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Liu J, Zhang Y, Wu B, Wang S, Bin-Chia Wu D, You R. Cost-Effectiveness of Testing for NS5A Resistance to Optimize Treatment of Elbasvir/Grazoprevir for Chronic Hepatitis C in China. Front Pharmacol 2021; 12:717504. [PMID: 34721016 PMCID: PMC8554024 DOI: 10.3389/fphar.2021.717504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/13/2021] [Indexed: 12/05/2022] Open
Abstract
Objectives: Baseline presence of nonstructural protein 5A (NS5A) resistance-associated variants can attenuate the efficacy of new direct-acting antivirals. A potential method to attain the higher efficacy would be to screen for NS5A polymorphisms prior to the initiation of therapy and to adjust the treatment length based on the test results. However, baseline testing adds additional costs and it is unclear whether this would represent a high value strategy for chronic hepatitis C in China. Methods: A hybrid model compared 1) standard 12-weeks treatment (no testing), 2) shortened 8-weeks treatment (no testing), and 3) baseline testing with 12-/8-weeks treatment for those with/without NS5A polymorphisms from a lifetime Chinese health care payer perspective. All model inputs were retrieved from clinical trials and publically available literature. And sensitivity analyses were also conducted to assess the impact of uncertainty. Results: Baseline testing was associated with overall increase in total health care cost of USD 13.50 and in QALYs of 0.002 compared with standard 12-weeks treatment (no testing), yielded in an ICER of USD 6750/QALY gained. Scenario analyses suggested that shortened 8-weeks treatment (no testing) was found to be lower costs and great QALYs compared with other two strategies when the sustained virologic response (SVR) rate increased to 95%. Sensitivity analyses indicated that the results were robust. Conclusions: Our results suggest prior assessment of NS5A sensitivity followed by optimizing treatment duration was an economic strategy. In addition, shortened 8-weeks treatment (no testing) was shown to be dominant with the SVR rate increased to 95%.
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Affiliation(s)
- Jinyu Liu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin Wu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sen Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - David Bin-Chia Wu
- School of Pharmacy, Monash University Malaysia, Kuala Lumpur, Malaysia.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Ruxu You
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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2
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Hung HY, Chen CY, Liao YH. A Retrospective Cohort Study: Safety and Effectiveness of Elbasvir/Grazoprevir ± Ribavirin Compared With Ombitasvir/Paritaprevir/Ritonavir/Dasabuvir ± Ribavirin in Patients With Chronic Hepatitis C Genotype 1 Infection. Front Pharmacol 2021; 12:640317. [PMID: 34566631 PMCID: PMC8458878 DOI: 10.3389/fphar.2021.640317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 08/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The direct-acting antiviral (DAA) agents are widely used to treat hepatitis C virus (HCV) genotype (GT) 1 infection, while it may cause severe liver damage. The objectives of the study were to evaluate the incidence of drug-induced liver injury (DILI), sustained virologic response at post-treatment week 12 (SVR12), and recurrence rates in HCV GT 1 infection. Methods: This was a retrospective cohort study that included patients diagnosed with HCV GT 1 infection, who had received intervention and treatment with elbasvir/grazoprevir (EBR/GZR) ± ribavirin (RBV) versus ombitasvir/paritaprevir/ritonavir (OBV/PTV/r) + dasabuvir ± RBV (as control group) for 12 or 24 weeks at a regional hospital in southern Taiwan between April 2016 and August 2018. The primary outcome of the study was to compare the incidence rate ratio (IRR) of DILI via Poisson regression, and the secondary outcome was to evaluate the effectiveness of two treatment regimens expressed as a percentage. Results: The study included 149 patients in the control group and 105 patients in the intervention group of which 99.33 and 98.1% patients, respectively, achieved SVR12. In the control group, one patient experienced relapse, whereas in the intervention group, two patients relapsed. Furthermore, in the control group, a total of nine patients developed DILI as determined during follow-up care. Of these patients, three were 55-84 years old. In the intervention group, six patients developed DILI. The IRR of DILI caused by EBR/GZR treatment was 2.84 times higher than that caused by the OBV/PTV/r treatment regimen. Conclusion: There was no significant difference between the studied DAA regimens regarding the incidence of DILI and effectiveness during the treatment. DILI occurrence during therapy did not affect the cure rate of medication. The present study results can provide reference data for drug selection among patients with HCV. Trial registration: The study was approved by DMF-CYCH (CYCH IRB No: 2018067).
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Affiliation(s)
- Hsuan-Yu Hung
- Department of Pharmacy, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Chung-Yu Chen
- Master Program in Clinical Pharmacy, School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yi-Hsiang Liao
- Chinese Medical Department, Park One International Hospital, Kaohsiung, Taiwan
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3
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Kong F, Wen X, Wen X, Wang X, Wu G, Lin S, Wang L, Xing H, Yan X, Zheng S, Ning Q, Wang Z, Zhang L, Lin J, Tong Z, Huang C, Su M, Tong L, Jia J, Xin Y, Zhu Q, Wang J, Chen L, Li X, Wu X, Niu D, Liu Q, Wei W, Zhang Y, Li G, Niu J. Seraprevir and sofosbuvir for treatment of chronic hepatitis C virus infection: A single-arm, open-label, phase 3 trial. J Gastroenterol Hepatol 2021; 36:2375-2382. [PMID: 33491236 PMCID: PMC8518536 DOI: 10.1111/jgh.15412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/13/2020] [Accepted: 01/13/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIM This single-arm, open-label, multicenter, phase 3 trial evaluated the efficacy and safety of seraprevir, an hepatitis C virus (HCV) nonstructural protein 3/4A (NS3/4A) inhibitor, combined with sofosbuvir for treating Chinese patients with chronic HCV infection without cirrhosis. METHODS Treatment-naive or interferon-experienced adult patients without cirrhosis were treated with a universal, combinational regimen of seraprevir 100 mg, twice daily and sofosbuvir 400 mg, once daily, for 12 or 24 weeks. The primary efficacy endpoint was sustained virologic response at week 12 after treatment (SVR12). RESULTS Overall, 205 patients with genotype 1 HCV infection without cirrhosis were enrolled from 23 sites, 202 of whom completed the full treatment and post-treatment course and 3 discontinued follow-up. In total, 27 patients (13.2%) were interferon experienced. SVR12 was achieved by 201 out of 205 (98.0% [95% CI, 95.1%, 99.5%]) patients, 100.0% of patients with genotype 1a, and 98.0% of genotype 1b. In the other exploratory study, SVR 12 was achieved by 100% patients with genotype 2 (n = 21), genotype 3 (n = 7), and genotype 6 (n = 8). The majority of adverse events were mild to moderate and transient and did not require a specific medical intervention. CONCLUSIONS The all-oral, ribavirin-free regimen of seraprevir and sofosbuvir is an effective and well-tolerated treatment option for Chinese patients mono-infected with HCV, including those with a history of interferon treatment.
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Affiliation(s)
- Fei Kong
- Department of HepatologyThe First Hospital of Jilin UniversityChangchunChina,Department of Epidemiology and Biostatistics, School of Public HealthJilin UniversityChangchunChina
| | - Xiaoyu Wen
- Department of HepatologyThe First Hospital of Jilin UniversityChangchunChina
| | - Xiaofeng Wen
- Department of HepatologyLiuzhou People's HospitalLiuzhouChina
| | - Xiaozhong Wang
- Department of HepatologyXinjiang Uygur Autonomous Region Traditional Chinese Medicine HospitalUrumqiChina
| | - Guicheng Wu
- Department of HepatologyChongqing University Three Gorges Hosipital, Chongqing Three Gorges Central HospitalChongqingChina
| | - Shide Lin
- Department of Infectious DiseasesAffiliated Hospital of Zunyi Medical UniversityZunyiChina
| | - Li Wang
- Department of HepatologyPublic Health Clinical Center of ChengduChengduChina
| | - Huichun Xing
- Department of Hepatology Division 3Beijing Ditan Hospital, Capital Medical UniversityBeijingChina
| | - Xuebing Yan
- Department of Infectious DiseaseThe Affiliated Hospital of Xuzhou Medical UniversityXuzhouChina
| | - Sujun Zheng
- Difficult and Complicated Liver Diseases and Artificial Liver CenterBeijing YouAn Hospital, Capital Medical UniversityBeijingChina
| | - Qin Ning
- Department of Infectious Diseases, Tongji Hospital Affiliated to Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Zheng Wang
- Department of Infectious DiseasesWuxi No. 5 People's HospitalWuxiChina
| | - Liaoyun Zhang
- Department of Infectious DiseasesThe First Affiliated Hospital of Shanxi Medical UniversityTaiyuanChina
| | - Jianmei Lin
- Department of Infectious DiseasesSichuan Provincial People's HospitalChengduChina
| | - Zhaowei Tong
- Department of Infectious DiseasesHuzhou Central HospitalHuzhouChina
| | - Chengyu Huang
- Department of HepatologyChongqing Public Health Medical CenterChongqingChina
| | - Minghua Su
- Department of Infectious DiseaseThe First Affiliated Hospital of Guangxi Medical UniversityNanningChina
| | - Lixin Tong
- Center of Liver DiseasesThe First Affiliated Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Jidong Jia
- Liver Research Center, Beijing Friendship HospitalCapital Medical UniversityBeijingChina
| | - Yongning Xin
- Department of Infectious DiseaseQingdao Municipal HospitalQingdaoChina
| | - Qingjing Zhu
- Department of HepatologyWuhan Public Health Medical CenterWuhanChina
| | - Jing Wang
- Department of HepatologyThe Affiliated TCM Hospital of Southwest Medical UniversityLuzhouChina
| | - Li Chen
- General Manager OfficeShanghai Viromedicine Co., Ltd.ShanghaiChina
| | - Xiaowen Li
- General Manager OfficeShanghai Viromedicine Co., Ltd.ShanghaiChina
| | - Xuegang Wu
- Department of Clinical ResearchShanghai Viromedicine Co., Ltd.ShanghaiChina
| | - Duan Niu
- Department of Clinical ResearchShanghai Viromedicine Co., Ltd.ShanghaiChina
| | - Quan Liu
- Department of Emerging Infectious Diseases, Institute of Translational MedicineThe First Hospital of Jilin UniversityChangchunChina
| | - Wei Wei
- Institute of Virology and AIDS ResearchThe First Hospital of Jilin UniversityChangchunChina
| | - Yuexin Zhang
- Department of Infectious DiseasesFirst Affiliated Hospital of Xinjiang Medical UniversityUrumqiChina
| | - Guangming Li
- Cirrhosis DepartmentZhengzhou Sixth Municipal People's HospitalZhengzhouChina
| | - Junqi Niu
- Department of HepatologyThe First Hospital of Jilin UniversityChangchunChina
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4
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Nangia G, Vierling JM, Kwo P, Brown DD, Klopfer SO, Robertson MN, Haber BA, Reddy KR. Safety and tolerability of elbasvir/grazoprevir in chronic hepatitis C virus therapy: Integrated analysis from clinical trials. J Viral Hepat 2020; 27:1222-1233. [PMID: 32594612 DOI: 10.1111/jvh.13357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022]
Abstract
Direct-acting antiviral treatments for chronic hepatitis C virus (HCV) infection are generally safe; however, understanding the safety profile of each regimen is essential for their continued use. Safety data were pooled from 12 clinical trials of elbasvir/grazoprevir (EBR/GZR) that enrolled adult participants with HCV infection. Pooled analyses are presented for participants receiving EBR/GZR for 12 weeks and those receiving EBR/GZR plus ribavirin (RBV) for 16-18 weeks. Safety data are also presented for participants with comorbidities receiving EBR/GZR for 12 weeks in individual clinical trials (chronic kidney disease [CKD] stage 4/5, inherited blood disorders [IBLD] or receiving opioid agonist therapy [OAT]). Among 1743 participants receiving EBR/GZR for 12 weeks, 1068 (61.3%) reported ≥1 adverse event (AE) and 491 had AEs (28.2%) considered drug-related. The most frequent AEs were headache (10.6%), fatigue (8.7%), nasopharyngitis (5.8%), nausea (5.1%) and diarrhoea (5.0%). Serious AEs were reported by 37 participants (2.1%), and 12 (0.7%) discontinued treatment due to an AE. In populations with CKD 4/5 or IBLD or receiving OAT, safety was similar in participants receiving EBR/GZR for 12 weeks and those receiving placebo. Some AEs occurred at higher frequencies in participants receiving RBV compared with those receiving EBR/GZR alone: fatigue (32.7% vs 8.7%); headache (21.6% vs 10.6%); and nausea (15.8% vs 5.1%). Safety was similar in participants with and those without cirrhosis. Grade 3/4 alanine aminotransferase elevations were reported in 0.7% participants. EBR/GZR is a safe treatment option for individuals with HCV genotype (GT) 1 or GT4 infections, even those with challenging comorbidities such as CKD or IBLD and those receiving OAT.
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Affiliation(s)
- Gayatri Nangia
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Paul Kwo
- Department of Medicine-Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | | | - K Rajender Reddy
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
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5
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Rao H, Yang X, Tan Y, Ning Q, Yang D, Wang J, Yang Y, Zheng S, Yang D, Hou J, Xie Q, Zhao C, Zhang L, Mao X, Sun T, Bai L, Zhang F, Jin J, Zhao Y, Wang M, Xie W, Ma Y, Quan J, Yan X, An P, Lin F, Jia J, Hu X, Gong Z, Wu J, Chen Y, Jia Z, Lin M, Wang G, Zhu Y, Zhang Y, Xie H, Luo L, Ren Q, Huang R, Wei L. Efficacy and Safety of All-oral Emitasvir and Sofosbuvir in Patients with Genotype 1b HCV Infections without Cirrhosis. J Clin Transl Hepatol 2020; 8:255-261. [PMID: 33083247 PMCID: PMC7562795 DOI: 10.14218/jcth.2020.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/05/2020] [Accepted: 08/12/2020] [Indexed: 02/05/2023] Open
Abstract
Background and Aims: Emitasvir is a new type of hepatitis C virus (HCV) nonstructural protein 5A (NS5A) inhibitor, and the data of phase 2 trial has shown emitasvir-sofosbuvir to have good safety and tolerance. We conducted this phase 3 trial to further verify the efficacy and safety. Methods: We evaluated the antiviral activity and safety of a 12-week regimen of emitasvir phosphate (100 mg) combined with sofosbuvir (400 mg) once daily in non-cirrhotic patients with genotype 1 HCV infection. The primary endpoint was a sustained virological response at 12 weeks (SVR12) after the end of treatment. Results: Of the 362 patients enrolled in the trial, 39.8% were male, 99.2% had HCV genotype 1b, 0.8% had genotype 1a and 79.8% were treatment-naïve. The average age was 47.2 years. All patients completed the treatment and follow-up. All 3 patients with genotype 1a achieved SVR. Two genotype 1b treatment-naïve patients experienced virologic relapse. The rate of SVR12 was 99.7% (358/359), and SVR24 was 99.4% (357/359) in genotype 1b. Overall, 36.2% had resistance-associated substitutions (RASs) in NS5A and 98.3% had RASs in NS5B at baseline. The RASs at baseline had no effect on the rates of response. Serious adverse events were reported in 16 patients and were not related to emitasvir-sofosbuvir. Most adverse events did not require therapy. Conclusions: The 12 weeks of treatment with emitasvir-sofosbuvir was a highly efficient and safe treatment for a wide range of patients with HCV genotype 1b infection without cirrhosis, who had not been treated or who had been treated with interferon-based regimen previously.
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Affiliation(s)
- Huiying Rao
- Peking University People’s Hospital, Peking University Hepatology Institute, National Clinical Research Center for Infectious Disease, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Beijing International Cooperation Base for Science and Technology on NAFLD Diagnosis, Beijing, China
| | - Xingxiang Yang
- Department of Infectious Diseases, Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
| | - Youwen Tan
- Department of Hepatology, The Third People’s Hospital of Zhenjiang, Zhenjiang, Jiangsu, China
| | - Qin Ning
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Daokun Yang
- Department of Infectious Diseases, The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, Henan, China
| | - Jiefei Wang
- Shanghai Public Health Clinical Center, Shanghai, China
| | - Yongfeng Yang
- Department of Hepatology, The Second Hospital of Nanjing, Nanjing, Jiangsu, China
| | - Sujun Zheng
- Center of Artificial liver, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Dongliang Yang
- Department of Infectious Disease, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jinlin Hou
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Caiyan Zhao
- Department of Infectious Diseases, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lunli Zhang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xiaorong Mao
- Department of Infectious Diseases, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Tong Sun
- Department of Infectious Diseases, Wuxi Fifth People’s Hospital, Wuxi, Jiangsu, China
| | - Lang Bai
- Infectious Diseases Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fuchun Zhang
- Department of Hepatology, Guangzhou Eighth People’s Hospital, Guangzhou, Guangdong, China
| | - Jinglan Jin
- Department of Hepato-Biliary-Pancreatic Diseases, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yingren Zhao
- Department of Infectious Diseases, Xi’an Jiaotong University First Affiliated Hospital, Xi’an, Shaanxi, China
| | - Maorong Wang
- Department of Infectious Diseases, DiBaYi Hospital of the Chinese People’s Liberation Army, Nanjing, Jiangsu, China
| | - Wen Xie
- Hepatology Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yingjie Ma
- Department of Infectious Diseases, Zhengzhou People’s Hospital, Zhengzhou, Henan, China
| | - Jun Quan
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xuebing Yan
- Department of Infectious Diseases, Xuzhou Medical College Affiliated Hospital, Xuzhou, Jiangsu, China
| | - Ping An
- Department of Infectious Diseases, Shenyang Sixth People’s Hospital, Shenyang, Liaoning, China
| | - Feng Lin
- Department of Infectious Diseases, Hainan General Hospital, Haikou, Hainan, China
| | - Jidong Jia
- Hepatology Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiaoxuan Hu
- Department of Infectious Diseases, Hunan Provincial People’s Hospital, Changsha, Hunan, China
| | - Zuojiong Gong
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jie Wu
- Department of Infectious Diseases, Wuhan central hospital, Wuhan, Hubei, China
| | - Yongping Chen
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhansheng Jia
- Department of Infectious Diseases, Tangdu Hospital, The Fourth Military Medical University of the People’s Liberation Army, Xi’an, Shaanxi, China
| | - Minghua Lin
- Department of Hepatology, Meng Chao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Guiqiang Wang
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China
| | - Yueyong Zhu
- Department of Infectious Diseases, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yingjun Zhang
- State Key Laboratory of Anti-Infective Drug Development (NO.2015DQ780357), Sunshine Lake Pharma Co., Ltd, Dongguan, Guangdong, China
- Correspondence to: Lai Wei, Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, No. 168, Litang Road, Changping District, Beijing 102218, China. Tel: +86-10-56118881, Fax: +86-10-56118500, E-mail: ; Yingjun Zhang, State Key Laboratory of Anti-Infective Drug Development (NO. 2015DQ780357), Sunshine Lake Pharma Co., Ltd., No. 368, Zhen’an Road, Chang’an Town, Dongguan, Guangdong 523871, China. Tel: +86-769-88615888-2337, Fax: +86-769-85370222-2337, E-mail:
| | - Hongming Xie
- State Key Laboratory of Anti-Infective Drug Development (NO.2015DQ780357), Sunshine Lake Pharma Co., Ltd, Dongguan, Guangdong, China
| | - Lin Luo
- State Key Laboratory of Anti-Infective Drug Development (NO.2015DQ780357), Sunshine Lake Pharma Co., Ltd, Dongguan, Guangdong, China
| | - Qingyun Ren
- State Key Laboratory of Anti-Infective Drug Development (NO.2015DQ780357), Sunshine Lake Pharma Co., Ltd, Dongguan, Guangdong, China
| | - Rui Huang
- Peking University People’s Hospital, Peking University Hepatology Institute, National Clinical Research Center for Infectious Disease, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Beijing International Cooperation Base for Science and Technology on NAFLD Diagnosis, Beijing, China
| | - Lai Wei
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- Correspondence to: Lai Wei, Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, No. 168, Litang Road, Changping District, Beijing 102218, China. Tel: +86-10-56118881, Fax: +86-10-56118500, E-mail: ; Yingjun Zhang, State Key Laboratory of Anti-Infective Drug Development (NO. 2015DQ780357), Sunshine Lake Pharma Co., Ltd., No. 368, Zhen’an Road, Chang’an Town, Dongguan, Guangdong 523871, China. Tel: +86-769-88615888-2337, Fax: +86-769-85370222-2337, E-mail:
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6
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Zarębska-Michaluk D, Jaroszewicz J, Buczyńska I, Simon K, Lorenc B, Tudrujek-Zdunek M, Tomasiewicz K, Sitko M, Garlicki A, Janczewska E, Dybowska D, Halota W, Pawłowska M, Pabjan P, Mazur W, Czauż-Andrzejuk A, Berak H, Horban A, Socha Ł, Klapaczyński J, Piekarska A, Blaszkowska M, Belica-Wdowik T, Dobracka B, Tronina O, Deroń Z, Białkowska-Warzecha J, Laurans Ł, Flisiak R. Real-world experience with Grazoprevir/Elbasvir in the treatment of previously "difficult to treat" patients infected with hepatitis C virus genotype 1 and 4. J Gastroenterol Hepatol 2020; 35:1238-1246. [PMID: 31734959 DOI: 10.1111/jgh.14936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/04/2019] [Accepted: 11/13/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Grazoprevir/elbasvir (GZR/EBR) was approved for the treatment of chronic hepatitis C virus (HCV) genotype 1 and 4 infected patients with or without compensated liver cirrhosis. The aim of this study was to assess GZR/EBR regimen in the real-world experience, particularly in previously "difficult-to-treat" patients with chronic kidney diseases, human immunodeficiency virus-coinfected, cirrhotics, and treatment-experienced. METHODS The analysis included patients treated with GZR/EBR selected from 10 152 individuals from the EpiTer-2 database, large national real-world study evaluating antiviral treatment in 22 Polish hepatology centers between 2015 and 2018. Data were completed retrospectively and submitted online. RESULTS A total of 1615 patients who started GZR/EBR therapy in 2017 and 2018 with a female predominance (54%) and median age of 54 years were analyzed. The majority were infected with GT1b (89%) and treatment naïve (81%). Liver cirrhosis was diagnosed in 19%, and 70% of patients had comorbidities, of which chronic renal disease was present in 7% and HIV-coinfection in 4%. Overall, a sustained virologic response (SVR) was achieved by 95% according to intent-to-treat (ITT) and 98% after exclusion of lost to follow up (modified ITT). No differences were found in cure rate between all included patients and subpopulations previously considered as difficult-to-treat. Majority of patients completed the treatment course as scheduled, adverse events were mostly mild and did not lead to therapy discontinuation. CONCLUSIONS GZR/EBR treatment carried-out in patients infected with HCV genotype 1 and 4 demonstrated good tolerability and an excellent SVR rate with no effectiveness reduction in so called difficult-to-treat populations.
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Affiliation(s)
| | - Jerzy Jaroszewicz
- Department of Infectious Diseases and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Iwona Buczyńska
- Department of Infectious Diseases and Hepatology, Medical University Wrocła, Wrocław, Poland
| | - Krzysztof Simon
- Department of Infectious Diseases and Hepatology, Medical University Wrocła, Wrocław, Poland
| | - Beata Lorenc
- Pomeranian Center of Infectious Diseases, Medical University Gdańsk, Gdańsk, Poland
| | | | | | - Marek Sitko
- Department of Infectious and Tropical Diseases, Jagiellonian University, Kraków, Poland
| | - Aleksander Garlicki
- Department of Infectious and Tropical Diseases, Jagiellonian University, Kraków, Poland
| | - Ewa Janczewska
- Department of Basic Medical Sciences, ID Clinic, Hepatology Outpatient Department, School of Public Health in Bytom, Medical University of Silesia, Bytom, Poland
| | - Dorota Dybowska
- Department of Infectious Diseases and Hepatology, Ludwik Rydygier Collegium Medicum in Bydgoszcz Faculty of Medicine, Nicolaus Copernicus University, Toruń, Poland
| | - Waldemar Halota
- Department of Infectious Diseases and Hepatology, Ludwik Rydygier Collegium Medicum in Bydgoszcz Faculty of Medicine, Nicolaus Copernicus University, Toruń, Poland
| | - Małgorzata Pawłowska
- Department of Infectious Diseases and Hepatology, Ludwik Rydygier Collegium Medicum in Bydgoszcz Faculty of Medicine, Nicolaus Copernicus University, Toruń, Poland
| | - Paweł Pabjan
- Department of Infectious Diseases, Jan Kochanowski University, Kielce, Poland
| | - Włodzimierz Mazur
- Clinical Department of Infectious Diseases, Medical University of Silesia, Katowice, Poland
| | - Agnieszka Czauż-Andrzejuk
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, Poland
| | - Hanna Berak
- Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Andrzej Horban
- Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Łukasz Socha
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Jakub Klapaczyński
- Department of Internal Medicine and Hepatology, Central Clinical Hospital of the Ministry of Internal Affairs and Administration, Warsaw, Poland
| | - Anna Piekarska
- Department of Infectious Diseases and Hepatology, Medical University of Łódź, Łódź, Poland
| | - Maria Blaszkowska
- Department of Infectious Diseases and Hepatology, Medical University of Silesia, Katowice, Poland
| | - Teresa Belica-Wdowik
- Regional Center for Diagnosis and Treatment of Viral Hepatitis and Hepatology, Kraków, Poland
| | | | - Olga Tronina
- Department of Transplantation Medicine, Nephrology, and Internal Diseases, Medical University of Warsaw, Warszawa, Poland
| | - Zbigniew Deroń
- Ward of Infectious Diseases and Hepatology, Biegański Regional Specialist Hospital, Łódź, Poland
| | | | - Łukasz Laurans
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, Szczecin, Poland.,Multidisciplinary Regional Hospital, Gorzów Wielkopolski, Poland
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, Poland
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7
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Elbasvir/grazoprevir for hepatitis C virus genotype 1b East-Asian patients receiving hemodialysis. Sci Rep 2020; 10:9180. [PMID: 32513953 PMCID: PMC7280513 DOI: 10.1038/s41598-020-66182-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/12/2020] [Indexed: 11/26/2022] Open
Abstract
Data regarding the efficacy and tolerability of elbasvir/grazoprevir (EBR/GZR) for East-Asian hepatitis C virus genotype 1b (HCV GT1b) patients receiving hemodialysis were limited. We prospectively recruited 40 HCV GT1b hemodialysis patients who received EBR/GZR for 12 weeks at 6 academic centers in Taiwan. The efficacy endpoints were sustained virologic response 12 weeks off-therapy (SVR12) by intention-to-treat (ITT) modified ITT (mITT) analyses. Patients’ baseline characteristics, early viral kinetics and HCV resistance-associated substitutions (RASs) at HCV non-structural 3 and 5 A (NS3 and NS5A) regions potentially affecting SVR12 were analyzed. The tolerability for EBR/GZR was also assessed. The SVR12 rates by ITT and mITT analyses were 95% (38 of 40 patients; 95% confidence interval (CI): 83.5–98.6%) and 100% (38 of 38 patients; 95% CI: 90.8–100%), respectively. Patients’ baseline characteristics, on-treatment viral decline, and baseline HCV RASs did not affect SVR12. All patients tolerated treatment well. Among 5 patients who had serious adverse events (AEs) including one death due to on-treatment suicide and the other death due to off-therapy acute myocardial infarction, none of these events were judged related to EBR/GZR. The common AEs included upper respiratory tract infection (7.5%), fatigue (5.0%) and anorexia (5.0%). Nine (22.5%) and 8 (20.0%) patients had on-treatment hemoglobin levels of 9.0–10.0 g/dL and 7.0–9.0 g/dL. Three (7.5%) patients had on-treatment elevated alanine aminotransferase (ALT) quotient > 2.5, in whom one (2.5%) had EBR/GZR-induced late ALT elevation. No patients developed hyperbilirubinemia or hepatic decompensation. In conclusion, treatment with EBR/GZR is effective and well-tolerated for East-Asian HCV GT1b patients receiving hemodialysis.
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8
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Fadl N, Salem TZ. Hepatitis C genotype 4: A report on resistance-associated substitutions in NS3, NS5A, and NS5B genes. Rev Med Virol 2020; 30:e2120. [PMID: 32478480 DOI: 10.1002/rmv.2120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/20/2022]
Abstract
AUTHOR CONTRIBUTION FN performed the literature review and wrote the manuscript; STZ coauthored, edited, and reviewed the manuscript. ABSTRACT Treatment response in Hepatitis C virus (HCV) has generated varied effects in patients. Recently, nonresponsive and relapse patients related to host and genotype variabilities have been reported in clinical trials. However, these trials included minimal sample sizes of patients with genotype 4, the most prevalent genotype in Egypt and the Middle East, compared with genotypes 1 and 2. The genetic variabilities that have been detected within the HCV genes, especially the ones associated with genotype 4, and are linked to treatment response, will be the focus of this review with emphasis on direct acting antiviral agents. In addition, the major studies and clinical trials performed globally and their inclusivity of genotype 4 are reported. This review also delineates future study areas and missing data that need further investigation when it comes to genotype 4.
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Affiliation(s)
- Nahla Fadl
- Biomedical Sciences Program, University of Science and Technology, Zewail City of Science and Technology, Giza, Egypt
| | - Tamer Z Salem
- Biomedical Sciences Program, University of Science and Technology, Zewail City of Science and Technology, Giza, Egypt.,Department of Microbial Genetics, AGERI, ARC, Giza, Egypt
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Zhdanov K, Isakov V, Burnevich E, Kizhlo S, Bakulin I, Pokrovsky V, Liang L, Hwang P, Talwani R, Haber BA, Robertson MN. Elbasvir/Grazoprevir for HCV Infection in Russia: A Randomized Trial. Hepat Med 2020; 12:61-68. [PMID: 32368162 PMCID: PMC7183329 DOI: 10.2147/hmer.s241418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/02/2020] [Indexed: 01/03/2023] Open
Abstract
Purpose Hepatitis C virus (HCV) infection is a major healthcare concern in Russia, where almost 5 million individuals are viremic. Elbasvir/grazoprevir is a fixed-dose combination therapy for the treatment of HCV genotype 1 and genotype 4 infection. The present analysis aimed to assess the safety and efficacy of elbasvir/grazoprevir in individuals with HCV infection enrolled at Russian study sites in the C-CORAL study. Patients and Methods C-CORAL (Protocol PN-5172-067; NCT02251990) was a Phase 3, placebo-controlled, double-blind study conducted throughout Asia and Russia. Treatment-naive participants with chronic HCV infection were randomly assigned to receive immediate or deferred treatment with elbasvir 50 mg/grazoprevir 100 mg once daily for 12 weeks. Participants in the immediate-treatment group received elbasvir/grazoprevir for 12 weeks, and those in the deferred-treatment group received placebo for 12 weeks, followed by open-label elbasvir/grazoprevir for 12 weeks. The primary endpoint was sustained virologic response at 12 weeks after completion of therapy (SVR12). Results One hundred and nineteen Russian participants were randomized (immediate-treatment group, n=88; deferred-treatment group, n=31). Most participants were white (99%) with HCV genotype 1b infection (97%) and mild-to-moderate (F0–F2) fibrosis (70%). SVR12 was achieved by 98.9% participants in the immediate-treatment group and by 100% of those receiving deferred elbasvir/grazoprevir in the deferred-treatment group. One participant relapsed with nonstructural protein 5A (NS5A) L28M and Y93H resistance-associated substitutions at baseline and at time of failure. Drug-related adverse events were reported by 19% of participants receiving elbasvir/grazoprevir in the immediate-treatment group and by 16% of those receiving placebo in the deferred-treatment group. No serious adverse event or deaths occurred, and no participant discontinued treatment owing to an adverse event. Conclusion Elbasvir/grazoprevir for 12 weeks was highly effective in treatment-naive Russian individuals with HCV genotype 1b infection.
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Affiliation(s)
| | - Vasily Isakov
- Department of Gastroenterology & Hepatology, Federal Research Centre of Nutrition, Biotechnology and Food Safety, Moscow, Russia
| | - Eduard Burnevich
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Svetlana Kizhlo
- City Center for AIDS and Infectious Diseases Treatment and Prophylaxis, St. Petersburg, Russia
| | - Igor Bakulin
- I.I. Mechnikov North-Western State Medical University of the Ministry of Health of the Russian Federation, St. Petersburg, Russia
| | - Vadim Pokrovsky
- Department of AIDS, Central Research Institute of Epidemiology, Moscow, Russia
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10
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Smolders EJ, Jansen AME, Ter Horst PGJ, Rockstroh J, Back DJ, Burger DM. Viral Hepatitis C Therapy: Pharmacokinetic and Pharmacodynamic Considerations: A 2019 Update. Clin Pharmacokinet 2019; 58:1237-1263. [PMID: 31114957 PMCID: PMC6768915 DOI: 10.1007/s40262-019-00774-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
It has been estimated by the World Health Organization (WHO) that over 71 million people were infected with the hepatitis C virus (HCV) in 2015. Since then, a number of highly effective direct-acting antiviral (DAA) regimens have been licensed for the treatment of chronic HCV infection: sofosbuvir/daclatasvir, sofosbuvir/ledipasvir, elbasvir/grazoprevir, sofosbuvir/velpatasvir, glecaprevir/pibrentasvir, and sofosbuvir/velpatasvir/voxilaprevir. With these treatment regimens, almost all chronic HCV-infected patients, even including prior DAA failures, can be treated effectively and safely. It is therefore likely that further development of DAAs will be limited. In this descriptive review we provide an overview of the clinical pharmacokinetic characteristics of currently available DAAs by describing their absorption, distribution, metabolism, and excretion. Potential drug-drug interactions with the DAAs are briefly discussed. Furthermore, we summarize what is known about the pharmacodynamics of the DAAs in terms of efficacy and safety. We briefly discuss the relationship between the pharmacokinetics of the DAAs and efficacy or toxicity in special populations, such as hard to cure patients and patients with liver cirrhosis, liver transplantation, renal impairment, hepatitis B virus or HIV co-infection, bleeding disorders, and children. The aim of this overview is to educate/update prescribers and pharmacists so that they are able to safely and effectively treat HCV-infected patients even in the presence of underlying co-infections or co-morbidities.
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Affiliation(s)
- Elise J Smolders
- Department of Pharmacy, Isala Hospital, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
- Department of Pharmacy, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Anouk M E Jansen
- Department of Pharmacy, Isala Hospital, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Peter G J Ter Horst
- Department of Pharmacy, Isala Hospital, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Jürgen Rockstroh
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - David J Back
- Department of Clinical and Molecular Pharmacology, University of Liverpool, Liverpool, UK
| | - David M Burger
- Department of Pharmacy, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
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11
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Lee YJ, Heo J, Kim DY, Chung WJ, Tak WY, Kim YJ, Paik SW, Sim E, Kulasingam S, Talwani R, Haber B, Hwang P. An integrated analysis of elbasvir/grazoprevir in Korean patients with hepatitis C virus genotype 1b infection. Clin Mol Hepatol 2019; 25:400-407. [PMID: 31132846 PMCID: PMC6933128 DOI: 10.3350/cmh.2019.0006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/04/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS In the Republic of Korea, an estimated 231,000 individuals have chronic hepatitis C virus (HCV) infection. The aim of the present analysis was to evaluate the safety and efficacy of elbasvir/grazoprevir (EBR/GZR) administered for 12 weeks in Korean patients who were enrolled in international clinical trial phase 3 studies. METHODS This was a retrospective, integrated analysis of data from patients with HCV genotype (GT) 1b infection enrolled at Korean study sites in four EBR/GZR phase 3 clinical trials. Patients were treatment-naive or had previously failed interferon-based HCV therapy, and included those with human immunodeficiency virus coinfection or ChildPugh class A cirrhosis. All patients received EBR 50 mg/GZR 100 mg once daily for 12 weeks. The primary endpoint was sustained virologic response at 12 weeks after completion of therapy (SVR12, HCV RNA <15 IU/mL). RESULTS SVR12 was achieved by 73 of 74 (98.6%) patients. No patients had virologic failure and one discontinued from the study after withdrawing consent. SVR12 rates were uniformly high across all patient subgroups. A total of 16 patients had nonstructural protein 5A resistance-associated substitutions at baseline (16/73, 22%), all of whom achieved SVR12. Adverse events (AEs) reported in >5% of patients were fatigue (6.8%), upper respiratory tract infection (5.4%), headache (5.4%), and nausea (5.4%). Thirteen patients (17.6%) reported drug-related AEs, two serious AEs occurred, and two patients discontinued treatment owing to an AEs. CONCLUSION In this retrospective analysis, EBR/GZR administered for 12 weeks was well-tolerated and highly effective in Korean patients with HCV GT1b infection.
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Affiliation(s)
- Youn Jae Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jeong Heo
- Department of Internal Medicine, College of Medicine, Pusan National University, Busan, Korea.,Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Won Young Tak
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Woon Paik
- Department of Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
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12
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Xie Q, Xuan JW, Tang H, Ye XG, Xu P, Lee IH, Hu SL. Hepatitis C virus cure with direct acting antivirals: Clinical, economic, societal and patient value for China. World J Hepatol 2019; 11:421-441. [PMID: 31183003 PMCID: PMC6547290 DOI: 10.4254/wjh.v11.i5.421] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/05/2019] [Accepted: 04/19/2019] [Indexed: 02/06/2023] Open
Abstract
About 10 million people in China are infected with hepatitis C virus (HCV), with the seroprevalence of anti-HCV in the general population estimated at 0.6%. Delaying effective treatment of chronic hepatitis C (CHC) is associated with liver disease progression, cirrhosis, hepatocellular carcinoma, and liver-related mortality. The extrahepatic manifestations of CHC further add to the disease burden of patients. Managing CHC-related advanced liver diseases and systemic manifestations are costly for both the healthcare system and society. Loss of work productivity due to reduced well-being and quality of life in CHC patients further compounds the economic burden of the disease. Traditionally, pegylated-interferon plus ribavirin (PR) was the standard of care. However, a substantial number of patients are ineligible for PR treatment, and only 40%-75% achieved sustained virologic response. Furthermore, PR is associated with impairment of patient-reported outcomes (PROs), high rates of adverse events, and poor adherence. With the advent of direct acting antivirals (DAAs), the treatment of CHC patients has been revolutionized. DAAs have broader eligible patient populations, higher efficacy, better PRO profiles, fewer adverse events, and better adherence rates, thereby making it possible to cure a large proportion of all CHC patients. This article aims to provide a comprehensive evaluation on the value of effective, curative hepatitis C treatment from the clinical, economic, societal, and patient experience perspectives, with a focus on recent data from China, supplemented with other Asian and international experiences where China data are not available.
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Affiliation(s)
- Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Jian-Wei Xuan
- Health Economic Research Institute, School of Pharmacy, Sun Yat-Sen University, Guangzhou 510006, Guangdong Province, China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao-Guang Ye
- Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, Guangdong Province, China
| | - Peng Xu
- Gilead Sciences Inc, Shanghai 200122, China
| | - I-Heng Lee
- Gilead Sciences Inc, Foster City, CA 94404, United States
| | - Shan-Lian Hu
- School of Public Health, Fudan University, Shanghai 200032, China
- Shanghai Health Development Research Center, Shanghai 200032, China.
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