Liver histology of children with chronic hepatitis treated with interferon-alpha alone or in combination with lamivudine

The effectiveness of combination therapy with interferon and nucleoside analogs in pediatric patients with chronic hepatitis B: a systematic review and meta-analysis

BACKGROUND

It is a challenging issue regarding the optimal antiviral treatment of children with chronic hepatitis B (CHB). The efficacy comparison of interferon (IFN) or nucleos(t)ide analogs (NAs) monotherapy with their combination could better understand this issue.

METHODS

PubMed, EMBASE, Cochrane Library, Wanfang, CNKI, and abstracts of major international hepatology meetings were searched from inception to Feb 8, 2022. Randomized control trials and observational studies reporting the efficacy of combination therapy with IFN and NAs in children with CHB were eligible.

RESULTS

A total of 17 studies were included. Compared with IFN monotherapy, combination therapy with IFN and NAs was significantly associated with increased rates of HBV DNA undetectable, HBeAg clearance, HBeAg seroconversion, alanine transaminase (ALT) normalization as well as the composite treatment response both at the end of treatment and during the follow-up period (RRs ranged from 1.23 to 1.75). A favorable trend for HBsAg seroconversion was found in IFN plus NAs-treated children, but not for the HBsAg clearance at the end of treatment. Although a similar trend towards the superiority of the combination therapy versus NAs monotherapy was observed (RRs ranged from 1.24 to 2.33) except for the HBV DNA undetectable rate at the end of treatment, the number of reported studies was limited.

CONCLUSIONS

Combination therapy with IFN and NAs is more effective than IFN monotherapy in viral suppression and serological response for children with CHB. More studies were still needed to reveal the efficacy of this combination therapy compared with NAs monotherapy.

Interferon-alpha-2a and zinc combination therapy in children with chronic hepatitis B infection

Zinc has been reported to enhance the response to interferon (IFN) or PEG-IFN plus ribavirin therapy, improve liver function, and ameliorate hematologic side effects in patients with chronic hepatitis C. However, the role of zinc supplementation during IFN therapy in chronic hepatitis B infection (CHB) remains unclear. We therefore aimed to report the results of zinc and IFN-alpha-2a therapy in children with CHB. Twenty-two naive, HBeAg-positive children (mean age 10.4 ± 4.4 years) received IFN-α2a (9 MU/m(2) sc) for 6 months plus peroral zinc (7.5 mg/day for <10 years and 10 mg/day for >10 years) for 12 months. Serum zinc, alanine aminotransferase (ALT), complete blood count, hepatitis B virus DNA (HBV DNA), and serological markers were measured. Histological (HR) and sustained response (SR) were evaluated at 6 months after completion of therapy. Normalization of ALT, HBeAg seroconversion, and HBV DNA < 10,000 copies/ml were considered as SR. HR was defined as decrease in Knodell histological activity index (HAI) score by at least 2 points compared to baseline. End of therapy ALT level and log HBV DNA were significantly lower than pretherapy levels (p = 0.001 and p = 0.001, respectively), while zinc level was not different. Portal inflammation score significantly decreased after therapy (p = 0.043), however, total HAI and other HAI components were not different. SR and HR were 25% and 52.9%. In conclusion as a first study investigating the effect of zinc and IFN combination therapy in children with CHB, SR and HR rates were not better than previously reported monotherapy or combination therapies.

Combination therapy of lamivudine and interferon-alpha in pediatric patients with chronic hepatitis B in Bangladesh: a safe and effective therapeutic approach for pediatric CHB patients in developing countries

Hepatitis B virus (HBV) is mainly transmitted during birth or perinatal period, however, treatment is not usually recommended for pediatric patients with chronic hepatitis B (CHB). Twelve pediatric patients with CHB in Bangladesh were treated with both lamivudine and interferon. Lamivudine was given at a dose of 3 mg/kg, daily for 12 months. Two months after commencement of lamivudine therapy, all patents were given interferon-alpha (3 million IU/square meter of body surface area) three times weekly, subcutaneously for 10 months. Combination therapy was safe for all pediatric CHB patients. The levels of serum HBV DNA became undetectable (less than 500 copies/ml) in 8 patients and reduced in 4 patients after the end of therapy. Anti-HBe was detected in 10 of 12 patients at this time point. The levels of serum alanine aminotransferase (ALT) were significantly reduced in these patients (p less than 0.05) due to therapy. Neither flare of HBV DNA nor elevation of serum ALT were detected during follow-up. In conclusion, combination therapy with lamivudine and interferon-alpha represents a new and novel therapeutic option for treatment of pediatric CHB patients.

Hepatitis B therapy in children

Chronic hepatitis B virus (HBV) infection is a major cause of liver disease throughout the world, leading to cirrhosis and hepatocellular carcinoma in many individuals. Children are more likely to develop chronic HBV infection as they demonstrate greater immunotolerance to the virus, and response to therapy in children remains disappointing. Three therapeutic agents for chronic HBV infection in children have been approved in the USA, including standard IFN-alpha, lamivudine and adefovir. IFN-alpha has been the most effective ( approximately 30% hepatitis B e antigen [HBeAg] seroconversion; 10% hepatitis B surface antigen [HBsAg] seroconversion), although benefits are primarily observed in children with alanine aminotransferase levels over two-times the upper limit of normal and must be weighed against significant side effects. Studies comparing the long-term outcome of chronic hepatitis B in children treated with IFN-alpha and in untreated controls show that the rate of anti-HBeAb seroconversion tends to overlap in treated and untreated patients within a few years of follow-up, suggesting that IFN-alpha simply accelerates a spontaneous event. Lamivudine's virologic response rates mirror those of IFN-alpha (23-31% HBeAg seroconversion) with easier administration and a better safety profile but lower HBsAg seroconversion (2-3%) and high rates of drug resistance. Adefovir data show low rates of resistance and a good safety profile, but virologic response was limited to adolescent patients and was lower than that of lamivudine (16% HBeAg seroconversion; <1% HBsAg seroconversion). Entecavir and tenofovir, both approved therapies for adults with chronic HBV infection, are in trials for use in children. Future therapies will probably include these agents as well as combined therapies. Finally, watchful waiting of children is an option since current therapies are only 30% effective at best, although the long-term impact of therapy in childhood on rates of cirrhosis and hepatocellular carcinoma remains unknown.

Systematic review: combination therapies for treatment-naïve chronic hepatitis B

BACKGROUND

There is a renewed interest in use of combination therapies in treatment-naïve chronic hepatitis B (CHB) because of limitations of monotherapies.

AIM

To discuss the current status of combination therapies in treatment-naïve CHB.

METHODS

PubMed search was done using 'combination', 'sequential' and 'chronic hepatitis B' as the search terms.

RESULTS

The two most popular combination therapies include 'combination of nucleos(t)ide analogues' and 'combination of interferons and nucleos(t)ide analogues'. Combination therapies using two nucleos(t)ide analogues do not lead to higher long-term efficacy. However, addition of a nucleos(t)ide analogue with a good resistance profile to a nucleos(t)ide analogue with a lower genetic barrier to resistance decreases the risk of emergent resistance to the latter. Greater sustained virological, biochemical and seroconversion rates are observed with addition of lamivudine to conventional interferon, but pegylated-interferon monotherapy is equally effective as combination with lamivudine. Again, resistance to lamivudine is lower with its combination with interferons.

CONCLUSIONS

The answer to the question whether hepatitis B can be treated better with combination or monotherapy remains largely unknown. Additional trials are warranted of combination therapies of peginterferon and potent nucleos(t)ide analogues or therapies with the combined use of nucleos(t)ide analogues or immunomodulators.