Long-term effect of interferon therapy in chronic hepatitis B

Sequential changes of serum ferritin levels and their clinical significance in lamivudine-treated patients with chronic viral hepatitis B

AIM: To study the sequential changes of serum ferritin levels in lamivudine-treated patients with chronic viral hepatitis B and the clinical implications.

METHODS: Thirty-eight patients with chronic viral hepatitis B were prospectively studied during their treatment with lamivudine. Each patient received 100 mg oral lamivudine daily for 12 mo, and was observed and tested for blood biochemistry and hepatitis B virus (HBV) DNA levels and serum ferritin levels at baseline and at 3, 6 and 12 mo during the treatment. Serum HBV DNA levels were quantitatively determined using fluorescent quantitative polymerase chain reaction (FQ-PCR), and serum ferritin levels were measured by radioimmunoassay. The sequential changes of serum ferritin levels and their relationships with virological, serological and biochemical responses in the patients were analyzed.

RESULTS: All the patients had a baseline HBV DNA level higher than 1 × 10⁷ copies/L as determined by FQ-PCR and positive HBsAg and HBeAg and abnormal ALT levels. At the end of the 12-mo treatment, 19 of the 38(50.00%) patients had undetectable serum HBV DNA levels by FQ-PCR, and 12(31.58%) became negative for serum HBeAg and 10(26.32%) had seroconversion from HBeAg to HBeAb. Nineteen out of the 38(50.00%) patients had biochemically normal ALT levels after 12-mo lamivudine treatment. Sequential determination showed that lamivudine treatment significantly reduced ferritin levels in chronic hepatitis B patients. When the patients were divided into different groups according to their post-treatment virological, serological and biochemical responses for analysis of the sequential changes of ferritin levels, it was found that the decrease of ferritin levels in HBV DNA-negative group was significantly more obvious than that in HBV DNA-positive group at 6 mo during the treatment (P = 0.013). Consecutive comparisons showed that ferritin levels at 3 mo of treatment were obviously decreased as compared with the baseline levels (P < 0.05) in HBeAg-negative group, and the decrease of serum ferritin levels in patients with normalized ALT was more significant than that in patients with abnormal ALT at the end of the 12-mo treatment (P = 0.048).

CONCLUSION: Lamivudine treatment can reduce the serum ferritin levels in chronic viral hepatitis B patients and decreases of ferritin levels can be more significant in patients exhibiting virological, serological and biochemical responses, indicating that dynamic observation of serum ferritin levels in patients with chronic viral hepatitis B during lamivudine treatment might be helpful for monitoring and predicting patients’ responses to the therapy.

Lamivudine does not increase the efficacy of interferon in the treatment of mutant type chronic viral heaptitis B

AIM: To study the role of lamivudine in improving the efficiency of interferon for the treatment of mutant type chronic hepatitis B.

METHODS: Fifteen patients with mutant type chronic hepatitis B were prospectively studied. All patients had liver histology and serology to prove the diagnosis of chronic hepatitis B. Each patient received 4.5 millionunits of interferon alpha-2a thrice weekly and 100 mg of oral lamivudine daily for 24 wk. Patients were observed and tested for blood chemistry every week for the initial 4 wk and every 2 wk thereafter during the treatment until 24 wk. After the end of treatment, patients were followed up at 4-week intervals for an additional 6 mo. Serum HBV DNA levels were tested using the liquid phase molecular hybridization assay. Those with non-detectable HBV DNA were also tested using the real-time polymerase chain reaction. One patient, who did not finish treatment due to depression, was excluded.

RESULTS: At the end of treatment, 7 (50%) patients had serum ALT levels within normal limits; 12 (86%) patients had serum HBV DNA levels < 5 pg/mL using the liquid phase molecular hybridization assay, but only 8 (67%) were < 20 copies/dL using the real-time polymerase chain reaction. Six months after treatment, only two (14%) patients had a sustained complete response to the combination therapy with serum ALT level < 35 iu/L and undetectable serum HBV DNA levels.

CONCLUSION: These pilot data showed that lamivudine did not increase the efficacy of interferon in the treatment of mutant type chronic hepatitis B. The liquid phase molecular hybridization assay was not sensitive enough to detect the low HBV DNA levels during combined interferon and lamivudine therapy.

Introduction of lamivudine for the treatment of chronic hepatitis B: expected clinical and economic outcomes based on 4-year clinical trial data

BACKGROUND

Chronic hepatitis B (CHB) is associated with a significant burden of illness and treatment involves substantial health-care costs. This study estimates clinical outcomes and cost-effectiveness of lamivudine compared with other treatment scenarios for CHB, from an Australian health-care provider perspective.

METHODS

A two-step modeling approach depicted clinical progression of hepatitis B in hypothetical patient cohorts using three different treatment scenarios: scenario A, lamivudine and alpha-interferon (IFN-alpha) available; scenario B, IFN-alpha available only; and scenario C, no treatment available. Assumptions were based on clinical trials, published studies, a hepatologist's questionnaire and an expert panel follow up. One-year clinical outcomes and costs were estimated using a decision tree, while lifetime costs and outcomes were estimated using available clinical trial data for lamivudine (up to 4 years therapy duration) and a Markov model.

RESULTS

The analysis considered only patients with pretreatment elevated alanine aminotransferase levels > or = 2 x upper limit of normal. In the short term, the introduction of lamivudine is expected to result in almost 3.5 times more CHB patients receiving therapy (lamivudine or IFN-alpha) compared to IFN-alpha only (67% compared to 20%, respectively). Hence, scenario A subsequently doubled the seroconversion rate. The incremental cost-effectiveness ratio was $3341 Australian per additional seroconversion. Also, non-seroconverted lamivudine patients are less likely to progress to cirrhosis than those receiving IFN-alpha/no treatment. One-year progression to cirrhosis was estimated at 5.1% with scenario A, compared to 12.2% and 12.7%, scenarios B and C, respectively. From the long-term analysis, lamivudine is expected to increase life expectancy by years and reduce the lifetime risk of compensated cirrhosis, decompensated cirrhosis and hepatocellular carcinoma by 6%, 12% and 12%, respectively. Additionally, the introduction of lamivudine decreases lifetime costs by $548, thus making it a cost-saving and life-extending strategy. In both short- and long-term models, worst case scenarios in sensitivity analyses still associate lamivudine with a favorable cost-effectiveness ratio.

CONCLUSION

Introduction of lamivudine is expected to improve health outcomes in CHB patients, resulting in overall savings in health-care costs. In this model, compared with IFN-alpha only and no treatment, lamivudine allowed more CHB patients to be treated, increased the seroconversion rate, delayed disease progression and prolonged life expectancy.

Cost-effectiveness analysis of lamivudine for the treatment of chronic hepatitis B

OBJECTIVE

To estimate the short term and long term cost effectiveness, from a healthcare perspective, associated with the introduction of lamivudine for chronic hepatitis B.

DESIGN

The analysis used a 2-step modelling approach. A decision tree was used to estimate clinical outcomes and costs after 1 year. The 1-year results were then extrapolated to 70 years using a Markov model.

PATIENTS

The study population comprised hypothetical cohorts of patients with chronic hepatitis B, representative of those likely to receive treatment in clinical practice in Australia.

MAIN OUTCOME MEASURES AND RESULTS

In the short term, more patients sero-converted when lamivudine was available, with an incremental cost-effectiveness ratio of 3341 Australian dollars ($A) per additional seroconversion. In the long term, the introduction of lamivudine increased life expectancy by 3.9 years [3.2 quality-adjusted life-years (QALYs)] compared with when interferon-alpha was the only treatment, or 4.6 years (3.8 QALYs) compared with no treatment. There were reductions in lifetime risk of developing compensated cirrhosis, decompensated cirrhosis and hepatocellular carcinoma of 5, 11 and 11%, respectively, when lamivudine was available. The incremental cost of having lamivudine available, as opposed to interferon-alpha only, was $A633 per year of life saved or $A735 per QALY.

CONCLUSION

The introduction of lamivudine is expected to reduce and delay the progression of chronic hepatitis B, increasing the life expectancy and quality of life of patients for a small overall increase in healthcare costs.

Interferon treatment in hepatitis B surface antigen-positive hepatitis B e antibody-positive chronic hepatitis B: role of hepatitis B core antibody IgM titre in patient selection and treatment monitoring

Chronic hepatitis B infection with the hepatitis B e antigen (HBeAg)-negative variant is associated with a severe clinical course and a low response rate to interferon (IFN). In an attempt to improve the chances of sustained response to interferon we designed a pilot study, using titres of IgM antibodies to hepatitis B core antigen (HBcAb IgM) to guide treatment initiation. Eighteen adults who were HBeAg-negative with biopsy-proven chronic active hepatitis (seven with cirrhosis) entered the study. They were followed-up bimonthly with routine liver function tests, and HBcAb IgM titres were also determined. Treatment (lymphoblastoid IFN 5 million units (MU) m(-2) three times weekly for 6 months) was started when the HBcAb IgM titre was increasing. Fifteen (83.3%) patients had normal alanine aminotransferase (ALT) levels and undetectable HBV DNA at the end of treatment. HBcAb IgM decreased in all responders. We observed a relapse in four patients (three with cirrhosis), in the first year after treatment, with an increase in ALT, HBV DNA and titre of HBcAb IgM. Eleven patients (61.1%) had a sustained response and eight of these 11 patients were followed-up for more than 18 months; two responders cleared hepatitis B surface antigen (HBsAg). Hence, the rate of sustained response to IFN in HBeAb-positive patients with chronic hepatitis is improved if treatment is started when HBcAb IgM levels are increasing.

Decreased nitric oxide production in chronic viral hepatitis B and C

Nitric oxide is a free radical gas molecule which may be implicated in antiviral defense. However, there is no information about its possible role in chronic viral hepatitis B and C. In this study we have analyzed the serum levels of NO2- (as an index of nitric oxide generation) from patients with chronic viral hepatitis B and C and relationship of same with the response to interferon therapy. Serum samples were analysed from 61 patients with chronic hepatitis B, 60 patients with chronic hepatitis C, 11 with chronic liver disease of nonviral origin, and 23 healthy controls. Levels of NO2- were statistically higher in healthy controls (P < 0.001) than in patients with chronic liver disease. No relation was found between NO2- and viremia or response to interferon therapy in patients with chronic hepatitis B. In contrast in chronic hepatitis C, responder patients had significantly higher NO2- than nonresponders (P < 0.01). With respect to the relation between NO2- levels and liver damage, patients with cirrhosis had lower NO2- levels than the rest of the patients (P < 0.001). In conclusion, patients with chronic viral hepatitis have low serum NO2- levels.

Clinical economics review: cost-effectiveness in the therapy of liver disease

There have been many advances made in the management of patients with liver disease both in diagnosis and in the treatment of underlying liver disease and its complications, although comparatively few of these have been rigorously subjected to full cost-effectiveness evaluation. In this review, we have analysed a small number of the therapeutic interventions; while these have been well evaluated clinically, very few have been analysed from the viewpoint of cost-effectiveness and, thus, it is difficult to make many definitive claims. It is hoped that future studies will consider these aspects as well.

Long-term biochemical and virological response to natural interferon-alpha in patients with chronic hepatitis C

To determine the long-term response to interferon-alpha, 134 patients with chronic hepatitis C were followed for more than a year after therapy. Follow-up was stopped for 14 patients and 43 patients received retreatment. The remaining 77 patients were followed for 26-46 months, and 39 of them achieved long-term sustained alanine aminotransferase (ALT) normality. This normality was achieved in 35/38 short-term sustained responders, which was significantly higher (P < 0.001) than in the short-term relapsers (2/38) and the short-term nonresponders (2/44). Hepatitis C virus (HCV) RNA remained negative in 27 (73%) of 37 patients in the long-term sustained ALT normality group. However, only one (1.6%) of 63 long-term responders was negative for HCV RNA. The results of HCV RNA testing for the long-term period agreed with those at three to six months after therapy. Serum ALT levels during the first six months after therapy and HCV RNA testing at three to six months after therapy are important for predicting long-term sustained ALT normality and HCV RNA negativity.

Genetic heterogeneity in the precore region of hepatitis B virus in hepatitis B e antigen-negative chronic hepatitis B patients: spontaneous seroconversion and interferon-induced seroconversion

To elucidate the relationship between the clinical severity of chronic liver disease and the precore mutations in hepatitis B e antigen (HBeAg)-negative hepatitis B virus (HBV) carriers, mutations were investigated in the precore region of HBV DNA in 20 chronic hepatitis B patients who seroconverted either spontaneously or after the administration of alpha-interferon (IFN), and 5 asymptomatic carriers. The precore mutation with a stop codon at nucleotide 1896 was found in all patients, irrespective of the histology and in all asymptomatic carriers. The second mutation at nucleotide 1899 was found in 40% of cases studied but always followed by the first mutation at nucleotide 1896. The mixed viral infection of precore mutant and wild-type HBV virus was found in 40% of seroconverted cases after IFN treatment and in sera of HBV carriers obtained within a year after the spontaneous seroconversion. These data suggest that the precore mutants prevail over wild-type HBV in all HBeAg-negative HBV carriers within several years after the seroconversion, but their prevalence could not confine the clinical severity of chronic liver disease.