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Khalil R, Al-Mahzoum K, Barakat M, Sallam M. An Increase in the Prevalence of Clinically Relevant Resistance-Associated Substitutions in Four Direct-Acting Antiviral Regimens: A Study Using GenBank HCV Sequences. Pathogens 2024; 13:674. [PMID: 39204274 PMCID: PMC11356961 DOI: 10.3390/pathogens13080674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 08/01/2024] [Accepted: 08/08/2024] [Indexed: 09/03/2024] Open
Abstract
Direct-acting antivirals (DAAs) revolutionized the therapeutics of chronic hepatitis C. The emergence and transmission of HCV variants with resistance-associated substitutions (RASs) can undermine HCV treatment. This study aimed to assess the prevalence and temporal trends of RASs in HCV, with a particular focus on clinically relevant RASs (cr-RASs). Near-complete HCV GenBank sequences archived in the Los Alamos HCV Database were analyzed. The study period was divided into two phases: before 2011 and from 2011 onward. Identification of RASs across three DAA classes (NS3, NS5A, and NS5B inhibitors) was based on the 2020 EASL guidelines. The AASLD-IDSA recommendations were used to identify cr-RASs for three HCV genotypes/subtypes (1a, 1b, and 3) and four DAA regimens: ledipasvir/sofosbuvir; elbasvir/grazoprevir; sofosbuvir/velpatasvir; and glecaprevir/pibrentasvir. The final HCV dataset comprised 3443 sequences, and the prevalence of RASs was 50.4%, 60.2%, and 25.3% in NS3, NS5A, and NS5B, respectively. In subtype 1a, resistance to ledipasvir/sofosbuvir was 32.8%, while resistance to elbasvir/grazoprevir was 33.0%. For genotype 3, resistance to sofosbuvir/velpatasvir and glecaprevir/pibrentasvir was 4.2% and 24.9%, respectively. A significant increase in cr-RASs was observed across the two study phases as follows: for ledipasvir/sofosbuvir in subtype 1a, cr-RASs increased from 30.2% to 35.8% (p = 0.019); for elbasvir/grazoprevir in subtype 1a, cr-RASs increased from 30.4% to 36.1% (p = 0.018); In subtype 1b, neither ledipasvir/sofosbuvir nor elbasvir/grazoprevir showed any cr-RASs in the first phase, but both were present at a prevalence of 6.5% in the second phase (p < 0.001); for sofosbuvir/velpatasvir in genotype 3, cr-RASs increased from 0.9% to 5.2% (p = 0.006); and for glecaprevir/pibrentasvir, cr-RASs increased from 12.0% to 29.1% (p < 0.001). The rising prevalence of HCV RASs and cr-RASs was discernible. This highlights the necessity for ongoing surveillance and adaptation of novel therapeutics to manage HCV resistance effectively. Updating the clinical guidelines and treatment regimens is recommended to counteract the evolving HCV resistance to DAAs.
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Affiliation(s)
- Roaa Khalil
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan
| | - Kholoud Al-Mahzoum
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan
| | - Muna Barakat
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman 11931, Jordan
| | - Malik Sallam
- Department of Pathology, Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan
- Department of Clinical Laboratories and Forensic Medicine, Jordan University Hospital, Amman 11942, Jordan
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2
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Dammacco F, Lauletta G, Vacca A. The wide spectrum of cryoglobulinemic vasculitis and an overview of therapeutic advancements. Clin Exp Med 2023; 23:255-272. [PMID: 35348938 PMCID: PMC8960698 DOI: 10.1007/s10238-022-00808-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/14/2022] [Indexed: 11/11/2022]
Abstract
Immunoglobulins that reversibly precipitate at temperatures below 37 °C are called cryoglobulins (CGs). Cryoglobulinemia often manifests as cryoglobulinemic vasculitis (CV), whose symptoms range in severity from purpuric eruptions to life-threatening features. The majority of CV patients are infected with hepatitis C virus (HCV), whereas lymphoproliferative disorders or connective tissue diseases (CTD) are commonly diagnosed among patients with CV of non-infectious origin. In the absence of detectable associated disease, cryoglobulinemia is classified as "essential" (EMC). All HCV-positive CV patients should be given direct-acting antiviral agents (DAAs) that are consistently able to induce a sustained virologic response (SVR). Glucocorticoids (GCs) can mitigate CV-associated vasculitis, but they have no role as maintenance therapy. Cyclophosphamide restrains the hyperactive phase(s) of the disease and the post-apheresis rebound of newly synthesized CGs. Its use has been largely replaced by rituximab (RTX) in patients unresponsive to DAAs, patients progressing to B-cell non-Hodgkin lymphoma (B-NHL) and patients in whom CV persists or reappears after clearance of HCV. Therapeutic apheresis is an emergency treatment for CV patients with hyperviscosity syndrome. HCV-positive CV patients are at an increased risk of developing NHL, but the achievement of SVR can effectively prevent HCV-related NHL or induce the remission of an already established lymphoma, even without chemotherapy. The treatment of patients with IgM or IgG monoclonal cryoglobulins and an underlying immunoproliferative disorder is based on the regimens adopted for patients with the same B-cell malignancies but without circulating CGs. For patients with CTD, GCs plus alkylating agents or RTX are similarly effective as first-line therapy and in the relapse/refractory setting. In patients with EMC, treatment should consist of GCs plus RTX, with the dose of GCs tapered as soon as possible to reduce the risk of infectious complications.
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Affiliation(s)
- Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro” Medical School, Polyclinic, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Gianfranco Lauletta
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro” Medical School, Polyclinic, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro” Medical School, Polyclinic, Piazza Giulio Cesare, 11, 70124 Bari, Italy
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3
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Rademacher L, Fromme M, Strnad P. Cleaning up alpha-1 antitrypsin deficiency related liver disease. Curr Opin Gastroenterol 2023; 39:163-168. [PMID: 37144533 DOI: 10.1097/mog.0000000000000919] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE OF REVIEW Alpha-1 antitrypsin deficiency (AATD) is one of the most common genetic disorders arising due to mutations in alpha-1 antitrypsin (AAT) gene affecting primarily the lung and the liver. This review summarizes the pathophysiology and clinical manifestation of different AATD genotypes and discusses the recent therapeutic developments. The focus is on the severe, rare homozygous Pi∗ZZ and the common heterozygous Pi∗MZ genotype. RECENT FINDINGS Pi∗ZZ individuals harbor an up to 20 times higher risk of liver fibrosis and cirrhosis than noncarriers and liver transplantation is currently the only available therapeutic option. AATD constitutes a proteotoxic disorder arising from hepatic AAT accumulation and the currently most promising data come from a phase 2, open-label trial of fazirsiran, a hepatocyte-targeted siRNA. Pi∗MZ subjects display an increased risk of advanced liver disease and at the latter stage, a faster deterioration than individuals without AAT mutation. SUMMARY Although the fazirsiran data offer a glimpse of hope to AATD patients, a consensus on appropriate study endpoint, a careful patient selection as well as monitoring of long-term safety will be essential for an approval.
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Affiliation(s)
- Laura Rademacher
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Healthcare Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
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4
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Hale AJ, Mathur S, Dejace J, Lidofsky SD. Statewide Assessment of the Hepatitis C Virus Care Cascade for Incarcerated Persons in Vermont. Public Health Rep 2023; 138:265-272. [PMID: 35264027 PMCID: PMC10031835 DOI: 10.1177/00333549221077070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Incarcerated persons in the United States have a high burden of hepatitis C virus (HCV) infection. This study assessed the impact of a statewide effort in Vermont to treat HCV in this group. METHODS We performed a retrospective, observational cohort study of all HCV-infected persons who were imprisoned in Vermont during the 19-month study period (December 2018-June 2020). The cascade of care comprised opt-out HCV screening, full access to direct-acting antiviral treatment (without hepatic fibrosis-based treatment restrictions), HCV specialist involvement, and medication-assisted treatment for patients with opioid use disorder. The primary outcome was sustained virologic response at 12 weeks after treatment completion (SVR12). RESULTS The study included 217 HCV-infected patients; the median age was 35 years (range, 18-73 years), 89% were male, 76% had opioid use disorder, 67% had a psychiatric comorbidity, and 9% had cirrhosis. Of the 217 patients, 98% had a liver fibrosis assessment, 59% started direct-acting antiviral treatment, 55% completed direct-acting antiviral treatment, and 51% achieved documented SVR12. Of the 129 HCV-infected persons who started direct-acting antiviral treatment, 92% completed therapy and 86% achieved documented SVR12. Psychiatric comorbidity was not significantly associated with achieving SVR12 (odds ratio = 0.67; 95% CI, 0.27-1.65; P = .38), nor was receiving medication-assisted treatment for patients with opioid use disorder (odds ratio = 1.45; 95% CI, 0.62-2.56; P = .45). CONCLUSIONS This study reports the highest SVR12 rate achieved in a state incarcerated population to date. HCV treatment in incarcerated populations is a practical and efficacious strategy that should serve a foundational role in HCV elimination.
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Affiliation(s)
- Andrew J. Hale
- University of Vermont Medical Center,
Burlington, VT, USA
- Larner College of Medicine, University
of Vermont, Burlington, VT, USA
| | - Shivani Mathur
- Larner College of Medicine, University
of Vermont, Burlington, VT, USA
| | - Jean Dejace
- University of Vermont Medical Center,
Burlington, VT, USA
- Larner College of Medicine, University
of Vermont, Burlington, VT, USA
| | - Steven D. Lidofsky
- University of Vermont Medical Center,
Burlington, VT, USA
- Larner College of Medicine, University
of Vermont, Burlington, VT, USA
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5
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Poordad F, Felizarta F, Yao BB, Overcash JS, Hassanein T, Agarwal K, Gane E, Shaw D, Waters M, Krishnan P, Topp A, Burroughs M, Nevens F. Durability of sustained virological response to glecaprevir/pibrentasvir and resistance development: A long-term follow-up study. Liver Int 2022; 42:1278-1286. [PMID: 35220658 DOI: 10.1111/liv.15211] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/14/2022] [Accepted: 02/16/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS This study aimed to determine durability of sustained virologic response (SVR) in hepatitis C virus-infected participants treated with glecaprevir- and/or pibrentasvir-containing regimens. METHODS M13-576, a rollover study, evaluated the durability of SVR in a follow-up period of approximately 3 years after hepatitis C virus genotype 1-6-infected participants received a glecaprevir- and/or pibrentasvir-containing regimen in previous phase 2/3 clinical trials. The primary efficacy endpoint was the percentage of participants maintaining SVR and the percentage of participants experiencing relapse or reinfections. Resistance-associated substitutions and safety outcomes related to liver progression were also assessed. RESULTS Of 384 participants enroled, 377 participants were included in the as-observed population and 287 participants completed the study. In prior studies, 99.7% (376/377) of participants achieved SVR12; of those, an observed 99.5% (374/376) and 100% (286/286) completing the study, maintained SVR. After non-responder imputation of missing data, 286/376 participants (76%) maintained SVR. The participant previously not achieving SVR was a treatment-experienced male with compensated cirrhosis who had NS3 and NS5A substitutions at enrolment, which remained detectable for 12 months. Of the two participants not maintaining SVR, one was re-infected and one experienced late relapse at post-treatment week 60. Five participants (all with a fibrosis stage ≥F3) had hepatocellular carcinoma. No events were deemed related to glecaprevir/pibrentasvir. CONCLUSIONS Glecaprevir/pibrentasvir demonstrated long-term durability of efficacy after SVR12 was achieved. Hepatic-related decompensation events were not seen. Owing to low incidence of virologic failure, conclusions were not drawn on persistence of resistance-associated substitutions.
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Affiliation(s)
- Fred Poordad
- The Texas Liver Institute, University of Texas Health, San Antonio, Texas, USA
| | | | | | | | - Tarek Hassanein
- Southern California GI and Liver Centers and Southern California Research Center, Coronado, California, USA
| | - Kosh Agarwal
- Institute of Liver Studies, Kings College Hospital NHS Foundation Trust, London, UK
| | - Edward Gane
- New Zealand Liver Transplant Unit, University of Auckland, Auckland, New Zealand
| | - David Shaw
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | | | | | | | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospital KULeuven, Leuven, Belgium
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6
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Goyal A, Duke ER, Cardozo-Ojeda EF, Schiffer JT. Modeling explains prolonged SARS-CoV-2 nasal shedding relative to lung shedding in remdesivir treated rhesus macaques. iScience 2022; 25:104448. [PMID: 35634576 PMCID: PMC9130309 DOI: 10.1016/j.isci.2022.104448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/19/2022] [Accepted: 05/16/2022] [Indexed: 12/12/2022] Open
Abstract
In clinical trials, remdesivir decreased recovery time in hospitalized patients with SARS- CoV-2 and prevented hospitalization when given early during infection, despite not reducing nasal viral loads. In rhesus macaques, early remdesivir prevented pneumonia and lowered lung viral loads, but viral loads increased in nasal passages after five days. We developed mathematical models to explain these results. Our model raises the hypotheses that: 1) in contrast to nasal passages viral load monotonically decreases in lungs during therapy because of infection-dependent generation of refractory cells, 2) slight reduction in lung viral loads with an imperfect agent may result in a substantial decrease in lung damage, and 3) increases in nasal viral load may occur due to a blunting of peak viral load which decreases the intensity of the innate immune response. We demonstrate that a higher potency drug could lower viral loads in nasal passages and lung.
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Affiliation(s)
- Ashish Goyal
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center
| | - Elizabeth R Duke
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center.,Department of Medicine, University of Washington, Seattle
| | | | - Joshua T Schiffer
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center.,Department of Medicine, University of Washington, Seattle.,Clinical Research Division, Fred Hutchinson Cancer Research Center
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7
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Saleh S, Mohammed A, Davila J, Paranji N, Bolin N. Disparities in Hepatocellular Cancer Screening in Cirrhotic Patients With Psychiatric Disorders. Cureus 2022; 14:e23516. [PMID: 35494904 PMCID: PMC9037762 DOI: 10.7759/cureus.23516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 11/29/2022] Open
Abstract
Background Patients with psychiatric disorders are at an increased risk of developing liver diseases, including hepatocellular carcinoma (HCC). HCC is a leading cause of cancer-related deaths in the United States. The aim of this study was to re-examine the association of psychiatric illness with HCC and assess its impact on screening practices and the outcomes of HCC. Materials and methods We performed a retrospective manual chart review of all patients diagnosed with HCC at a major safety-net hospital in Cleveland, Ohio, from January 2010 to December 2019. Patients were divided into two groups, those with and those without psychiatric illness. The patient characteristics recorded included psychiatric illnesses, etiology of liver disease, radiographic screening intervals, and tumor board recommendations upon initial diagnosis. We analyzed data using Statistical Product and Service Solutions version 26.0 (IBM Corp., Armonk, NY). We analyzed the qualitative and quantitative differences between the groups using the chi-square or Fisher’s exact tests for categorical variables and t-test for continuous variables. Results There were a total of 393 patients with a diagnosis of HCC. Among them, 128 (32.5%) were diagnosed with at least one psychiatric illness. Fewer patients with psychiatric illness (33.6%) underwent screening within six months before being diagnosed with HCC compared to those without psychiatric illness (49.8%) (p = 0.002). Patients with psychiatric illness (71.1%) were more likely to have been seen by a gastroenterologist or hepatologist before their diagnosis of HCC compared to those without psychiatric illness (55.1%) (p =0.002). Patients with psychiatric illness were more likely to be offered systemic chemotherapy or hospice (39.1%) compared to those without psychiatric illness (29.1%) (p =0.039). Discussion A significant number of HCC patients in our study group have an underlying psychiatric illness. Patients with psychiatric disorders are prone to high-risk behaviors, likely predisposing them to chronic liver disease and HCC. Patients with psychiatric disorders are less compliant with screening practices. Our findings suggest that psychiatric illnesses tend to be diagnosed with more extensive HCC, which is less amenable to curative treatment. Significant efforts need to be made to identify barriers to HCC screening in cirrhotic patients with psychiatric disorders.
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8
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Duke ER, Williamson BD, Borate B, Golob JL, Wychera C, Stevens-Ayers T, Huang ML, Cossrow N, Wan H, Mast TC, Marks MA, Flowers ME, Jerome KR, Corey L, Gilbert PB, Schiffer JT, Boeckh M. CMV viral load kinetics as surrogate endpoints after allogeneic transplantation. J Clin Invest 2021; 131:133960. [PMID: 32970635 DOI: 10.1172/jci133960] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 09/17/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUNDViral load (VL) surrogate endpoints transformed development of HIV and hepatitis C therapeutics. Surrogate endpoints for CMV-related morbidity and mortality could advance development of antiviral treatments. Although observational data support using CMV VL as a trial endpoint, randomized controlled trials (RCTs) demonstrating direct associations between virological markers and clinical endpoints are lacking.METHODSWe performed CMV DNA PCR on frozen serum samples from the only placebo-controlled RCT of ganciclovir for early treatment of CMV after hematopoietic cell transplantation (HCT). We used established criteria to assess VL kinetics as surrogates for CMV disease or death by weeks 8, 24, and 48 after randomization and quantified antiviral effects captured by each marker. We used ensemble-based machine learning to assess the predictive ability of VL kinetics and performed this analysis on a ganciclovir prophylaxis RCT for validation.RESULTSVL suppression with ganciclovir reduced cumulative incidence of CMV disease and death for 20 years after HCT. Mean VL, peak VL, and change in VL during the first 5 weeks of treatment fulfilled the Prentice definition for surrogacy, capturing more than 95% of ganciclovir's effect, and yielded highly sensitive and specific predictions by week 48. In the prophylaxis trial, the viral shedding rate satisfied the Prentice definition for CMV disease by week 24.CONCLUSIONSOur results support using CMV VL kinetics as surrogates for CMV disease, provide a framework for developing CMV preventative and therapeutic agents, and support reductions in VL as the mechanism through which antivirals reduce CMV disease.FUNDINGMerck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
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Affiliation(s)
- Elizabeth R Duke
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | | | - Bhavesh Borate
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Jonathan L Golob
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | - Chiara Wychera
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | | | | | - Hong Wan
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | | | - Mary E Flowers
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | - Keith R Jerome
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | - Lawrence Corey
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | - Peter B Gilbert
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | - Joshua T Schiffer
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | - Michael Boeckh
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
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9
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Hepatitis C-Positive Donors in Cardiac Transplantation: Problems and Opportunities. Curr Heart Fail Rep 2021; 17:106-115. [PMID: 32474734 DOI: 10.1007/s11897-020-00466-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW With the growing need for donor hearts and longer transplant waiting lists, there is a growing interest in expanding the donor pool by reconsidering previously excluded donor candidates. There has been an increase in solid organ availability due to drug overdose deaths in the setting of the recent opioid epidemic. However, these donors often have transmissible infections such as hepatitis C. In this review, we discuss the challenges associated with heart transplantation from hepatitis C-infected donors as well as the recent advancements that are making the use of these organs possible. RECENT FINDINGS With the introduction and widespread use of nucleic acid testing (NAT), the ability to distinguish viremic donors and those that have cleared the virus has become a reality. In addition, with the emergence of direct antiviral agents, there is an increase in data showing the short-term outcomes and success of hepatitis C treatment for recipients of viremic donor hearts. As techniques to distinguish donor hepatitis C infection status and successful treatments emerge, the percentage of accepted hepatitis C donor hearts is increasing. A number of studies showing success with hepatitis C organ transplants present a promising new avenue for organ procurement essential to meet the increasing demand for donor hearts.
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10
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Direct antivirals and cognitive impairment in hepatitis C: a clinical-neurophysiologic study. J Neurovirol 2020; 26:870-879. [PMID: 32910431 PMCID: PMC7716927 DOI: 10.1007/s13365-020-00904-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/05/2020] [Accepted: 08/26/2020] [Indexed: 12/26/2022]
Abstract
Cognition was assessed in hepatitis C virus (HCV) patients, who did not meet the criteria for a minimal hepatic encephalopathy. Their liver function was compensated. We then disentangled potential cognitive changes associated with a sustained virologic response at 12 weeks (SVR-12), following treatment with direct antiviral agents (DAAs). We studied 23 selected HCV patients with a battery of standard neuropsychological tests, and with recordings of the P300 wave, a cerebral potential of “cognitive” significance. There was a baseline evaluation (T0) and a second one 6 months later (T1). We had 2 control groups of comparable age and sex, i.e., 15 patients suffering from non-alcoholic fatty liver disease (NAFLD) and 15 healthy subjects. At T0, we detected a significant (p < 0.05) cognitive impairment in the HCV group, which involved episodic and working memory, attention, visuospatial and verbal abilities, executive functions, and logic reasoning. The P300 latency was significantly (p < 0.05) delayed in the group. At T1, we observed some significant (p < 0.05) HCV recovery in given test domains, e.g., memory, executive functions, and reasoning. Accordingly, the P300 latency shortened significantly (p < 0.05). HCV patients exhibited subtle cognitive defects, somehow independent of their liver condition, possibly linked to direct or indirect brain involvement by the virus. These defects partly recovered following the SVR-12, as achieved through DAAs. The P300 wave was a valid neurophysiologic counterpart of these changes. DAAs can have a role in the early preservation of cognition in HCVs.
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11
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Schiffer JT, Johnston C, Wald A, Corey L. An Early Test-and-Treat Strategy for Severe Acute Respiratory Syndrome Coronavirus 2. Open Forum Infect Dis 2020; 7:ofaa232. [PMID: 32661497 PMCID: PMC7313828 DOI: 10.1093/ofid/ofaa232] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/08/2020] [Indexed: 01/08/2023] Open
Abstract
As coronavirus disease 2019 cases and deaths continue to expand globally, there is an urgent need to develop, test, and approve effective antiviral therapies. Currently, a majority of clinical trials are evaluating therapies in patients who are already hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection. Given that the median time between development of symptoms and need for hospitalization is 1 week, a golden opportunity to intervene early is being missed. Indeed, for many other viral infections, early treatment soon after development of symptoms is associated with decreased mortality, lower hospitalization rates, and lower likelihood of transmission to others. In this study, we advocate for randomized, double-blind, placebo controlled, clinical trials to evaluate promising agents early during SARS CoV-2 infection.
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Affiliation(s)
- Joshua T Schiffer
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Christine Johnston
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Anna Wald
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Lawrence Corey
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
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12
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Ali S, Ali M, Paudyal V, Rasheed F, Ullah S, Haque S, Ur-Rehman T. A Randomized Controlled Trial to Assess the Impact of Clinical Pharmacy Interventions on Treatment Outcomes, Health Related Quality of Life and Medication Adherence Among Hepatitis C Patients. Patient Prefer Adherence 2019; 13:2089-2100. [PMID: 31997877 PMCID: PMC6917610 DOI: 10.2147/ppa.s224937] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/30/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The role of specialized pharmacy services remains unexplored in clinical practice for hepatitis C patients in Pakistan. This study aimed to evaluate the impact of clinical pharmacy interventions on treatment outcomes, health-related quality of life (HRQoL), and medication adherence among hepatitis C patients. METHODS A randomized control trial was conducted at two tertiary-care teaching hospitals in Pakistan. Hepatitis C patients who attended the outpatient clinics between October 2015 and September 2018 were randomized to two groups [usual care (UC) and pharmaceutical care (PC)] in a 1:1 ratio, applying simple envelope method. The PC group received pharmaceutical care led by a clinical pharmacist. The care that patients received included education and counseling on medication compliance, labeling of medication packs, and monitoring of adverse drug events, led by a qualified clinical pharmacist during the 15- to 20-minute monthly sessions, while the UC group received standard care at hospital, which did not involve clinical pharmacist input. Outcome measures, such as sustained virological response, HRQoL, and adherence rate (pharmacy data) were assessed at enrolment and distinct time intervals: 4 weeks, 8 weeks, and end of treatment. RESULTS A total of 931 patients were included in the study (UC 466 and PC 465), with mean age 42.35±1.9 years. Sustained virological response at 12 weeks was achieved in 86.0% patients in the PC group, significantly (p<0.001) higher than the UC (69.3%) group. Fewer patients (9.9%) in the PC group reported mobility problems, significantly fewer (p<0.001) than the UC group (11.8%). Self-care, usual activity, pain, and depression were relieved significantly in the PC group compared to the UC group. The EuroQol visual analogue scale (baseline 56.1 of UC group versus 55.2 for PC group) was raised to 71.8 and 71.9 in the UC and PC groups, respectively. Medication adherence was significantly improved (p<0.001) in the PC group (88.6%) when compared to the UC group (77.9%, 95% CI 88.9%-91.9%). CONCLUSION Pharmacist-led clinical pharmacy interventions as part of multidisciplinary care had a significant impact on improving cure rates, HRQoL, and medication adherence for hepatitis C patients. This study suggests that clinical pharmacists should be incorporated into the multidisciplinary health-care team for care of hepatitis C patients.
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Affiliation(s)
- Salamat Ali
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
- Services Institute of Medical Sciences, Lahore, Pakistan
| | - Mashhood Ali
- Department of Gastroenterology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | - Vibhu Paudyal
- School of Pharmacy, University of Birmingham, Birmingham, UK
| | - Faisal Rasheed
- Pakistan Institute of Nuclear Sciences and Technology, Islamabad, Pakistan
| | - Shahan Ullah
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Sayeed Haque
- Institute of Applied Health Research Medical Statistics, University of Birmingham, Birmingham, UK
| | - Tofeeq Ur-Rehman
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
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Domínguez-Domínguez L, Lagarde M, Bisbal O, Matarranz M, Rubio R, Pulido F. Sustained virological response at week 12 after interferon-free therapy as criterion for HCV cure definition: Validation in a real-life cohort of HIV-coinfected patients. Enferm Infecc Microbiol Clin 2019; 38:275-278. [PMID: 31668860 DOI: 10.1016/j.eimc.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 07/07/2019] [Accepted: 07/25/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Sustained virological response (SVR) 12 weeks after the end-of-therapy (EOT) has been correlated with SVR24 for HCV-monoinfection. We aim to validate SVR12 as criterion for definition of HCV cure in HIV-coinfected patients treated with all-oral direct-acting antivirals (DAA). METHODS Prospectively observational study including HIV/HCV-coinfected subjects who received DAA and had HCV-RNA measures at weeks 12 and 24 after EOT. Every patient who took ≥1 drug dose was analyzed. RESULTS DAA were prescribed to 423 patients, of whom 387 had HCV-RNA measures both at weeks 12 and 24 after EOT. SVR12 was confirmed in 379/387 patients, while SVR24 was confirmed in 377/387 subjects. The positive-predictive-value (PPV) of SVR12 for SVR24 was 99.5% (95%CI: 98.1-99.9). One of the recurrences was clinically suspected to be a late relapse. CONCLUSIONS SVR12 has a high PPV for HCV cure in HIV/HCV-coinfection, though further follow-up could be necessary for those with deeper immunosuppression.
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Affiliation(s)
- Lourdes Domínguez-Domínguez
- HIV Unit, Internal Medicine Department, Biomedical Research Institute Imas12, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - María Lagarde
- HIV Unit, Internal Medicine Department, Biomedical Research Institute Imas12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Otilia Bisbal
- HIV Unit, Internal Medicine Department, Biomedical Research Institute Imas12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Mariano Matarranz
- HIV Unit, Internal Medicine Department, Biomedical Research Institute Imas12, Hospital Universitario 12 de Octubre, Madrid, Spain; Servicio de Medicina Interna, Hospital Infanta Leonor, Madrid, Spain
| | - Rafael Rubio
- HIV Unit, Internal Medicine Department, Biomedical Research Institute Imas12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Federico Pulido
- HIV Unit, Internal Medicine Department, Biomedical Research Institute Imas12, Hospital Universitario 12 de Octubre, Madrid, Spain
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14
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Bach TA, Zaiken K. Outcomes of treatment with direct-acting antivirals for infection with hepatitis C virus genotypes 1-4 in an ambulatory care setting. Am J Health Syst Pharm 2019; 74:S1-S9. [PMID: 28213381 DOI: 10.2146/ajhp160567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Outcomes with direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) genotypes 1-4 were determined. METHODS A total of 360 patients at 36 clinical sites in Massachusetts with HCV genotypes 1-4 and a prescription for at least one DAA medication between May 2011 and October 2015 were included. The primary investigator completed a retrospective and concurrent chart review, and data were collected through April 2016. RESULTS A total of 446 patients were assessed for eligibility into the study, with 86 patients excluded. The majority of patients were white males with genotype 1 infection. About half of the patients were treatment naive (TN), and 40% of patients had documented cirrhosis. TN patients without cirrhosis had the highest overall sustained virologic response (SVR) rate at 107 of 109 (98.2%), followed by treatment-experienced (TE) patients without cirrhosis at 59 of 63 (93.7%), TN patients with cirrhosis at 40 of 46 (87.0%), and TE patients with cirrhosis at 64 of 79 (81.0%) when boceprevir- and telaprevir-containing regimens were excluded. A total of 7 of 360 (1.9%) patients reported missing at least one dose of medication. Adverse drug reactions reported in the electronic medical record (EMR) were collected for analysis and included patients who received at least one dose of medication and had adequate EMR documentation. CONCLUSION In patients treated with DAAs for infection with HCV genotypes 1-4, variables favoring achievement of SVR included an age of <45 years, a body mass index of <25 kg/m2, absence of cirrhosis, a fibrosis score of 0-2, and being TN.
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15
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Scott N, Stoové M, Wilson DP, Keiser O, El-Hayek C, Doyle J, Hellard M. Eliminating hepatitis C virus as a public health threat among HIV-positive men who have sex with men: a multi-modelling approach to understand differences in sexual risk behaviour. J Int AIDS Soc 2019; 21. [PMID: 29314670 PMCID: PMC5810343 DOI: 10.1002/jia2.25059] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/18/2017] [Indexed: 12/12/2022] Open
Abstract
Introduction Outbreaks of hepatitis C virus (HCV) infections among HIV‐positive men who have sex with men (MSM) have been observed globally. Using a multi‐modelling approach we estimate the time and number of direct‐acting antiviral treatment courses required to achieve an 80% reduction in HCV prevalence among HIV‐positive MSM in the state of Victoria, Australia. Methods Three models of HCV transmission, testing and treatment among MSM were compared: a dynamic compartmental model; an agent‐based model (ABM) parametrized to local surveillance and behavioural data (“ABM1”); and an ABM with a more heterogeneous population (“ABM2”) to determine the influence of extreme variations in sexual risk behaviour. Results Among approximately 5000 diagnosed HIV‐positive MSM in Victoria, 10% are co‐infected with HCV. ABM1 estimated that an 80% reduction in HCV prevalence could be achieved in 122 (inter‐quartile range (IQR) 112 to 133) weeks with 523 (IQR 479 to 553) treatments if the average time from HCV diagnosis to treatment was six months. This was reduced to 77 (IQR 69 to 81) weeks if the average time between HCV diagnosis and treatment commencement was decreased to 16 weeks. Estimates were consistent across modelling approaches; however ABM2 produced fewer incident HCV cases, suggesting that treatment‐as‐prevention may be more effective in behaviourally heterogeneous populations. Conclusions Major reductions in HCV prevalence can be achieved among HIV‐positive MSM within two years through routine HCV monitoring and prompt treatment as a part of HIV care. Compartmental models constructed with limited behavioural data are likely to produce conservative estimates compared to models of the same setting with more complex parametrizations.
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Affiliation(s)
- Nick Scott
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Vic., Australia
| | - Mark Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Vic., Australia
| | - David P Wilson
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Carol El-Hayek
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia
| | - Joseph Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Vic., Australia
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Vic., Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Vic., Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Vic., Australia
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Wei L, Huang YH. Long-term outcomes in patients with chronic hepatitis C in the current era of direct-acting antiviral agents. Expert Rev Anti Infect Ther 2019; 17:311-325. [PMID: 30856022 DOI: 10.1080/14787210.2019.1588112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Within the past decade, antiviral treatment for chronic hepatitis C virus (HCV) infection has evolved from interferon (IFN)-based regimens to IFN-free oral direct-acting antiviral agents (DAAs). However, data on long-term outcomes in HCV patients treated by DAAs are limited and complex. Areas covered: Original studies and meta-analyses reporting data on the impacts of IFN - and DAA-based treatments on late relapse, liver fibrosis/cirrhosis, decompensation progression, hepatocellular carcinoma (HCC) occurrence and recurrence, need for liver transplantation, mortality, and other topics of interest for long-term observation of HCV patients treated with DAAs. Articles published up to June 2018, and proceedings from annual meetings of major international liver diseases associations (from 2015 to June 2018) were reviewed. Relevant references from selected papers were also reviewed. Expert opinion: In HCV patients treated with DAAs or IFN-based regimens, late relapse beyond 12 weeks after completion of treatment is uncommon. Results from long-term follow-up studies suggest responders to antiviral treatment achieve benefits on regression of fibrosis/cirrhosis, decreasing risk of progression to liver decompensation, reductions in the need for liver transplantation and mortality. Well-designed studies with robust comparisons are needed to determine the effect of DAAs on the recurrence of HCC in the future.
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Affiliation(s)
- Lai Wei
- a Center for Hepatology Pancrease Disease, Beijing Tsinghua Changgung Hospital , Tsinghua University , Beijing.,b Peking University Hepatology Institute, Beijing Key Laboratory for Hepatitis C and Immunotherapy for Liver Disease , Peking University People's Hospital , Beijing
| | - Yi-Hsiang Huang
- c Division of Gastroenterology and Hepatology , Taipei Veterans General Hospital , Taipei
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Domínguez-Domínguez L, Bisbal O, Matarranz M, Lagarde M, Pinar Ó, Hernando A, Lumbreras C, Rubio R, Pulido F. Predictive factors of hepatitis C virus eradication after interferon-free therapy in HIV coinfection. Eur J Clin Microbiol Infect Dis 2019; 38:725-734. [DOI: 10.1007/s10096-019-03488-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 01/13/2019] [Indexed: 12/14/2022]
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18
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Pecoraro V, Banzi R, Cariani E, Chester J, Villa E, D'Amico R, Bertele' V, Trenti T. New Direct-Acting Antivirals for the Treatment of Patients With Hepatitis C Virus Infection: A Systematic Review of Randomized Controlled Trials. J Clin Exp Hepatol 2019; 9:522-538. [PMID: 31516269 PMCID: PMC6728536 DOI: 10.1016/j.jceh.2018.07.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/07/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND New direct-acting antiviral agents (DAAs) approved for the treatment of patients infected by Hepatitis C virus (HCV) are well tolerated and increase sustained virological response (SVR) rate. We summarize current evidence on the efficacy and safety from comparative randomized controlled trials (RCTs) of DAAs. METHODS We systematically searched MEDLINE, Embase, Scopus, CENTRAL, and Lilacs as well as a list of reference literature. We included RCTs comparing DAAs with placebo or active control and reporting response rates and adverse events according to antiviral regimens. Risk ratios (RRs) were pooled as appropriate. We assessed the risk of bias of included studies and graded the quality of evidence according to the GRADE method. RESULTS We included 28 RCTs, enrolling more than 7000 patients. The quality of evidence was generally low. Twelve-week treatment with DAAs in naïve patients significantly increased SVR12 and SVR24 compared with placebo (RR 1.4, 95% CI 1.3-1.6; RR 1.5, 95% CI 1.4-1.6, respectively). This means that for every 1000 patients, 240 or 260 more patients experienced SVR12 or SVR24 if treated with any DAAs. We could not find RCTs assessing progression of liver disease or development of hepatocellular carcinoma. DAAs were not associated with higher incidence of serious adverse events or discontinuation due to adverse events. CONCLUSIONS This systematic review confirms that new DAAs are more effective in inducing SVR than placebo. Outside clinical trials, in real word, HCV cure with DAA regimens occurs in less than 90% of patients, so further comparative evaluations are needed to establish their long-term effects.
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Key Words
- AE, adverse event
- CI, confidence interval
- DAA, direct-acting antiviral agent
- HCC, hepatocellular carcinoma
- HCV, Hepatitis C virus
- NNPIs, nonnucleoside polymerase inhibitors
- NPIs, nucleoside polymerase inhibitors
- PEG-IFN, pegylated interferon
- PrIs, protease inhibitors
- RAVs, resistance-associated variants
- RBV, Ribavirin
- RCT, randomized controlled trial
- RR, risk ratio
- SAEs, serious adverse events
- SE, standard error
- SVR, sustained virological response
- hepatitis C
- liver
- meta-analysis
- outcome research
- systematic review
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Affiliation(s)
- Valentina Pecoraro
- Unit of Laboratory Medicine, Ospedale Civile Sant'Agostino Estense, Modena, Italy,Center for Drug Regulatory Policies, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy,Address for correspondence. Pecoraro Valentina, Unit of Laboratory Medicine, Ospedale Civile Sant'Agostino Estense, Modena, Italy.
| | - Rita Banzi
- Center for Drug Regulatory Policies, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Elisabetta Cariani
- Unit of Laboratory Medicine, Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Johanna Chester
- Department of Surgery, Medical, Dentistry and Morphological Sciences, University of Modena e Reggio Emilia, Italy
| | - Erica Villa
- Department of Gastroenterology – AOU Modena, Modena, Italy
| | - Roberto D'Amico
- Cochrane Italy – University of Modena and Reggio Emilia, Italy
| | - Vittorio Bertele'
- Center for Drug Regulatory Policies, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Tommaso Trenti
- Unit of Laboratory Medicine, Ospedale Civile Sant'Agostino Estense, Modena, Italy
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Scott N, Sacks-Davis R, Pedrana A, Doyle J, Thompson A, Hellard M. Eliminating hepatitis C: The importance of frequent testing of people who inject drugs in high-prevalence settings. J Viral Hepat 2018; 25:1472-1480. [PMID: 30047625 DOI: 10.1111/jvh.12975] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/27/2018] [Accepted: 06/30/2018] [Indexed: 12/11/2022]
Abstract
Modelling suggests that more frequent screening of people who inject drugs (PWID) and an improved care cascade are required to achieve the WHO hepatitis C virus (HCV) elimination target of an 80% reduction in incidence by 2030. We determined the testing frequencies (2-yearly, annually, 6-monthly and 3-monthly) and retention in care required among PWID to achieve the HCV incidence reduction target through treatment as prevention in low (25%), medium (50%) and high (75%) chronic HCV prevalence settings. Mathematical modelling of HCV transmission among PWID, capturing testing, treatment and other features of the care cascade were employed. In low-prevalence settings, 2-yearly antibody testing of PWID was estimated to reach the elimination target by 2027-2030 depending on retention in care, with annual testing reducing the time by up to 3 years. In medium-prevalence settings, if close to 90% testing coverage were achieved, then annual antibody testing of PWID would be sufficient. If testing coverage were lower (80%), 6-monthly antibody testing with at least 70% retention in care or annual HCV RNA/cAg testing would be required. In high-prevalence settings, even 3-monthly HCV RNA/cAg testing of PWID was unable to achieve the incidence reduction target. Thus, for geographical areas or subpopulations with high prevalence, WHO incidence targets are unlikely to be met without 3-monthly RNA/cAg testing accompanied by other prevention measures. Novel testing strategies, such as rapid point-of-care antibody testing or replacing antibody testing with RNA/cAg tests as a screening tool, can provide additional population-level impacts to compensate for imperfect follow-up or testing coverage.
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Affiliation(s)
- Nick Scott
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Rachel Sacks-Davis
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Alisa Pedrana
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Joseph Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Alexander Thompson
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Victoria, Australia
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20
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Advanced liver fibrosis and care continuum in emergency department patients with chronic hepatitis C. Am J Emerg Med 2018; 37:286-290. [PMID: 30409463 DOI: 10.1016/j.ajem.2018.08.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/25/2018] [Accepted: 08/27/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND FIB-4, a non-invasive serum fibrosis index (which includes age, ALT, AST, and platelet count), is frequently available during ED visits. Our objective was to define 1-year HCV-related care outcomes of ED patients with known HCV, for the overall group, and both those with and without advanced fibrosis. METHODS As part of an ongoing HCV linkage-to-care (LTC) program, HCV-infected ED patients were identified retrospectively via medical record review. Components of FIB-4 were abstracted, and patients with an FIB-4 > 3.25 were classified with advanced fibrosis and characterized with regards to downstream HCV care continuum outcomes at one-year after enrollment. RESULTS Of the 113 patients with known HCV, 38 (33.6%) had advanced fibrosis. One-year outcomes along the HCV care continuum after ED encounter for 'all' 113, 75 'without advanced fibrosis', and 38 'advanced fibrosis' patients, respectively, were as follows: agreeing to be linked to care [106 (93.8%), 72 (96.0%), 34 (89.5%)]; LTC [38 (33.6%), 21 (28.0%), 17 (44.7%)]; treatment initiation among those linked [16 (42.1%), 9 (42.9%), 7 (41.2%)]; sustained virologic response 4 weeks post-treatment among those treated [15 (93.8%), 9 (100.0%), 6 (85.7%)]; documented all-cause mortality [10 (8.8%), 3 (4.0%), 7 (18.4%)]. Notably, 70% of those who died had advanced fibrosis. For those with advanced liver fibrosis, all-cause mortality was significantly higher, than those without (18.4% versus 4.0%, p = 0.030). CONCLUSIONS Over one-third of HCV-infected ED patients have advanced liver fibrosis, incomplete LTC, and higher mortality, suggesting this readily-available FIB-4 might be used to prioritize LTC services for those with advanced fibrosis.
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21
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Barnett PG, Joyce VR, Lo J, Gidwani-Marszowski R, Goldhaber-Fiebert JD, Desai M, Asch SM, Holodniy M, Owens DK. Effect of Interferon-Free Regimens on Disparities in Hepatitis C Treatment of US Veterans. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:921-930. [PMID: 30098669 DOI: 10.1016/j.jval.2017.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To determine whether implementation of interferon-free treatment for hepatitis C virus (HCV) reached groups less likely to benefit from earlier therapies, including patients with genotype 1 virus or contraindications to interferon treatment, and groups that faced treatment disparities: African Americans, patients with HIV co-infection, and those with drug use disorder. METHODS Electronic medical records of the US Veterans Health Administration (VHA) were used to characterize patients with chronic HCV infection and the treatments they received. Initiation of treatment in 206,544 patients with chronic HCV characterized by viral genotype, demographic characteristics, and comorbid medical and mental illness was studied using a competing events Cox regression over 6 years. RESULTS With the advent of interferon-free regimens, the proportion treated increased from 2.4% in 2010 to 18.1% in 2015, an absolute increase of 15.7%. Patients with genotype 1 virus, poor response to previous treatment, and liver disease had the greatest increase. Large absolute increases in the proportion treated were observed in patients with HIV co-infection (18.6%), alcohol use disorder (11.9%), and drug use disorder (12.6%) and in African American (13.7%) and Hispanic (13.5%) patients, groups that were less likely to receive interferon-containing treatment. The VHA spent $962 million on interferon-free treatments in 2015, 1.5% of its operating budget. CONCLUSIONS The proportion of patients with HCV treated in VHA increased sevenfold. The VHA was successful in implementing interferon treatment in previously undertreated populations, and this may become the community standard of care.
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Affiliation(s)
- Paul G Barnett
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA; VA Center for Innovation to Implementation, Menlo Park, CA, USA.
| | - Vilija R Joyce
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Jeanie Lo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Risha Gidwani-Marszowski
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA; VA Center for Innovation to Implementation, Menlo Park, CA, USA; Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven M Asch
- VA Center for Innovation to Implementation, Menlo Park, CA, USA; Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mark Holodniy
- Public Health Research Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Douglas K Owens
- VA Center for Innovation to Implementation, Menlo Park, CA, USA; Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
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Hepatitis C Management Simplification From Test to Cure: A Framework for Primary Care Providers. Clin Ther 2018; 40:1234-1245. [PMID: 29983266 DOI: 10.1016/j.clinthera.2018.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/09/2018] [Accepted: 05/09/2018] [Indexed: 12/23/2022]
Abstract
This article proposes a strategy for primary care providers to begin treating patients with hepatitis C virus (HCV). We are motivated by the need to expand HCV treatment and by developments that have simplified treatment for most patients. This article presents 5 steps to achieving quality HCV treatment in the primary care setting: (1) accurate diagnosis via reflex testing; (2) risk stratification and identifying comorbidities via pretreatment evaluation; (3) simple, once-daily, pan-genotypic HCV treatment regimens; (4) minimized on-treatment monitoring: and (5) posttreatment monitoring and high-quality care for comorbidities such as cirrhosis and injection drug use. We provide indications for referral to specialists: notably children, patients with genotype 3 and cirrhosis, advanced liver or kidney disease, previous treatment failures, drug interactions with recommended regimens, and hepatitis B co-infection. Finally, potential barriers for providers are discussed, as well as further research findings and policy interventions that can promote HCV treatment in the primary care setting. We believe that a substantial portion of patients with HCV can be treated safely and effectively by nonspecialists and that the engagement of primary care providers is critical to efforts to end the HCV epidemic.
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23
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The Mexican consensus on the treatment of hepatitis C. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2017.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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Aiza-Haddad I, Ballesteros-Amozurrutia A, Borjas-Almaguer OD, Castillo-Barradas M, Castro-Narro G, Chávez-Tapia N, Chirino-Sprung RA, Cisneros-Garza L, Dehesa-Violante M, Flores-Calderón J, Flores-Gaxiola A, García-Juárez I, González-Huezo MS, González-Moreno EI, Higuera-de la Tijera F, Kershenobich-Stalnikowitz D, López-Méndez E, Malé-Velázquez R, Marín-López E, Mata-Marín JA, Méndez-Sánchez N, Monreal-Robles R, Moreno-Alcántar R, Muñoz-Espinosa L, Navarro-Alvarez S, Pavia-Ruz N, Pérez-Ríos AM, Poo-Ramírez JL, Rizo-Robles MT, Sánchez-Ávila JF, Sandoval-Salas R, Torre A, Torres-Ibarra R, Trejo-Estrada R, Velarde-Ruiz Velasco JA, Wolpert-Barraza E, Bosques-Padilla F. The Mexican consensus on the treatment of hepatitis C. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:275-324. [PMID: 29803325 DOI: 10.1016/j.rgmx.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/17/2017] [Accepted: 11/02/2017] [Indexed: 12/12/2022]
Abstract
The aim of the Mexican Consensus on the Treatment of HepatitisC was to develop clinical practice guidelines applicable to Mexico. The expert opinion of specialists in the following areas was taken into account: gastroenterology, infectious diseases, and hepatology. A search of the medical literature was carried out on the MEDLINE, EMBASE, and CENTRAL databases through keywords related to hepatitisC treatment. The quality of evidence was subsequently evaluated using the GRADE system and the consensus statements were formulated. The statements were then voted upon, using the modified Delphi system, and reviewed and corrected by a panel of 34 voting participants. Finally, the level of agreement was classified for each statement. The present guidelines provide recommendations with an emphasis on the new direct-acting antivirals, to facilitate their use in clinical practice. Each case must be individualized according to the comorbidities involved and patient management must always be multidisciplinary.
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Affiliation(s)
| | | | - O D Borjas-Almaguer
- Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | | | - G Castro-Narro
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | | | - L Cisneros-Garza
- Centro de Enfermedades Hepáticas del Hospital San José, Monterrey, Nuevo León, México
| | | | - J Flores-Calderón
- Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Ciudad de México, México
| | | | - I García-Juárez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | - E I González-Moreno
- Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | | | | | - E López-Méndez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - R Malé-Velázquez
- Instituto de Salud Digestiva y Hepática, Guadalajara, Jalisco, México
| | | | - J A Mata-Marín
- Hospital de Infectología del Centro Médico Nacional «La Raza», Ciudad de México, México
| | | | - R Monreal-Robles
- Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | | | - L Muñoz-Espinosa
- Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | | | - N Pavia-Ruz
- Hospital Infantil de México «Federico Gómez», Ciudad de México, México
| | - A M Pérez-Ríos
- Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - J L Poo-Ramírez
- Clínica San Jerónimo de Salud Hepática y Digestiva, Ciudad de México, México
| | | | - J F Sánchez-Ávila
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | - A Torre
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
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The New Direct Antiviral Agents and Hepatitis C in Thoracic Transplantation: Impact on Donors and Recipients. CURRENT TRANSPLANTATION REPORTS 2018; 5:145-152. [PMID: 29774177 PMCID: PMC5945716 DOI: 10.1007/s40472-018-0192-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Purpose of Review The landscape of abdominal organ transplantation has been altered by the emergence of curative direct-acting antiviral agents for hepatitis C. Expansion of the thoracic donor pool to include the hearts and the lungs from hepatitis C-positive donors holds promise to increase available donor organs. Recent Findings Case reports have documented separate lung and heart transplant patients who acquired, and then were cured of, donor-derived hepatitis C using these newer, more effective therapies. Single sites and national consortia are underway to help make this approach part of the standard-of-care. Pangenotypic therapies may simplify the paradigm. Summary Organs from donors with active hepatitis C viremia are likely suitable for transplant as long as the organ is otherwise acceptable. Best-practices for “informed-risk” transplant include a team-based approach and a selection of the antiviral regimen based on insurer’s formulary, potential drug interactions, and genotype.
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Dobler CC, Morgan RL, Falck-Ytter Y, Montori VM, Murad MH. Assessing the validity of surrogate endpoints in the context of a controversy about the measurement of effectiveness of hepatitis C virus treatment. BMJ Evid Based Med 2018; 23:50-53. [PMID: 29595129 DOI: 10.1136/bmjebm-2017-110852] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 01/27/2023]
Abstract
Surrogate endpoints are often used in clinical trials, as they allow for indirect measures of outcomes (eg, shorter trials with less participants). Improvements in surrogate endpoints (eg, reduction in low density lipoprotein cholesterol, normalisation of glycated haemoglobin) achieved with an intervention are, however, not always associated with improvements in patient-important outcomes. The common tendency in evidence-based medicine is to view results based on surrogate endpoints as less certain than results based on long term, final patient-important outcomes and rate them as 'lower quality evidence'. However, careful appraisal of the validity of a surrogate endpoint as a measure of the final, patient-important outcome is more useful than an automatic judgement. In this guide, we use a contemporary and currently highly debated example of the surrogate endpoint 'sustained viral response' (ie, viral eradication considered to represent successful treatment) in patients treated for chronic hepatitis C virus. We demonstrate how the validity of a surrogate endpoint can be critically appraised to assess the quality of the evidence (ie, the certainty in estimates) and the implications for decision-making.
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Affiliation(s)
- Claudia C Dobler
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yngve Falck-Ytter
- Division of Gastroenterology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Mahale P, Engels EA, Li R, Torres HA, Hwang LY, Brown EL, Kramer JR. The effect of sustained virological response on the risk of extrahepatic manifestations of hepatitis C virus infection. Gut 2018; 67. [PMID: 28634198 PMCID: PMC6292199 DOI: 10.1136/gutjnl-2017-313983] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Chronic HCV infection is associated with several extrahepatic manifestations (EHMs). Data on the effect of sustained virological response (SVR) on the risk of EHMs are limited. METHODS We conducted a retrospective cohort study using data of patients from the US Veterans Affairs HCV Clinical Case Registry who had a positive HCV RNA test (10/1999-08/2009). Patients receiving interferon-based antiviral therapy (AVT) were identified. SVR was defined as negative HCV RNA at least 12 weeks after end of AVT. Risks of eight incident EHMs were evaluated in Cox regression models. RESULTS Of the 160 875 HCV-infected veterans, 31 143 (19.4%) received AVT, of whom 10 575 (33.9%) experienced SVR. EHM risk was reduced in the SVR group compared with untreated patients for mixed cryoglobulinaemia (adjusted HR (aHR)=0.61; 95% CI 0.39 to 0.94), glomerulonephritis (aHR=0.62; 95% CI 0.48 to 0.79), porphyria cutanea tarda (PCT) (aHR=0.41; 95% CI 0.20 to 0.83), non-Hodgkin's lymphoma (NHL) (aHR=0.64; 95% CI 0.43 to 0.95), diabetes (aHR=0.82; 95% CI 0.76 to 0.88) and stroke (aHR=0.84; 95% CI 0.74 to 0.94), but not for lichen planus (aHR=1.11; 95% CI 0.78 to 1.56) or coronary heart disease (aHR=1.12; 95% CI 0.81 to 1.56). Risk reductions were also observed when patients with SVR were compared with treated patients without SVR for mixed cryoglobulinaemia, glomerulonephritis, PCT and diabetes. Significant reductions in the magnitude of aHRs towards the null with increasing time to initiation of AVT after HCV diagnosis were observed for glomerulonephritis, NHL and stroke. CONCLUSIONS Risks of several EHMs of HCV infection are reduced after AVT with SVR. However, early initiation of AVT may be required to reduce the risk of glomerulonephritis, NHL and stroke.
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Affiliation(s)
- Parag Mahale
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas,Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Eric A. Engels
- Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Ruosha Li
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas
| | - Harrys A. Torres
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lu-Yu Hwang
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas
| | - Eric L. Brown
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas
| | - Jennifer R. Kramer
- Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas,Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas
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Younossi ZM, Stepanova M, Jacobson IM, Asselah T, Gane EJ, Lawitz E, Foster GR, Roberts SK, Thompson AJ, Willems BE, Welzel TM, Pearlman B, Younossi I, Racila A, Henry L. Sofosbuvir and velpatasvir with or without voxilaprevir in direct-acting antiviral-naïve chronic hepatitis C: patient-reported outcomes from POLARIS 2 and 3. Aliment Pharmacol Ther 2018; 47:259-267. [PMID: 29181842 DOI: 10.1111/apt.14423] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 09/28/2017] [Accepted: 10/28/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic hepatitis C infection leads to impairment of patient-reported outcomes (PROs). Treatment with direct-acting antiviral regimens results in short- and long-term improvement of these outcomes. AIM To assess PROs in patients treated with a newly developed direct-acting antiviral, a fixed-dose combination of sofosbuvir/velpatasvir (SOF/VEL) with/without voxilaprevir (VOX). METHODS The PRO data were collected from participants of POLARIS-2 and POLARIS-3 clinical trials (DAA-naïve, all HCV genotypes). Participants self-administered SF-36v2, FACIT-F, CLDQ-HCV and WPAI:SHP instruments at baseline, during treatment, and in follow-up. RESULTS Of 1160 patients, 611 received SOF/VEL/VOX and 549 received SOF/VEL (52.8 ± 11.0 years, 55.9% male, 75.4% treatment-naïve, 33.9% cirrhotic). The sustained viral response at 12 weeks (SVR12) rates were 95%-98%. During treatment, improvements in most PRO scores were significant (all but one P < .01) and ranged from, on average, +2.3 to +15.0 points (on a 0-100 scale) by the end of treatment. These improvements were similar between SOF/VEL/VOX and SOF/VEL arms (all P > .05). After treatment discontinuation, patients treated with both regimens achieved significant and clinically meaningful PRO gains (+2.7 to +16.7 by post-treatment week 12, +3.9 to +20.1 by post-treatment week 24; all but one P < .001). Multivariate analysis showed that depression, anxiety and cirrhosis were the most consistent independent predictors of PRO impairment while no association of PROs with the treatment regimen choice was found (all P > .05). CONCLUSIONS The pan-genotypic regimens with SOF/VEL with or without VOX not only have excellent efficacy and safety, but also significantly positively impact patients' experience both during treatment and after achieving sustained virologic response in DAA-naïve patients with HCV.
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Abstract
Viral suppression of human immunodeficiency virus (HIV) with combination antiviral therapy (cART) has led to increasing longevity but has not enabled a complete return to health among aging HIV-infected individuals (HIV+). Viral coinfections are prevalent in the HIV+ host and are implicated in cancer, liver disease, and accelerated aging. We must move beyond a simplistic notion of HIV becoming a "chronic controllable illness" and develop an understanding of how viral suppression alters the natural history of HIV infection, especially at the intersection of HIV with other common viral coinfections in the context of an altered, aging immune system.
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Scott N, Doyle JS, Wilson DP, Wade A, Howell J, Pedrana A, Thompson A, Hellard ME. Reaching hepatitis C virus elimination targets requires health system interventions to enhance the care cascade. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:107-116. [PMID: 28797497 DOI: 10.1016/j.drugpo.2017.07.006] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/28/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Modelling suggests that achieving the World Health Organization's elimination targets for hepatitis C virus (HCV) is possible by scaling up use of direct-acting antiviral (DAA) therapy. However, poor linkage to health services and retention in care presents a major barrier, in particular among people who inject drugs (PWID). We identify and assess the cost-effectiveness of additional health system interventions required to achieve HCV elimination targets in Australia, a setting where all people living with HCV have access to DAA therapy. METHODS We used a dynamic HCV transmission and liver-disease progression mathematical model among current and former PWID, capturing testing, treatment and other features of the care cascade. Interventions tested were: availability of point-of-care RNA testing; increased testing of PWID; using biomarkers in place of liver stiffness measurement; and scaling up primary care treatment delivery. RESULTS The projected treatment uptake in Australia reduced the number of people living with HCV from approximately 230,000 in 2015 to approximately 24,000 by 2030 and reduced incidence by 45%. However, the majority (74%) of remaining infections were undiagnosed and among PWID. Scaling up primary care treatment delivery and using biomarkers in place of liver stiffness measurement only reduced incidence by a further 1% but saved AU$32 million by 2030, with no change to health outcomes. Additionally replacing HCV antibody testing with point-of-care RNA testing increased healthcare cost savings to AU$62 million, increased incidence reduction to 64% and gained 11,000 quality-adjusted life years, but critically, additional screening of PWID was required to achieve HCV elimination targets. CONCLUSION Even with unlimited and unrestricted access to HCV DAA treatment, interventions to improve the HCV cascade of care and target PWID will be required to achieve elimination targets.
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Affiliation(s)
- Nick Scott
- Burnet Institute, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia.
| | - Joseph S Doyle
- Burnet Institute, Melbourne, VIC 3004, Australia; Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC 3004, Australia
| | | | - Amanda Wade
- Burnet Institute, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia
| | - Jess Howell
- Burnet Institute, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia; Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia; Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, VIC 3165, Australia
| | | | - Alexander Thompson
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia; Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, VIC 3165, Australia
| | - Margaret E Hellard
- Burnet Institute, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia; Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC 3004, Australia
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Doyle JS, Thompson AJ, Higgs P, Stoove M, Dietze PM, Hellard ME. New hepatitis C antiviral treatments eliminate the virus. Lancet 2017; 390:358-359. [PMID: 28689663 DOI: 10.1016/s0140-6736(17)31817-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/23/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Joseph S Doyle
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC 3004, Australia.
| | - Alexander J Thompson
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Peter Higgs
- Department of Public Health, LaTrobe University, Bundoora, VIC, Australia
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A fixed-dose combination of ledipasvir and sofosbuvir ± ribavirin for treatment of hepatitis C infection: a systematic review and meta-analysis. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0401-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gray E, O'Leary A, Bergin C, Cannon M, Courtney G, Crosbie O, De Gascun CF, Fanning LJ, Feeney E, Houlihan DD, Kelleher B, Lambert JS, Lee J, Mallon P, McConkey S, McCormick A, McKiernan S, McNally C, Murray F, Sheehan G, Stewart S, Walsh C, Norris S. Effectiveness of interferon-free therapy for the treatment of HCV-patients with compensated cirrhosis treated through the Irish early access program. Expert Rev Gastroenterol Hepatol 2017; 11:593-601. [PMID: 28276815 DOI: 10.1080/17474124.2017.1292850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We investigated the real-world effectiveness of interferon-free regimens for the treatment of patients with compensated cirrhosis infected with hepatitis C virus (HCV). METHOD Using the Irish national HCV treatment registry, the effectiveness and safety of interferon-free regimens for HCV-infected patients treated between April 2015 and August 2016, was determined. RESULTS A SVR12 was achieved in 86% of subjects treated with sofosbuvir/ledipasvir ± ribavirin (SOF/LDV±RBV), 93% treated with paritaprevir, ombitasvir and ritonavir combined with dasabuvir ± ribavirin (3D±RBV) and 89% treated with sofosbuvir/daclatasvir ± ribavirin (SOF/DCV±RBV). The discontinuation rate was 5% and the on-treatment mortality rate was 1%. CONCLUSION The availability of interferon-free regimens represents a significant breakthrough for the treatment of HCV infection. Treatments options, with high SVR12 rates, are now available for patients with compensated cirrhosis who were unsuitable for treatment with interferon-based regimens. Data obtained from studies conducted in real world practice provide robust information fundamental for input into future economic evaluations for agents used for the treatment of HCV infection.
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Affiliation(s)
- E Gray
- a School of Medicine, Trinity College Dublin , Dublin , Ireland
| | - A O'Leary
- b National Centre for Pharmacoeconomics, St. James' Hospital , Dublin , Ireland.,c School of Pharmacy, Royal College of Surgeons of Ireland , Dublin , Ireland
| | - C Bergin
- a School of Medicine, Trinity College Dublin , Dublin , Ireland.,e St James' Hospital , Dublin , Ireland
| | - M Cannon
- f Beaumont Hospital , Dublin , Ireland
| | - G Courtney
- g St. Luke's Hospital , Kilkenny , Ireland
| | - O Crosbie
- h Cork University Hospital , Cork , Ireland
| | - C F De Gascun
- i National Virus Reference Laboratory , University College Dublin , Dublin , Ireland
| | - L J Fanning
- j Molecular Virology Diagnostic & Research Laboratory, Department of Medicine , University College Cork , Cork , Ireland
| | - E Feeney
- k St. Vincent's University Hospital , Dublin , Ireland
| | - D D Houlihan
- k St. Vincent's University Hospital , Dublin , Ireland
| | - B Kelleher
- d Mater Misericordiae University Hospital , Dublin , Ireland
| | - J S Lambert
- d Mater Misericordiae University Hospital , Dublin , Ireland.,n School of Medicine , University College Dublin , Dublin , Ireland
| | - J Lee
- l University College Hospital , Galway , Ireland
| | - Pwg Mallon
- d Mater Misericordiae University Hospital , Dublin , Ireland.,n School of Medicine , University College Dublin , Dublin , Ireland
| | | | - A McCormick
- k St. Vincent's University Hospital , Dublin , Ireland
| | | | - C McNally
- f Beaumont Hospital , Dublin , Ireland
| | - F Murray
- f Beaumont Hospital , Dublin , Ireland
| | - G Sheehan
- d Mater Misericordiae University Hospital , Dublin , Ireland
| | - S Stewart
- d Mater Misericordiae University Hospital , Dublin , Ireland
| | - C Walsh
- m University of Limerick , Limerick , Ireland
| | - S Norris
- a School of Medicine, Trinity College Dublin , Dublin , Ireland.,e St James' Hospital , Dublin , Ireland
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Fox DS, McGinnis JJ, Tonnu-Mihara IQ, McCombs JS. Comparative treatment effectiveness of direct acting antiviral regimens for hepatitis C: Data from the Veterans administration. J Gastroenterol Hepatol 2017; 32:1136-1142. [PMID: 27869323 DOI: 10.1111/jgh.13652] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/03/2016] [Accepted: 11/08/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Data addressing real world effectiveness of direct acting antiviral agents in hepatitis C infected patients are now emerging. This study compared the sustained virologic response rates achieved 12 weeks post-treatment in patients treated with three such agents by the Veterans Health Administration. METHODS A retrospective cohort study was conducted using patients who terminated treatment by July 1, 2015. Data were retrieved from the Veterans Health Administration electronic medical records system. Patients were included if sufficient viral load laboratory data were available to determine sustained virologic response. Applying an intention to treat approach and logistic regression analysis, the sustained virologic response rates achieved were compared across drug regimens. RESULTS A total of 11 464 patients met study selection criteria. Without controlling for other risk factors, sustained virologic response at least 12 weeks post treatment was achieved in 92% of ledipasvir/ sofosbuvir, 86% of ombitasvir/paritaprevir/ritonavir/dasabuvir, and 83% of simeprevir/sofosbuvir patients. After adjusting for patient characteristics, simeprevir/sofosbuvir (93.3%) and ledipasvir/sofosbuvir (96.2%) patients were statistically more likely than ombitasvir/paritaprevir/ritonavir/dasabuvir (91.8%) patients to demonstrate sustained virologic response. Human immunodeficiency virus, hepatitis B infection, diabetes, obesity, previous treatment history and augmentation therapy using ribavirin did not impact sustained virologic response rates. Sustained virologic response rates were lower for patients under age 65, with cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, indications of fibrosis, or a non-genotype 1 infection. Women and Caucasian patients were more likely to achieve a sustained virologic response. CONCLUSIONS All three direct acting antiviral regimens appear highly effective in achieving sustained virologic response.
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Affiliation(s)
- D Steven Fox
- Department of Medicine, Keck School of Medicine, Leonard Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, USA
| | - Justin J McGinnis
- Department of Pharmaceutical and Health Economics, School of Pharmacy, Leonard Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, USA.,Clinical Pharmacy Programs Development and Research, Veterans Affairs Long Beach Healthcare System, Long Beach, California, USA
| | - Ivy Q Tonnu-Mihara
- Clinical Pharmacy Programs Development and Research, Veterans Affairs Long Beach Healthcare System, Long Beach, California, USA
| | - Jeffrey S McCombs
- Department of Pharmaceutical and Health Economics, School of Pharmacy, Leonard Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, USA
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Kanda T, Nakamura M, Yasui S, Haga Y, Tawada A, Suzuki E, Ooka Y, Takahashi K, Sasaki R, Wu S, Nakamoto S, Arai M, Imazeki F, Yokosuka O. Treatment of Real-World HCV Genotype 2-Infected Japanese Patients with Sofosbuvir plus Ribavirin. BIOLOGY 2017; 6:biology6020030. [PMID: 28486403 PMCID: PMC5485477 DOI: 10.3390/biology6020030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/04/2017] [Accepted: 05/06/2017] [Indexed: 12/23/2022]
Abstract
The aim of this study was to characterize the treatment response and tolerability of sofosbuvir plus ribavirin therapies in Japanese patients infected with hepatitis C virus (HCV) genotype (GT)-2. This retrospective study analyzed 114 Japanese HCV GT-2 patients treated for 12 weeks with 400 mg of sofosbuvir plus weight-based ribavirin daily. This treatment led to higher sustained virologic response at 12-weeks post-treatment (SVR12) rates in both treatment-naïve and treatment-experienced patients. The efficacy of this treatment in compensated cirrhotics was the same as that in patients with chronic hepatitis. HCV GT-2a infection and lower estimated glomerular filtration rates (eGFR) tended to be associated with SVR12. Of 114 patients, 113 completed the combination of sofosbuvir plus ribavirin for 12 weeks. Seven patients without SVR12 did not have HCV NS5B-S282 mutations. The overall SVR12 rate was 90.4% (103 of 114). More effective therapeutic options with less adverse events are desired to achieve higher SVR rates in HCV GT-2 Japanese patients.
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Affiliation(s)
- Tatsuo Kanda
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Masato Nakamura
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Shin Yasui
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Yuki Haga
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Akinobu Tawada
- Safety and Health Organization, Chiba University, 1-33 Yayoicho, Inage-ku, Chiba 263-8522, Japan.
| | - Eiichiro Suzuki
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Yoshihiko Ooka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Koji Takahashi
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Reina Sasaki
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Shuang Wu
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Shingo Nakamoto
- Department of Molecular Virology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Makoto Arai
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Fumio Imazeki
- Safety and Health Organization, Chiba University, 1-33 Yayoicho, Inage-ku, Chiba 263-8522, Japan.
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
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Ramos H, Linares P, Badia E, Martín I, Gómez J, Almohalla C, Jorquera F, Calvo S, García I, Conde P, Álvarez B, Karpman G, Lorenzo S, Gozalo V, Vásquez M, Joao D, de Benito M, Ruiz L, Jiménez F, Sáez-Royuela F, Asociación Castellano y Leonesa de Hepatología (ACyLHE). Interferon-free treatments in patients with hepatitis C genotype 1-4 infections in a real-world setting. World J Gastrointest Pharmacol Ther 2017; 8:137-146. [PMID: 28533924 PMCID: PMC5421113 DOI: 10.4292/wjgpt.v8.i2.137] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/14/2017] [Accepted: 02/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigated the real-world effectiveness and safety of various regimens of interferon-free treatments in patients infected with hepatitis C virus (HCV).
METHODS We performed an observational study to analyze different antiviral treatments administered to 462 HCV-infected patients, of which 56.7% had liver cirrhosis. HCV RNA after 4 wk of treatment and at 12 wk after treatment sustained virologic response (SVR) as well as serious adverse events (SAEs) was analyzed first for the whole cohort and then separately in patients who met or did not meet the inclusion criteria of a clinical trial (CT-met and CT-unmet, respectively).
RESULTS The most frequently prescribed treatment was simeprevir/sofosbuvir (36.4%), followed by sofosbuvir/ledipasvir (24.9%) and ombitasvir/paritaprevir/ritonavir (r)/dasabuvir (19.9%). Ribavirin (RBV) was administered in 198 patients (42.9%). SVRs occurred in 437/462 patients (94.6%). The SVRs ranged between 93.3% and 100% for genotypes 1-4. SVRs were achieved in 96.2% patients in the CT-met group vs 91.9% patients in the CT-unmet group (P = 0.049). Undetectable HCV RNA at week 4 occurred in 72.9% of the patients. In the univariate analysis, the factors associated with SVRs were lower liver stiffness, absence of cirrhosis, higher platelet count, higher albumin levels, no RBV dose reduction, undetectable HCV RNA at week 4 and CT-met group. In the multivariate analysis, only albumin was an independent predictor of treatment failure (P = 0.04). Eleven patients (2.4%) developed SAEs; 5.2% and 0.7% of the patients in the CT-unmet and CT-met groups, respectively (P = 0.003).
CONCLUSION A high proportion of patients with HCV infection achieved SVRs. For patients who did not meet the CT criteria, treatment regimens must be optimized.
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Jacobson IM, Lim JK, Fried MW. American Gastroenterological Association Institute Clinical Practice Update-Expert Review: Care of Patients Who Have Achieved a Sustained Virologic Response After Antiviral Therapy for Chronic Hepatitis C Infection. Gastroenterology 2017; 152:1578-1587. [PMID: 28344022 DOI: 10.1053/j.gastro.2017.03.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic hepatitis C virus infection is well-recognized as a common blood-borne infection with global public health impact affecting 3 to 5 million persons in the United States and more than 170 million persons worldwide. Chronic hepatitis C virus infection is associated with significant morbidity and mortality due to complications of liver cirrhosis and hepatocellular carcinoma. Current therapies with all-oral direct-acting antiviral agents are associated with high rates of sustained virologic response (SVR), generally exceeding 90%. SVR is associated with a reduced risk of liver cirrhosis, hepatic decompensation, need for liver transplantation, and both liver-related and all-cause mortality. However, a subset of patients who achieve SVR will remain at long-term risk for progression to cirrhosis, liver failure, hepatocellular carcinoma, and liver-related mortality. Limited evidence is available to guide clinicians on which post-SVR patients should be monitored vs discharged, how to monitor and with which tests, how frequently should monitoring occur, and for how long. In this clinical practice update, available evidence and expert opinion are used to generate best practice recommendations on the care of patients with chronic hepatitis C virus who have achieved SVR.
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Affiliation(s)
- Ira M Jacobson
- Department of Medicine, Mount Sinai Beth Israel Medical Center, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Joseph K Lim
- Section of Digestive Diseases and Yale Liver Center, Yale University School of Medicine, New Haven, Connecticut
| | - Michael W Fried
- Division of Gastroenterology and Hepatology, UNC Liver Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Relapse of HCV Genotype 1b Infection After Sofosbuvir/Ledipasvir Treatment Presenting as De Novo Cryoglobulinemic Vasculitis. ACG Case Rep J 2017; 4:e21. [PMID: 28184378 PMCID: PMC5291713 DOI: 10.14309/crj.2017.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 11/28/2016] [Indexed: 11/21/2022] Open
Abstract
Relapse of hepatitis C virus (HCV) genotype 1 infection after combination therapy with sofosbuvir and ledipasvir is unusual. We report a treatment-naïve, non-cirrhotic patient in whom the relapse of genotype 1b HCV infection was accompanied by de novo cryoglobulinemic vasculitis and glomerulonephritis, requiring hemodialysis for acute renal failure. Sequence analysis revealed several resistance-associated variants in the HCV NS5a gene but not in NS3/4A. The patient’s vasculitis was successfully treated with immunosuppression and plasmapheresis, followed by retreatment of HCV with a combination of sofosbuvir, simeprevir, and ribavirin. The patient achieved sustained virological response, recovered his renal function, and remains in remission from cryoglobulinemia.
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Jensen DM, Asselah T, Dieterich D, Foster GR, Sulkowski MS, Zeuzem S, Mantry P, Yoshida EM, Moreno C, Ouzan D, Wright M, Morano LE, Buynak R, Bourlière M, Hassanein T, Nishiguchi S, Kao JH, Omata M, Paik SW, Wong DK, Tam E, Kaita K, Feinman SV, Stern JO, Scherer J, Quinson AM, Voss F, Gallivan JP, Böcher WO, Ferenci P. Faldaprevir, pegylated interferon, and ribavirin for treatment-naïve HCV genotype-1: pooled analysis of two phase 3 trials. Ann Hepatol 2017; 15:333-49. [PMID: 27049487 DOI: 10.5604/16652681.1198803] [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: 02/04/2023]
Abstract
INTRODUCTION & AIM Faldaprevir is a potent once-daily (q.d.) hepatitis C virus (HCV) NS3/4A protease inhibitor. The STARTVerso1 and STARTVerso2 phase 3 studies evaluated faldaprevir plus peginterferon alfa-2a/ribavirin (PegIFN/RBV) in treatment-naïve patients with chronic HCV genotype-1 infection. MATERIAL AND METHODS Patients were randomized 1:2:2 to receive placebo, faldaprevir 120 mg q.d. (12 or 24 weeks) or faldaprevir 240 mg q.d. (12 weeks) all with PegIFN/RBV (24-48 weeks). Faldaprevir 120 mg for 12 weeks only (STARTVerso1 only) required early treatment success (ETS, HCV RNA < 25 IU/mL at week 4 and undetected at week 8). All faldaprevir-treated patients with ETS stopped PegIFN/RBV at week 24. Primary endpoint: sustained virologic response 12 weeks post-treatment (SVR12). RESULTS SVR12 rates were significantly higher for patients treated with faldaprevir 120 or 240 mg (72% and 73%, respectively) compared with placebo (50%); estimated differences (adjusted for trial, race, and genotype-1 subtype) faldaprevir 120 mg 24% (95% CI: 17-31%, P < 0.0001), faldaprevir 240 mg 23% (95% CI: 16-30%, P < 0.0001). Subgroup analyses consistently showed higher SVR12 rates for patients receiving faldaprevir compared with placebo. The incidence of adverse events (AEs) was similar in faldaprevir 120-mg and placebo groups and slightly higher in the faldaprevir 240-mg group. Serious Aes were reported in 6%, 7%, and 8% of patients in placebo, faldaprevir 120-mg, and faldaprevir 240-mg groups, respectively. CONCLUSION Addition of faldaprevir to PegIFN/RBV increased SVR12 in patients with HCV genotype-1, and was well tolerated. Faldaprevir 120 mg is effective in the treatment of HCV genotype-1. ClinicalTrials.gov: NCT01343888 and NCT01297270.
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Affiliation(s)
| | - Tarik Asselah
- Hôpital Beaujon, APHP, University Paris-Diderot and INSERM CRB3, Clichy, France
| | - Douglas Dieterich
- Icahn School of Medicine at Mount Sinai, New York, NY, USA. 4 Queen Mary University of London, London, UK
| | | | | | | | - Parvez Mantry
- The Liver Institute at Methodist Dallas Medical Center, Dallas, TX, USA
| | | | - Christophe Moreno
- CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Denis Ouzan
- Institut Arnault Tzanck, St. Laurent du Var, France
| | - Mark Wright
- Wellcome Trust Clinical Research Facility, Southampton, UK
| | | | - Robert Buynak
- Northwest Indiana Center for Clinical Research, Valparaiso, IN, USA
| | | | | | | | | | - Masao Omata
- Yamanashi Central and Kita Hospitals, Yamanashi, Japan
| | - Seung W Paik
- Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
| | - David K Wong
- Toronto Western Hospital Liver Center, Toronto, ON, Canada
| | | | - Kelly Kaita
- HSC University of Manitoba, Winnipeg, MB, Canada
| | - S Victor Feinman
- Hepatitis Centre, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Jerry O Stern
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | | | | | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | - Wulf O Böcher
- Afiliacja Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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Gimeno-Ballester V, Mar J, O'Leary A, Adams R, San Miguel R. Cost-effectiveness analysis of therapeutic options for chronic hepatitis C genotype 3 infected patients. Expert Rev Gastroenterol Hepatol 2017; 11:85-93. [PMID: 27500437 DOI: 10.1080/17474124.2016.1222271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study provides a cost-effectiveness analysis of therapeutic strategies for chronic hepatitis C genotype 3 infected patients in Spain. METHODS A Markov model was designed to simulate the progression in a cohort of patients aged 50 years over a lifetime horizon. RESULTS Sofosbuvir (SOF) plus peginterferon and ribavirin for 12 weeks was a cost-effective option when compared to standard of care (SoC) in the treatment of both 'moderate fibrosis' and 'cirrhotic' patients. Incremental cost-effectiveness ratios were €35,276/QALY and €18,374/QALY respectively. ICERs for SOF plus daclatasvir (DCV) regimens versus SoC were over the threshold limit considered, at €56,178/QALY and €77,378/QALY for 'moderate fibrosis' and 'cirrhotic' patients respectively. CONCLUSION Addition of SOF to IFN-based regimens for genotype 3 was cost-effective for both 'moderate fibrosis' and 'cirrhotic' patients. IFN-free options including SOF and DCV association required price reductions lower than the list prices to be considered cost-effective.
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Affiliation(s)
- Vicente Gimeno-Ballester
- a Department of Pharmacy , Hospital Universitario Miguel Servet , Zaragoza , Spain.,b Faculty of Pharmacy , University of Granada , Granada , Spain
| | - Javier Mar
- c Clinical Management Service , Hospital Alto Deba , Mondragon , Spain
| | - Aisling O'Leary
- d National Centre for Pharmacoeconomics , St James Hospital , Dublin , Ireland
| | - Róisín Adams
- d National Centre for Pharmacoeconomics , St James Hospital , Dublin , Ireland
| | - Ramón San Miguel
- b Faculty of Pharmacy , University of Granada , Granada , Spain.,d National Centre for Pharmacoeconomics , St James Hospital , Dublin , Ireland.,e Department of Pharmacy , Complejo Hospitalario de Navarra , Pamplona , Spain
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Tao T, Jiang X, Chen Y, Song Y. Efficacy and Safety of Ledipasvir/Sofosbuvir with and without Ribavirin in Patients with Chronic Hepatitis C Virus Genotype 1 Infection: a meta-analysis. Int J Infect Dis 2016; 55:56-71. [PMID: 28040553 DOI: 10.1016/j.ijid.2016.12.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 11/16/2016] [Accepted: 12/21/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The addition of ribavirin (RBV) to the combination treatment of Ledipasvir (LDV) and Sofosbuvir (SOF) remains controversial in the treatment of hepatitis C virus (HCV) infection. We performed a meta-analysis to assess the efficacy and safety of the LDV-SOF with and without RBV in treating HCV genotype 1 patients. METHOD The electronical databases of PubMed Medline, EMBASE database, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov website with registered trials were searched. Eligible studies were randomized controlled trials (RCTs) and prospective cohort studies that assessed the efficacy and safety of LDV-SOF with or without RBV in patients with HCV genotype 1 (GT 1). Two reviewers independently screened studies, extracted data and assessed methodology quality. Review Manager 5.3 software was used to analyze the data. RESULTS Seven studies involving 2,626 patients with HCV GT 1 - some of whom had cirrhosis - were included in this meta-analysis. The addition of RBV to LDV- SOF regimen neither significantly improved sustained viral response at 12 weeks (SVR12) after the last dose of treatment (RR=1.00, 95%CI 0.99-1.01, p=0.99) nor decreased virologic breakthrough (RR=1.01, 95%CI 0.14-7.19, p=0.99) and relapse (RR=1.36, 95% CI 0.81-2.29, p=0.24). There was no significant difference in the incidence of discontinuation (RR=0.61, 95%CI 0.25-1.53, p=0.30) between LDV- SOF therapy and LDV- SOF plus RBV. LDV- SOF plus RBV therapy had significantly higher rate of the overall adverse events (RR=0.88, 95%CI=0.84- 0.92, p<0.00001). LDV - SOF therapy had higher incidence of serious adverse events (RR=1.60, 95%CI=1.00-2.56, p=0.05) than LDV-SOF plus RBV. CONCLUSION This meta-analysis suggests that LDV-SOF based therapy is a safe and effective treatment for patients with GT 1 HCV. The addition of RBV to LDV-SOF may increase toxicity without achieving improved efficacy. However, due to the relatively small sample sizes and moderate risk of bias of included studies, large-scale and high-quality clinical research is still needed to confirm the results.
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Affiliation(s)
- Tingting Tao
- Key Laboratory of Drug Targeting and Drug Delivery System, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xuehua Jiang
- Key Laboratory of Drug Targeting and Drug Delivery System, Ministry of Education, West China School of Pharmacy, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yuehong Chen
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yiran Song
- Eli Lilly and Company, Suzhou, Jiangzu, People's Republic of China
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Matsuda T, McCombs JS, Tonnu-Mihara I, McGinnis J, Fox DS. The Impact of Delayed Hepatitis C Viral Load Suppression on Patient Risk: Historical Evidence from the Veterans Administration. ACTA ACUST UNITED AC 2016; 19:333-351. [DOI: 10.1515/fhep-2015-0041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract
Background:
The high cost of new hepatitis C (HCV) treatments has resulted in “watchful waiting” strategies being developed to safely delay treatment, which will in turn delay viral load suppression (VLS).
Objective:
To document if delayed VLS adversely impacted patient risk for adverse events and death.
Methods:
187,860 patients were selected from the Veterans Administration’s (VA) clinical registry (CCR), a longitudinal compilation of electronic medical records (EMR) data for 1999–2010. Inclusion criteria required at least 6 months of CCR/EMR data prior to their HCV diagnosis and sufficient data post-diagnosis to calculate one or more FIB-4 scores. Primary outcome measures were time-to-death and time-to-a composite of liver-related clinical events. Cox proportional hazards models were estimated separately using three critical FIB-4 levels to define early and late viral response.
Results:
Achieving an undetectable viral load before the patient’s FIB-4 level exceed pre-specified critical values (1.00, 1.45 and 3.25) effectively reduced the risk of an adverse clinical events by 33–35% and death by 21–26%. However, achieving VLS after FIB-4 exceeds 3.25 significantly reduced the benefit of viral response.
Conclusions:
Delaying VLS until FIB-4 >3.25 reduces the benefits of VLS in reducing patient risk.
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Carter W, Connelly S, Struble K. Reinventing HCV Treatment: Past and Future Perspectives. J Clin Pharmacol 2016; 57:287-296. [PMID: 27654843 DOI: 10.1002/jcph.830] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/15/2016] [Indexed: 12/13/2022]
Abstract
This review paper summarizes the epidemiology of hepatitis C virus (HCV) and chronic HCV infection, including HCV virology and treatment regimens. Specifically, we focus on the evolution of past, current, and future HCV treatment options, the reasons for treatment failure, and the impact of resistance-associated variants on treatment success.
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Affiliation(s)
- Wendy Carter
- Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Division of Antiviral Products, Silver Spring, MD, USA
| | - Sarah Connelly
- Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Division of Antiviral Products, Silver Spring, MD, USA
| | - Kimberly Struble
- Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Division of Antiviral Products, Silver Spring, MD, USA
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Sarrazin C, Isakov V, Svarovskaia ES, Hedskog C, Martin R, Chodavarapu K, Brainard DM, Miller MD, Mo H, Molina JM, Sulkowski MS. Late Relapse Versus Hepatitis C Virus Reinfection in Patients With Sustained Virologic Response After Sofosbuvir-Based Therapies. Clin Infect Dis 2016; 64:44-52. [PMID: 27737953 DOI: 10.1093/cid/ciw676] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/22/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The development of direct-acting antivirals in recent years has dramatically enhanced rates of viral eradication to >90% in patients with chronic hepatitis C virus (HCV) infection. To determine true treatment efficacy and define the most appropriate retreatment, it is important to distinguish virologic relapse from reinfection when patients in whom HCV is eradicated during treatment become infected with a new HCV strain after treatment. METHODS We investigated the prevalence of late recurrent viremia (patients with sustained virologic response 12 weeks after the end of treatment but detectable HCV RNA at follow-up week 24) and used refined phylogenetic analysis of multiple HCV genes to distinguish virologic relapse from reinfection. RESULTS Across 11 phase 3 clinical trials of ledipasvir-sofosbuvir (SOF) and SOF, only 12 of 3004 patients had detectable HCV RNA following sustained virologic response 12 weeks after the end of treatment. Of these 12 patients with late recurrent viremia, 11 had the same HCV genotype/subtype at baseline and at recurrence. Phylogenetic analysis demonstrated that 58% (7 of 12) of these patients were successfully treated with the SOF-based regimen, with HCV eradication achieved, but became reinfected with a different HCV strain after treatment. The remaining 5 patients with late recurrent viremia had virologic relapse in which the HCV present at baseline persisted in the liver or another compartment and reemerged in the blood 24 weeks after treatment. CONCLUSIONS The incidence of late recurrent viremia was low. Distinguishing reinfection from virologic relapse has implications for determining true treatment efficiency and selecting optimal retreatment strategies.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Hongmei Mo
- Gilead Sciences, Foster City, California
| | | | - Mark S Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Omata M, Kanda T, Wei L, Yu ML, Chuang WL, Ibrahim A, Lesmana CRA, Sollano J, Kumar M, Jindal A, Sharma BC, Hamid SS, Dokmeci AK, Al-Mahtab M, McCaughan GW, Wasim J, Crawford DHG, Kao JH, Yokosuka O, Lau GKK, Sarin SK. APASL consensus statements and recommendations for hepatitis C prevention, epidemiology, and laboratory testing. Hepatol Int 2016; 10:681-701. [PMID: 27229718 PMCID: PMC5003900 DOI: 10.1007/s12072-016-9736-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 04/20/2016] [Indexed: 02/06/2023]
Abstract
The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on "APASL consensus statements and recommendations for management of hepatitis C" in March 2015 to revise the "APASL consensus statements and management algorithms for hepatitis C virus infection" (Hepatol Int 6:409-435, 2012). The working party consisted of expert hepatologists from the Asian-Pacific region gathered at the Istanbul Congress Center, Istanbul, Turkey on 13 March 2015. New data were presented, discussed, and debated during the course of drafting a revision. Participants of the consensus meeting assessed the quality of the cited studies. The finalized recommendations for hepatitis C prevention, epidemiology, and laboratory testing are presented in this review.
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Affiliation(s)
- Masao Omata
- Yamanashi Prefectural Central Hospital, 1-1-1 Fujimi, Kofu-shi, Yamanashi, 400-8506, Japan.
- The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Tatsuo Kanda
- Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Lai Wei
- Peking University People's Hospital, Peking University Hepatology Institute, Beijing, China
| | - Ming-Lung Yu
- Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Wang-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Alaaeldin Ibrahim
- GI/Liver Division, Department of Internal Medicine, University of Benha, Banha, Egypt
| | | | - Jose Sollano
- University Santo Tomas Hospital, Manila, Philippines
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Saeed S Hamid
- Department of Medicine, Aga Khan University and Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - A Kadir Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Mamun Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, 1000, Bangladesh
| | - Geofferey W McCaughan
- Royal Prince Alfred Hospital, Centenary Institute, University of Sydney, Sydney, Australia
| | - Jafri Wasim
- Department of Medicine, Aga Khan University and Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - Darrell H G Crawford
- University of Queensland, School of Medicine, Woolloongabba, QLD, 4102, Australia
| | - Jia-Horng Kao
- National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Osamu Yokosuka
- Graduate School of Medicine, Chiba University, Chiba, Japan
| | - George K K Lau
- The Institute of Translational Hepatology, Beijing 302 Hospital, Beijing, China
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Garbuglia AR, Visco-Comandini U, Lionetti R, Lapa D, Castiglione F, D’Offizi G, Taibi C, Montalbano M, Capobianchi MR, Paci P. Ultrasensitive HCV RNA Quantification in Antiviral Triple Therapy: New Insight on Viral Clearance Dynamics and Treatment Outcome Predictors. PLoS One 2016; 11:e0158989. [PMID: 27560794 PMCID: PMC4999094 DOI: 10.1371/journal.pone.0158989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 06/25/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Identifying the predictive factors of Sustained Virological Response (SVR) represents an important challenge in new interferon-based DAA therapies. Here, we analyzed the kinetics of antiviral response associated with a triple drug regimen, and the association between negative residual viral load at different time points during treatment. METHODS Twenty-three HCV genotype 1 (GT 1a n = 11; GT1b n = 12) infected patients were included in the study. Linear Discriminant Analysis (LDA) was used to establish possible association between HCV RNA values at days 1 and 4 from start of therapy and SVR. Principal component analysis (PCA) was applied to analyze the correlation between HCV RNA slope and SVR. A ultrasensitive (US) method was established to measure the residual HCV viral load in those samples which resulted "detected <12IU/ml" or undetectable with ABBOTT standard assay, and was retrospectively used on samples collected at different time points to establish its predictive power for SVR. RESULTS According to LDA, there was no association between SVR and viral kinetics neither at time points earlier than 1 week (days 1 and 4) after therapy initiation nor later. The slopes were not relevant for classifying patients as SVR or no-SVR. No significant differences were observed in the median HCV RNA values at T0 among SVR and no-SVR patients. HCV RNA values with US protocol (LOD 1.2 IU/ml) after 1 month of therapy were considered; the area under the ROC curve was 0.70. Overall, PPV and NPV of undetectable HCV RNA with the US method for SVR was 100% and 46.7%, respectively; sensitivity and specificity were 38.4% and 100% respectively. CONCLUSION HCV RNA "not detected" by the US method after 1 month of treatment is predictive of SVR in first generation Protease inhibitor (PI)-based triple therapy. The US method could have clinical utility for advanced monitoring of virological response in new interferon based DAA combination regimens.
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Affiliation(s)
- Anna Rosa Garbuglia
- Laboratory of Virology, “Lazzaro Spallanzani” National Institute for Infectious Diseases, IRCCS, Rome, Italy
- * E-mail:
| | - Ubaldo Visco-Comandini
- Clinical Department, “Lazzaro Spallanzani” National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Raffaella Lionetti
- Clinical Department, “Lazzaro Spallanzani” National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Daniele Lapa
- Laboratory of Virology, “Lazzaro Spallanzani” National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | | | - Gianpiero D’Offizi
- Clinical Department, “Lazzaro Spallanzani” National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Chiara Taibi
- Clinical Department, “Lazzaro Spallanzani” National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Marzia Montalbano
- Clinical Department, “Lazzaro Spallanzani” National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Maria Rosaria Capobianchi
- Laboratory of Virology, “Lazzaro Spallanzani” National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Paola Paci
- Istituto di Analisi dei Sistemi ed Informatica “Antonio Ruberti” (IASI)—CNR, Rome, Italy
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Kyle RP, Moodie EEM, Klein MB, Abrahamowicz M. Correcting for Measurement Error in Time-Varying Covariates in Marginal Structural Models. Am J Epidemiol 2016; 184:249-58. [PMID: 27416840 DOI: 10.1093/aje/kww068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 02/16/2016] [Indexed: 01/03/2023] Open
Abstract
Unbiased estimation of causal parameters from marginal structural models (MSMs) requires a fundamental assumption of no unmeasured confounding. Unfortunately, the time-varying covariates used to obtain inverse probability weights are often error-prone. Although substantial measurement error in important confounders is known to undermine control of confounders in conventional unweighted regression models, this issue has received comparatively limited attention in the MSM literature. Here we propose a novel application of the simulation-extrapolation (SIMEX) procedure to address measurement error in time-varying covariates, and we compare 2 approaches. The direct approach to SIMEX-based correction targets outcome model parameters, while the indirect approach corrects the weights estimated using the exposure model. We assess the performance of the proposed methods in simulations under different clinically plausible assumptions. The simulations demonstrate that measurement errors in time-dependent covariates may induce substantial bias in MSM estimators of causal effects of time-varying exposures, and that both proposed SIMEX approaches yield practically unbiased estimates in scenarios featuring low-to-moderate degrees of error. We illustrate the proposed approach in a simple analysis of the relationship between sustained virological response and liver fibrosis progression among persons infected with hepatitis C virus, while accounting for measurement error in γ-glutamyltransferase, using data collected in the Canadian Co-infection Cohort Study from 2003 to 2014.
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48
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Thokala P, Simpson EL, Tappenden P, Stevens JW, Dickinson K, Ryder S, Harrison P. Ledipasvir-Sofosbuvir for Treating Chronic Hepatitis C: A NICE Single Technology Appraisal-An Evidence Review Group Perspective. PHARMACOECONOMICS 2016; 34:741-750. [PMID: 26892974 DOI: 10.1007/s40273-016-0387-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The National Institute for Health and Care Excellence (NICE) invited Gilead, the company manufacturing ledipasvir-sofosbuvir (LDV/SOF), to submit evidence for the clinical effectiveness and cost effectiveness of LDV/SOF for treating chronic hepatitis C. The School of Health and Related Research (ScHARR) Technology Assessment Group was commissioned as the Evidence Review Group (ERG). This paper describes the company's submission (CS), the ERG review and the subsequent decision of the NICE Appraisal Committee (AC). The ERG produced a critical review of the clinical effectiveness and cost-effectiveness evidence of LDV/SOF based upon the CS. The clinical effectiveness data for LDV/SOF were taken from ten trials: three phase III trials and seven phase II trials. Trials compared different durations of LDV/SOF, with and without ribavirin (RBV). There were no head-to-head trials comparing LDV/SOF with any comparator listed in the NICE scope. Data from the trials were mostly from populations with genotype 1 (GT1) disease, although some limited data were available for populations with genotypes 3 and 4. For GT1 treatment-naïve patients, sustained viral response for 12 weeks (SVR12) rates for LDV/SOF ranged from 93.1 to 99.4 % for subgroups of patients with non-cirrhotic disease, whilst SVR rates of 94.1 to 100 % were reported for subgroups of patients with compensated cirrhosis. For GT1 treatment-experienced patients, SVR12 rates ranging from 95.4 to 100 % were reported for subgroups of non-cirrhotic patients, and SVR rates ranging from 81.8 to 100 % were reported within subgroups of patients with compensated cirrhosis. Comparator data were not searched systematically as part of the submission, but were based on the company's previous NICE submission of sofosbuvir, with additional targeted searches. The ERG's critical appraisal of the company's economic evaluation highlighted a number of concerns. The ERG's base case analyses suggested that the incremental cost-effectiveness ratios (ICERs) for LDV/SOF (+RBV) are dependent on (a) treatment durations, (b) whether patients have been previously treated and (c) whether patients have liver cirrhosis or not. The AC concluded that it was appropriate to use the approach taken in the ERG's exploratory analyses, in line with the marketing authorisation, which considered people with and without cirrhosis separately, and estimated the cost effectiveness for each recommended treatment duration of LDV/SOF.
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Affiliation(s)
- P Thokala
- University of Sheffield, Sheffield, UK.
| | | | | | | | | | - S Ryder
- Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, UK
| | - P Harrison
- King's College Hospital, Denmark Hill, London, UK
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49
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FakhriRavari A, Malakouti M, Brady R. Interferon-Free Treatments for Chronic Hepatitis C Genotype 1 Infection. J Clin Transl Hepatol 2016; 4:97-112. [PMID: 27350940 PMCID: PMC4913075 DOI: 10.14218/jcth.2016.00007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/22/2016] [Accepted: 03/27/2016] [Indexed: 12/19/2022] Open
Abstract
Hepatitis C virus (HCV) infection affects as many as 185 million people globally, many of whom are chronically infected and progress over time to cirrhosis, decompensated liver disease, hepatocellular carcinoma, and eventually death without a liver transplant. In the United States, HCV genotype 1 constitutes about 75% of all infections. While interferon and ribavirin therapy was the cornerstone of treatment for many years, interferon-free treatments have become the standard of care with the emergence of new direct-acting agents, resulting in more effective treatment, shorter duration of therapy, better tolerability, lower pill burden, and ultimately better adherence. This review will summarize the evidence for the currently available combination therapies as well as emerging therapies in phase 3 trials for treatment of HCV genotype 1.
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Affiliation(s)
- Alireza FakhriRavari
- Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, San Antonio, Texas, USA
- *Correspondence to: Alireza FakhriRavari, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, 4301 Broadway CPO 99, San Antonio, Texas 78209, USA. Tel: +1-210-883-1142, Fax: +1-210-822-1516, E-mail:
| | - Mazyar Malakouti
- University of Texas Health Science Center, San Antonio, Texas, USA
| | - Rebecca Brady
- Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, San Antonio, Texas, USA
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50
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Puri P, Saraswat VA, Dhiman RK, Anand AC, Acharya SK, Singh SP, Chawla YK, Amarapurkar DN, Kumar A, Arora A, Dixit VK, Koshy A, Sood A, Duseja A, Kapoor D, Madan K, Srivastava A, Kumar A, Wadhawan M, Goel A, Verma A, Shalimar, Pandey G, Malik R, Agrawal S. Indian National Association for Study of the Liver (INASL) Guidance for Antiviral Therapy Against HCV Infection: Update 2016. J Clin Exp Hepatol 2016; 6:119-45. [PMID: 27493460 PMCID: PMC4963318 DOI: 10.1016/j.jceh.2016.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
India contributes significantly to the global burden of HCV. While the nucleoside NS5B inhibitor sofosbuvir became available in the Indian market in March 2015, the other directly acting agents (DAAs), Ledipasvir and Daclatasvir, have only recently become available in the India. The introduction of these DAA in India at a relatively affordable price has led to great optimism about prospects of cure for these patients as not only will they provide higher efficacy, but combination DAAs as all-oral regimen will result in lower side effects than were seen with pegylated interferon alfa and ribavirin therapy. Availability of these newer DAAs has necessitated revision of INASL guidelines for the treatment of HCV published in 2015. Current considerations for the treatment of HCV in India include the poorer response of genotype 3, nonavailability of many of the DAAs recommended by other guidelines and the cost of therapy. The availability of combination DAA therapy has simplified therapy of HCV with decreased reliance of evaluation for monitoring viral kinetics or drug related side effects.
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Key Words
- ALT, alanine aminotransferase
- ANC, absolute neutrophil count
- AST, aspartate aminotransferase
- CH-C, chronic hepatitis C
- CTP, Child-Turcotte-Pugh
- DAA, directly acting antiviral agents
- DCV, daclatasvir
- EIA, enzyme immunoassay
- ESRD, end-stage renal disease
- EVR, early virological response
- FCH, fibrosing cholestatic hepatitis
- GT, genotype
- HCV
- HCV, hepatitis C virus
- HCWs, healthcare workers
- HIV, human immunodeficiency virus
- INASL, Indian National Association for Study of the Liver
- IU, international units
- LDV, ledipasvir
- LT, liver transplantation
- NS, nonstructural protein
- NSI, needlestick injury
- PCR, polymerase chain reaction
- Peg-IFNα, pegylated interferon alfa
- RBV, ribavirin
- RVR, rapid virological response
- SOF, sofosbuvir
- 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 Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Anil C. Anand
- Department of Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India
| | - Subrat K. Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack 753007, India
| | - Yogesh K. Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | | | - Ajay Kumar
- Department of Gastroenterology and Hepatology, Fortis Escorts Liver and Digestive Diseases Institute, New Delhi 110076, India
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi 110060, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Banaras Hindu University, Varanasi 221005, India
| | - Abraham Koshy
- Department of Hepatology, Lakeshore Hospital, Cochin 682304, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana 141001, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Dharmesh Kapoor
- Department of Gastroenterology, Global Hospital, Hyderabad 500004, India
| | - Kaushal Madan
- Department of Gastroenterology, Artemis Hospital, Gurgaon 122001, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi 110060, India
| | - Manav Wadhawan
- Department of Gastroenterology and Hepatology, Fortis Escorts Liver and Digestive Diseases Institute, New Delhi 110076, India
| | - Amit Goel
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Abhai Verma
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Gaurav Pandey
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Rohan Malik
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Swastik Agrawal
- Department of Gastroenterology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, India
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