Randomized controlled trial of recombinant interferon-alpha 2b in the treatment of Chinese patients with chronic hepatitis C

Features of hepatitis C virus infection, current therapies and ongoing clinical trials in ten Asian Pacific countries

Estimated hepatitis C virus (HCV) infection rates in the general populations were 1.3, 0.9, 0.4-1.0, 14.7, 0.1-0.3, 0.9-1.9, 1.0-2.0, 5, 4.4-8.6 and 0.5-1.3 % in Australia, Bangladesh, Mainland China, Egypt, Hong Kong, India, Japan, Pakistan, Taiwan and Turkey, respectively. The main HCV genotypes (Gs) are G1, G3, G1b, G4, G1b, G3, G1b, G3, G1b and G2, and G1 in Australia, Bangladesh, Mainland China, Egypt, Hong Kong, India, Japan, Pakistan, Taiwan and Turkey, respectively. Of IL28B genotypes, favorable alleles are ~50 % in Australia and Turkey, but 60-70 % in most of the other Asian countries. Peginterferon plus ribavirin is available in all ten Asian Pasific countries. In addition, HCV NS3/4A protease inhibitors with peginterferon plus ribavirin are currently available in several countries. Clinical trials of interferon-free regimens for HCV are ongoing in most of the ten Asian Pacific countries.

Health-related quality of life and impact of antiviral treatment in Chinese patients with chronic hepatitis C in Taiwan

AIM

To evaluate health-related quality of life (HRQOL) in Chinese patients with chronic hepatitis C (CH-C), and the impact of antiviral treatment.

METHODS

Short Form 36 (SF-36) Health-related Quality of Life Questionnaires to interview CH-C patients, and age- and sex-matched control subjects at outpatient clinics of a medical center in Taiwan were used. Data were transformed to scores for comparisons of eight major SF-36 domains. We also enrolled consecutive CH-C patients who completed one course of antiviral treatment (interferon alpha with ribavirin), and measured the HRQOL before, at the 12th wk of treatment, at the end of treatment, and at mo 6, after stopping the treatment to evaluate the impact of antiviral treatment.

RESULTS

A total of 371 outpatients were enrolled, including 182 with CH-C and 189 age- and sex-matched subjects without CH-C. CH-C subjects had obviously lower educational status (P<0.01). Mean scores of domains in general health, physical functioning, role-physical, role-emotional, vitality, and mental health of the SF-36 were significantly lower in subjects with CH-C than those without CH-C (P<0.05). In an analysis of 47 CH-C patients who received and completed the whole course of antiviral treatment, mean scores of all domains were significantly lower at wk 12 of treatment compared to baseline. The scores returned to pretreatment values by the end of treatment, but were significantly increased at mo 6 after stopping the treatment. Among the 47 CH-C patients, 21 had sustained responses and 26 had non-sustained responses to antiviral treatment. Compared to pretreatment values, subjects with sustained responses had significantly lower social functioning scores at wk 12 of treatment, and scores for all SF-36 domains returned to pretreatment values, and increased significantly at mo 6 after stopping the treatment. For non-sustained virological responders, scores of all SF-36 domains significantly decreased at wk 12 of treatment, and did not increase significantly by the end of treatment, or at mo 6 after stopping the treatment when compared to the pretreatment values.

CONCLUSION

HRQOL in CH-C patients is significantly impaired in most SF-36 domains. Antiviral treatment impaired HRQOL of CH-C subjects during early treatment, mainly in non-sustained virological responders, and improved at mo 6 after stopping the treatment, mainly in sustained virological responders.

A decade of trials of interferon-alpha for chronic hepatitis C. A meta-regression analysis

The most relevant randomized controlled trials of interferon-alpha (IFN) for naive patients with chronic hepatitis C (CHC) published in a decade, just before appearance of pegylated IFN trials in 2000, were included in this paper. Its purpose is to review the relationship between sustained biochemical response in active versus control group versus usual clinical variables as IFN regimens, cirrhosis, genotype and versus less frequently addressed variables as funding, methodological quality or location of principal author. Meta-analysis estimates of global treatment effect varied according to trial design: group 1=IFN versus placebo/no treatment, 32 RCTs, 2499 pts, OR 9.5 (6.3-14.2); group 2a=comparison of IFN schedules, 43 RCTs, 7454 pts, OR 1.6 (1.4-1.9); group 2b=IFN+other drugs versus standard IFN, 30 RCTs, 4737 pts, OR 2.0 (1.6-2.6). Fixed effects (arm-level) meta-regression on the complete data set (171 arms, 10,580 pts) revealed that sustained response was most likely in experimental arms of IFN+ribavirin or other drugs (OR 2.4), arms using yearly schedule (OR 2.0), trial principal author from Asia (OR 1.7), trial sample size >200 (OR 1.4) and arms enrolling less than 50% of cirrhotics (OR 1.3). Moreover, focus was on some significant interactions too, as the effect of trial's quality interacting to the recorded funding (more benefit if no-profit, less if for-profit) and the effect of trial funding interacting to the location of first author (more benefit if from Asia). Three main effects (experimental arm, cirrhosis, funding) and one interaction (funding*location of principal author) explained 31% of between study variability in a random-effect meta-regression. In a subgroup analysis on a data set including available information on HCV genotype (93 arms, around 7000 pts), meta-regression revealed that genotype 1 or 4 less than 50% per arm and specialistic journal were significant predictors of either biochemical (transaminases) or virological (HCV-RNA) sustained response, in a model including the same main effects identified in the complete data set analysis. Finally, although mostly captured by different IFN regimens along time, heterogeneity of effect in a large set of (not-pegylated) IFN trials was also explained by HCV genotype and variables of quality and reporting, such as trial's principal author from Asia.

High versus standard doses interferon-alpha in the treatment of naïve chronic hepatitis C patients in Taiwan: a 10-year cohort study

Background

Interferon-alpha monotherapy is effective in less than one-third patients with chronic hepatitis C. The dose-effect, tolerability and durability of interferon-alpha treatment and its long-term effect on the prevention of cirrhosis and hepatocellular carcinoma in naïve Taiwanese patients with chronic hepatitis C have not been well investigated. We conducted the present cohort study treated with high and standard interferon-alpha to illustrate the issues.

Methods

We performed a long-term virologic and histological follow-up of 214 chronic hepatitis C patients treated with interferon-alpha, 3 million units (3-MU, n = 80) or 6-MU (n = 134) thrice weekly for 24 weeks, in Taiwan between 1992 and 2001.

Results

There was no difference in the incidence of discontinuation between 3-MU and 6-MU groups (4/80, 5.0% versus 10/134. 7.5%). The 6-MU group had similar incidence of adverse events with the 3-MU group, except that 6-MU group had significantly higher incidence of psychological manifestations, mainly presented as irritability. The rates of sustained virological response (SVR) were significantly higher in 6-MU regimen (37.1%) than in 3-MU regimen (23.7%, p < 0.05) in per protocol analysis. Based on multivariate analysis, baseline viral load was strongly associated with SVR, followed by hepatitis C virus genotype, interferon-alpha regimen, and liver fibrosis. A histological improvement in necroinflammatory activity, but not in fibrosis was observed in the follow-up biopsy performed 0.5–5.5 years (mean: 1.9 years, n = 51) after end-of-treatment. Among patients without SVR, there was more activity improvement in 6-MU group. The durability of SVR was 100% (18/18) and 97.8% (45/46) for 3-MU and 6-MU group, respectively, in a mean follow-up period of 6.81 years (5.25–9.18 years). For 163 baseline non-cirrhotic patients, 9 of 84 (10.7%) non-responders and 3 of 79 (3.8%) sustained responders progressed to cirrhosis during a mean follow-up period of 5.52 and 5.74 years, respectively (p = 0.067, Kaplan-Meier survival analysis, log-rank test). For all 200 patients, hepatocellular carcinoma was detected in 12 of 113 (10.6%) non-responders and one of 87 (1.1%) sustained responders during a mean follow-up period of 5.67 and 5.73 years, respectively (p < 0.01, Kaplan-Meier survival analysis, log-rank test).

Conclusion

We confirm the dose effect of interferon-alpha in chronic hepatitis C. Six-MU regimen had better efficacy than 3-MU regimen in virologic and histological responses. Both regimens had good tolerability and durability in Taiwan. Sustained response could reduce the incidence of cirrhotic change and hepatocarcinogenesis.

Randomized trial of three different regimens for 24 weeks for re-treatment of chronic hepatitis C patients who failed to respond to interferon-alpha monotherapy in Taiwan

With the favorable result of interferon (IFN)-ribavirin combination therapy for 24 weeks among naive Taiwanese chronic hepatitis C (CHC) patients, the optimal regimens of re-treatment for CHC patients who failed initial IFN monotherapy is not well-established. The study evaluated the effectiveness of re-treatment for 24 weeks with 3 different regimens and predictors for sustained virological response (SVR).

METHODS

Total 120 Taiwanese CHC patients (81 males, 70 relapsers, mean age: 48.6 years) who failed initial IFN monotherapy were enrolled. They were assigned randomly (with a ratio of 1:1:2) to receive one of the three regimens for re-treatment for 24 weeks; group A: IFN 6 million units (MU) monotherapy (N=30), group B: combination therapy with ribavirin and IFN 3 MU (N=30) or group C: combination therapy with ribavirin and IFN 6 MU (N=60). The intention-to-treat rate of sustained virological response (SVR) was 38.3%. The SVR rate in group C (53.3%) was significantly higher than group A (16.7%, P<0.005) and group B (30%, P<0.05). Drop-out rates were similar between the three groups. Patients achieving SVR had significant improvement histologically. Hepatitis C virus (HCV) genotype non-1b infection, lower pretreatment HCV RNA levels, combined with ribavirin and with higher IFN dose, and relapsers were independent predictors for SVR.

CONCLUSION

We concluded that more than one-third Taiwanese CHC patients achieved SVR after 24 weeks re-treatment and combination therapy, especially with higher dose of IFN, yielded higher efficacy.

Glucose intolerance in Chinese patients with chronic hepatitis C

AIM: To investigate the prevalence and the risk factors of glucose intolerance in Chinese patients with chronic hepatitis C and to evaluate the relationship between interferon (IFN) treatment and glucose intolerance in these patients.

METHODS: Prospective cross-sectional study was done to evaluate the prevalence of glucose intolerance in Chinese patients with chronic hepatitis C virus (HCV) infection from the outpatient clinic of Department of Family Medicine, Taipei Veterans General Hospital. Chronic hepatitis C was defined as persistent presence of anti-HCV and persistent elevation of liver transaminase for at least 1.5 folds for at least 6 months. Moreover, patients were further categorized into normal fasting glucose and glucose intolerance (diabetes mellitus (DM) and impaired fasting glucose) according to the diagnostic criteria of American Diabetic Association.

RESULTS: Totally, 359 Chinese patients with chronic hepatitis C were enrolled (212 males and 147 females, mean age = 58.1 ± 13.0 years). One hundred and twenty-three patients (34.3%) had received various forms of IFN treatment. One hundred and twenty-five patients (34.6%) had glucose intolerance, including 99 patients (27.6%) with DM and 26 patients (7.0%) with impaired fasting glucose. In comparison with those with normal fasting glucose levels, patients with chronic hepatitis C with glucose intolerance were significantly older, had a significantly higher body mass index, and they were more likely to suffer from obesity, to have family history of diabetes and to have had previous IFN treatment. Stepwise multivariate logistic regression revealed significantly that age 57 years, obesity, previous history of IFN treatment and the presence of family history of diabetes were independent risk factors associated with the presence of glucose intolerance in chronic hepatitis C patients.

CONCLUSION: In conclusion, 34.6% of Chinese patients with chronic hepatitis C had glucose intolerance. Chronic hepatitis C patients who were older in age, obese, had previous IFN treatment history and had family history of diabetes were prone to develop glucose intolerance. To our knowledge, this is the first population-based report to confirm that interferon treatment to be an independent risk factor to develop glucose intolerance.

Hepatic steatosis in chronic hepatitis C virus infection: prevalence and clinical correlation

BACKGROUND AND AIMS

Hepatic steatosis is a histological characteristic in patients with chronic hepatitis C virus (HCV) infection. The aim of this study was to evaluate the prevalence of hepatic steatosis in Chinese patients with chronic hepatitis C, and to look for possible correlation with various histopathological changes and to look for possible correlation with various clinical and pathologic variables.

METHODS

One hundred and six patients were enrolled, and patients with alcoholism or diabetes mellitus were excluded. Clinical, biochemical and virologic data, including HCV genotype and serum HCV-RNA titer and histological findings, were compared between patients with and without hepatic steatosis.

RESULTS

Fifty-five (52%) of the 106 patients with chronic hepatitis C had hepatic steatosis. Patients with hepatic steatosis had significantly higher mean serum levels of triglyceride and gamma-glutamyl transpeptidase, higher body mass index, and a higher incidence of obesity compared with patients without hepatic steatosis. No significant differences in serum HCV-RNA titer and HCV genotype or the response to interferon therapy were noted between the two groups. Histological analysis showed patients with hepatic steatosis had a significantly higher mean fibrotic score than patients without hepatic steatosis (1.9 +/- 1.2 vs 1.3 +/- 1.0; P = 0.016). There were no significant differences in the severity of necroinflammation, the presence of lymphoid aggregation/follicle or bile duct damage between the two groups. Multivariate logistic regression analysis showed that independent predictors associated with hepatic steatosis were obesity or a histology fibrotic score of > or = 2.

CONCLUSION

It was found that 52% of Chinese patients with chronic hepatitis C had hepatic steatosis. Patients with hepatic steatosis were more frequently obese and had more severe hepatic fibrosis.

A randomized, double-blind, controlled trial of consensus interferon in the treatment of Chinese patients with chronic hepatitis C

OBJECTIVE

Patients with chronic hepatitis C virus (HCV) infection have an increased risk of developing cirrhosis or hepatocellular carcinoma. Consensus interferon (CIFN) offers sustained clinical efficacy to patients studied in the Western countries. This randomized, double-blind, controlled trial in 75 Chinese patients with chronic hepatitis C compared treatment with CIFN or placebo to determine whether CIFN had efficacy and safety in Chinese patients similar to that in Western patients.

METHODS

Patients were randomized to receive CIFN (3 microg or 9 microg) or placebo given subcutaneously 3 times/wk for 24 wk, followed by 24 wk of observation. Efficacy was assessed by normalization of serum alanine transaminase (ALT) and clearance of serum HCV RNA concentrations to undetectable levels by reverse-transcription polymerase chain reaction.

RESULTS

There was a greater benefit with CIFN 9 microg than with CIFN 3 microg or placebo. At the end of 24 wk of treatment, the ALT response was 64%, 38.5%, and 8.4% for the 9-microg, 3-microg, and placebo-treated groups, respectively. After an additional 24 wk of observation, sustained ALT responses were 44%, 23.1%, and 12.5% for the 9-microg, 3-microg, and placebo-treated groups, respectively. HCV RNA clearance at the end of treatment was 56%, 42.3%, and 4.2%; and after 24 wk of additional observation, 40%, 11.5%, and 0% for the 9-microg, 3-microg, and placebo-treated groups, respectively. There were no unexpected adverse reactions to CIFN.

CONCLUSIONS

The results show that administration of CIFN subcutaneously at 9 microg 3 times a week is safe and can effectively reduce serum ALT and HCV RNA concentrations in Chinese patients with chronic hepatitis C.

Clinical significance of portal lymphoid aggregates/follicles in Chinese patients with chronic hepatitis C

OBJECTIVE

Portal lymphoid aggregates/follicles (lymphoid A/F) is a characteristically histological finding in patients with chronic hepatitis C. We assessed the prevalence of lymphoid A/F in Chinese patients with chronic hepatitis C and evaluated the correlation of this phenomenon with clinical, biochemical, immunological, virological, and other histological features of these patients.

METHODS

Eighty-nine Chinese patients with chronic hepatitis C were enrolled and portal lymphoid A/F was evaluated in liver biopsy. Clinical, biochemical, immunological, histological, and virological data, including serum HCV RNA titer and HCV genotype and the response to interferon therapy, were compared between patients with and without portal lymphoid A/F.

RESULTS

Twenty-nine (33%) of 89 patients with chronic hepatitis C had portal lymphoid A/F. Patients with lymphoid A/F had a significantly higher frequency of HCV genotype 1b infection (p = 0.039) and had a significantly higher mean score of bile duct damage, periportal necroinflammation, and portal inflammation in liver histologies when compared with patients without lymphoid A/F. No significant difference in sex distribution, mean age, history of blood transfusion, serum liver biochemistry, presence of serum autoantibodies/cryoglobulinemia, serum viral titer, and response to interferon therapy was noted between the two groups. Multivariate logistic regression analysis showed HCV genotype 1b infection and periportal necroinflammation were significant independent predictors associated with portal lymphoid A/F.

CONCLUSIONS

The presence of portal lymphoid A/F in Chinese patients with chronic hepatitis C was significantly correlated with HCV genotype 1b infection and periportal necroinflammation.

Quantitative measurement of serum HCV RNA in patients with chronic hepatitis C: comparison between Amplicor HCV monitor system and branched DNA signal amplification assay

Quantitative measurement of serum hepatitis C virus (HCV) RNA is important in predicting and monitoring the therapeutic effects of interferon in treating patients with chronic hepatitis C. We compared two commercial available assays, Roche Amplicor HCV Monitor test kits and Chiron branched DNA signal amplification (bDNA) assay, in quantitative measurement of serum HCV RNA in 74 patients with chronic hepatitis C. The serum HCV RNA of each of these patients was qualitatively positive by conventional reverse transcription-nested polymerase chain reaction. Serum HCV RNA was detected positive by the Amplicor test kits in 63 (85%) patients and by the bDNA assay in 58 (78%) patients (P > 0.05). The quantitative results of HCV RNA detected by both assays showed a good linear correlation (r = 0.56, P < 0.001). Amplicor test kits detected 5 patients with low viremia which were below the detection limit of the bDNA assay (2.0 x 10(5) genome equivalents/ml). However, the mean HCV RNA values detected by the Amplicor test kits was 1.26 log lower than that of the bDNA assay. The Amplicor test kits detected only 5 samples (8%) with a HCV RNA value greater than 5 x 10(6) copies/ml, while the bDNA assay detected 23 samples (40%) with a HCV RNA value greater than 5 x 10(6) genome equivalents/ml (P < 0.01). HCV genotype did not affect the positive rate of HCV RNA measurement detected by both assays. However, a significantly higher mean serum HCV RNA value was noted in HCV genotype 1b as compared with the other genotypes. We concluded that the Roche Amplicor HCV Monitor test kits and the Chiron branched DNA signal amplification assay are equally sensitive in the quantitative measurement of serum HCV RNA in patients with chronic hepatitis C and can be reliably used in measuring HCV viremia clinically.

Quantitative measurement of serum HCV RNA in patients with chronic hepatitis C: comparison between Amplicor HCV monitor system and branched DNA signal amplification assay

Quantitative measurement of serum hepatitis C virus (HCV) RNA is important in predicting and monitoring the therapeutic effects of interferon in treating patients with chronic hepatitis C. We compared two commercial available assays, Roche Amplicor HCV Monitor test kits and Chiron branched DNA signal amplification (bDNA) assay, in quantitative measurement of serum HCV RNA in 74 patients with chronic hepatitis C. The serum HCV RNA of each of these patients was qualitatively positive by conventional reverse transcription-nested polymerase chain reaction. Serum HCV RNA was detected positive by the Amplicor test kits in 63 (85%) patients and by the bDNA assay in 58 (78%) patients (P > 0.05). The quantitative results of HCV RNA detected by both assays showed a good linear correlation (r = 0.56, P < 0.001). Amplicor test kits detected 5 patients with low viremia which were below the detection limit of the bDNA assay (2.0 x 10(5) genome equivalents/ml). However, the mean HCV RNA values detected by the Amplicor test kits was 1.26 log lower than that of the bDNA assay. The Amplicor test kits detected only 5 samples (8%) with a HCV RNA value greater than 5 x 10(6) copies/ml, while the bDNA assay detected 23 samples (40%) with a HCV RNA value greater than 5 x 10(6) genome equivalents/ml (P < 0.01). HCV genotype did not affect the positive rate of HCV RNA measurement detected by both assays. However, a significantly higher mean serum HCV RNA value was noted in HCV genotype 1b as compared with the other genotypes. We concluded that the Roche Amplicor HCV Monitor test kits and the Chiron branched DNA signal amplification assay are equally sensitive in the quantitative measurement of serum HCV RNA in patients with chronic hepatitis C and can be reliably used in measuring HCV viremia clinically.

Predictive factors in eradicating hepatitis C virus using a relatively small dose of interferon

Interferon (IFN) can reduce hepatitis C virus load and even eliminate the virus in 30-40% of patients. Several predictive factors for eradication of the virus have been reported and a higher dose of IFN tends to result in elimination of the virus. However, a small dose of IFN sometimes is as effective as a large dose in eradicating the virus. The predictive factors for such a response are not well established. We retrospectively analysed 50 patients with chronic hepatitis C who were treated with relatively small amounts of IFN (equal or less than 252 million units). Eleven patients were responders (elimination of hepatitis C virus (HCV) and normalization of alanine amino transferase (ALT) for at least 6 months), but the remaining 39 were non-responders. Multivariate analysis showed that the pretreatment viral load and total dose of IFN per kilogram of bodyweight were significant predictive factors of response to therapy. We also assessed the amino acid substitutions in the IFN sensitivity determining region (ISDR), NS5A codon 2209-2248, of HCV in serum samples obtained from 31 patients with HCV genotype 1b. The presence of more than one amino acid substitution in the ISDR tended to correlate with HCV genotype 1b elimination. As IFN is expensive and has a number of serious side effects, our study suggests that the optimal dose of IFN may vary from one patient to another and that more stringent criteria should be used to select the optimal dose for therapy.

Alpha interferon therapy in Danish haemophiliac patients with chronic hepatitis C: results of a randomized controlled open label study comparing two different maintenance regimens following standard interferon-alpha-2b treatment

Following a survey among all Danish haemophiliac patients 49 HIV-negative patients with chronic hepatitis C were offered enrollment in a randomized controlled open label study comparing two different maintenance regimens following standard interferon-alpha-2b treatment. Dose modifications and treatment discontinuation were based upon changes in transaminase levels. Forty-seven patients enrolled received 3 MU of alpha interferon thrice weekly (TIW) for 3 months. Twenty-six nonresponders had their dose increased to 6 MU TIW for an additional 3 months, while 21 responding patients continued on 3 MU TIW. At 6 months, 25 patients with a complete or a partial biochemical response were randomly allocated to either a fixed dose regimen (13 patients) (3 or 6 MU thrice weekly) or an individualized dose regimen (12 patients) tapering interferon dose from 3 or 6 MU by one-third every 2 months if transaminases were persistently normal. The remaining 22 biochemical nonresponders were followed for an additional 6 months without further treatment. After 12 months of treatment, 18 patients (38%) had a virological response, irrespective of regimen, and seven patients (16%) had a sustained virological and biochemical response after 6 months of follow up. Overall, the individualized treatment regimen did not seem to offer any advantage over the fixed dose regimen. The response to alpha interferon treatment in Danish haemophiliac patients with chronic hepatitis C immediately after treatment is comparable to that obtained in previous studies among nonhaemophiliacs. However, a sustained virological and biochemical response was seen in only 16% of treatment patients.