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Wong YJ, Tran S, Huang CF, Hsu YC, Preda C, Toyoda H, Liu J, Jun DW, Landis C, Huang DQ, Gila A, Negoita L, Yasuda S, Tseng CH, Tsai PC, Uojima H, Nozaki A, Chuma M, Atsukawa M, Ishigami M, Itokawa N, Iio E, Lam CPM, Watanabe T, Asai A, Yokohama K, Abe H, Enomoto M, Kawada N, Tamori A, Lee DH, Jun MJ, Do S, Vo DKH, Liu L, Li J, Ji F, Wang W, Li Y, Wang X, Guo F, Xu Q, Jing L, Ye Q, Pan H, Zhang J, Wen X, Wang Q, Ren H, Cai D, Shang J, Liu J, Lu C, Zang W, Li J, Niu J, Zhang M, Wu C, Huang R, Maeda M, Nakanishi A, Yeh ML, Chuang WL, Huang JF, Dai C, Ishikawa T, Takaguchi K, Senoh T, Trinh HN, Takahashi H, Eguchi Y, Quek SXZ, Haga H, Ogawa E, Wong G, Buti M, Fukunishi S, Ueno Y, Yuen MF, Tanaka Y, Lim SG, Cheung R, Yu ML, Nguyen MH. Real-world treatment outcome with protease inhibitor direct-acting antiviral in advanced hepatitis C cirrhosis: a REAL-C study. Hepatol Int 2023; 17:1150-1161. [PMID: 37273170 DOI: 10.1007/s12072-023-10547-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/04/2023] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Current guidelines discourage the use of direct-acting antiviral (DAA) containing protease-inhibitor (PI) in advanced HCV cirrhosis. We aimed to compare the real-world tolerability of PI vs. non-PI DAA regimens in this population. METHODS We identified advanced cirrhosis patients treated with DAA from the REAL-C registry. The primary outcome was significant worsening or improvement in CPT or MELD scores following DAA treatment. RESULTS From the REAL-C registry of 15,837 patients, we included 1077 advanced HCV cirrhosis patients from 27 sites. 42% received PI-based DAA. Compared to non-PI group, the PI group was older, had higher MELD and higher percentage with kidney disease. Inverse probability of treatment weighting (IPTW; matching on age, sex, history of clinical decompensation, MELD, platelet, albumin, Asia site, Asian ethnicity, hypertension, hemoglobin, genotype, liver cancer, ribavirin) was used to balance the two groups. In the IPTW-matched cohorts, the PI and non-PI groups had similar SVR12 (92.9% vs. 90.7%, p = 0.30), similar percentages of significant worsening in CTP or MELD scores at posttreatment week 12 and 24 (23.9% vs. 13.1%, p = 0.07 and 16.5% vs. 14.6%, p = 0.77), and similar frequency of new HCC, decompensating event, and death by posttreatment week 24. In multivariable analysis, PI-based DAA was not associated with significant worsening (adjusted odds ratio = 0.82, 95% CI 0.38-1.77). CONCLUSION Tolerability and treatment outcomes were not significantly different in advanced HCV cirrhosis treated with PI-based (vs. non-PI) DAA up to CTP-B or MELD score of 15. Safety of PI-based DAA in those with CTP-C or MELD beyond 15 awaits further data.
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Affiliation(s)
- Yu Jun Wong
- Gastroenterology and Hepatology, Changi General Hospital, SingHealth, Singapore, Singapore
- SingHealth Duke-NUS Medicine Academic Clinical Program, Singapore, Singapore
| | - Sally Tran
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Chung-Feng Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Hepatitis Research Center, College of Medicine and Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Yao-Chun Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Carmen Preda
- Clinical Institute of Fundeni, Gastroenterology and Hepatology, Bucharest, Romania
| | - Hidenori Toyoda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Joanne Liu
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA, USA
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Charles Landis
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, WA, USA
| | - Daniel Q Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrei Gila
- Clinical Institute of Fundeni, Gastroenterology and Hepatology, Bucharest, Romania
| | - Livia Negoita
- Clinical Institute of Fundeni, Gastroenterology and Hepatology, Bucharest, Romania
| | - Satoshi Yasuda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Cheng-Hao Tseng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Pei-Chien Tsai
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Hepatitis Research Center, College of Medicine and Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Akito Nozaki
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Makoto Chuma
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Masanori Atsukawa
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norio Itokawa
- Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
| | - Etsuko Iio
- Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Carla Pui-Mei Lam
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
| | - Tsunamasa Watanabe
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Akira Asai
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Keisuke Yokohama
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Hiroshi Abe
- Division of Gastroenterology and Hepatology, Shinmatsudo Central General Hospital, Chiba, Japan
| | - Masaru Enomoto
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Norifumi Kawada
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Akihiro Tamori
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Dong Hyun Lee
- Department of Gastroenterology, Good Gang-An Hospital, Busan, South Korea
| | - Mi Jung Jun
- Department of Gastroenterology, Good Gang-An Hospital, Busan, South Korea
| | - Son Do
- Digestive Health Associates of Texas, Plano, TX, USA
| | - Dang K H Vo
- Digestive Health Associates of Texas, Plano, TX, USA
| | - Li Liu
- Department of Hepatology, The Third People's Hospital of Kunming City, Kunming, China
| | - Junyi Li
- Department of Hepatology, The Third People's Hospital of Kunming City, Kunming, China
| | - Fanpu Ji
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wenjun Wang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yu Li
- Department of Infectious Diseases, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Xiaozhong Wang
- Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi, China
| | - Fen Guo
- Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi, China
| | - Qiang Xu
- Affiliated Traditional Chinese Medicine Hospital of Xinjiang Medical University, Urumqi, China
| | - Liang Jing
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin, China
| | - Qing Ye
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin, China
| | - Hongying Pan
- Department of Hepatology, Zhejiang Provincial People's Hospital Affiliated to Zhejiang University, Hangzhou, China
| | - JiaJie Zhang
- Department of Hepatology, Zhejiang Provincial People's Hospital Affiliated to Zhejiang University, Hangzhou, China
| | - Xie Wen
- Center of Liver Diseases, Beijing Ditan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Qi Wang
- Center of Liver Diseases, Beijing Ditan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Hong Ren
- Department of Infectious Diseases, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dachuan Cai
- Department of Infectious Diseases, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia Shang
- Department of Infectious Diseases, Henan Provincial People's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Junping Liu
- Department of Infectious Diseases, Henan Provincial People's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Chengzheng Lu
- Department of Gastroenterology and Hepatology, The Second People's Hospital of Tianjin, Tianjin, China
| | - Wenqian Zang
- Department of Gastroenterology and Hepatology, The Second People's Hospital of Tianjin, Tianjin, China
| | - Jia Li
- Department of Gastroenterology and Hepatology, The Second People's Hospital of Tianjin, Tianjin, China
| | - Junqi Niu
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Mingyuan Zhang
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Chao Wu
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Rui Huang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Mayumi Maeda
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Akiko Nakanishi
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, China
| | - Ming-Lun Yeh
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Hepatitis Research Center, College of Medicine and Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Wan-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Hepatitis Research Center, College of Medicine and Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Jee-Fu Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Hepatitis Research Center, College of Medicine and Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - ChiaYen Dai
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Hepatitis Research Center, College of Medicine and Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Toru Ishikawa
- Department of Gastroenterology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Koichi Takaguchi
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Tomonori Senoh
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Huy N Trinh
- San Jose Gastroenterology, San Jose, CA, USA
| | - Hirokazu Takahashi
- Liver Center, Saga University Hospital, Saga, Japan
- Division of Metabolism and Endocrinology, Faculty of Medicine, Saga University, Saga, Japan
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga, Japan
- Division of Metabolism and Endocrinology, Faculty of Medicine, Saga University, Saga, Japan
| | - Sabrina Xin Zi Quek
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Hiroaki Haga
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, China
| | - Eiichi Ogawa
- Department of General Internal Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Grace Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Maria Buti
- Liver Unit, Department of Internal Medicine, Hospital Universiti Valle d'Hebron and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Shinya Fukunishi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Yoshiyuki Ueno
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, China
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Yasuhito Tanaka
- Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Seng Gee Lim
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
- Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Hepatitis Research Center, College of Medicine and Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA.
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA.
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Torgersen J, Newcomb CW, Carbonari DM, Rentsch CT, Park LS, Mezochow A, Mehta RL, Buchwalder L, Tate JP, Bräu N, Bhattacharya D, Lim JK, Taddei TH, Justice AC, Re VL. Protease inhibitor-based direct-acting antivirals are associated with increased risk of aminotransferase elevations but not hepatic dysfunction or decompensation. J Hepatol 2021; 75:1312-1322. [PMID: 34333102 PMCID: PMC8604762 DOI: 10.1016/j.jhep.2021.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 07/14/2021] [Accepted: 07/18/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Cases of acute liver injury (ALI) have been reported among chronic HCV-infected patients receiving protease inhibitor (PI)-based direct-acting antiviral (DAA) regimens, but no analyses have compared the risk of ALI in patients receiving PI- vs. non-PI-based DAAs. Thus, we compared the risk of 3 ALI outcomes between patients (by baseline Fibrosis-4 [FIB-4] group) receiving PI-based or non-PI-based DAAs. METHODS We conducted a cohort study of 18,498 patients receiving PI-based DAA therapy (paritaprevir/ritonavir/ombitasvir±dasabuvir, elbasvir/grazoprevir, glecaprevir/pibrentasvir) matched 1:1 on propensity score to those receiving non-PI-based DAAs (sofosbuvir/ledipasvir, sofosbuvir/velpatasvir) in the 1945-1965 Veterans Birth Cohort (2014-2019). During exposure to DAA therapy, we determined development of: i) alanine aminotransferase (ALT) >200 U/L, ii) severe hepatic dysfunction (coagulopathy with hyperbilirubinemia), and iii) hepatic decompensation. We used Cox regression to determine hazard ratios (HRs) with 95% CIs for each ALI outcome within groups defined by baseline FIB-4 (≤3.25; >3.25). RESULTS Among patients with baseline FIB-4 ≤3.25, those receiving PIs had a higher risk of ALT >200 U/L (HR 3.98; 95% CI 2.37-6.68), but not severe hepatic dysfunction (HR 0.67; 95% CI 0.19-2.39) or hepatic decompensation (HR 1.01; 95% CI 0.29-3.49), compared to those receiving non-PI-based regimens. For those with baseline FIB-4 >3.25, those receiving PIs had a higher risk of ALT >200 U/L (HR, 2.15; 95% CI 1.09-4.26), but not severe hepatic dysfunction (HR, 1.23 [0.64-2.38]) or hepatic decompensation (HR, 0.87; 95% CI 0.41-1.87), compared to those receiving non-PI-based regimens CONCLUSION: While risk of incident ALT elevations was increased in those receiving PI-based DAAs in both FIB-4 groups, the risk of severe hepatic dysfunction and hepatic decompensation did not differ between patients receiving PI- or non-PI-based DAAs in either FIB-4 group. LAY SUMMARY Cases of liver injury have been reported among patients treated with protease inhibitor-based direct-acting antivirals for hepatitis C infection, but it is not clear if the risk of liver injury among people starting these drugs is increased compared to those starting non-protease inhibitor-based therapy. In this study, patients receiving protease inhibitor-based treatment had a higher risk of liver inflammation than those receiving a non-protease inhibitor-based treatment, regardless of the presence of pre-treatment advanced liver fibrosis/cirrhosis. However, the risk of severe liver dysfunction and decompensation were not higher for patients treated with protease inhibitor-based regimens.
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Affiliation(s)
- Jessie Torgersen
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Craig W. Newcomb
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dena M. Carbonari
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher T. Rentsch
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Lesley S. Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Alyssa Mezochow
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rajni L. Mehta
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lynn Buchwalder
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Janet P. Tate
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Norbert Bräu
- James J. Peters VA Medical Center, Bronx, NY and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Debika Bhattacharya
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joseph K. Lim
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Amy C. Justice
- VA Connecticut Healthcare System, West Haven, CT, USA,Department of Medicine, Yale School of Medicine, New Haven, CT, USA,Division of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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