Ribavirin facilitates early viral kinetics in chronic hepatitis C patients receiving daclatasvir/asunaprevir

HCV treatment outcome depends on SNPs of IFNL3-Gene polymorphisms (rs12979860) and cirrhotic changes in liver parenchyma

The allelic discrimination of IFNL3-(rs12979860 C > T) polymorphism reveals ambiguous associations with the effectiveness of oral HCV treatment. Solitary intra peripheral-blood-mononuclear-cells (PBMCs) HCV-RNA antisense-strands are independently detected in naïve and experienced cases regardless of viremia or hepatic-parenchymal alterations. We examined the frequencies of IFNL3-genetic variants with chronic-HCV-induced liver changes during the sustained virologic response (SVR) by evaluating the PBMCs- HCV-PCR after oral antiviral therapy. Methods: Twelve weeks after finishing oral antiviral therapy, the effects of IFNL3-genetic variants were evaluated in three groups of patients: Group-I (n = 25) showed HCV-RNA negativity in both serum and PBMCs-, group II (n = 52) showed positivity of HCV-RNA in PBMCs, and group-III (n = 25) had positive HCV-RNA in serum. The genetic variants of the IFNL3-gene were estimated for all the enrolled cases and correlated with their hepatic image changes. Results: IFNL3-(rs12979860) genotyping in post-direct acting antivirals (DAAs) SVR and HCV-relapse revealed: a) high frequency of CC-genotype and C-allele in group I compared to group II (P < 0.005) and group III(P ≤ 0.05) when hepatic-parenchyma looks normal by ultrasound b) frequent CT-genotype and T-allele in group II compared with I(P < 0.01) and III(P < 0.05) when liver tissues are bright (early cirrhotic-changes) c) frequent TT-genotype and T-allele in group III relative to I (P < 0.05) and II (P ≤ 0.08) when liver-tissues appear coarse by ultrasound. Conclusion: Outcomes of HCV treatment depend on host IFNL3-gene polymorphism and hepatic-parenchymal changes. A high frequency of wild-CC-genotype and C-allele is observed in patients with normal hepatic parenchyma and that achieved SVR. Solitary relapse in PBMCs occurs on increasing CT-genotype frequency when liver tissues are bright. Serologic relapse is detected when TT-genotype and T-allele are dominant in association with the cirrhotic liver. Therefore, IFNL3-gene-SNP analysis as a genetic predictor in relation to ultra-sonographic hepatic-parenchymal changes could be valuable for selecting the patients with the highest priority for treatment.

Hepatitis C viral RNA in blood mononuclear cells of patients treated with directly acting antivirals

BACKGROUND AND STUDY AIMS

Occult hepatitis C viral infection (OCI) may have serious complications, such as relapse, ongoing histological impairment, hepatic decompensation, hepatocellular carcinoma, and the possible risk of transmission. This study was conducted to assess the occurrence and prevalence of secondary OCI in patients with chronic hepatitis C viral infection (HCV) who received a complete course of directly acting antivirals (DAAs).

PATIENTS AND METHODS

Antiviral therapy consisted of sofosbuvir + daclatasvir ± ribavirin for 12 weeks to 90 treatment-naive, compensated, chronic HCV patients. Plasma and peripheral blood mononuclear cells (PBMCs) were tested for HCV RNA viral load by quantitative, reverse transcription, real-time PCR at 8, 12 (Group I, n = 45), and 24 (Group II, n = 45) weeks after treatment initiation.

RESULTS

By week 8, only 2 and 7 patients were positive for HCV RNA in plasma and PBMCs, respectively. No HCV RNA was detected by weeks 12 or 24 in the PBMCs of Groups I and II, respectively. Older age was significantly associated with HCV RNA positivity in plasma and PBMCs (n = 8) at week 8 compared with HCV RNA negativity (n = 82). No other significant differences were observed for any other variables.

CONCLUSION

The development of secondary OCI among easy-to-treat patients following a full course of DAA treatment doesn't exist, hence, we do not recommend testing the HCV RNA in the PBMCs after complete course of treatment in this patient category. The detection of HCV RNA in PBMCs is recommended as a confirmatory test of cure following a shortened DAA treatment regimen.

Treatment of hepatitis C virus infection with direct-acting antivirals plus ribavirin eliminates viral RNA from peripheral blood mononuclear cells and reduces virologic relapse in diverse hepatic parenchymal changes

Elimination of hepatitis C virus (HCV) may fail, leading to a non-response outcome because of inappropriate testing for viral RNA in peripheral blood mononuclear cells (PBMCs). Sequelae of HCV genotype 4 therapy with sofosbuvir and daclatasvir ± ribavirin were assessed in our study at the 12^th week after end of treatment (EOT) by screening for viral genomic RNA in serum and PBMCs with correlation to hepatic parenchymal changes. We recruited 102 out of 2165 patients who had received sofosbuvir/daclatasvir, either alone (n = 1573) or together with ribavirin (n = 592). Subjects were classified into three groups based on testing by single-step reverse transcription PCR: group I, HCV negative in both serum and PBMCs (n = 25); group II, HCV positive in PBMCs only (n = 52); and group III, HCV positive in both serum and PBMCs (n = 25). Groups I and II (n = 77) were selected out of 2102 (every 27^th subject), while group III (n = 25) were selected from every second or third serologic relapse (n = 63). The pre-sampling population (n = 2165) showed sustained virologic response (SVR) in 33.21%; serologic relapse in 2.91%; HCV RNA only in PBMCs (66.79%) compared to serologic relapses and potential cure (P < 0.0001); higher serologic (38 out of 63, P = 0.03210) and cellular (36 out of 52, P = 0.0002) relapses in dual therapy than in triple therapy. The post-sampling population (n = 102) showed more HCV relapses in dual (50 out of 60) than in triple (27 out of 42) therapy (P = 0.0351); increased HCV antisense RNA strand in relapses compared to positive-sense strands alone (P < 0.001); and significant SVR events in undetectable (15 out of 31) compared to early (10 out of 55, P = 0.0058) and cirrhotic liver tissue changes (0 out of 16, P = 0.0006). In summary, HCV treatment with sofosbuvir/daclatasvir is followed by higher rates of serologic and intracellular viral RNA relapse than treatment with sofosbuvir/daclatasvir plus ribavirin. Cellular and serum viral RNA relapses are accompanied by HCV-induced hepatic pathology. An increased SVR with no detectable liver tissue changes was observed after triple therapy due to elimination of HCV RNA from PBMCs.

Unmet needs of chronic hepatitis C in the era of direct-acting antiviral therapy

The treatment of chronic hepatitis C (CHC) has been revolutionized in an era of all-oral direct-acting antivirals (DAAs) since 2014. Satisfactory treatment efficacy and tolerability can be provided by novel DAAs. Nevertheless, there are still some unmet needs and emerging issues in the treatment of CHC in the DAA era. Certain hard-to-cure populations are prone to have inferior treatment responses, including patients with severe liver decompensation, active hepatocellular carcinoma (HCC), and hepatitis C virus (HCV) genotype 3 (HCV-3) infection and those who experience multiple DAA treatment failures. Hepatitis B virus (HBV) reactivation during and after DAA treatment has raised concern regarding the use of prophylactic antivirals against HBV throughout DAA treatment. However, the standard strategy for the use of prophylactic antivirals is not uniform across regional guidelines. In the post-sustained virological response (SVR) period, HCC still occurs in a substantial proportion of patients. Due to the relatively short follow-up period, the net benefit of the achievement of an SVR by DAAs in the reduction of extrahepatic manifestations has not yet been determined. Attention must also be paid to HCV reinfection, particularly in high-risk populations. The most critical and unmet need for HCV elimination is the large gap in the HCV care cascade at the population level. To accomplish the World Health Organization (WHO)'s goal for HCV elimination by 2030, the expansion of access to HCV care requires a continuous effort to overcome practical and political challenges.

Sofosbuvir/velpatasvir/voxilaprevir plus ribavirin for chronic hepatitis C patients with direct acting antiviral failures: Implications for viral elimination in Taiwan

Despite the excellent antiviral effects of direct acting antivirals (DAAs) for hepatitis C virus (HCV) infection with subsequent decrease of morbidity and mortality, a small proportion (5%) of the treated patients do not respond to first-line DAAs and have persistent viremia. Rescue therapy for patients with DAA failures is thus mandatory from both clinical and public health perspectives. Sofosbuvir/velpatasvir/voxilaprevir (SOF/VEL/VOX), a fixed-dose pangenotypic rescue agent, has been approved by the Food and Drug Administration (FDA) and European Medical Agency (EMA) for retreating HCV patients who fail prior DAA therapies. However, this agent has not been licensed by health authorities of Taiwan. Herein we reported two cases who successfully cleared HCV by using SOF/VEL/VOX plus ribavirin (RBV) after virologic failures to first-line pangenotypic SOF/VEL. Furthermore, we discussed the current unmet medical needs and clinical implications of SOF/VEL/VOX on the perspectives of HCV elimination in Taiwan.