Management of hepatitis C

Challenges of Treating an Acute Hepatitis C Virus Infection With Concurrent Seizure Treatment in a Free Clinic

Currently, there is limited data evaluating the coadministration of first-generation anticonvulsants for epilepsy treatment and direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) infection. There is a potential risk of suboptimal DAA serum concentrations that could potentially lead to HCV treatment failure. In this report, we describe the case of an uninsured, non-Hispanic Black male in his mid-40s with a history of generalized epilepsy that was managed with phenytoin 100mg twice a day and divalproex 500mg extended-release once daily. He was diagnosed with an acute hepatitis C viral infection with a genotype of 1a. Due to the viral genotype, treatment naivety, and lack of cirrhosis, the recommended treatment is to start glecaprevir/pibrentasvir, but the concomitant use of phenytoin and glecaprevir/pibrentasvir is not recommended due to a drug-drug interaction that could lead to subtherapeutic DAA levels and possible treatment failure. Through shared decision-making and close follow-up, we slowly weaned the patient off phenytoin, replaced it with levetiracetam, and started glecaprevir/pibrentasvir. We successfully eradicated the patient’s HCV infection, and no breakthrough seizures were reported. Although an unprecedented case and with the limited data evaluating the coadministration of DAAs and treatment of acute HCV infection, we were able to successfully treat and achieve full remission of the HCV infection. By virtue of this case report, we hope to encourage others to report similar cases and spread awareness regarding the difficulties in management.

Current position of viral load versus hepatitis C core antigen testing

Quantification of hepatitis C virus (HCV) RNA (viral load) is the most widely used marker to diagnose and confirm active HCV infection. The HCV core antigen forms part of the internal structure of the virus and, like HCV RNA, its detection also indicates viral replication and presents certain advantages over viral load testing such as its lower cost, the greater stability of the target, the possibility of working with the same primary tube as that used for HCV serology, and the rapidity of obtaining results, since there is no need to work in batches, unlike the situation with most viral load platforms. Although the core antigen has lower analytical sensitivity than HCV RNA for the detection of low viremia levels, several studies and guidelines have already shown their utility in the identification of patients with active HCV infection. This article summarises current platforms for viral load determination, including point-of-care systems, and also reviews the indications attributed to this marker by the main HCV treatment guidelines. The article also reviews the characteristics of HCV core antigen, the available platforms for its determination, its correlation with viral load determination, and the indications for this marker in the distinct guidelines.

M2 macrophages contribute to cell proliferation and migration of breast cancer

Breast cancer is a kind of malignant tumor that severely threatens women's lives and health worldwide. Tumor-associated macrophages (TAMs) have been reported to mediate tumor progression, while the mechanism still needs further identification. In this study, we found that M2 macrophages promoted increased cell proliferation and migration as well as reduced expression of interferon regulatory factor 7 (IRF7) and increased the expression of miR-1587 in breast cancer cells. Overexpression of IRF7 or miR-1587 knockdown reversed M2 macrophage-induced cell proliferation and migration as well as tumor growth in vivo. Mechanistically, miR-1587 targeted the 3'-untranslated region (3'-UTR) of IRF7 mRNA to regulate its protein expression leading to tumor progression. Collectively, this study revealed that the miR-1587/IRF7 axis mediates M2 macrophage-induced breast cancer progression, and this sheds light on further clinical therapy for breast cancer by targeting TAMs as well as the miR-1587/IRF7 axis.

Activation of type I interferon antiviral response in human neural stem cells

BACKGROUND

Neural stem cells (NSCs) residing in the central nervous system play an important role in neurogenesis. Several viruses can infect these neural progenitors and cause severe neurological diseases. The innate immune responses against the neurotropic viruses in these tissue-specific stem cells remain unclear.

METHODS

Human NSCs were transfected with viral RNA mimics or infected with neurotropic virus for detecting the expression of antiviral interferons (IFNs) and downstream IFN-stimulated antiviral genes.

RESULTS

NSCs are able to produce interferon-β (IFN-β) (type I) and λ1 (type III) after transfection with poly(I:C) and that downstream IFN-stimulated antiviral genes, such as ISG56 and MxA, and the viral RNA sensors RIG-I, MDA5, and TLR3, can be expressed in NSCs under poly(I:C) or IFN-β stimulation. In addition, our results show that the pattern recognition receptors RIG-I and MDA5, as well as the endosomal pathogen recognition receptor TLR3, but not TLR7 and TLR8, are involved in the activation of IFN-β transcription in NSCs. Furthermore, NSCs infected with the neurotropic viruses, Zika and Japanese encephalitis viruses, are able to induce RIG-I-mediated IFN-β expression.

CONCLUSION

Human NSCs have the ability to activate IFN signals against neurotropic viral pathogens.

Sexual transmission of Hepatitis C Virus infection in a heterosexual population: A systematic review

Background: Hepatitis C virus (HCV) infection is an important cause of liver disease worldwide. Identification of risk factors can guide screening and prevention. Sexual transmission in monogamous heterosexual relationships is rare but it is uncertain which sexual behaviours are linked to HCV transmission. This review aimed to determine risk factors for sexual HCV transmission in heterosexuals in low HCV prevalence countries (PROSPERO registration CRD42016051099).

Methods: We searched Medline, Embase, Science Citation Index-Expanded, Social Sciences Citation index, Conference proceedings (Web of Science), CINAHL, Scopus, LILACS, PubMed, and grey literature (04/11/2016).

We included studies published in/after the year 2000 that examined sexual risk factors for HCV infection, other than interspousal transmission, in heterosexual adults (≥18 years). We excluded prisoners, people who inject drugs (PWIDs), people co-infected with HIV or from high prevalence countries. Two reviewers completed study selection, data extraction, risk of bias and quality of evidence assessment (GRADE) independently. Meta-analysis could not be conducted.

Results: Eight studies were included, examining seven factors (multiple sex partners, receiving/providing sex commercially, PWID partner, and unprotected vaginal, oral, anal sex). None were significant, except the evidence for the factor having a PWID partner was conflicting.

Conclusions: We are uncertain about the results due to the very low quality of evidence (GRADE). A more liberal approach to review inclusion criteria might be useful in further identifying factors associated with an increased risk of sexual transmission of HCV infection in a heterosexual population. However, caution should be applied to avoid the impact of confounders on the findings.

Hepatitis C virus load in parenchyma cells correlates with hepatic injury in infected patients

The association between serum hepatitis C virus (HCV) load and hepatic injury in HCV-infected patients has been extensively investigated. The present study aimed to investigate the association between HCV load in hepatic parenchyma cells and hepatic injury in HCV-infected patients. A total of 56 HCV-infected patients were included in the present retrospective study. The serum HCV mRNA was determined using quantitative polymerase chain reaction, while the hepatic parenchyma cell volume and HCV mRNA in hepatic parenchyma cells were also determined. Hepatic injury was evaluated on the basis of the severity of inflammation and fibrosis. The results demonstrated that there were evident differences in the mean serum HCV RNA levels and the HCV load/parenchyma cell volume among the various grades of hepatic inflammation (G1-G4) when groups with the least and most inflammation were compared (G1 vs. G4; P<0.05). Significant differences in the HCV load existed between groups divided according to the fibrosis grade; in addition, differences existed between fibrosis grades S1 and S2, and S2 and S4 when comparing serum HCV RNA levels (P<0.05). Similarly, differences existed between every two fibrosis stages (S0 vs. S4, S2 vs. S3, and S2 vs. S4; P<0.05) when viral loads and parenchyma cell volumes were compared (F=2.860, P<0.05). Furthermore, the fibrosis staging was correlated with the viral load/parenchyma cell volume (F=2.670, P<0.05). In conclusion, hepatic fibrosis grade was found to be associated with HCV load in parenchyma cells. The results of the present study demonstrated that the viral load in parenchyma cells is a more appropriate index compared with the serum viral load for evaluating HCV replication in hepatocytes, and may function as an important factor in HCV-infected hepatic injury evaluation.

Combined Serum Biomarkers in Non-Invasive Diagnosis of Non-Alcoholic Steatohepatitis

BACKGROUND

Non-alcoholic steatoheaptitis (NASH), the critical stage of non-alcoholic fatty liver disease (NAFLD), is of chronic progression and can develop cirrhosis even hepatocellular carcinoma (HCC). However, non-invasive biomarkers for NASH diagnosis remain poorly applied in clinical practice. Our study aims at testing the accuracy of the combination of cytokeratin-18 M30 fragment (CK-18-M30), fibroblast growth factor 21 (FGF-21), interleukin 1 receptor antagonist (IL-1Ra), pigment epithelium-derived factor (PEDF) and osteoprotegerin (OPG) in diagnosing NAFLD and NASH.

METHODS

179 patients with biopsy-proven NAFLD were enrolled as training group, 91 age- and gender-matched healthy subjects were recruited at the same time as controls. 63 other NAFLD patients were separately collected as validation group. 45 alcoholic fatty liver disease (AFLD) patients, 50 hepatitis B virus (HBV) patients, 52 hepatitis C virus (HCV) patients were also included. Serum biomarker levels were measured by enzyme-linked immunosorbent assay.

RESULTS

Serum levels of CK-18-M30, FGF-21, IL-1Ra and PEDF increased, while OPG decreased in a stepwise fashion in controls, non-NASH NAFLD patients and NASH patients (P < 0.01). The area under receiver-operating characteristics curve to diagnose NASH was 0.86 for CK-18-M30, 0.89 for FGF-21, 0.89 for IL-1Ra, 0.89 for PEDF and 0.89 for OPG. CK-18-M30 had 70% negative predictive value (NPV) and 79% positive predictive value (PPV) to diagnose NASH. A 5-step approach measuring CK-18-M30 followed by FGF21, IL-1Ra, PEDF and OPG gradually improved the NPV to 76% and PPV to 85%, which reached 80% and 76% respectively in the validation cohort.

CONCLUSION

Compared to single biomarker, stepwise combination of CK-18-M30, FGF-21, IL-1Ra, PEDF and OPG can further improve the accuracy in diagnosing NASH.

Extensive psoriasis induced by pegylated interferon alfa-2a and ribavirin in the treatment of chronic hepatitis C

A 56-year-old man with chronic hepatitis C was treated with pegylated interferon alfa-2a in combination with ribavirin. However, psoriatic lesions appeared and worsened dramatically during therapy. Because of the extensive skin eruptions, he stopped therapy for chronic hepatitis C and subsequently started narrow-band ultraviolet B phototherapy and topical calcipotriol/betamethasone dipropionate ointment. After this, the psoriasis improved in a slow but comprehensive manner. Our case suggests that physicians should keep in mind the possibility of psoriasis as a side effect of interferon treatment for chronic hepatitis C.

Influence of HLA alleles in response to treatment with pegylated interferon-alpha and ribavirin in patients with chronic hepatitis C

The objective of this study was to analyse the possible role of HLA polymorphism of chronically infected hepatitis C virus patients in the response outcome to treatment with pegylated interferon-alpha plus ribavirin. To that end, 144 Brazilian patients infected only with genotype 1 of the virus were treated with pegylated interferon-alpha at 1.5 μg kg(-1) in conjunction with ribavirin (1000 mg if patient weight was <75 kg and 1250 mg if >75 kg) for 48 weeks. The patients did not have concomitant HBV or HIV infections or liver disease, did not undergo previous antiviral treatment, and were followed up for 24 weeks after the end of treatment to assure they presented a sustained virological response. Patients were classified according to response to treatment in responsive (SVR), nonresponsive (NRS) and relapsers (REL). HLA class I and class II typing were carried out through PCR-SSO using Luminex technology. A statistically higher frequency of DRB1*11 patients was observed in the SVR group (39.6% vs. 14.3%P = 0.0012; Pc = 0.0156; OR = 3.94; 95% CI = 1.8-8.8). HLA-DQB1*03 patients were also more frequent in the SVR group, but the P value lost significance after Bonferroni correction (62.3% vs. 41.7%P = 0.024; Pc = 0.14, OR = 2.3; 95% CI = 1.14-4.60). HLA class II antigens can positively influence the response to treatment with pegylated interferon-alpha and ribavirin.

[A case of pegylated interferon alpha-2a monotherapy in a peritoneal dialysis patient with chronic hepatitis C]

Pegylated interferon (PEG-IFN) is now the standard treatment for chronic hepatitis C. But, there are few reports about patients with end stage renal disease, and treatment protocol for HCV infection has not been determined, particularly in patients on peritoneal dialysis. We experienced a case of a peritoneal dialysis patient with chronic hepatitis C who was successfully treated with PEG-IFN monotherapy. A 50-year old man was undergoing peritoneal dialysis because of diabetic nephropathy. Considering that his HCV genotype was 2, we decided to treat him with PEG-IFN alpha-2a monotherapy 4 month after the beginning of peritoneal dialysis. We adopted a 90 mg of PEG-IFN administration. After the injection of PEG-IFN, dialysate concentration of PEG-IFN did not change significantly. HCV-RNA disappeared at the 4th week and sustatined virus response was achieved thereafter. No side effects were observed during the treatment of 24 weeks. PEG-IFN monotherapy with dose modification may be a safe and effective treatment for HCV infection in patients undergoing peritoneal dialysis.

Optimal control of hepatitis C antiviral treatment programme delivery for prevention amongst a population of injecting drug users

In most developed countries, HCV is primarily transmitted by injecting drug users (IDUs). HCV antiviral treatment is effective, and deemed cost-effective for those with no re-infection risk. However, few active IDUs are currently treated. Previous modelling studies have shown antiviral treatment for active IDUs could reduce HCV prevalence, and there is emerging interest in developing targeted IDU treatment programmes. However, the optimal timing and scale-up of treatment is unknown, given the real-world constraints commonly existing for health programmes. We explore how the optimal programme is affected by a variety of policy objectives, budget constraints, and prevalence settings. We develop a model of HCV transmission and treatment amongst active IDUs, determine the optimal treatment programme strategy over 10 years for two baseline chronic HCV prevalence scenarios (30% and 45%), a range of maximum annual budgets (£50,000-300,000 per 1,000 IDUs), and a variety of objectives: minimising health service costs and health utility losses; minimising prevalence at 10 years; minimising health service costs and health utility losses with a final time prevalence target; minimising health service costs with a final time prevalence target but neglecting health utility losses. The largest programme allowed for a given budget is the programme which minimises both prevalence at 10 years, and HCV health utility loss and heath service costs, with higher budgets resulting in greater cost-effectiveness (measured by cost per QALY gained compared to no treatment). However, if the objective is to achieve a 20% relative prevalence reduction at 10 years, while minimising both health service costs and losses in health utility, the optimal treatment strategy is an immediate expansion of coverage over 5-8 years, and is less cost-effective. By contrast, if the objective is only to minimise costs to the health service while attaining the 20% prevalence reduction, the programme is deferred until the final years of the decade, and is the least cost-effective of the scenarios.

Hepatitis C virus quasispecies in chronically infected children subjected to interferon-ribavirin therapy

Accumulating evidence suggests that certain features of hepatitis C virus (HCV), especially its high genetic variability, might be responsible for the low efficiency of anti-HCV treatment. Here, we present a bioinformatic analysis of HCV-1a populations isolated from 23 children with chronic hepatitis C (CHC) subjected to interferon-ribavirin therapy. The structures of the viral quasispecies were established based on a 132-amino-acid sequence derived from E1/E2 protein, including hypervariable region 1 (HVR1). Two types of HCV populations were identified. The first type, found in non-responders, contained a small number of closely related variants. The second type, characteristic for sustained responders, was composed of a large number of distantly associated equal-rank variants. Comparison of 445 HVR1 sequences showed that a significant number of variants present in non-responding patients are closely related, suggesting that certain, still unidentified properties of the pathogen may be key factors determining the result of CHC treatment.

Is autoimmune hepatitis a frequent finding among HCV patients with intense interface hepatitis?

AIM: To evaluate the overlap of autoimmune hepatitis in hepatitis C virus (HCV)-infected patients with intense interface hepatitis.

METHODS: Among 1759 patients with hepatitis C submitted to liver biopsy, 92 (5.2%) presented intense interface hepatitis. These patients were evaluated regarding the presence of antinuclear antibody (ANA), anti-smooth muscle antibody (SMA) and anti-liver/kidney microsomal antibody (LKM-1), levels of γ-globulin and histological findings related to autoimmune hepatitis (plasma cell infiltrate and presence of rosettes).

RESULTS: Among patients with hepatitis C and intense interface hepatitis there was a low prevalence of autoantibodies (ANA = 12%, SMA = 5%, LKM-1 = 0%) and the median γ-globulin level was within the normal range. Typical histological findings of autoimmune disease were observed in only two cases (2%). After applying the score for diagnosis of autoimmune hepatitis, only one patient was classified with a definitive diagnosis of autoimmune hepatitis. Since overlap with autoimmune hepatitis was not the explanation for the intense necroinflammatory activity in patients with chronic hepatitis C we sought to identify the variables associated with this finding. The presence of intense interface hepatitis was associated with more advanced age, both at the time of infection and at the time of the biopsy, and higher prevalence of blood transfusion and alcohol abuse.

CONCLUSION: Although possible, overlap with autoimmune hepatitis is a very rare association in HCV-infected patients with intense interface hepatitis, an unusual presentation which seems to be related to other host variables.

Peginterferon-alpha-2b plus ribavirin therapy in patients with chronic hepatitis C as assessed by a multi-institutional questionnaire in Japan

BACKGROUND AND AIM

There has so far been no questionnaire report on patients who were treated with peginterferon plus ribavirin (PEG IFN+RBV) therapy. The purpose of this study was to investigate the problems of this therapy by a questionnaire survey.

PATIENTS AND METHODS

A survey of 681 patients with chronic hepatitis C who received treatment with PEG IFN+RBV was conducted in the Kyushu region of Japan. Using an original questionnaire, the survey was conducted prior to the treatment, during the third month of treatment, at the completion of treatment or the discontinuation of treatment, and at 6 months after the completion of treatment.

RESULTS

It was indicated that the patients had a high level of comprehension and understanding of chronic hepatitis C and PEG IFN+RBV treatment. However, the results also indicated that patients had a high level of anxiety. Side effects were adequately dealt with by physicians. However, dermatological symptoms were not adequately explained to the patients, although they were the second most severe side-effect. It was also revealed that side-effects were most distressing during the first and second months after the start of treatment.

CONCLUSION

The questionnaire survey provided new information that has never been reported. It is believed that understanding this information is important for future treatment.

Excellent superiority and specificity of COBAS TaqMan HCV assay in an early viral kinetic change during pegylated interferon alpha-2b plus ribavirin treatment

BACKGROUND

An early virological response (EVR) after the start of interferon (IFN) treatment for chronic hepatitis C leads to a successful virological outcome. To analyze an association between sustained virological response (SVR) and EVR by comparing TaqMan with Amplicor assays in HCV genotype 1-infected patients treated with pegylated (PEG)-IFN alpha-2b plus ribavirin (RBV).

METHODS

We retrospectively analyzed a total of 80 HCV genotype 1 patients (39 SVR and 41 non-SVR patients), who received an enough dosage and a complete 48-week treatment of PEG-IFN alpha-2b plus RBV. Serum HCV RNA levels were measured by both TaqMan and Amplicor assays for each patients at Weeks 2, 4, 8 and 12 after the start of the antiviral treatment.

RESULTS

Of the 80 patients with undetectable HCV RNA by Amplicor, 17 (21.3%) patients were positive for HCV RNA by TaqMan at Weeks 12. The quantification results showed that no significant difference in the decline of HCV RNA level between TaqMan and Amplicor 10-fold method assays within the initial 12 weeks of the treatment was found. However, the qualitative analysis showed significant differences of the positive predictive rates for SVR were found between TaqMan (100% at weeks 4 and 100% at weeks 8) and Amplicor (80.0% and 69.6%, respectively).

CONCLUSIONS

The COBAS TaqMan HCV assay is very useful for monitoring HCV viremia during antiviral treatment to predict a SVR in HCV genotype 1 patients.

Human leukocyte antigen alleles and the response to pegylated interferon/ribavirin therapy in chronic hepatitis C patients

Human leukocyte antigens (HLAs) may play a role in the clinical evolution of hepatitis C virus (HCV) infection. The present study was aimed at elucidating the association between the HLA loci and responses to combination therapy with pegylated interferon-alpha 2a (PEG-IFN) and ribavirin in Taiwanese. We enrolled a total of 208 treatment-naïve Taiwanese chronic hepatitis C (CHC) patients treated with combination therapy. Patients with sustained virological response (SVR) had a significantly higher frequency of genotype non-1b infection, lower pretreatment HCV RNA levels and a higher frequency of mild hepatic fibrosis (fibrosis score: F: 0-2). The HLA A24 and B40 alleles were significantly associated with SVR after adjusted for the other three confounding factors including HCV genotype, hepatic fibrosis and pretreatment serum HCV RNA levels. Haplotypes (B40-DRB1*3, B46- DRB1*9, Cw1- DQB1*3, and Cw1- DRB1*9) were significantly associated with SVR to combination therapy. For 167 patients with genotype 1b infection and viral load < or =5.6 logIU/ml or genotype non-1b infection, the B46 was significantly associated with sustained response with OR (odds ratio) [95% CI (confidence interval) of 0.047 (0.168-0.988)]. Haplotypes B40-DRB1*3, B46- DRB1*9, Cw1- DQB1*3, Cw1- DRB1*9 and DQB1*3- DRB1*9 were found to be associated with SVR to PEG-IFN/ribavirin therapy with OR (95% CI) of 0.179 (0.032-0.989), 0.313 (0.107-0.918), 0.350 (0.145-0.845), 0.282 (0.105-0.759) and 0.412 (0.174-0.978), respectively. We concluded that the virological and the host immunogenetic factors may possibly predict the response to combination therapy in CHC patients.

Oral mucosal conditions in chronic hepatitis C Brazilian patients: a cross-sectional study

OBJECTIVE

Our purpose was to carry out an epidemiological study to assess the prevalence of oral mucosal conditions in Brazilian patients with chronic hepatitis C.

METHODS

A cross-sectional survey was carried out on 215 patients with chronic hepatitis C who were examined for oral mucosal conditions, including oral mucosal lesions and variations of normality.

RESULTS

The prevalence of patients with chronic hepatitis C presenting oral mucosal conditions was 96.3 percent (207 patients). Oral mucosal lesions were present in 147 patients (68.4 percent), whereas variations of normality were observed in 173 patients (80.5 percent). The most common lesions included cheek biting in 42 cases (19.5 percent), candidiasis in 39 cases (18.1 percent), and leukoplakia in 28 cases (13.0 percent). The association of oral lichen planus with hepatitis C virus (HCV) infection proved to be statistically significant (P = 0.002). The most frequent variations of normality included Fordyce's spots in 96 cases (44.7 percent), lingual varicosities in 67 cases (31.2 percent), and fissured tongue in 60 cases (27.9 percent).

CONCLUSION

The prevalence of patients with chronic hepatitis C presenting oral mucosal conditions was 96.3 percent. Despite this high prevalence, only the association between oral lichen planus and hepatitis C showed statistical significance. Considering that HCV infection may be associated with extrahepatic disorders, such as oral manifestations, efforts should be made to clarify the possible relation between oral conditions and HCV infection. This may be helpful in the earlier diagnosis of the infection mainly in asymptomatic patients.

Peginterferon/ribavirin treatment achieves a higher compliance rate than interferon/ribavirin combination in patients chronically infected with HCV on methadone maintenance

INTRODUCTION

Chronic hepatitis C virus infection (HCV) is the most common infectious disease among intravenous drug users.

AIMS

To determine and compare compliance rates between two groups of chronic HCV patients from the methadone substitution program of the National Greek Organization Against Drugs treated with either pegylated interferon alpha-2b/ribavirin or with interferon alpha-2b/ribavirin during 48 weeks of therapy and 24 weeks of follow-up. Furthermore, to evaluate the efficacy of each treatment modality.

METHODS

Forty-five consecutive methadone maintenance (MM) patients (group A, 36 males, nine females) were treated with pegylated interferon alpha-2b (weight-based dosing 1.5 microg/kg/week) and ribavirin 1000-1200 mg/day orally. Sixty-five consecutive MM patients (group B, 52 males, 13 females) were treated with interferon alpha-2b (6 MIU, three times/week) and ribavirin with the doses reported above. During the study, all patients were followed up periodically by hepatologists, internists, and psychiatrists.

RESULTS

Baseline characteristics were similar between the two groups. Thirty-four out of 45 patients (75.6%) from group A and 31 of 65 patients (47.7%) from group B completed therapy (P =0.006). Thirty-two (71.1%) patients from group A and 27 patients (41.5%) from group B were followed-up until the end of week 72 (P = 0.004). At the end of the follow-up, sustained virologic response was achieved in 23 of 45 (51.1%) patients from group A and 21 of 65 patients (32.3%) from group B (P =0.075).

CONCLUSION

Pegylated interferon alpha-2b/ribavirin treatment achieved a significantly higher compliance rate than interferon alpha-2b/ribavirin in MM patients with chronic HCV infection. After 24 weeks of follow-up, response rates were similar for patients who were compliant to treatment for both groups.

5,5'- and 6,6'-dialkyl-5,6-dihydro-1H-pyridin-2-ones as potent inhibitors of HCV NS5B polymerase

The discovery of 5,5'- and 6,6'-dialkyl-5,6-dihydro-1H-pyridin-2-ones as potent inhibitors of the HCV RNA-dependent RNA polymerase (NS5B) is described. Several of these agents also display potent antiviral activity in cell culture experiments (EC50 <0.10 microM). In vitro DMPK data for selected compounds as well as crystal structures of representative inhibitors complexed with the NS5B protein are also disclosed.

Successful interferon desensitization in a patient with chronic hepatitis C infection

Treatment of hepatitis C, even when absolutely necessary, is almost impossible when interferon cannot be administered for any reason. We report a 65-year-old patient with chronic hepatitis C virus (HCV) infection and fibrosis, who was unable to receive interferon because of systemic hypersensitivity. The patient was desensitized successfully through gradual incremental exposure to interferon, and HCV infection was eradicated after a complete course of treatment, with no further allergic reactions. This case report that describes successful eradication of hepatitis C in a patient with advanced liver disease after desensitization to interferon revealed that desensitization may not necessarily damage the therapeutic efficacy of the drug.

Virological and epitope evolution of HCV infection from acute hepatitis C to subsequent episodes of HCV-related acute liver cell necrosis

AIM

To evaluate the virological and clinical events occurring during a 3-year follow-up in three patients who, after symptomatic acute hepatitis C (AHC), experienced subsequent episodes of HC virus (V)-related acute liver cell necrosis.

PATIENTS AND METHODS

The three patients were investigated for viral variability in the core, E1/E2, and NS5b regions during different phases of infection, and a computer-assisted analysis of the variation of known predicted epitopes in the consensus sequence was performed.

RESULTS

The first patient showed numerous genetic variations, which may be related to the maintenance of a chronic HCV infection state and to episodes of liver disease exacerbation. The second patient showed minimal viral variations associated with apparent resolution of the infection, but the same virus isolate, based on phylogenetic analysis, produced a second acute episode after the occult phase. The third patient, after the resolution of AHC, manifested a second episode of HCV infection by a different HCV sub-genotype.

CONCLUSION

Episodes of HCV-related acute liver cell necrosis after AHC may be associated to different virological patterns, such as the establishment of a chronic HCV infection, a reactivation of an occult virus, or a reinfection by a different HCV genotype.

Hepatitis After Intravenous Injection of Sublingual Buprenorphine in Acute Hepatitis C Carriers: Report of Two Cases of Disappearance of Viral Replication After Acute Hepatitis

Objective

To report 2 cases of acute hepatitis related to intravenous administration of buprenorphine in hepatitis C–infected patients.

Case Summary

Two patients, aged 33 and 50 years, respectively, who were hepatitis C virus (HCV) carriers were treated with sublingual buprenorphine 8 mg/day for addiction. Several years after initiation of buprenorphine, they were hospitalized because of clinical hepatitis with jaundice that developed after intravenous injection of buprenorphine. Serum alanine aminotransferase rose to 100 times the upper limit of normal (ULN) in the first patient and to 21 times the ULN in the second. As cofactors, the first patient had consumed alcohol, and the second patient took aspirin 600 mg in addition to the injection of buprenorphine 20 mg 4 days before the onset of jaundice. After stopping the intravenous injections, both patients continued sublingual buprenorphine therapy, with no relapse of hepatitis. Interestingly, in these 2 patients, buprenorphine-induced hepatitis was followed by the disappearance of HCV RNA.

Discussion

Most cases of hepatotoxicity related to buprenorphine have occurred in hepatitis C–infected patients. The main mechanism for buprenorphine-induced hepatitis is a mitochondrial defect, exacerbated by cofactors with additional potential to induce mitochondria dysfunction (eg, HCV, alcohol, concomitant medications). According to the Naranjo probability scale, buprenorphine was found to be the probable cause of acute hepatitis in both patients. In addition, we assessed the relationship between intravenous buprenorphine and acute hepatitis using 2 scales for causality assessment of hepatotoxicity (the Council for International Organizations of Medical Sciences scale and the Maria & Victorino scale). The diagnosis of intravenous buprenorphine-induced hepatitis was classified as probable in both cases. In addition, these 2 cases illustrate that acute hepatitis in a carrier of chronic HCV may occasionally facilitate the clearance of virus.

Conclusions

Although buprenorphine is well tolerated when used at recommended sublingual doses, patients should be informed about the risk of acute hepatitis with misuse of the drug by the intravenous route. These cases illustrate that, in carriers of chronic HCV, acute hepatitis may modify the host's immunotolerance and facilitate clearance of the virus.

Peg-interferon alpha-2a versus Peg-interferon alpha-2b in nonresponders with HCV active chronic hepatitis: a pilot study

BACKGROUND

The efficacy and tolerability of Peg-Interferon alpha-2a (Peg-IFNalpha-2a) versus Peg-Interferon alpha-2b (Peg-IFNalpha-2b) were compared in a patient cohort with hepatitis C virus (HCV)-related active chronic hepatitis, unresponsive to previous antiviral treatment with standard IFN (6 MU three times/week) plus ribavirin (10.6 mg/kg/day) for a period of at least 3 months.

PATIENTS AND METHODS

A total of 143 patients were enrolled and randomized into two treatment groups (A-B). Group A (71 patients) received one vial of Peg-IFNalpha-2a weekly (180 microg) subcutaneously whereas Group B (72 patients) received 1.5 microg/kg of Peg-IFNalpha-2b weekly subcutaneously. Interferon was combined with ribavirin (15 mg/kg/day) in both groups and all patients who demonstrated nondetectable HCV-RNA or a >or=2(log) reduction in viral load at week 12, were treated for 48 weeks, with a 24-week follow up.

RESULTS

Group A (10/71) and Group B (8/72) patients discontinued treatment due to severe side effects. At the end of therapy, HCV-RNA was undetectable in 17/71 (23.9%) Group A and in 19/72 (26.4%) of Group B patients. When terminating follow up, a sustained virological response was observed in 14/71 in Group A (19.7%) and 13/72 in Group B (18.0%).

CONCLUSIONS

Within the limits of the relatively small sample size, Peg-IFNalpha-2a and Peg-IFNalpha-2b demonstrated nonstatistically significant differences in effectiveness in patients nonresponsive to previous antiviral treatment.

A randomized study of extended treatment with peginterferon alpha-2b plus ribavirin based on time to HCV RNA negative-status in patients with genotype 1b chronic hepatitis C

OBJECTIVES

The treatment of patients with hepatitis C virus (HCV) genotype 1 with peginterferon plus ribavirin treatment for more than 48 weeks demonstrated high sustained virological response (SVR) rates. Although many studies extended the duration of therapy from 48 weeks to 72 weeks, the optimal duration has not yet been determined.

METHODS

A total of 113 genotype 1b patients with high viral load were randomized at baseline to the standard (n=56) or extended (n=57) treatment group. The standard group patients received 48 weeks of peginterferon plus ribavirin treatment. In the extended group, the treatment was performed for 44 weeks after patients became negative for HCV RNA (total duration 48-68 weeks).

RESULTS

The SVR rate of the standard and extended group was 36% (20 of 56) and 53% (30 of 57; P=0.07). However, the extended group patients who became negative for HCV RNA between weeks 16 and 24 had a significantly higher SVR rate (78%; 7 of 9) than that of standard group (9%, 1 of 11; P=0.005). The predictive factors for the SVR were the treatment regimen (the standard vs. extended treatment) and the time to HCV RNA negative-status.

CONCLUSIONS

The extended treatment significantly increased the SVR rate in patients who were HCV RNA negative at 16-24 weeks.

A support vector machine approach to assess drug efficacy of interferon-alpha and ribavirin combination therapy

BACKGROUND

Interferon-alpha (IFNalpha) in combination with ribavirin can be used for the treatment of patients with chronic hepatitis C. This therapeutic approach achieves an overall sustained response rate of approximately 40%, but treatment takes 6-12 months and patients often experience significant adverse reactions.

OBJECTIVE

We aim to develop a tool to distinguish potential responders from nonresponders prior to initiation of IFNalpha-ribavirin treatment.

METHODS

Using single nucleotide polymorphisms (SNPs) and viral genotype, we applied the support vector machine (SVM) algorithm to build a tool to predict responsiveness to IFNalpha-ribavirin combination therapy. Furthermore, we utilized the SVM algorithm with the recursive feature elimination method to identify a subset of factors that are significantly more influential than the others.

RESULTS AND CONCLUSION

The SVM model is a promising method for inferring responsiveness to IFNalpha dealing with the complex nonlinear relationship between factors (such as SNPs and viral genotype) and successful therapy. In this study, we demonstrate that our tool may allow patients and doctors to make more informed decisions by analyzing host SNP and viral genotype information.

Early and sustained virological response in non-responders with chronic hepatitis C: a randomized open-label study of pegylated interferon-alpha-2a versus pegylated interferon-alpha-2b

OBJECTIVES

The purpose of this randomized open-label study was to assess the efficacy of treatment with pegylated interferon-alpha-2a versus pegylated interferon-alpha-2b, both plus ribavirin, in inducing early and sustained virological response (EVR and SVR) in chronic hepatitis C non-responders.

PATIENTS AND METHODS

A total of 108 patients with chronic hepatitis C who were non-responders to previous combined therapy (standard interferon-alpha plus ribavirin for > or = 3 months) were enrolled and equally randomized into two groups in this intention-to-treat analysis. The patients exhibited similar baseline features. One group received subcutaneous pegylated interferon-alpha-2a 180 microg once weekly, while the other was treated with subcutaneous pegylated interferon-alpha-2b 1.5 microg/kg once weekly. Ribavirin 15 mg/kg/day was included in both protocols. Treatment duration for EVR was 12 weeks. Patients who demonstrated non-detectable hepatitis C virus (HCV) RNA or a > or = 2 log(10) reduction in viral load at week 12 continued therapy up to 48 weeks, with assessments every 3 months during a follow-up of 24 weeks.

RESULTS

All patients in both groups completed the EVR study, then seven patients receiving pegylated interferon-alpha-2a and seven patients receiving pegylated interferon-alpha2b discontinued treatment as a result of severe adverse effects. After 12 weeks of treatment, viral load reduction was >2 log(10) with both pegylated interferon-alpha-2a (-2.53) and pegylated interferon-alpha-2b (-2.48) with no significant difference. At the end of week 48, HCV RNA was undetectable in 14 of 54 patients (25.9%) receiving pegylated interferon-alpha-2a and in 15 of 54 patients (27.7%) receiving pegylated interferon-alpha-2b. When terminating follow-up, an SVR was observed in 11 of 54 patients (20.4%) who received pegylated interferon-alpha-2a and 10 of 54 patients (18.4%) receiving pegylated interferon-alpha-2b. The incidence and severity of adverse events was similar in both groups.

CONCLUSIONS

Our results seem to show that in chronic hepatitis C patients who are non-responsive to previous therapy, EVR to the two pegylated interferons did not significantly differ with a similar therapeutic efficacy defined as SVR.

Exacerbation of oral lichen planus lesions during treatment of chronic hepatitis C with pegylated interferon and ribavirin

It is estimated that 170-200 million people in the world are chronically infected with the hepatitis C virus. This fact indicates that the prevention and treatment of hepatitis C virus infection are a priority in public health care. To date, the best treatment consists of the combination of pegylated interferon (IFN) and ribavirin. IFN is costly and associated with low tolerance and severe side effects. Ribavirin is also problematic because it causes secondary anemia in most patients. It has been described that oral lichen planus (OLP) can appear or be exacerbated during the treatment of chronic hepatitis C. The improvement of the lesions of OLP after the discontinuation of therapy suggests that IFN may induce or worsen these lesions in some patients. This study examines three cases of exacerbation of OLP during the treatment of chronic hepatitis C with pegylated IFN and ribavirin.

Glial fibrillary acidic protein as an early marker of hepatic stellate cell activation in chronic and posttransplant recurrent hepatitis C

Activated alpha-smooth muscle actin (alpha-SMA)-positive hepatic stellate cells (HSCs) are pericytes responsible for fibrosis in chronic liver injury. The glial fibrillary acidic protein (GFAP), commonly expressed by astrocytes in the central nervous system, is expressed in vivo in the liver in a subpopulation of quiescent stellate cells. In the rat, increased GFAP expression in the acute response to injury and down-regulation in the chronic response have been observed, whereas reports concerning GFAP expression in human liver are still conflicting. We investigated the utility of GFAP compared to alpha-SMA as an immunohistochemical marker of early activated HSCs in chronic and posttransplant recurrent hepatitis C and correlated GFAP expression with vascular remodeling and fibrosis progression. With immunohistochemistry and a semiquantitative scoring system, the expression of GFAP and alpha-SMA in HSCs and the microvessel density were analyzed in biopsies from normal livers obtained from cadaveric donors [donor liver (DL); n = 21] and from livers from posttransplant hepatitis C virus recurrent hepatitis (HCV-PTR) patients (n = 19), hepatitis C virus chronic hepatitis (HCV-CH) patients, (n = 12), and hepatitis C virus cirrhosis (HCV-C) patients (n = 16). The percentage of alpha-SMA-positive HSCs was significantly higher in the HCV-PTR, HCV-CH, and HCV-C groups compared to the DL group (P < 0.01). The percentage of GFAP-positive HSCs was significantly higher in the HCV-PTR group compared to the DL, HCV-C (P < 0.01), and HCV-CH (P < 0.05) groups and in the HCV-CH group compared to the DL group (P < 0.01), inversely correlating with the extent of fibrosis and microvessel density (P < 0.01). In the HCV-PTR group, the percentage of GFAP-positive HSCs correlated with fibrosis progression (P < 0.01). In conclusion, GFAP could represent a useful marker of early activation of HSCs in HCV-CH and seems to predict fibrosis progression in HCV-PTR.

Effect of pegylated interferon treatments for chronic active hepatitis C on quality of life

Health-related quality of life (HRQoL) during therapy was found to be improved in patients treated with peginterferon alpha-2a compared to patients receiving interferon alpha-2a. This study aimed to assess the effect of different pegylated interferon therapies used in the treatment of patients with chronic hepatitis C on HRQoL. Forty chronic hepatitis C patients were enrolled. 22 patients were given a combination of peginterferon alpha-2a plus ribavirin and 18 patients received a combination of peginterferon alpha-2b plus ribavirin for 48 weeks. Patients completed a Short Form-36 (SF-36) questionnaire at the start of treatment and at week 12, week 24 and week 48 of treatment and week 24 posttreatment to evaluate HRQoL. In conclusion, the effect of both combination treatments on quality of life was similar.

Pyrrolo[1,2-b]pyridazin-2-ones as potent inhibitors of HCV NS5B polymerase

Pyrrolo[1,2-b]pyridazin-2-one analogs were discovered as a novel class of inhibitors of genotype 1 HCV NS5B polymerase. Structure-based design led to the discovery of compound 3 k, which displayed potent inhibitory activities in biochemical and replicon assays (IC(50) (1b)<10nM; EC(50) (1b)=12 nM) as well as good stability towards human liver microsomes (HLM t(1/2)>60 min).

Gene-gene and gene-environment interactions in interferon therapy for chronic hepatitis C

INTRODUCTION

In studies of pharmacogenomics, it is essential to address gene-gene and gene-environment interactions to describe complex traits involving pharmacokinetic and pharmacodynamic mechanisms. In this work, our goal is to detect gene-gene and gene-environment interactions resulting from an analysis of chronic hepatitis C patients' clinical factors including SNPs, viral genotype, viral load, age and gender.

MATERIALS & METHODS

We collected blood samples from 523 chronic hepatitis C patients who had received interferon and ribavirin combination therapy. Based on the treatment strategy for chronic hepatitis C patients, we focused our search for candidate genes involved in pathways related to interferon signaling and immunomodulation. To investigate gene-gene and gene-environment interactions, we implemented an artificial neural network-based method for identifying significant interactions between clinical factors with the fivefold crossvalidation method and permutation tests. The artificial neural network model was trained by an algorithm with an adaptive momentum and learning rate.

RESULTS

A total of 20 SNPs were selected from six candidate genes including adenosine deaminase-RNA-specific (ADAR), caspase 5 (CASP5), interferon consensus sequence binding protein 1 (ICSBP1), interferon-induced protein 44 (IFI44), phosphoinositide-3-kinase catalytic gamma polypeptide (PIK3CG), and transporter 2 ATP-binding cassette subfamily B (TAP2) genes. By applying our artificial neural network-based approach, IFI44 was found in the significant two-locus, three-locus and four-locus gene-gene effect models, as well as in the significant two-factor and three-factor gene-environment effect models. Furthermore, viral genotype remained in the best two-factor, three-factor and four-factor gene-environment models. These results support the hypothesis that IFI44 and viral genotype may play a role in the pharmacogenomics of interferon treatment. In addition, our approach identified a panel of ten clinical factors that may be more significant than the others for further study.

CONCLUSION

We demonstrated that our artificial neural network-based approach is a promising method to assess the gene-gene and gene-environment interactions for interferon and ribavirin combination treatment in chronic hepatitis C patients by using clinical factors such as SNPs, viral genotype, viral load, age and gender.

L-carnitine treatment reduces steatosis in patients with chronic hepatitis C treated with alpha-interferon and ribavirin

BACKGROUND

Hepatic steatosis is a common presentation in patients with chronic hepatitis C. Interferon alpha exerts both antiviral and immunomodulating actions, and influences on lipid metabolism. The aim of our study was to test whether L-carnitine reduces steatosis in patients treated with interferon and ribavirin.

PATIENTS AND METHODS

A total of 70 patients were randomly assigned to receive either leucocyte IFN alpha at a dose of 3 MIU thrice a week plus 1,000 mg ribavirin per day for 12 months (group A) or IFN alpha and ribavirin at the same dose plus 2 g carnitine per day (group B).

RESULTS

Comparison of the two treatments showed significant differences between the mean values of the following parameters at the end of the treatment: ALT -68 vs -95 IU/ml (P < 0.05), total cholesterol 0.08 vs -0.91 mmol/l (P < 0.05) and triglycerides +0.25 vs -20 mmol/l (P < 0.05); and at the follow-up: AST -35 vs -65 IU/ml (P < 0.05) and ALT -55 vs -84 IU/ml (P < 0.05). All values were lower in group B (IFN + Ribavirin + Carnitine) than in group A (IFN plus Ribavirin). When comparing those patients treated with IFN + ribavirin with those treated with IFN plus ribavirin plus carnitine, the response at the end of the treatment was 48% vs 56%, and the sustained response 39% vs 46%, respectively.

CONCLUSIONS

Combined treatment with L: -carnitine, ribavirin and IFN alpha resulted in greater antihyperlipidaemic effects and than with ribavirin and IFN alpha alone. The results of this study suggest that L: -carnitine may have a role among the reduction of steatosis strategies in patients with hepatitis C treated with IFN alpha and ribavirin.

Novel HCV NS5B polymerase inhibitors derived from 4-(1',1'-dioxo-1',4'-dihydro-1'lambda(6)-benzo[1',2',4']thiadiazin-3'-yl)-5-hydroxy-2H-pyridazin-3-ones. Part 3: Further optimization of the 2-, 6-, and 7'-substituents and initial pharmacokinetic assessments

5-Hydroxy-3(2H)-pyridazinone derivatives were investigated as inhibitors of genotype 1 HCV NS5B polymerase. Lead optimization led to the discovery of compound 3a, which displayed potent inhibitory activities in biochemical and replicon assays [IC(50) (1b)<10nM; IC(50) (1a)=22 nM; EC(50) (1b)=5nM], good stability toward human liver microsomes (HLM t(1/2)>60 min), and high ratios of liver to plasma concentrations 12h after a single oral administration to rats.

The course of hepatitis C viraemia in transfusion recipients prior to availability of antiviral therapy

Knowing the likely distribution of intervals from hepatitis C infection to first RNA-negativity is important in deciding about therapeutic intervention. Prospectively collected sera and data from the Transfusion-transmitted Viruses Study (1974-1980) provide specific dates of infection and pattern of alanine aminotransferase (ALT) elevations. We examined frequency, timing and correlates of spontaneous resolution for 94 acutely infected transfusion recipients followed for a median of 9.5 months. Later, follow-up sera (>10 years) were available for 27 of the 94 cases from a Veterans Administration (VA) Study (1989-1990). Twenty-five (27%) of the 94 cases were classified as probably resolved during the episode itself. First RNA negativity occurred at 6-50 weeks (median, 19.5 weeks) after infection, and 5-43 weeks (median, 11 weeks) after ALT elevation. Thirteen of the 25 cases remained RNA-negative subsequently; 12 others had 1-6 RNA-positive sera intercalated between first and last RNA-negative results. RNA negativity, therefore, began variably and was interrupted in 12 cases of 25 (48%) by transient RNA-positive sera. Five of these 25 patients who were RNA-negative in the last study specimen had late, Veterans Administration Study follow-up; none showed viraemia. Of the remaining 69 transfusion transmitted virus study recipients, whose last serum was RNA-positive, two cleared viraemia after the last study serum but before late follow-up. Eleven (16%) had 23 intercalated RNA-negative sera before last positivity. RNA status, therefore, needs monitoring for many months before judging the spontaneous outcome as transient negativity may occur. Resolution was significantly more common in women and symptomatic cases; it was not associated with viral load in the infectious donation, HCV genotype, or the recipient's age.

Efficacy and safety of peginterferon-alpha2b and ribavirin combination therapy in children with chronic hepatitis C infection

BACKGROUND

Interferon (IFN)-alpha2b plus ribavirin is approved for treatment of hepatitis C in children; however, little is known about efficacy and tolerability of pegylated IFN (PEG-IFN)-alpha2b in this population. The objective of this study was to test the efficacy and safety of PEG-IFN-alpha2b plus ribavirin in children with chronic hepatitis C.

METHODS

Thirty children 3-16 years of age who had detectable hepatitis C virus (HCV) RNA for >or=3 years after exposure and elevated alanine aminotransferase values received PEG-IFN-alpha2b 1.0 microg/kg/wk plus ribavirin 15 mg/kg/d for 24 weeks (genotype 2/3) or 48 weeks (genotype 1/4). The primary endpoint was sustained virologic response (SVR), defined as undetectable HCV RNA (<50 IU/mL) at week 24 of follow-up.

RESULTS

SVR was achieved in 50% of patients (3/3 genotype 3; 12/27 genotype 1/4). At week 12, 52% of patients were HCV RNA negative and 72% had a >2 log10 decrease in viral load, compared with baseline; 87% and 71% of these patients, respectively, attained an SVR. Therapy was discontinued in 3 patients as a result of adverse events. No patient required ribavirin dose reduction; PEG-IFN-alpha2b dose was reduced in 23% of patients to manage neutropenia.

CONCLUSIONS

Combination therapy with PEG-IFN-alpha2b and ribavirin treatment was effective in children with chronic hepatitis C. Virologic status at week 12 identified future responders and nonresponders. PEG-IFN-alpha2b and ribavirin were reasonably well tolerated, with no unexpected or permanent adverse effects. Further studies are needed to identify the optimum treatment regimen for this patient population.

Virological pattern in plasma, peripheral blood mononuclear cells and liver tissue and clinical outcome in chronic hepatitis B and C virus coinfection

BACKGROUND

We aim to evaluate in chronic hepatitis B virus-hepatitis C virus (HBV-HCV) coinfection the interplay of these viruses in liver tissue, peripheral blood mononuclear cells (PBMC), and plasma and to analyze the effect on disease course and response to treatment.

METHODS

We enrolled 19 patients with chronic HBV-HCV coinfection, 20 with chronic HCV and 20 with chronic HBV infection at their first liver biopsy, all were naive for antiviral therapy. The patients' plasma, PBMC and liver biopsy samples were tested for HBV DNA and/or HCV RNA by real-time PCR, according to the presence/absence of hepatitis B surface antigen and antibodies against HCV in the serum.

RESULTS

Contemporary presence of HBV DNA and HCV RNA was rare in plasma (5.3% of cases) and PBMC (10.6%), but frequent in liver tissue (52.6%). Of 10 cases circulating only HCV RNA and treated with pegylated interferon (PEG-IFN) plus ribavirin for 12 months, two showed a sustained response, and eight cleared HCV RNA but became HBV-DNA-positive in plasma; these eight had detectable HBV DNA in liver at baseline. One patient, who was plasma HBV-DNA-positive/HCV-RNA-negative at baseline, showed a sustained response after 18 months of PEG-IFN treatment; another, who was plasma HBV-DNA/HCV-RNA-positive at baseline, cleared only HCV RNA during 12 months of PEG-IFN plus ribavirin treatment. Seven cases remained untreated.

CONCLUSION

Despite a reciprocal inhibition in plasma, HBV and HCV frequently coexist in liver tissue, a condition to be taken into consideration when deciding therapy.

Haematological support during peg-interferon therapy for HCV-infected haemophiliacs improves virological outcomes

Hepatitis C virus-infected haemophiliacs are traditionally under represented in international treatment studies thus data assessing response to pegylated-interferon (peg-IFN) and ribavirin (RBV) in HCV mono-infected or HCV/HIV co-infected haemophiliacs are few. Since 2001, 37 haemophiliac patients have received peg-IFN and RBV according to centre-based investigator initiated protocols. Primary end points were: early virological response (EVR); end of treatment response (EOTR) and sustained virological response (SVR). An intention-to-treat analysis was used. Secondary end points were adverse events, haemopoietic stem cell growth factor use, therapy discontinuations and dose reductions. Hepatitis C virus mono-infection group (Mono-I) numbered 20 (60% genotype 1). HCV/HIV co-infected group (Co-I) numbered 17 (59% genotype 1/4). Primary end points were: EVR 76%, EOTR 70% and SVR 43%. Comparison of Mono-I to Co-I demonstrated: EVR rates of 70% and 82%, respectively; EOTR rates of 65% and 76%, respectively, and SVR rates of 35% and 53%, respectively. SVR rates genotype 1/4 group - 17% (Mono-I) vs. 30% (Co-I); SVR rates genotype 2/3 group - 63% (Mono-I) vs. 86% (Co-I). Therapy discontinuations: six of 20 (30%) Mono-I vs. three of 17 (18%) Co-I. Dose reductions: two of 20 (10%) Mono-I vs. zero of 17 Co-I. Haematological support factor use: one of 20 (5%) Mono-I vs. four of 17 (23.5%) Co-I. Virological outcomes to peg-IFN and RBV in HCV-infected haemophiliacs are comparable to published data relating to other HCV-infected cohorts. Good virological outcomes can be achieved in HIV co-infected haemophiliacs particularly when growth factors are used to facilitate full dosing of peg-IFN and RBV.

Clinical trial: comparison of weekly once versus twice half-dose weekly administration of pegylated interferon alpha 2b in combination with ribavirin for the treatment of HCV-1 positive patients with chronic hepatitis C

BACKGROUND

Pegylated interferon (PEG-IFN) alpha2b is currently used as a once weekly injection in combination with ribavirin for the treatment of chronic hepatitis C.

AIM

To test whether twice half-dose weekly administration may improve the virological response in difficult-to-treat hepatitis C virus-1 patients.

METHODS

Thirty patients were treated with 1.5 microg/kg of PEG-IFN alpha2b given once weekly for 48 weeks (group A) and were compared with 30 patients treated with the same dose of PEG-IFN alpha2b divided in twice weekly doses of 0.75 microg/kg for the initial 4 weeks (group B). All patients were hepatitis C virus-1 positive and received weight-based ribavirin (800-1400 mg/daily).

RESULTS

Weekly twice half-dose administration of PEG-IFN alpha2b for the first 4 weeks was associated with lower rates of biochemical and virological response at all time points compared with a once weekly schedule, and with significantly higher rates of in-therapy breakthrough leading to significantly lower rates of end of therapy response (week 48). The rate of sustained virological response was of 56.7% in group A and 36.7% in group B.

CONCLUSIONS

Weekly twice half-dose administration of PEG-IFN alpha2b is not superior to the standard once weekly schedule, and might be less efficacious.

Sexual transmission of hepatitis C

It is generally agreed that the hepatitis C virus (HCV) can be efficiently transmitted parenterally, although data on viral transmission by sexual or non-sexual intrafamilial contact are conflicting. Since data collection began in 1989, the first study dealt with the risk of sexual transmission among multiple sex partners. Other investigations followed, emphasizing that risk increases in specific groups such as patients co-infected with HIV and HBV, sex workers, homosexuals, illicit drug users and patients attended at sexually transmittable disease clinics. The question arises as to what might be the risk for monogamous heterosexuals in the general population, in which one of the partners has HCV? The literature provides overall rates that vary from zero to 27%; however, most studies affirm that the chances of sexual transmission are low or almost null, with rates for this mode fluctuating from zero to 3%. Intrafamilial transmission is strongly considered but inconclusive, since when mentioning transmission between sex partners within the same household, specific situations also should be considered, such as the sharing of personal hygiene items, like razorblades, toothbrushes, nail clippers and manicure pliers, which are important risk factors in HCV transmission. In this review, we discuss the hypotheses of sexual and/or intrafamilial transmission.

[Treatment options for chronic hepatitis C virus infection]

INTRODUCTION

The incidence of chronic hepatitis C virus (HCV) infection is rather high. Its most frequent consequences are chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma.

TREATMENT OF CHRONIC HCV INFECTION

In treatment of chronic HCV infection, interferons have antiviral, anriproliferative, and immunoregulatory action. Within the cell, they induce protein synthesis, inhibiting viral replication. The most important among them are RNA dependent protein kinase, and eukaryotic initiation factor. However, viral proteins prevent their phosphorylation and activation. In order to overcome this problem, treatment is prolonged, higher doses of lFN are used, as well as induction therapy. The optimal period for viral response is 52 weeks, while induction therapy has shown controversial results.

Treatment of hepatitis C virus infection

Acute and chronic hepatitis C virus (HCV) infection remains a serious health problem worldwide, however, there has been advancement in the treatment of HCV infection due to standard treatment using pegylated interferon and ribavirin. The literature indicates that therapy for HCV is becoming more individualized. In addition to considering genotype and viral RNA levels before treatment, achievement of an early virologic response (EVR) and a rapid virologic response (RVR) is now possible during therapy. Moreover, problem patients, such as non-responders, relapsers, HIV or HBV co-infected patients, patients with liver cirrhosis, and pre- or post-liver transplantation patients are an increasing fraction of the patients requiring treatment. This article reviews the literature regarding standard treatments and problem patients with acute and chronic HCV infection. It also includes discussion on contraindications and side effects of treatment with interferon and ribavirin, as well as new drug development.