Pharmacokinetics and drug interactions of medications used to treat hepatitis C virus infection in the setting of chronic kidney disease and kidney transplantation

Effects of comorbid conditions and prescribed chronic medications on the treatment plan for chronic hepatitis C infection: A cross-sectional retrospective study

Background

Chronic hepatitis C (CHC) infection is a potentially life-threatening condition characterized by various complications, including end-stage liver disease and cirrhosis. The mortality rate associated with CHC has been increasing due to the presence of comorbidities and the use of chronic medications. Therefore, the objective of this study was to investigate the impact of these comorbidities and chronic medications on the treatment plan for CHC.

Methods

To achieve this objective, a cross-sectional retrospective study was conducted at a tertiary hospital in Jeddah, Saudi Arabia. The study population included patients aged 12 years and above who were diagnosed with CHC between 2016 and 2021. Patients below the age of 12 were excluded from the study. A total of 170 patients with CHC were included in the analysis. The study aimed to evaluate the relationship between CHC complications and the treatment approach.

Results

The mean age of the study participants was 66.78 years, with a higher proportion of female patients. The findings revealed a significant association between hypertension (p = 0.042) and cirrhosis (p = 0.007) with changes in the treatment plan for CHC. Moreover, the presence of diabetes mellitus (p = 0.045), renal diseases (p < 0.001), and hypothyroidism (p = 0.004) were significantly associated with HCV clearance after the initiation of therapy. Additionally, the use of proton pump inhibitors (p = 0.033) and levothyroxine (p = 0.025) was found to be associated with a higher rate of CHC clearance.

Conclusion

In conclusion, this study highlights the prevalence of comorbid conditions and the use of chronic medications among patients with CHC. The findings emphasize the importance of considering the effects of comorbidities and chronic medications when developing treatment plans for CHC infections. By taking these factors into account, healthcare professionals can optimize the management of CHC and improve patient outcomes.

Comparative Survival Analysis of Dialysis and Renal Transplantation in HBV-Infected End-Stage Renal Disease Patients

BACKGROUND

The potential risks and benefits of kidney transplantation in patients with end-stage renal disease (ESRD) infected with hepatitis B virus (HBV) have been a subject of debate. This study aimed to provide real-world data on the relative risks of death and clinical outcomes associated with kidney transplantation in this context.

METHODS

We conducted a longitudinal cohort study using the National Health Insurance Research Database from 1997 to 2013, extracting cohorts of patients who are HBV-infected ESRD. The main outcome measure was overall survival, whereas the secondary measure was the relative risk of death and survival benefit through propensity-score matching (1:1).

RESULTS

Of the 4895 patients who are HBV-infected with ESRD, 172 renal transplant recipients were enrolled for analysis. There was a numeric trend towards higher overall survival rates in renal transplant recipients, although this was not statistically significant (P = .057). A significant survival benefit was observed in the renal transplant group if the follow-up was longer than one year (P = 0.007). The relative risks of death among renal transplant recipients were initially higher at 2.0 times that of patients on chronic dialysis, presenting in a hyperbolic pattern with equal risks at 462 days. The likelihood of survival became equal until 1649 days.

CONCLUSIONS

Our study suggests that kidney transplantation may be a viable option for patients who are HBV-infected with ESRD, given the significant improvement in quality of life and reduction of death risks observed four to five years after successful transplantation. This real-world data can help clinicians make informed decisions regarding the management of ESRD in patients who are HBV-infected.

Outcomes of short-duration antiviral prophylaxis for hepatitis C positive donor kidney transplants

Trials describing 4- to 12-week courses of direct-acting antiviral drugs (DAAs) to treat hepatitis C virus (HCV) transmission from infected donors to uninfected kidney transplant recipients (D+/R- transplants) may be limited in "real-world" application by costs and delayed access to DAAs. We previously reported HCV transmission of 13% among D+/R- transplants with 2- to 4-day pangenotypic sofosbuvir/velpatasvir (SOF/VEL) perioperative prophylaxis, where one patient with HCV transmission was a nonresponder to first-line full-course DAA. Here, we report new data with a 7-day prophylaxis protocol (N = 50), as well as cumulative treatment and outcome data on all HCV D+/R- transplants (N = 102). Overall, nine patients (9/102; 9%; 95% CI: 5%-16%) developed HCV transmission, with a significant decline noted in the 7-day group (2/50; 4%; 95% CI: 0%-13%) compared with 2- to 4-day prophylaxis (7/52; 13%; 95% CI: 5%-25%). All patients with HCV transmission achieved sustained virologic response post full-course therapy (including one nonresponder from initial trial). A 1:1 matched analysis (N = 102) with contemporary HCV D-/R- transplants (controls) showed that although the pretransplant wait time was significantly shorter for D+/R- compared with D-/R- (mean: 1.8 vs. 4.4 years; p < .001), there were no differences in infections, rejection, development of de novo donor-specific antibody, or transplant outcomes up to 6 months of transplant.

Influence of drug-drug interactions on effectiveness and safety of direct-acting antivirals against hepatitis C virus

OBJECTIVES

Direct-acting antivirals are the recommended treatment for hepatitis C-infected patients. Drug-drug interactions with concomitant treatments can cause lack of effectiveness and/or safety. The objective of this study is to characterise drug-drug interactions of direct-acting antivirals and to analyse their influence both on the effectiveness of antiviral treatment and on the overall safety of pharmacological treatment in hepatitis C-infected patients.

METHODS

Observational and prospective cohort study for 3 years in the pharmaceutical care outpatient consultation of a general hospital, undertaking detection, evaluation and management of drug-drug interactions by clinical pharmacists and physicians. The main outcome measures were sustained virologic response at week 12 for effectiveness and serious drug-related adverse events for safety. Multivariate statistical analysis applied to: (a) patient basal characteristics related to presence of drug-drug interactions; (b) previous antiviral treatments, viral genotype, cirrhosis, decompensations and presence of drug-drug interactions related to the effectiveness of direct-acting antivirals.

RESULTS

Of a total of 1092 patients, the majority of them were men, around 60 years old and HCV-genotype 1 mono-infected, with a high basal viral load, naive to antiviral treatment, treated with ledipasvir/sofosbuvir and without cirrhosis. 24.5% had drug-drug interactions. Proton pump inhibitors were the concomitant drugs that caused the most drug-drug interactions. Age ≥65 years and direct-acting antivirals based on protease inhibitors were independently related to the presence of drug-drug interactions (p≤0.012). All (100%) of the therapeutic recommendations based on detected drug-drug interactions were implemented; 97.7% of patients with interactions versus 99.0% without them reached sustained virologic failure (p=0.109). The serious adverse events rates were 1.5% and 1.3% in patients with and without drug-drug interactions, respectively (p=0.841).

CONCLUSIONS

Drug-drug interactions are frequent among hepatitis C-infected patients receiving treatment with direct-acting antivirals. However, the collaboration between physicians and clinical pharmacists makes it possible to detect, evaluate, avoid or clinically manage these drug-drug interactions, in order to maintain whole treatment therapeutic safety and the effectiveness of direct-acting antivirals.

2020 Taiwan consensus statement on the management of hepatitis C: Part (II) special populations

Hepatitis C virus (HCV) infection is a silent killer that leads to rapid progression of liver cirrhosis and hepatocellular carcinoma (HCC). High prevalence of HCV infection has been reported in Taiwan, especially in high-risk populations including people who inject drugs (PWID) and patients requiring dialysis. Besides, certain populations merit special considerations due to suboptimal outcome, potential drug-drug interaction, or possible side effect. Therefore, in the second part of this 2-part consensus, the Taiwan Association for the Study of the Liver (TASL) proposes the treatment recommendations for the special population in order to serve as guidance to optimizing the outcome in the direct-acting antiviral (DAA) era. Special populations include patients with acute or recent HCV infection, previous DAA failure, chronic kidney disease, decompensated cirrhosis, HCC, liver and other solid organ transplantations, receiving an HCV viremic organ, hepatitis B virus (HBV) and HCV dual infection, HCV and human immunodeficiency virus (HIV) coinfection, active tuberculosis infection, PWID, bleeding disorders and hemoglobinopathies, children and adolescents, and pregnancy. Moreover, future perspectives regarding the management of hepatitis C are also discussed and summarized in this consensus statement.

Frequency of Potential Drug-Drug Interactions in the Changing Field of HCV Therapy

Background

With the introduction of direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection, drug-drug interactions (DDIs) emerged as significant challenge. Since then, HCV therapy and the infected population have rapidly changed. So far, very limited data are available regarding the clinical relevance of DDIs when using most modern DAA regimens. We aimed to assess how the importance of DDIs has evolved over time.

Methods

From January 2014 to July 2018, 668 consecutive HCV patients were evaluated for their outpatient medication and assessed for DDIs with DAAs. Different time periods were defined based on market approval of key DAAs: A (01/2014-11/2014), B (11/2014-08/2016), and C (08/2016-07/2018).

Results

The frequency of patients with real-world DDIs was highest in period B (A: 37.1%, B: 49.6%, C: 38.8%). The recently approved DAAs (period C) theoretically showed a lower DDI risk profile. However, real-world DDIs were still comparable to period A, as HCV patients' characteristics changed (eg, age ≥75 years: A: 3.1%, B: 9.8%, C: 5.6%; polypharmacy/patients with ≥8 drugs: A: 11.1%, B: 15.2%, C: 17.2%). Furthermore, although DDIs via CYP 3A4 became less important for some modern regimens, other mechanisms like an altered pH value in the stomach, causing reduced bioavailability, evolved. Relevant DDIs most frequently occurred with proton pump inhibitors, metamizole, statins, and carvedilol.

Conclusions

DDIs during antiviral treatment still affect about 40% of HCV patients. The lower DDI potential of modern DAA regimens is partly counteracted by changing patient characteristics. Therefore, DDIs should not be underestimated.

Use of HCV-infected organs in solid organ transplantation: An ethical challenge but plausible option

Due to the unfortunate epidemic of opioid overdose deaths among people who inject drugs (PWID) in North America, there has been an increase in the availability of hepatitis C (HCV)-positive organs for transplantation and consequently the potential to decrease waiting times for solid organ transplantation if an HCV-uninfected recipient is willing to accept an HCV-positive donor. The confidence in this potential new strategy comes as a result of the advent of safe and highly effective pan-genotypic direct-acting antivirals (DAAs). This promising strategy has been the most widely studied in kidney transplantation. Liver transplantation has positive results preliminarily, but has even less available data because viable HCV-infected donor livers are typically transplanted into HCV-infected individuals. Further, while HCV-infected heart and lung transplantation, which face additional post-transplant issues, have shown encouraging results, these studies are small scale and are limited by short-term follow-up. Thus, it would be premature to implement this strategy as standard of care without large scale clinical and real-world trials and longer-term follow-up studies. Further, the ethics of this practice need to be considered. While some transplant professionals argue that more harm will be done by not utilizing HCV-infected organs, others contend that cautiously conducted multi-centre studies involving extensive post-transplant follow-up are paramount prior to endorsing widespread implementation of this strategy. The ethical permissibility of this practice hinges on whether access to DAA therapy can be secured in advance, and prospective recipients understand and accept all the risks associated with acquiring HCV.