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Wei X, Zhao J, Yang L. Cost-effectiveness of new antiviral treatments for non-genotype 1 hepatitis C virus infection in China: a societal perspective. BMJ Glob Health 2021; 5:bmjgh-2020-003194. [PMID: 33246983 PMCID: PMC7703443 DOI: 10.1136/bmjgh-2020-003194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022] Open
Abstract
Objective This study aimed to estimate the cost-effectiveness of direct-acting antivirals (DAAs) among patients with non-genotype 1 for the eradication of hepatitis C virus (HCV) infection in China. Methods A decision-analytic Markov model was developed to estimate the lifetime costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) for DAAs and pegylated interferon plus ribavirin (PEG-RBV) from a societal perspective. The model inputs were derived from the literature, a patient survey, HCV expert opinions and a specialised drug price database available in China. Sensitivity analysis was conducted to evaluate the model robustness and calculate reasonable prices of DAAs. Results For patients infected with HCV genotype 2, the pan-genotypic regimen sofosbuvir/velpatasvir (SOF/VEL) was the most cost-effective strategy compared with PEG-RBV, with an ICER of US$5653/QALY. For genotype 3, the combination of sofosbuvir plus daclatasvir (SOF-DCV) was the most cost-effective approach, with an ICER of US$3314/QALY. All DAA regimens for genotype 6 were cost-saving, and sofosbuvir plus ribavirin (SOF-RBV) was the optimal regimen. One-way sensitivity analysis demonstrated that the ICERs were most sensitive to the utility values, discount rate and drug costs. Probabilistic sensitivity analysis indicated that using a threshold equal to one time the gross domestic product (GDP) per capita in China (US$9769/QALY, 2018), the probability of SOF/VEL, SOF-DCV and SOF-RBV being cost-effective was 58%, 83% and 71% for genotype 2, 3 and 6, respectively. Threshold analysis showed that the price of DAAs should be reduced by some degree to achieve better affordability. Conclusions DAAs were cost-effective compared with traditional treatments. A reasonable reduction in the price of DAAs will increase drug affordability and is of great significance as a global strategy to eradicate viral hepatitis.
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Affiliation(s)
- Xia Wei
- Department of Health policy and management, School of Public Health, Peking University, Beijing, China
| | - Jingyu Zhao
- Department of Health policy and management, School of Public Health, Peking University, Beijing, China
| | - Li Yang
- Department of Health policy and management, School of Public Health, Peking University, Beijing, China
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Baatarkhuu O, Lee JS, Amarsanaa J, Kim DY, Ahn SH, Naranzul N, Enkhtuya D, Choijamts N, Batbayar P, Otgonbayar R, Saruul BU, Gantuul C, Gegeebadrakh B, Tuvshinbayar N, Badamsuren D, Ulzmaa G, Otgonbold J, Han KH. Efficacy and safety of ledipasvir/sofosbuvir in 5,028 Mongolian patients infected with genotype 1 hepatitis C virus: A multicenter study. Clin Mol Hepatol 2021; 27:125-135. [PMID: 33242929 PMCID: PMC7820214 DOI: 10.3350/cmh.2020.0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIMS Ledipasvir/sofosbuvir (LDV/SOF) shows high efficacy and safety in patients with genotype 1-hepatitis C virus (HCV). We aimed to investigate the efficacy and safety of LDV/SOF in real-world Mongolian patients. METHODS Between 2015 to 2019, 23 (0.5%) and 5,005 patients (99.5%) with genotype 1a and 1b HCV, respectively, were treated with a fixed-dose tablet containing 90 mg ledipasvir and 400 mg sofosbuvir for 12 weeks, and 81 patients (1.6%) with previous experience of interferon (IFN)-based treatment received additional 1,000 mg ribavirin. HCV RNA was measured at 4, 12, and 24 weeks after the first dose to determine rapid virologic response, end of treatment response (ETR), and sustained virologic response at 12 weeks after end of treatment (SVR12). RESULTS Most patients (n=5,008; 99.6%) achieved ETR and SVR12 without virologic relapse. Patients with genotype 1a showed low rates of ETR and SVR12 in only 16 patients (69.6%). There was no significant difference in SVR12 rate between patients regardless of IFN experience (n=81; 1.6%), cirrhosis (n=1,151; 22.9%), HCV RNA >6×106 IU/mL (n=866; 17.2%), or liver stiffness >9.6 kPa (n=1,721; 34.2%) (100.0%, 99.3%, 99.4%, and 99.4%, respectively). No severe adverse events (AEs) were reported, and there was no dose reduction or interruption due to AE. The most common AEs were headache (n=472; 9.4%), fatigue (n=306; 6.2%), abdominal discomfort (n=295; 5.9%), and skin rash (n=141; 2.8%). CONCLUSION LDV/SOF showed high efficacy and safety for patients with genotype 1, especially 1b HCV, in Mongolia. The real-world data might be applicable to patients in other Asian-Pacific countries.
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Affiliation(s)
- Oidov Baatarkhuu
- Department of Infectious Diseases, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Mongolian Academy of Medical Sciences, Ulaanbaatar, Mongolia
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
| | - Jae Seung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jazag Amarsanaa
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Hepatology, Happy Veritas Liver Diagnostics Center, Ulaanbaatar, Mongolia
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Nyamsuren Naranzul
- Department of Infectious Diseases, School of Medicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
| | - Damba Enkhtuya
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Hepatology, Happy Veritas Liver Diagnostics Center, Ulaanbaatar, Mongolia
| | - Nagir Choijamts
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Hepatology, Happy Veritas Liver Diagnostics Center, Ulaanbaatar, Mongolia
| | - Purev Batbayar
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Hepatology, Happy Veritas Liver Diagnostics Center, Ulaanbaatar, Mongolia
| | - Radnaa Otgonbayar
- Department of Internal Medicine, University General Hospital, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Bat-Ulzii Saruul
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Hepatology, National Center for Communicable Diseases, Ulaanbaatar, Mongolia
| | - Chuluunbaatar Gantuul
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Hepatology, National Center for Communicable Diseases, Ulaanbaatar, Mongolia
| | - Baljinnyam Gegeebadrakh
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Gastroenterology, Second State Central Hospital, Ulaanbaatar, Mongolia
| | - Narangerel Tuvshinbayar
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Gastroenterology, Second State Central Hospital, Ulaanbaatar, Mongolia
| | - Dorjgotov Badamsuren
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Gastroenterology, Third State Central Hospital, Ulaanbaatar, Mongolia
| | - Galsan Ulzmaa
- Mongolian Association for the Study of Liver Diseases, Ulaanbaatar, Mongolia
- Department of Gastroenterology, Third State Central Hospital, Ulaanbaatar, Mongolia
| | - Jamiyandorj Otgonbold
- School of Dentistry, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Zeng QL, Yu ZJ, Shang J, Xu GH, Sun CY, Liu N, Li CX, Lv J, Liu YM, Liang HX, Li ZQ, Pan YJ, Hu QY, Li W, Zhang DW, Wang FS. Short-term Peginterferon-Induced High Functional Cure Rate in Inactive Chronic Hepatitis B Virus Carriers With Low Surface Antigen Levels. Open Forum Infect Dis 2020; 7:ofaa208. [PMID: 32626791 PMCID: PMC7324053 DOI: 10.1093/ofid/ofaa208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/28/2020] [Indexed: 12/25/2022] Open
Abstract
Background None of the current guidelines recommend antiviral therapy for inactive hepatitis B virus (HBV) carriers (IHCs). Methods In this real-world, multicenter, nonrandomized study, 32 participants meeting the inclusion criteria were enrolled 1:1 for treatment with peginterferon α-2b or monitoring without treatment based on participant preference. The expected treatment duration was 48 weeks. The primary end point was hepatitis B surface antigen (HBsAg) loss. The HBV vaccine could be injected after HBsAg loss. Results All patients had HBsAg levels of <20 IU/mL. The mean baseline HBsAg levels were 6.6 IU/mL and 5.8 IU/mL in the treated and untreated groups, respectively. Fifteen (93.8%) participants achieved HBsAg loss, 5 obtained HBsAg seroconversion after undergoing a mean of 19.7 weeks of therapy in the treated group, and no one in the follow-up group achieved HBsAg loss during a mean follow-up time of 12.6 months (P < .0001). Generally, the therapy was well tolerated. Nine of 11 individuals who exhibited HBsAg loss benefited from receiving the HBV vaccine. Conclusions This study provides justification for further studies of short-course peginterferon α-2b for the functional cure of IHCs with low HBsAg levels. Additionally, HBV vaccine injection is beneficial after interferon-induced HBsAg loss.
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Affiliation(s)
- Qing-Lei Zeng
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zu-Jiang Yu
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Jia Shang
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
| | - Guang-Hua Xu
- Department of Infectious Diseases, The Affiliated Hospital of Yan'an University, Yan'an, Shaanxi Province, China
| | - Chang-Yu Sun
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Na Liu
- Department of Infectious Diseases, The Affiliated Hospital of Yan'an University, Yan'an, Shaanxi Province, China
| | - Chun-Xia Li
- Department of Infectious Diseases, The Affiliated Hospital of Yan'an University, Yan'an, Shaanxi Province, China
| | - Jun Lv
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yan-Min Liu
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Hong-Xia Liang
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhi-Qin Li
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Ya-Jie Pan
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Qiu-Yue Hu
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wei Li
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
| | - Da-Wei Zhang
- Treatment and Research Center for Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fu-Sheng Wang
- Treatment and Research Center for Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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Nguyen DT, Tran TTT, Nghiem NM, Le PT, Vo QM, Day J, Rahman M, Le HM. Effectiveness of sofosbuvir based direct-acting antiviral regimens for chronic hepatitis C virus genotype 6 patients: Real-world experience in Vietnam. PLoS One 2020; 15:e0233446. [PMID: 32433676 PMCID: PMC7239434 DOI: 10.1371/journal.pone.0233446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/05/2020] [Indexed: 12/22/2022] Open
Abstract
Background Hepatitis C virus (HCV) genotype 6 is the commonest cause of chronic hepatitis C infection in much of southeast Asia, but data on the effectiveness of direct-acting antiviral agents (DAAs) against this genotype are limited. We conducted a retrospective cohort study of patients attending the Hospital for Tropical Diseases (HTD), Ho Chi Minh City, Vietnam, to define the effectiveness of DAAs in the treatment of chronic HCV genotype 6 in actual practice. Methods We included all patients with genotype 6 infections attending our hospital between March 2016 and October 2017 who received treatment with sofosbuvir-based DAA treatment regimens, and compared their responses with those with genotype 1 infections. Results 1758 patients (1148 genotype 6, 65.4%; 610 genotype 1, 34.6%) were analyzed. The majority of patients (1480, 84.2%) received sofosbuvir/ledipasvir (SOF/LDV) ± ribavirin (RBV); 278 (15.8%) received sofosbuvir/Daclatasvir (SOF/DCV) ± RBV. The median age of the patients was 57 years, (interquartile range (IQR) 46–64 years) The baseline HCV viral load (log IU/ml) was significantly higher in patients infected with genotype 6 compared with those infected with genotype 1 (6.8, 5.3–6.6 versus 6.3, 5.3–6.5 log10 IU/ml, p = <0.001, Mann Whitney U test). A sustained virological response (SVR), defined as an undetectable viral load measured between 12 and 24 weeks after completing treatment, and indicating cure, was seen in 97.3% (1711/1758) of patients. Treatment failure, defined as HCV viral load ≥15 IU/ml ≥12 weeks after completing treatment appeared to be more frequent in patients infected with genotype 6 virus (3.2%, 37/1148) than in those infected with genotype 1 (1.7%, 10/610), p = 0.050 chi-squared test). We found no evidence that patient’s age, gender, liver cirrhosis, diabetes, HBV or HIV coinfection, prior treatment failure with pegylated interferon therapy, body mass index (BMI), aspartate aminotransferase to platelet ratio index (APRI), or fibrosis 4 (FIB-4) index were associated with treatment failure. Conclusions Our study suggests that patients with HCV genotype 6 infection in Vietnam may respond less well to treatment with sofosbuvir based DAAs than patients with genotype 1 infections. Further studies are needed to confirm this observation and to define whether it is driven by genotype-specific mutations.
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Affiliation(s)
| | - Thanh Thi Thanh Tran
- Oxford University Clinical Research Unit, Wellcome Trust Asia Programme, The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Ngoc My Nghiem
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Phuong Thanh Le
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Quang Minh Vo
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Jeremy Day
- Oxford University Clinical Research Unit, Wellcome Trust Asia Programme, The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Motiur Rahman
- Oxford University Clinical Research Unit, Wellcome Trust Asia Programme, The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
- * E-mail:
| | - Hung Mạnh Le
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
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McCabe L, White IR, Chau NVV, Barnes E, Pett SL, Cooke GS, Walker AS. The design and statistical aspects of VIETNARMS: a strategic post-licensing trial of multiple oral direct-acting antiviral hepatitis C treatment strategies in Vietnam. Trials 2020; 21:413. [PMID: 32423467 PMCID: PMC7236096 DOI: 10.1186/s13063-020-04350-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/25/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Eliminating hepatitis C is hampered by the costs of direct-acting antiviral treatment and the need to treat hard-to-reach populations. Access could be widened by shortening or simplifying treatment, but limited research means it is unclear which approaches could achieve sufficiently high cure rates to be acceptable. We present the statistical aspects of a multi-arm trial designed to test multiple strategies simultaneously and a monitoring mechanism to detect and stop individual randomly assigned groups with unacceptably low cure rates quickly. METHODS The VIETNARMS trial will factorially randomly assign patients to two drug regimens, three treatment-shortening strategies or control, and adjunctive ribavirin or no adjunctive ribavirin with shortening strategies (14 randomly assigned groups). We will use Bayesian monitoring at interim analyses to detect and stop recruitment into unsuccessful strategies, defined by more than 0.95 posterior probability that the true cure rate is less than 90% for the individual randomly assigned group (non-comparative). Final comparisons will be non-inferiority for regimens (margin 5%) and strategies (margin 10%) and superiority for adjunctive ribavirin. Here, we tested the operating characteristics of the stopping guideline for individual randomly assigned groups, planned interim analysis timings and explored power at the final analysis. RESULTS A beta (4.5, 0.5) prior for the true cure rate produces less than 0.05 probability of incorrectly stopping an individual randomly assigned group with a true cure rate of more than 90%. Groups with very low cure rates (<60%) are very likely (>0.9 probability) to stop after about 25% of patients are recruited. Groups with moderately low cure rates (80%) are likely to stop (0.7 probability) before overall recruitment finishes. Interim analyses 7, 10, 13 and 18 months after recruitment commences provide good probabilities of stopping inferior individual randomly assigned groups. For an overall true cure rate of 95%, power is more than 90% to confirm non-inferiority in the regimen and strategy comparisons, regardless of the control cure rate, and to detect a 5% absolute difference in the ribavirin comparison. CONCLUSIONS The operating characteristics of the stopping guideline are appropriate, and interim analyses can be timed to detect individual randomly assigned groups that are highly likely to have suboptimal performance at various stages. Therefore, our design is suitable for evaluating treatment-shortening or -simplifying strategies. TRIAL REGISTRATION ISRCTN registry: ISRCTN61522291. Registered on 4 October 2019.
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Affiliation(s)
- Leanne McCabe
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, WC1V 6LJ London, UK
| | - Ian R. White
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, WC1V 6LJ London, UK
| | | | | | - Sarah L. Pett
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, WC1V 6LJ London, UK
| | | | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, 90 High Holborn, WC1V 6LJ London, UK
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Systematic Review with Meta-Analysis: Efficacy and Safety of Direct-Acting Antivirals for Chronic Hepatitis C Genotypes 5 and 6. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2301291. [PMID: 31815126 PMCID: PMC6877942 DOI: 10.1155/2019/2301291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/14/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
Direct-acting antivirals (DAAs) are modern treatments for chronic hepatitis C infection, but majority of available evidence on its treatment effect covers genotypes 1 to 4. Therefore, the efficacy and safety of DAAs for genotypes 5 and 6 need to be analysed. Studies were identified from Medline, Scopus, and CENTRAL and a Chinese database CNKI, from inception until Dec 4, 2018. Clinical trials were included if they enrolled patients with genotypes 5 and/or 6 infection, any type of second-generation DAAs was studied, and sustained virological response was assessed at the 12th week after treatment (SVR12) as outcome measure. Meta-analysis using metaprop statistical program was applied for pooling proportions if data were sufficient (i.e., at least 2 studies). Thirteen studies were included in the analysis. Four studies assessed the efficacy of four DAA regimens in genotype 5 patients, which were mainly sofosbuvir (SOF) plus pegylated-interferon/ribavirin (PR) or other DAAs, with SVR12 ranging from 94.4% to 100%. Twelve studies assessed the efficacy of seven DAA regimens among genotype 6 patients, but only two DAA regimens (i.e., SOF + PR and SOF/ledipasvir) had sufficient data for pooling. The pooled SVR12 rates (95% CI) were 99.6% (92.2 to 100) for SOF + PR and 99.2% (96.5 to 100) for SOF/ledipasvir. No treatment-related serious adverse event was reported, while the nonserious adverse events were comparable to other genotypes. In conclusion, DAAs are effective and may be safe for the treatment of chronic hepatitis C genotypes 5 and 6. However, our evidence is based on noncomparative studies; hence, further larger-scale randomized controlled trials in these genotypes are still required.
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Thu Thuy PT, Bunchorntavakul C, Tan Dat H, Palecki J, Reddy KR. Sofosbuvir-ledipasvir with or without ribavirin for chronic hepatitis C genotype-1 and 6: real-world experience in Vietnam. Antivir Ther 2019; 23:415-423. [PMID: 29303482 DOI: 10.3851/imp3217] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Therapy with sofosbuvir-ledipasvir (SOF-LDV) has been very effective in chronic HCV genotype-1 in clinical trials and several real-world cohorts. However, the safety and efficacy data of SOF-LDV for HCV genotype-6 is quite limited. METHODS This open-label, clinical experience evaluated the safety and efficacy of SOF-LDV with or without ribavirin (RBV) for 12-24 weeks in patients with HCV genotype-1 (n=356) and genotype-6 (n=175) in Vietnam between September 2015 and May 2017. RESULTS Among 539 patients evaluated for therapy, 531 patients completed treatment with either SOF-LDV for 12 weeks (n=284); SOF-LDV + RBV for 12 weeks (n=109); SOF-LDV for 24 weeks (n=36); or SOF-LDV + RBV for 24 weeks (n=102). 45% were male with a mean age of 56.3 (range 20-87) years. The mean HCV RNA was 4,370,000 IU/ml and 72.7% had high viral load of >800,000 IU/ml. 17.3% failed prior interferon-based therapy and 52.5% had advanced fibrosis (F3-4) as noted by transient elastography. The overall sustained virological response (SVR12) rate was 99.6% (529/531). Virological relapses occurred in two patients with genotype-1 in the SOF-LDV for 12 weeks and SOF-LDV + RBV for 24 weeks treatment groups. There was no significant difference in demographic data and treatment outcomes between patients with genotype-1 versus 6. Adverse events were mild with all SOF-LDV regimens, but appeared to be more common with 24-week treatment groups. CONCLUSIONS SOF-LDV with or without RBV was highly effective and safe in Vietnamese patients with HCV genotype-1 and 6.
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Affiliation(s)
| | | | - Ho Tan Dat
- Medic Medical Center, Ho Chi Minh City, Vietnam
| | - Julia Palecki
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
OBJECTIVE Direct-acting antiviral agents (DAAs) have been approved for treating hepatitis C virus (HCV) infection in China. However, they are substantially more expensive. The current analysis will investigate the cost-effectiveness of novel regimens compared with pegylated interferon and ribavirin (PR) therapies for informing Chinese decision-makers. METHODS A Markov model was developed to measure economic and health outcomes of novel regimens for genotype 1b, 2, 3, and 6 HCV infections compared with PR treatment. Clinical, cost, and utility inputs were gathered from published sources. Discounted quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) are shown. The uncertainty was facilitated by one-way and probabilistic sensitivity analyses. RESULTS For genotype 1b HCV infection, the combination of paritaprevir, ritonavir, ombitasvir and dasabuvir was cost-saving compared with four competing alternatives. The ICERs of sofosbuvir plus ribavirin for genotypes 2 and 3 were lower than the threshold ($18,234/QALY). Among available strategies for patients with genotype 6, sofosbuvir in combination with ribavirin was the cost-saving alternative compared with PR. The results were robust to sensitivity analyses. CONCLUSIONS For both genotype 1b and 6 HCV infections in the context of Chinese patients, there were combinations of DAAs that were cost-saving compared with the usual PR treatment, and cost-effective for genotypes 2 and 3.
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Affiliation(s)
- Bin Wu
- a Medical Decision and Economic Group, Department of Pharmacy , Ren Ji Hospital, South Campus , School of Medicine , Shanghai Jiaotong University , Shanghai , PR China
| | - Zhenhua Wang
- b Department of Gastroenterology , Ren Ji Hospital , School of Medicine , Shanghai Jiaotong University , Shanghai , PR China
| | - Qing Xie
- c Department of Infectious Diseases, Ruijin Hospital , Shanghai Jiaotong University School of Medicine , Shanghai , PR China
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Luo A, Xu P, Wang J, Li Z, Wang S, Jiang X, Ren H, Luo Q. Efficacy and safety of direct-acting antiviral therapy for chronic hepatitis C genotype 6: A meta-analysis. Medicine (Baltimore) 2019; 98:e15626. [PMID: 31096473 PMCID: PMC6531202 DOI: 10.1097/md.0000000000015626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/15/2019] [Accepted: 04/18/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Because of the heterogeneity of hepatitis C virus (HCV) distribution of different genotypes, large-scale clinical trials on direct-acting antiviral (DAA) mainly included patients with genotype 1 and genotype 3 infection. Data on the efficacy of direct-acting antiviral agents in patients with chronic genotype 6 HCV infection are limited. METHODS The PubMed, Embase, and the Cochrane Libraries were searched comprehensively. All published clinical trials assessing the efficacy of DAA therapy for patients with chronic genotype 6 HCV infection were included. Sustained virological response (SVR) and rapid virological response (RVR) were pooled. Additional meta-analyses were also performed to compare the efficacy of DAA therapy in HCV-6 versus HCV-1 or HCV-3 patients. RESULTS Seventeen studies met the inclusion criteria and were included in our meta-analysis. The pooled SVR of all single arms was 95% [95% confidence interval (CI): 0.90-0.97]. The pooled RVR of all single arms was 97% (95% CI: 0.95-0.99). The SVR and RVR were both similar between HCV-6 and HCV-1 or HCV-3. Adverse events were common but rarely caused treatment interruption. CONCLUSION Based on the available data, our results indicate that DAA treatment is effective and safe for patients with genotype 6 HCV infection, and the efficacy was similar compared to patients with genotype 1 HCV or genotype 3 HCV infection.
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Mettikanont P, Bunchorntavakul C, Reddy KR. Systematic review: epidemiology and response to direct-acting antiviral therapy in genotype 6 chronic hepatitis C virus infection. Aliment Pharmacol Ther 2019; 49:492-505. [PMID: 30687952 DOI: 10.1111/apt.15100] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 10/07/2018] [Accepted: 11/27/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) genotype 6 (GT6) is predominantly encountered in Southeast Asia and data on GT6 response to direct-acting antiviral (DAA) therapy are relatively limited. AIM To review the epidemiology and virologic outcome of DAA regimens in HCV GT6 patients. METHODS Electronic literature search of PubMed, EMBASE, and The Cochrane Library databases were conducted. RESULTS Hepatitis C virus genotype 6 is the most genetically diverse, has a prevalence of 19.9%-95.6% in HCV infected patients in Southeast Asia and has been associated with a higher risk of HCC in those with cirrhosis. After an extensive literature review, a total of 20 studies were selected to assess study population and treatment outcomes (total of 938 GT6 patients were included); 12 were clinical trials and eight were observational studies. Sustained virologic response at week 12 (SVR 12) following glecaprevir/pibrentasvir (n = 4; 108 patients), ledipasvir/sofosbuvir (n = 8; 427 patients), sofosbuvir/velpatasvir with or without voxilaprevir (n = 5; 171 patients), sofosbuvir/daclatasvir (n = 3; 172 patients) and sofosbuvir with ribavirin (n = 3; 60 patients) was 98%-100%, 64%-100%, 100%, 88%-94% and 100%, respectively. Failure was mostly in those with cirrhosis and prior treatment experience. DAA therapy was well tolerated and with a serious adverse event rate of <5%. CONCLUSIONS Hepatitis C virus genotype 6 is genetically diverse and is highly prevalent in Asia. While SVR rates have been high, cirrhosis and prior treatment experience marginally compromise response to DAAs. Large scale and exclusive studies in HCV genotype 6 prevalent areas are needed, while the current evidence suggests that DAAs are highly effective and safe.
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Affiliation(s)
| | - Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Hu C, Yuan G, Liu J, Huang H, Ren Y, Li Y, Chen X, Li W, Wu T, Deng H, Peng Y, Zhang YY, Zhou Y. Sofosbuvir-Based Therapies for Patients with Hepatitis C Virus Infection: Real-World Experience in China. Can J Gastroenterol Hepatol 2018; 2018:3908767. [PMID: 30538973 PMCID: PMC6258099 DOI: 10.1155/2018/3908767] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/06/2018] [Accepted: 07/02/2018] [Indexed: 01/13/2023] Open
Abstract
Background and Aims There is scarcity of data in literature regarding the treatment response to sofosbuvir- (SOF-) based therapies in Chinese patients with chronic Hepatitis C Virus (HCV) infection. The aim of this study was to evaluate the efficacy and safety of SOF-based regimens for chronic hepatitis C (CHC) patients without cirrhosis in a real-world setting in mainland China. Methods A total of 226 patients receiving SOF plus daclatasvir (DCV), ledipasvir (LDV), or velpatasvir (VEL) were enrolled from December 2014 to June 2017. The primary observation point was the percentage of patients with a sustained virologic response (SVR) at posttreatment week 12 (SVR12), and all adverse events were monitored during treatment and follow-up period. Results The overall SVR12 rate was 96% (216/226), and individual SVR12 ranged from 93% to 100% in different treatment groups. No significant differences of efficacy were detected between genotypes 1b and 6a (98% for GT 1b versus 100% for GT 6a, P=0.322). Comparing the high success rates in GT 1b and 6a patients, SVR12 was relatively low in GT 3a and 3b patients. A significant difference in efficacy was observed between GT 3 and not GT 3 patients (77% versus 98%, respectively, P<0.001). No significant differences in efficacy were detected among different regimens (93% versus 97% versus 100%, respectively, P=0.153), gender (95% for male versus 96% for female, P=0.655), or baseline HCV RNA lever (96% versus 95%, respectively, P=0.614). Similar SVR rates were also obtained in naïve and previously treated patients (98% versus 93%, respectively, P=0.100). Conclusions NS5B polymerase inhibitor SOF plus one of the NS5A inhibitors, such as DCV, LDV, or VEL for 12 weeks was associated with high SVR12 rates and well tolerated in HCV-infected patients without cirrhosis. Moreover, patients with DAAs failure should be retreated with more effective regimens like SOF/VEL.
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Affiliation(s)
- Chengguang Hu
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guosheng Yuan
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junwei Liu
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Huaping Huang
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanyu Ren
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yinping Li
- Department of Infectious Diseases, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Xuefu Chen
- Department of Infectious Diseases, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Wei Li
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
| | - Tao Wu
- Department of Infectious Disease, Hainan General Hospital, Haikou City, Hainan Province, China
| | - Hong Deng
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yanzhong Peng
- Department of Infectious Diseases, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | | | - Yuanping Zhou
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China
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12
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Wei L, Xie Q, Hou JL, Jia J, Li W, Xu M, Li J, Wu S, Cheng J, Jiang J, Wang G, Yang Y, Mou Z, Gao ZL, Gong G, Niu JQ, Hu P, Tang H, Lin F, Dou X, Li L, Zhang LL, Nan Y, Massetto B, Yang JC, Knox SJ, Kersey K, German P, Mo H, Jiang D, Brainard DM, Jiang J, Ning Q, Duan Z. Sofosbuvir plus ribavirin with or without peginterferon for the treatment of hepatitis C virus: Results from a phase 3b study in China. J Gastroenterol Hepatol 2018; 33:1168-1176. [PMID: 29380415 DOI: 10.1111/jgh.14102] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/10/2018] [Accepted: 01/17/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Sofosbuvir is a nucleotide analog inhibitor of the hepatitis C virus (HCV) NS5B RNA polymerase with pangenotypic potency. This phase 3b study evaluated the safety and efficacy of sofosbuvir + ribavirin ± peginterferon in Chinese patients infected with HCV genotype 1, 2, 3, or 6. METHODS Patients with genotype 1 or 6 received sofosbuvir + peginterferon/ribavirin for 12 weeks or sofosbuvir + ribavirin for 24 weeks, depending on prior treatment and interferon eligibility. Patients with genotype 2 or 3 received sofosbuvir + ribavirin for 12 or 24 weeks, respectively. The primary endpoint was sustained virologic response at 12 weeks after the end of treatment (SVR12). RESULTS Of 389 patients, 42% had genotype 1, 16% genotype 2, 32% genotype 3, and 9% genotype 6. Half were male, 58% were treatment-naïve, and 15% had cirrhosis. SVR12 rates for patients receiving 12 weeks of sofosbuvir + peginterferon/ribavirin were 94% (95% confidence interval [CI], 87-98%) for HCV genotype 1 and 97% (95% CI, 84-100%) for genotype 6. SVR12 rates for those receiving sofosbuvir + ribavirin for 24 weeks were 95% (95% CI, 87-99%) for genotype 1, 100% (95% CI, 40-100%) for genotype 6, and 95% (95% CI, 90-98%) for genotype 3. For genotype 2 patients receiving sofosbuvir + ribavirin for 12 weeks, the SVR12 rate was 92% (95% CI, 83-97%). Twenty patients (5%) relapsed. Ten (3%) experienced serious adverse events. Three (< 1%) discontinued treatment because of adverse events, of whom one died because of treatment-unrelated adverse events. CONCLUSIONS Sofosbuvir-based regimens were highly effective and safe in Chinese patients with HCV genotype 1, 2, 3, or 6, suggesting sofosbuvir could serve as the backbone for HCV treatment in China irrespective of genotype.
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Affiliation(s)
- Lai Wei
- Peking University People's Hospital, Beijing, China
| | - Qing Xie
- Shanghai Jiaotong University Ruijin Hospital, Shanghai, China
| | - Jin Lin Hou
- Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Jidong Jia
- Beijing Friendship Hospital Affiliated with Capital Medical University, Beijing, China
| | - Wu Li
- The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Min Xu
- Guangzhou Eighth People's Hospital, Guangzhou, China
| | - Jun Li
- First Affiliated Hospital, Nanjiang Medical University, Nanjing, China
| | - Shanming Wu
- Clinical Center of Shanghai Public Health, Shanghai, China
| | - Jun Cheng
- Beijing Ditan Hospital Affiliated with Capital Medical University, Beijing, China
| | - Jianning Jiang
- The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | | | | | | | - Zhi Liang Gao
- The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Guozhong Gong
- The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jun Qi Niu
- The First Hospital of Jilin University, Changchun, China
| | - Peng Hu
- The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Tang
- West China Hospital, Sichuan University, Chengdu, China
| | - Feng Lin
- Hainan General Hospital, Hainan, China
| | - Xiaoguang Dou
- Shengjing Hospital of China Medical University, Shenyang, China
| | - Lanjuan Li
- The First Affiliated Hospital Zhejiang University Medical College, Hangzhou, China
| | - Lun Li Zhang
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuemin Nan
- The Third Hospital of Hebei Medical University, Hebei, China
| | | | | | | | | | | | - Hongmei Mo
- Gilead Sciences, Inc., Foster City, CA, USA
| | | | | | - Jiaji Jiang
- First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Qin Ning
- Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhongping Duan
- Beijing You'an Hospital Affiliated with Capital Medical University, Beijing, China
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13
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Tam E, Luetkemeyer AF, Mantry PS, Satapathy SK, Ghali P, Kang M, Haubrich R, Shen X, Ni L, Camus G, Copans A, Rossaro L, Guyer B, Brown RS. Ledipasvir/sofosbuvir for treatment of hepatitis C virus in sofosbuvir-experienced, NS5A treatment-naïve patients: Findings from two randomized trials. Liver Int 2018; 38:1010-1021. [PMID: 29091342 PMCID: PMC5930158 DOI: 10.1111/liv.13616] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/21/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS We report data from two similarly designed studies that evaluated the efficacy, safety, and optimal duration of ledipasvir/sofosbuvir (LDV/SOF) ± ribavirin (RBV) for retreatment of chronic hepatitis C virus (HCV) in individuals who failed to achieve sustained virological response (SVR) with prior SOF-based, non-NS5A inhibitor-containing regimens. METHODS The RESCUE study enrolled HCV mono-infected adults with genotype (GT) 1 or 4. Non-cirrhotic participants were randomized to 12 weeks of LDV/SOF or LDV/SOF + RBV. Compensated cirrhotic participants were randomized to LDV/SOF + RBV (12 weeks) or LDV/SOF (24 weeks). The AIDS Clinical Trials Group A5348 study randomized genotype 1 adults with HCV/HIV co-infection to LDV/SOF + RBV (12 weeks) or LDV/SOF (24 weeks). Both studies used SVR at 12 weeks post-treatment (SVR12) as the primary endpoint. RESULTS In the RESCUE study, 82 participants were randomized and treated, and all completed treatment. Overall, SVR12 was 88% (72/82); 81-100% in non-cirrhotic participants treated with LDV/SOF or LDV/SOF + RBV for 12 weeks and 80-92% in cirrhotic participants treated with LDV/SOF + RBV for 12 weeks or LDV/SOF for 24 weeks. Adverse events (AEs), mostly mild-to-moderate in severity, were experienced by 78% of participants, with headache and fatigue most frequently reported. One serious AE, not related to treatment, was observed. No premature discontinuations of study drug, or deaths occurred. In the A5348 study, seven participants were randomized (cirrhotic n = 1; GT1a n = 5) and all attained SVR12, with no serious AEs or premature discontinuations. CONCLUSIONS In this SOF-experienced, NS5A inhibitor-naïve population, which included participants with cirrhosis or HCV/HIV co-infection, high SVR12 rates were achieved.
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Affiliation(s)
| | - Anne F. Luetkemeyer
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Parvez S. Mantry
- The Liver Institute, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Sanjaya K. Satapathy
- Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Peter Ghali
- McGill University Health Centre, Royal Victoria Hospital, Montreal, QC, Canada
| | - Minhee Kang
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Liyun Ni
- Gilead Sciences, Foster City, CA, USA
| | | | | | | | | | - Robert S. Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York City, NY, USA
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14
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Hlaing NKT, Mitrani RA, Aung ST, Phyo WW, Serper M, Kyaw AMM, Bwa AH, Win KM, Reddy KR. Safety and efficacy of sofosbuvir-based direct-acting antiviral regimens for hepatitis C virus genotypes 1-4 and 6 in Myanmar: Real-world experience. J Viral Hepat 2017; 24:927-935. [PMID: 28475232 DOI: 10.1111/jvh.12721] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 04/03/2017] [Indexed: 12/20/2022]
Abstract
UNLABELLED This open-label, clinical experience investigated the safety and efficacy of direct-acting antiviral (DAA) hepatitis C virus (HCV) therapy in Myanmar; 344 patients completed treatment between June 2015 and May 2016. Patients with HCV genotypes 1-4 and 6 received one of four treatments: (i) Peg-interferon (PEG-IFN)+sofosbuvir (SOF)+ribavirin (RBV) for 12 weeks, (ii) SOF+RBV for 24 weeks, (iii) ledipasvir (LDV)+SOF for 12 weeks or (iv) daclatasvir (DCV)+SOF+RBV for 12 or 24 weeks. Genotype 3 was most common (n=133, 38.7%), followed by genotype 6 (n=122, 35.5%) and genotype 1 (n=86, 25%). Overall, 91% of patients achieved sustained virologic response (SVR); 99% in group 1, (n=148/149), 90% in group 2 (n=95/106), 78% in group 3 (n=65/83) and 100% in group 4 (n=6/6). In group 3, SVR rates were 96.8% in genotype 1 (n=30/31) and 64.1% in genotype 6 (n=25/39). Multivariable regression analysis identified advanced fibrosis (F3-4) (OR=.16 CI: 0.05-0.57, P=.005), genotype 6 (OR=.35, CI: 0.16-0.79, P=.012) and diabetes (OR=.29, CI: 0.12-0.71, P=.007) as negative independent predictors of response. Adverse events were mild with all-oral therapy. CONCLUSION DAA therapy ±PEG-IFN achieved high SVR rates. Genotype 6 patients had a low SVR to 12 weeks of LDV and SOF raising the need for other regimens, RBV or longer treatment duration in this population.
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Affiliation(s)
- N K T Hlaing
- Department of Hepatology, Mandalay General Hospital, Mandalay, Myanmar
| | - R A Mitrani
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - S T Aung
- Department of Hepatology, Yangon GI and Liver Centre, Yangon, Myanmar
| | - W W Phyo
- Department of Hepatology, Yangon GI and Liver Centre, Yangon, Myanmar
| | - M Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - A M M Kyaw
- Department of Hepatology, Mandalay General Hospital, Mandalay, Myanmar
| | - A H Bwa
- Department of Hepatology, Yangon GI and Liver Centre, Yangon, Myanmar
| | - K M Win
- Department of Hepatology, Yangon GI and Liver Centre, Yangon, Myanmar
| | - K R Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
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15
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Generic ledipasvir-sofosbuvir for patients with chronic hepatitis C: A real-life observational study. J Hepatol 2017; 66:1123-1129. [PMID: 28189754 DOI: 10.1016/j.jhep.2017.01.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Few patients from developing countries can afford brand name direct-acting antiviral agents for treating hepatitis C virus (HCV) infection, and controversy regarding the bioequivalence of generics exists. This study aimed to observe the safety and efficacy of 8 or 12weeks of generic ledipasvir-sofosbuvir with or without ribavirin for Chinese genotype 1b HCV-infected patients. METHODS In this open-labelled observational study, 63 cirrhotic (group 1) and 65 non-cirrhotic (group 2) patients were administered generic ledipasvir-sofosbuvir plus 1000-1200mg of ribavirin daily for 12 and 8weeks, respectively; and 64 non-cirrhotic patients (group 3) received ledipasvir-sofosbuvir for 8weeks. The primary efficacy endpoint was undetectable HCV RNA at week 12 (SVR12) after cessation of therapy. Safety and pharmacokinetic data were collected. RESULTS One hundred and eighty-seven patients completed treatment, and the latest undetectable HCV RNA was observed in three patients with cirrhosis at week 5 during treatment. Intention-to-treat analysis revealed 96.8% (61/63), 96.9% (63/65), and 96.9% (62/64) of SVR12 rates in groups 1, 2, and 3, respectively. One patient in group 3 relapsed at post-treatment week 4. The regimens were generally well-tolerated. The most common adverse events were fatigue (17.8%), diarrhea (10.9%), and headache (9.9%). Four patients discontinued therapy due to diarrhea and vomiting. One patient from group 2 discontinued treatment on day 29 because of drug-unaffordability; fortunately, she achieved SVR12. CONCLUSION This study demonstrated that 8 or 12weeks of generic ledipasvir-sofosbuvir with or without ribavirin are safe and effective for patients with genotype 1b HCV infection. LAY SUMMARY The price of Harvoni® has led to restrictions and access limitations in many developing and even developed countries with limited healthcare budgets. Gilead approved generic ledipasvir-sofosbuvir costs far less than Harvoni® and presents a similar cure rate for patients with chronic hepatitis C.
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16
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Chan HLY, Tsang OTY, Hui YT, Fung J, Lui GCY, Lai CL, Wong GLH, Chan KH, But DYK, Lai MS, Lao WC, Chan CKM, Lam YS, Seto WK, Li C, Yuen MF, Wong VWS. Real-life efficacy and safety of paritaprevir/ritonavir, ombitasvir, and dasabuvir in chronic hepatitis C patients in Hong Kong. J Gastroenterol Hepatol 2017; 32:1230-1233. [PMID: 27869328 DOI: 10.1111/jgh.13663] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/02/2016] [Accepted: 11/15/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIM In registration studies, combination therapy of paritaprevir/ritonavir, ombitasvir, and dasabuvir (PrOD) with and without ribavirin for 12-24 weeks can achieve > 90% sustained virological response (SVR) for genotype 1 hepatitis C virus (HCV) infection. However, data in Asia is scanty. We aimed to study the efficacy and safety of this combination therapy in chronic hepatitis C patients in Hong Kong. METHODS We retrospectively analyzed data from six local hospitals that have prescribed PrOD with and without ribavirin to patients with genotype 1 chronic HCV infection as part of a global compassionate program. RESULTS Among 41 patients treated, 35 (85%) patients had genotype 1b HCV infection, 6 (15%) had co-infection with human immunodeficiency virus, 35 (85%) failed previous peginterferon and ribavirin therapy, 25 (61%) had compensated liver cirrhosis, and 3 (7%) had liver transplantation. Thirty-five (85%) patients received 12-week treatment and six patients received 24-week treatment; 26 (63%) patients received ribavirin combination. Thirty-nine (95%; 95% confidence interval 88.5-100%) patients had undetectable HCV RNA at 12-week post-treatment, that is, SVR. The two patients who did not develop SVR discontinued treatment prematurely; both of them were treatment experienced with liver cirrhosis complicated by acute renal failure unrelated to the treatment of PrOD and ribavirin. No patient had hepatic decompensation. CONCLUSIONS Paritaprevir/ritonavir, ombitasvir, and dasabuvir with or without ribavirin is effective and safe in patients with genotype 1 HCV infection in real-life clinical setting in Hong Kong.
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Affiliation(s)
- Henry Lik-Yuen Chan
- Department of Medicine and Therapeutics and Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Owen Tak-Yin Tsang
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - Yee-Tak Hui
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - James Fung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Grace Chung-Yan Lui
- Department of Medicine and Therapeutics and Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Ching-Lung Lai
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics and Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Kam-Hon Chan
- Department of Medicine, North District Hospital, Hong Kong
| | - David Yiu-Kuen But
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Moon-Sing Lai
- Department of Medicine, North District Hospital, Hong Kong
| | - Wai-Cheung Lao
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Carmen Ka-Man Chan
- Department of Medicine and Therapeutics and Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Yip-Shun Lam
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Carlton Li
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics and Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
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17
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Respiratory adverse effects of Sofosbuvir-based regimens for treatment of chronic hepatitis C virus. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2016.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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18
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Abstract
With the arrival of all-oral directly acting antiviral (DAA) therapy with high cure rates, the promise of hepatitis C virus (HCV) eradication is within closer reach. The availability of generic DAAs has improved access to countries with constrained resources. However, therapy is only one component of the HCV care continuum, which is the framework for HCV management from identifying patients to cure. The large number of undiagnosed HCV cases is the biggest concern, and strategies to address this are needed, as risk factor screening is suboptimal, detecting <20% of known cases. Improvements in HCV confirmation through either reflex HCV RNA screening or ideally a sensitive point of care test are needed. HCV notification (e.g., Australia) may improve diagnosis (proportion of HCV diagnosed is 75%) and may lead to benefits by increasing linkage to care, therapy and cure. Evaluations for cirrhosis using non-invasive markers are best done with a biological panel, but they are only moderately accurate. In resource-constrained settings, only generic HCV medications are available, and a combination of sofosbuvir, ribavirin, ledipasvir or daclatasvir provides sufficient efficacy for all genotypes, but this is likely to be replaced with pangenetypic regimens such as sofosbuvir/velpatasvir and glecaprevir/pibrentaasvir. In conclusion, HCV management in resource-constrained settings is challenging on multiple fronts because of the lack of infrastructure, facilities, trained manpower and equipment. However, it is still possible to make a significant impact towards HCV eradication through a concerted effort by individuals and national organisations with domain expertise in this area.
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Affiliation(s)
- Seng Gee Lim
- Division of Gastroenterology and Hepatology, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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19
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Chang CY, Nguyen P, Le A, Zhao C, Ahmed A, Daugherty T, Garcia G, Lutchman G, Kumari R, Nguyen MH. Real-world experience with interferon-free, direct acting antiviral therapies in Asian Americans with chronic hepatitis C and advanced liver disease. Medicine (Baltimore) 2017; 96:e6128. [PMID: 28178174 PMCID: PMC5313031 DOI: 10.1097/md.0000000000006128] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Real-life data on interferon (IFN)-free direct acting antiviral (DAA) therapies for chronic hepatitis C (CHC) is limited for Asian Americans.To evaluate sustained virologic response (SVR) and adverse events (AE) in Asian Americans treated with sofosbuvir (SOF)-based, IFN-free DAA therapies.This is a retrospective study of 110 consecutive Asian Americans with HCV genotypes 1 to 3 or 6 treated with IFN-free SOF-based regimens for 8 to 24 weeks between February 2014 and March 2016 at a university center in Northern California.Mean age was 63 ± 12 years, mean BMI was 25 ± 6 (kg/m), and about half (52%) were male. Most patients were infected with HCV genotype 1 (HCV-1, 64%), followed by HCV-2 (14%), HCV-6 (13%), and HCV-3 (8%). Half had cirrhosis, and the majority of these (67%) had decompensation. Overall SVR12 was 93% (102/110), and highest among patients without cirrhosis, liver transplant, or HCC (100%, 37/37). SVR12 was lower among patients with HCC (82%, 14/17), decompensated cirrhosis (84%, 31/37), or liver transplant (89%, 17/19), regardless of treatment and genotype. Most common AEs were anemia (25%), fatigue (20%), and headache (12%). Anemia was highest in patients receiving SOF/RBV (67%). There was 1 treatment-unrelated serious adverse effect (SAE). There were 7 dose reductions due to anemia or fatigue from RBV and 2 treatment discontinuations due to fatigue or loss of insurance authorization.This real-life cohort of Asian American CHC patients treated with IFN-free SOF-based therapies showed high overall treatment response and good tolerability, despite very high rates of advanced disease and prior treatment failure.
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Affiliation(s)
- Christine Y. Chang
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
- University of California, Los Angeles School of Medicine, Los Angeles, CA
| | - Pauline Nguyen
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
| | - An Le
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
| | - Changqing Zhao
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
- Department of Cirrhosis, Institute of Liver Disease, Shuguang Hospital, Shanghai University of T.C.M., Shanghai, P.R. China
| | - Aijaz Ahmed
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
| | - Tami Daugherty
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
| | - Gabriel Garcia
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
| | - Glen Lutchman
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
| | - Radhika Kumari
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
| | - Mindie H. Nguyen
- Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto
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20
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Nonalcoholic fatty liver disease in Asia: emerging perspectives. J Gastroenterol 2017; 52:164-174. [PMID: 27637587 DOI: 10.1007/s00535-016-1264-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
As in the West, nonalcoholic fatty liver disease (NAFLD) is the commonest chronic liver disease in Asia, with a prevalence higher than 40 % in some countries. The risk factors for NAFLD development are similar to those in Western countries, including increased body mass index, diabetes, insulin resistance, and metabolic syndrome. NAFLD in Asians is associated with different extrahepatic manifestations involving the cardiovascular, gastrointestinal, and renal systems. A considerable proportion of Asians with NAFLD are described as having "lean" NAFLD. Present in approximately 20 % of the Asian population, lean NAFLD is closely linked with insulin resistance, diabetes, and other metabolic complications, but its association with disease progression to nonalcoholic steatohepatitis and cirrhosis remains to be defined. There is emerging evidence of the interactions of NAFLD with hepatitis B virus and hepatitis C virus infection in Asia. Unlike in Western countries, NAFLD constitutes only a minority of cirrhosis and hepatocellular carcinoma cases in Asia. Possible explanations are the lower prevalence of obesity and the overwhelming problem of viral hepatitis in Asia. With aging of the obesity cohort in Asia, NAFLD-related liver complications are expected to increase.
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21
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Lim SG, Aghemo A, Chen PJ, Dan YY, Gane E, Gani R, Gish RG, Guan R, Jia JD, Lim K, Piratvisuth T, Shah S, Shiffman ML, Tacke F, Tan SS, Tanwandee T, Win KM, Yurdaydin C. Management of hepatitis C virus infection in the Asia-Pacific region: an update. Lancet Gastroenterol Hepatol 2016; 2:52-62. [PMID: 28404015 DOI: 10.1016/s2468-1253(16)30080-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 08/05/2016] [Accepted: 08/10/2016] [Indexed: 12/12/2022]
Abstract
The Asia-Pacific region has disparate hepatitis C virus (HCV) epidemiology, with prevalence ranging from 0·1% to 4·7%, and a unique genotype distribution. Genotype 1b dominates in east Asia, whereas in south Asia and southeast Asia genotype 3 dominates, and in Indochina (Vietnam, Cambodia, and Laos), genotype 6 is most common. Often, availability of all-oral direct-acting antivirals (DAAs) is delayed because of differing regulatory requirements. Ideally, for genotype 1 infections, sofosbuvir plus ledipasvir, sofosbuvir plus daclatasvir, or ombitasvir, paritaprevir, and ritonavir plus dasabuvir are suitable. Asunaprevir plus daclatasvir is appropriate for compensated genotype 1b HCV if baseline NS5A mutations are absent. For genotype 3 infections, sofosbuvir plus daclatasvir for 24 weeks or sofosbuvir, daclatasvir, and ribavirin for 12 weeks are the optimal oral therapies, particularly for patients with cirrhosis and those who are treatment experienced, whereas sofosbuvir, pegylated interferon, and ribavirin for 12 weeks is an alternative regimen. For genotype 6, sofosbuvir plus pegylated interferon and ribavirin, sofosbuvir plus ledipasvir, or sofosbuvir plus ribavirin for 12 weeks are all suitable. Pegylated interferon plus ribavirin has been replaced by sofosbuvir plus pegylated interferon and ribavirin, and all-oral therapies where available, but cost and affordability remain a major issue because of the absence of universal health coverage. Few patients have been treated because of multiple barriers to accessing care. HCV in the Asia-Pacific region is challenging because of the disparate epidemiology, poor access to all-oral therapy because of availability, cost, or regulatory licensing. Until these problems are addressed, the burden of disease is likely to remain high.
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Affiliation(s)
- Seng Gee Lim
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore.
| | - Alessio Aghemo
- UOC Gastroenterologia ed Epatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Pei-Jer Chen
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University School of Medicine, Taipei, Taiwan
| | - Yock Young Dan
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore
| | - Edward Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Rino Gani
- Hepatology Division, Department of Internal Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Robert G Gish
- Stanford University Hospitals and Clinics, Palo Alto, CA, USA
| | - Richard Guan
- Department of Gastroenterology, Mount Elizabeth Medical Centre, Singapore, Singapore
| | - Ji Dong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Xicheng, Beijing, China
| | - Kieron Lim
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore
| | - Teerha Piratvisuth
- NKC Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospital, Parel, Mumbai, India
| | | | - Frank Tacke
- Department of Medicine III, University Hospital Aachen, Aachen, Germany
| | - Soek Siam Tan
- Department of Hepatology, Selayang Hospital, Selangor, Malaysia
| | - Tawesak Tanwandee
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok-noi, Bangkok, Thailand
| | | | - Cihan Yurdaydin
- Department of Gastroenterology, University of Ankara Medical School, Ankara, Turkey
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22
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Tang L, Ward H, Kattakuzhy S, Wilson E, Kottilil S. Dual sofosbuvir and ribavirin therapy for chronic hepatitis C infection. Expert Rev Gastroenterol Hepatol 2016; 10:21-36. [PMID: 26558305 DOI: 10.1586/17474124.2016.1119042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Sofosbuvir is the first pan-genotypic direct acting antiviral agent to be approved. This article provides an overview of the pharmacology of sofosbuvir and ribavirin and a comprehensive summary of the phase 2 and 3 studies supporting dual sofosbuvir and ribavirin therapy for chronic hepatitis C infection. With the production of generic formulations of sofosbuvir, we anticipate this regimen leading the first wave for widespread, IFN-free treatment and becoming first line for all genotypes (including genotype 1) for much of the world-in particular in developing and middle income countries. We discuss the continued challenges with this regimen including among patients with decompensated liver disease and post-liver transplant, and renal failure. We address concerns of emerging resistance. We also discuss the future prospects including the global uptake of sofosbuvir and ribavirin for the treatment of all genotypes.
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Affiliation(s)
- L Tang
- a Division of Clinical Care and Research , Institute of Human Virology, University of Maryland School of Medicine , Baltimore , MD , USA
| | - H Ward
- a Division of Clinical Care and Research , Institute of Human Virology, University of Maryland School of Medicine , Baltimore , MD , USA
| | - S Kattakuzhy
- a Division of Clinical Care and Research , Institute of Human Virology, University of Maryland School of Medicine , Baltimore , MD , USA
| | - E Wilson
- a Division of Clinical Care and Research , Institute of Human Virology, University of Maryland School of Medicine , Baltimore , MD , USA
| | - S Kottilil
- a Division of Clinical Care and Research , Institute of Human Virology, University of Maryland School of Medicine , Baltimore , MD , USA
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23
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Ferreira VL, Assis Jarek NA, Tonin FS, Borba HHL, Wiens A, Pontarolo R. Safety of interferon-free therapies for chronic hepatitis C: a network meta-analysis. J Clin Pharm Ther 2016; 41:478-85. [PMID: 27440554 DOI: 10.1111/jcpt.12426] [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: 05/30/2016] [Accepted: 06/27/2016] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Interferon-free (IFN-free) therapies for hepatitis C virus (HCV) have been developed to provide more effective, tolerable and safer therapeutic strategies. To date, no network meta-analysis (NMA) evaluating the safety profile of these regimens has been performed. This systematic review and NMA aimed to evaluate safety outcomes of IFN-free treatment options for chronic hepatitis C. METHODS A systematic review was performed according to PRISMA and Cochrane recommendations. A literature search was conducted in PubMed/Medline, Scopus, Cochrane Library, International Pharmaceutical Abstracts and Web of Science electronic databases and included only randomized clinical trials that provided safety outcomes of interest of evaluated second-generation direct-acting antivirals: incidence of any adverse events (AEs) and serious AE. NMA allowed estimating probability for the relative safety of the interventions. A consistency model was used to draw conclusions about relative safety of treatments, presented as odds ratio (OR) and corresponding 95% credible interval (CrI). RESULTS Fifty-one clinical trials were included (13 089 participants). Most participants had hepatitis C genotype 1 virus (76%) and were treated for 12 weeks. Two NMAs were built to investigate the incidence of AEs and serious AEs, comparing 13 and 10 IFN-free treatment options, respectively. For the outcome incidence of AEs, few significant differences were observed, which were explained by the presence of RBV. Elbasvir with grazoprevir and placebo were both safer than ombitasvir in combination with paritaprevir, ritonavir, daclatasvir plus RBV [ORs with 95% Crl of 4·09 (1·17-14·09) and 2·40 (1·19-4·77), respectively] and sofosbuvir with RBV [ORs with 95% Crl of 0·22 (0·07-0·72) and 2·69 (1·53-4·80), respectively]. Furthermore, elbasvir with grazoprevir was safer than sofosbuvir used with velpatasvir and RBV [OR 0·19 (95% CrI 0·03-0·98)]; ombitasvir in combination with paritaprevir, ritonavir, daclatasvir was safer than the same therapy but combined with RBV [OR 2·14 (95% CrI 1·09-4·44)]; and sofosbuvir used with velpatasvir was safer than sofosbuvir with RBV [OR 2·07 (95% CrI 1·13-3·79)]. Elbasvir with grazoprevir (50%) followed by placebo (28%) had the highest probabilities of less AEs. No significant differences were observed for serious AE outcomes. WHAT IS NEW AND CONCLUSION This meta-analysis included a large number of therapies. Small differences were observed in any AEs, but not in serious AEs.
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Affiliation(s)
- V L Ferreira
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
| | - N A Assis Jarek
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
| | - F S Tonin
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
| | - H H L Borba
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
| | - A Wiens
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
| | - R Pontarolo
- Department of Pharmacy, Pharmaceutical Sciences Postgraduate Program, Universidade Federal do Paraná, Curitiba, Brazil
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