that no dose reductions are needed.
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Affiliation(s)
- Martin Lagging
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden.
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Kagawa T, Kojima SI, Shiraishi K, Takashimizu S, Nagata N, Shiozawa H, Nishizaki Y, Ikeda A, Tei Y, Atsukawa K, Kamochi JI, Wasada M, Numata M, Arase Y, Hirose S, Yamada T, Hata Y, Watanabe N, Morizane T, Mine T. Weight-based high- and low-dose ribavirin in combination with peginterferon α-2b therapy for genotype 2 chronic hepatitis C: A randomized trial. Hepatol Res 2012; 42:351-8. [PMID: 22176474 DOI: 10.1111/j.1872-034x.2011.00944.x] [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: 12/14/2022]
Abstract
AIM The optimal ribavirin dose in the treatment of patients infected with hepatitis C virus (HCV) genotype 2 remains to be elucidated. We aimed to seek the optimal ribavirin dose required for this genotype in a randomized trial. METHODS We compared the efficacy and tolerability of the 24-week peginterferon α-2b (1.5 µg/kg/week) therapy in combination with a weight-based higher dose (600-1000 mg) and lower dose (400-800 mg) of ribavirin for genotype 2 patients. Noninferior margin was set at 10%. RESULTS A total of 120 patients were randomized to a higher-dose or a lower-dose group. Sustained virological response (SVR) by intention-to-treat analysis was achieved in 47/58 (81.0%, 90% confidential interval [CI]: 72.6-89.5) patients in the higher-dose group and 41/60 (68.3%, 90% CI: 58.5-78.2) patients in the lower-dose group (difference, -12.7%; 90% CI, -25.7 to 0.3). Relapse rates were 10% and 21.6% in the higher-dose and the lower-dose groups, respectively. Multiple logistic regression analysis showed that ribavirin dose/kg body weight was the only significant predictor of SVR (≥9.5 mg/kg per day vs <9.5 mg/kg per day; odds ratio = 3.34; 95% CI, 1.41-7.92; P = 0.006). Twenty-one (36.2%) in the higher-dose group required ribavirin dose reduction because of anemia, whereas seven patients (11.7%) did in the lower-dose group (P < 0.01). Three of the higher-dose group and two of the lower-dose group required premature termination of therapy. CONCLUSIONS Weight-based lower-dose ribavirin regimen was not equivalent to the higher-dose counterpart in the treatment of HCV genotype 2. We discourage treating these patients with low-dose ribavirin regimens. The peginterferon therapy in combination with ribavirin at a weight-based higher dose (600-1000 mg) remains the standard-of-care treatment for this genotype.
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Affiliation(s)
- Tatehiro Kagawa
- Division of Gastroenterology, Department of Internal Medicine, Tokai University School of Medicine, Isehara Division of Gastroenterology, Department of Internal Medicine, Tokai University Hachioji Hospital, Hachioji Ikegami General Hospital Division of Gastroenterology, Department of Internal Medicine, Tokai University Tokyo Hospital, Tokyo Division of Gastroenterology, Department of Internal Medicine, Tokai University Oiso Hospital, Nakagun Hadano Red Cross Hospital, Hadano Japan Medical Alliance Ebina General Hospital, Ebina Hiratsuka City Hospital, Hiratsuka Tomei-Atsugi Hospital, Atsugi Chigasaki Municipal Hospital, Chigasaki Kanagawa Dental College, Yokosuka, Japan
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Abstract
Over time, HCV therapy with pegylated interferon and ribavirin has evolved from a fixed duration strategy to one of response guided therapy and this has enabled us to optimize treatment duration. With the evolution of protease inhibitor based therapy, the paradigm of response guided therapy has further helped in decreasing treatment duration in greater number of patients and which then translates into shorter duration of adverse events. However, several population groups have done better with extended duration therapy as opposed to response guided therapy despite early viral clearance. These include the Black population, and those with cirrhosis, decreased interferon sensitivity, and unfavorable IL28B genotypes. The proper identification of those who might benefit from extended duration HCV therapy will undoubtedly lead to optimal care and outcomes.
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Affiliation(s)
- K Rajender Reddy
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia 19104, USA.
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Abstract
Genotype 3 is a common type of HCV infection, and standard therapy using pegylated interferon (PEG-IFN) and ribavirin (RBV) is quite effective in these patients. While a short course of 16 weeks may result in comparable end of therapy responses, relapse rates are often high. A 24-week course is therefore preferable, and is expected to result in sustained virological response (SVR) rates of more than 70%. The 24-week course is especially recommended in the presence of steatosis (often associated with Genotype 3 infection), fibrosis stage two or more, high BMI and high viral load. In patients who do not achieve a rapid viral response (RVR) with combination therapy, an extended course up to 48 weeks should be considered. While not as definite as for genotype 1 patients, the presence of the CC variant of IL28b could help in the initial prognosis and the need for additional treatment, if an RVR is not achieved. The role of directly acting antiviral agents (DAA) has not been fully evaluated in treatment naïve, non-responders and relapsers in genotype 3 patients. Initial results with the cyclophilin inhibitor Debio-025 are quite encouraging. There is an urgent need for large clinical trials using DAA and host modulators in patients with G3 infection.
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Affiliation(s)
- Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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Abstract
Genotype 2 (HCV-2) accounts for 8% of the patients with chronic hepatitis C virus in Europe. Because of the favourable response to interferon (IFN)-based treatment, this group is considered an 'easy-to-treat' genotype along with HCV-3. However, experimental and clinical data suggest possible differences between HCV-2 and -3. Recently, subtle differences in treatment efficacy have also been shown in response-guided treatment studies. In these studies, the duration of pegylated interferon (PEG-IFN) and ribavirin (RBV) treatment was tailored according to treatment response. Although SVR rates were similar between HCV-2 and HCV-3 patients after a rapid virological response (RVR), in the absence of RVR, the rates were lower in HCV-3 than in HCV-2. The triple combination treatment, including direct-acting antivirals (DAA) that will be commercialized in the coming months might increase SVR rates in this particular subgroup of patients. According to existing results, telaprevir might be beneficial in HCV-2 but not in HCV-3 patients. A nucleotide analogue polymerase inhibitor, PSI-7977 by Pharmasett has been shown to be active against both. The role of the IL28B polymorphism as a predictor of response to the current standard of care (SoC), PEG-IFN and RBV treatment is the subject of debate, but this mainly seems to be because of the small size of the samples in the studies performed so far. Existing results suggest that the genetic evaluation of IL28B may be useful in patients with HCV-2 for predicting response in patients without RVR.
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Affiliation(s)
- Alessandra Mangia
- Liver Unit, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy.
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Response to peginterferon-alfa 2b and ribavirin in Japanese patients with chronic hepatitis C genotype 2. Dig Dis Sci 2011; 56:3335-42. [PMID: 21604145 DOI: 10.1007/s10620-011-1750-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 05/05/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The current standard treatment for patients infected with hepatitis C virus (HCV) of genotype 2 is the combination of peginterferon (PEG-IFN) plus ribavirin (RBV) for 24 weeks. AIMS We assessed the sustained virological response (SVR) rates in HCV genotype 2-infected Japanese patients in relation to the duration of treatment. METHODS Between 2006 and 2009, among 147 patients with HCV genotype 2-infection in Chiba Prefecture, 138 consecutive patients were finally enrolled. Twenty-one, 97 and 20 patients were treated with PEG-IFN-alfa 2b plus RBV for 16, 24 and 48 weeks, respectively. Epidemiological data and treatment outcomes were retrospectively evaluated. HCV RNA was measured with COBAS AMPLICOR HCV Monitor Test v. 2.0. RESULTS The overall SVR rate was 82.6% (114 of 138): treatment-naïve patients, 86.4% (89 of 103); patients with history of previous treatment, 71.4% (25 of 35). Patients treated for 16, 24 and 48 weeks obtained SVR rates of 66.6% (14 of 21), 86.5% (84 of 97) and 80.0 (16 of 20), respectively. CONCLUSIONS The SVR rates of PEG-IFN-alfa 2b plus RBV in Japanese patients were similar to those in previous studies. Combination treatment for 24 weeks for some patients infected with HCV genotype 2 may be superior to that for 16 weeks. More precise patient selection will be needed to shorten the combination treatment.
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Gambarin-Gelwan M, Jacobson IM. Chronic hepatitis C genotype 2 and 3: are we ready for personalized medicine? J Hepatol 2011; 55:505-506. [PMID: 21601599 DOI: 10.1016/j.jhep.2011.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/03/2011] [Indexed: 12/04/2022]
Affiliation(s)
- Maya Gambarin-Gelwan
- Division of Gastroenterology and Hepatology, Center for the Study of Hepatitis C, Weill Cornell Medical College, NY, USA
| | - Ira M Jacobson
- Division of Gastroenterology and Hepatology, Center for the Study of Hepatitis C, Weill Cornell Medical College, NY, USA.
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EASL Clinical Practice Guidelines: management of hepatitis C virus infection. J Hepatol 2011; 55:245-64. [PMID: 21371579 DOI: 10.1016/j.jhep.2011.02.023] [Citation(s) in RCA: 968] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 01/19/2023]
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Ultra-rapid virological response, young age, low γ-GT/ALT-ratio, and absence of steatosis identify a subgroup of HCV Genotype 3 patients who achieve SVR with IFN-α(2a) monotherapy. Dig Dis Sci 2011; 56:3296-304. [PMID: 21994136 PMCID: PMC3208815 DOI: 10.1007/s10620-011-1933-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 09/21/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The standard treatment regimen for chronic HCV genotype 3 (HCV-G3) hepatitis consists of PEGylated interferon-α (IFN-α) and ribavirin at varying doses ranging from 400 to 1,200 mg and results in response rates of 80%. However, this therapy has substantial side-effects including anemia, is teratogenic, and costly. To reduce the side-effects of therapy, the role of monotherapy consisting of only IFN-α was investigated. METHODS A retrospective analysis of individual therapy courses of HCV-G3-infected patients who were treated with IFN-α(2a) monotherapy or a combination therapy with attention to the treatment outcome and the presence of IL28B rs12979860 and IL28B rs8099917 single-nucleotide polymorphism genotypes was performed. Conventional prognostic features in each case were assessed as well. RESULTS In the study, 15/30 (50%) of patients treated with IFN-α(2a) monotherapy and 32/36 (89%) treated with combination therapy achieved a sustained virological response (SVR). In addition, 7/11 (64%) of those treated initially with monotherapy and subsequently with combination therapy achieved an SVR. An "ultra-rapid" virological response occurring within 2 weeks of initiation of therapy (p = 0.005), young age (<40; p < 0.001) and low initial γ-GT/ALT-ratio (p = 0.03) were associated with a SVR to IFN-α(2a) monotherapy. An SVR in those treated with combination therapy was found to be associated with a rapid virological response (RVR) (p = 0.03). The absence of histologic steatosis was associated with SVR in all patient groups (p = 0.01). Therapy duration (24 vs. 48 weeks) did not affect the SVR in either group. As expected, combination therapy resulted in more hematological side-effects than did monotherapy. CONCLUSIONS An "ultra-rapid" virological response, young age, low initial γ-GT/ALT-ratio and absence of steatosis were each associated with an SVR in those receiving IFN-α(2a) monotherapy. Therefore, monotherapy in these patients should still be discussed independently of the existence of the IL28B polymorphisms.
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