Adherence to PEG/ribavirin treatment for chronic hepatitis C: prevalence, patterns, and predictors of missed doses and nonpersistence

Evaluation of chronic hepatitis B patients who voluntarily discontinued oral antiviral therapy: is there an answer to the controversial topic?

OBJECTIVE

The uncertain treatment duration for nucleos(t)ide analogues (NA) used in the treatment of chronic hepatitis B (CHB) is an important problem for both patients and physicians. The aim of this study was to evaluate the determinants of virologic relapse (VR) and the optimum time of treatment discontinuation in the follow-up of CHB patients who voluntarily discontinued treatment after virological suppression was achieved under NA use.

METHODS

Data from 138 patients from 11 centers were included in this registry-based study. Factors associated with VR were investigated using multivariate Cox regression analysis.

RESULTS

Ninety-nine (71.7%) of the patients were HBeAg (Hepatitis B e antigen) negative. During the 24-month follow-up period after treatment discontinuation, VR occurred in 58.7% (n = 81) of all patients and 57.6% (n = 57) of HBeAg-negative patients. The duration of NA treatment was significantly shorter (cutoff 60 months) in HBeAg-negative patients who later developed VR. In addition, the duration of virologic remission achieved under NA treatment was significantly shorter (cutoff 52 months) in those who later developed VR. In the Cox multivariate regression model of HBeAg-negative patients, having less than 60 months of NA treatment (HR = 2.568; CI:1.280-5.148; P  = 0.008) and the levels of alanine aminotransferase being equal to or higher than twice the upper level of normal at the beginning of treatment (HR = 3.753; CI:1.551-9.081; P  = 0.003) were found to be statistically significant and independently associated with VR.

CONCLUSION

The findings of this study may provide clinical guidance in terms of determining the most appropriate discontinuation time for NA.

Factors associated with hepatitis C treatment adherence: an integrative review

This integrative review examined factors associated with hepatitis C treatment adherence. The articles included were published in English, Spanish and Portuguese in the Lilacs, Medline, PsycINFO, Web of Science, Scopus and CINAHL databases, between 2000 and 2019. Initially, 540 publications were found and, after applying the study inclusion criteria, 22 articles were selected. Percentage non-adherence to treatment ranged from 12% to 32%. The variables identified as facilitating adherence were: receiving treatment for psychiatric disorders identified during treatment; knowing about medications and disease; receiving less complex treatment with greater likelihood of cure; fewer adverse events; social support; doctor-patient communication; and/or being in relationships. Barriers to adherence identified were: presence of depressive symptoms and other mental disorders; abuse of alcohol and psychoactive substances; education; age; ethnicity; unemployment; not having a steady partner; stigma; distance from health services; and the complexity and adverse effects of treatment. This review identified gaps in research on adherence.

Pretreatment Assessment of Psychosocial Readiness Is Not Associated with Improved Treatment Outcomes in a Safety-Net HCV Treatment Clinic

OBJECTIVES

Hepatitis C virus (HCV) is highly curable with antiviral therapy, and traditionally, treatment adherence has been critical for treatment success. We sought to determine whether assessing HCV treatment readiness with a structured treatment readiness tool was associated with increased rates of adherence and cure among patients at a safety-net HCV clinic.

METHODS

We administered the Psychosocial Readiness Evaluation and Preparation for HCV Treatment (PREP-C) tool to 50 patients and compared them with 50 patients who received the usual care. The outcome measures included achievement of treatment milestones (eg, adherence to treatment, clinic visit attendance) and sustained virologic response (cure).

RESULTS

We found no association between receiving the PREP-C assessment and outcomes, including referral to or starting HCV treatment, adherence to treatment, and HCV cure.

CONCLUSIONS

We found that receiving the PREP-C assessment did not improve treatment outcomes, suggesting that targeted pretreatment assessment is unnecessary even in a medically and psychosocially complex population.

Mental Disorders and Interferon Nontreatment in Hepatitis C Virus Infection-a Population Based Cohort Study

OBJECTIVE

This study investigates the association between mental disorders and interferon nontreatment in patients with chronic hepatitis C virus (HCV) infection in a large national sample.

METHODS

Using the National Health Insurance Research Database of Taiwan, we conducted a nationwide population-based study. Each case was matched to five controls by age, sex, urbanization, and income. Conditional logistic regression was used to assess odds of HCV nontreatment in different mental disorders.

RESULTS

From 1999 to 2013, we identified 92,970 subjects with HCV infection and 15,495 HCV cases (16.7%) had received IFN therapy. Other than chronic obstructive pulmonary disease, the medical diseases and mental disorders were significantly different between IFN and non-IFN treated HCV patients. After adjusting for medical diseases, depressive disorder and anxiety disorder was positively associated with receiving IFN therapy. Patients with schizophrenia, bipolar disorders and alcohol use disorders were significantly less likely to receive interferon. Antidepressant exposure (cumulative daily exposure or cumulative daily dose) was associated with lower odds of IFN treatment.

CONCLUSION

Our nationwide cohort study demonstrated that INF nontreatment rate was lower in certain mental disorders. Antidepressant exposure might lower the chance of receiving IFN treatment. Our results may help to identify and to overcome the obstacles for HCV treatment and further apply to DAAs regimen.

The challenges of hepatitis C management in Iran: A qualitative study with patients

BACKGROUND

The patient's perspective concerning the treatment process and the knowledge of the challenges and problems that they encounter can help to improve their treatment conditions.

AIM

The present study aimed at analyzing the experiences of hepatitis C virus (HCV) patients in Iran and the challenges encountered during the management and treatment process.

METHODS

Semi-structured in-depth and face-to-face interviews were conducted. The criteria for selecting patients were as follows: HCV-positive subjects, with confirmed diagnosis of HCV, and under treatment. Content analysis was used to analyze the data. MAXQDA Ver11 software was used to better manage data. This study is based on the "Consolidated Criteria for Reporting Qualitative Research" (COREQ) checklist.

RESULTS

Twenty-one HCV patients were interviewed. The mean age of participants was 36.14 ± 11.29 years. Seven themes with 20 subthemes emerged from the content analysis of the interviews, namely, (a) disease-related stigma, (b) lack of knowledge, (c) psychological problems, (d) financial problems, (e) complications of treatment, (f) lack of family and community support, and (g) health-care system.

CONCLUSION

The findings of this study showed that a range of economic, social, and cultural problems could affect the treatment of HCV patients. Health policy and decision makers should try to provide them with a better management.

Content Validity and Reliability of a Self-Report Measure of Medication Nonadherence in Hepatitis C Treatment

BACKGROUND

Nonadherence to direct-acting agents (DAAs) for hepatitis C (HCV) decreases viral response. To measure nonadherence to DAAs, a reliable, valid, and easily implemented method is needed.

AIMS

The goals of this study were to refine a previously validated (in patients with hypertension) self-report measure of extent of nonadherence and reasons for nonadherence in the context of DAAs and to obtain initial evidence of content validity and reliability.

METHODS

Phase I involved two focus groups with patients with HCV (n = 12) and one focus group with prescribers of HCV medications (n = 6) to establish content validity of reasons for nonadherence. Subsequent cognitive interviews with patients (n = 11) were conducted to refine items. Phase II was a prospective cohort study involving weekly administration of the refined measure by telephone to patients (n = 75) who are prescribed DAAs to evaluate reliability and consistency with viral response.

RESULTS

In the cohort study, internal consistency ranged from acceptable (α = .69) to very high (α = 1.00) across time points and was quite high on average (α = .91). Across the 75 participants, there were 895 measurement occasions; of those, nonadherence was reported on only 27 occasions (3%), all of which occurred in the first 12 weeks. These 27 occasions represented 19 (26%) different individuals. At 12 weeks, 1 (1%) of patients had a detectable HCV viral load; at 12-24 weeks posttreatment, 4 (5%) had a sustained viral response. Nonadherent patients reported an average of 1.41 reasons for nonadherence.

CONCLUSIONS

This multi-method study established content validity of reasons for nonadherence and reliability of extent of nonadherence. High rates of adherence and viral response were consistent with previous studies using other nonadherence measurement methods.

Antidepressant use and hepatocellular carcinoma in patients with hepatitis C who had received interferon therapy: A population-based cohort study

BACKGROUND

Using data from the National Health Insurance (NHI) of Taiwan, we conducted a nationwide population-based cohort study to investigate the association between antidepressant (ATD) use and the risk of hepatocellular carcinoma (HCC) in patients with hepatitis C virus (HCV) who had received interferon (IFN) therapy.

METHODS

This study included a total of 274,952 HCV-infected patients without hepatitis B virus infection who were enrolled in the NHI program between January 1, 1997 and December 31, 2013. Among these patients, only 10,713 (age ≥18 years) had received IFN therapy between 2004 and 2008. Among the patients who had received IFN therapy, 2014 had received ATDs, and 8684 had not. A Cox proportional hazards regression model was applied after adjusting for age, sex, income, urbanization, medical comorbidity, and medication use.

RESULTS

Compared with non-ATD-treated patients, ATD-treated patients were more likely to receive a diagnosis of alcohol-related disease, diabetes mellitus (DM), hypertension, and hyperlipidemia. ATD-treated patients had a significantly lower incidence of HCC than non-ATD-treated patients (P = 0.0019). Female, older (age ≥50 years), and non-DM patients who had received cumulative high doses of ATDs had a significantly lower risk of HCC than non-ATD-treated patients. After adjustment, only high-dose selective serotonin reuptake inhibitor (SSRI) use was inversely associated with HCC risk (adjusted hazard ratio 0.37, 95% confidence interval 0.19-0.71, P = 0.0027).

CONCLUSIONS

Our study showed that ATD use, especially a relatively high cumulative dose of SSRIs, in HCV-infected patients who had received IFN was associated with reduced HCC risk. Future clinical studies are warranted to explore the underlying mechanisms and to apply them to newer direct-acting antiviral agent treatments.

Factors affecting adherence and patient satisfaction with treatment: a cross-sectional study of 500 patients with acne vulgaris

Background: Acne Vulgaris is a chronic inflammatory disease that requires long-term treatment. Adherence to treatment is a problem in chronic diseases and may affect treatment outcomes.Objective: We aim to investigate treatment adherence and satisfaction of patients with acne and identify independent factors that affect them.Methods: Five hundred patients with acne were included in this cross-sectional study. Demographic and clinical characteristics of the patients were recorded. Severity of acne was assessed using the Investigator Global Assessment (IGA) scale, and a five-point Likert scale was used to assess patients' satisfaction and adherence.Results: Adherence to treatment was poor in 64.4% of the patients. Multivariate logistic regression analysis showed that using oral isotretinoin (OR: 4.1, 95% CI 2.44-6.92, p < .001) and satisfaction with treatment (OR: 2.1, 95% CI 1.31-3.43, p = .002) were independent factors that affect adherence in patients. 51.8% of the patients were satisfied with their treatments and treatment satisfaction was higher in females (OR: 2.2, 95% CI 1.3-3.8, p = .004) and patients using oral isotretinoin (OR: 14.8, 95% CI 9.4-23.2, p < .001).Conclusions: Treatment adherence is poor among patients with acne. Identifying the factor that affects adherence may help the dermatologist recognize non-adherent patients and develop strategies to improve adherence.

Development and Pilot-Testing of a Cognitive Behavioral Coping Skills Group Intervention for Patients with Chronic Hepatitis C

Psychosocial interventions for patients with chronic hepatitis C viral (HCV) infection are needed to attenuate the impact of extrahepatic symptoms, comorbid conditions, and treatment side effects on HCV health outcomes. We adapted empirically-supported interventions for similar patient populations to develop a Cognitive Behavioral Coping Skills group intervention for HCV patients (CBCS-HCV) undergoing treatment. The objectives of this paper are to describe the research activities associated with CBCS-HCV development and pilot testing, including: (1) formative work leading to intervention development; (2) preliminary study protocol; and (3) pilot feasibility testing of the intervention and study design. Formative work included a literature review, qualitative interviews, and adaption, development, and review of study materials. A preliminary study protocol is described. We evaluate the feasibility of conducting a randomized controlled trial (RCT) of the CBCS-HCV with 12 study participants in Wave 1 testing to examine: (a) feasibility of intervention delivery; (b) patient acceptability; (c) recruitment, enrollment, retention; (d) feasibility of conducting a RCT; (d) therapist protocol fidelity; and (e) feasibility of data collection. Numerous lessons were learned. We found very high rates of data collection, participant attendance, engagement, retention and acceptability, and therapist protocol fidelity. We conclude that many aspects of the CBCS-HCV intervention and study protocol were highly feasible. The greatest challenge during this Wave 1 pilot study was efficiency of participant enrollment due to changes in standard of care treatment. These findings informed two additional waves of pilot testing to examine effect sizes and potential improvements in clinical outcomes, with results forthcoming.

Does Hepatitis C Treatment Adherence Affect Risk of Liver Transplantation? A Historical Cohort Study

BACKGROUND

Chronic hepatitis C virus (HCV) is the primary cause of liver failure leading to transplantation, and medication adherence is essential to the therapeutic efficacy of HCV treatments. While there is evidence linking poor adherence with increased utilization and cost, published literature lacks examination of the association between medication adherence and risk of liver transplant. In addition, the impact of HCV treatment on total costs of liver transplantation is not well documented.

OBJECTIVES

To compare (a) the relative risk of liver transplant by adherence in patients treated for HCV and (b) the total health care costs in treated and untreated patients who require liver transplant.

METHODS

This observational, historical cohort study was conducted using administrative data from the Humana Research Database. To be included, patients were required to have a documented HCV diagnosis or treatment between January 1, 2008, and June 30, 2013. Patients were excluded if they had a hepatitis B diagnosis, were not fully insured by a commercial or Medicare Advantage Prescription Drug plan, or were outside the age range of 19-89 years. No minimum pre- or post-index enrollment period was required, and patients were followed for their entire post-index enrollment through December 31, 2013. The study population was divided into treated and untreated groups and then subdivided by presence or absence of a liver transplant. Date of liver transplant was defined as the index date for untreated liver transplant patients; otherwise, the index date was defined as either the date of first observed HCV treatment or diagnosis date (if no treatment or liver transplant). Cox proportional hazards models were used to estimate the relative risk of liver transplant by level of treatment adherence (> 80%, 50%-79%, and < 50%) based on proportion of days covered. General linearized models with log link and gamma distribution were used to compare median total health care costs from index date until end of study period (or death/disenrollment, whichever came first) between treated and untreated liver transplant patients. All costs were converted to 2013 U.S. dollars and reported as total costs per patient and per patient per month (PPPM) to account for varying follow-up periods.

RESULTS

Of the 53,423 patients identified with HCV, 10,377 met exclusion criteria, leaving 43,046 patients (primarily Caucasian, males, mean age of 58 years) in the initial cohort. Only 6.29% (n = 2,708) of the total HCV cohort received HCV treatment, and less than 1% (n = 366, 0.8%) received a liver transplant. Although there were no significant differences in the risk of liver transplant by adherence level, there was an upwards trend in the rate of liver transplant as adherence worsened (> 80%: 1.25%; 50%-79%: 1.30%; and < 50%: 1.99%), and the average days to liver transplant was longer with higher adherence (> 80%: 683; 50%-79%: 623; < 50%: 454). Only 48 (13.11%) patients who received a liver transplant were treated for HCV. Adjusted median total and PPPM health care costs measured from index date until end of the study period were significantly higher for patients who received HCV treatment compared with those who did not (total=$231,139 vs. $86,167, adjusted P < 0.001; PPPM=$20,583 vs. $5,778, adjusted P = 0.008), driven by HCV-related medical costs and total pharmacy costs.

CONCLUSIONS

Adherence with HCV regimens did not affect risk of liver transplant, underscoring the need for further evidence linking treatment adherence to future liver transplant risk. HCV-treated patients who required liver transplant incurred significantly higher health care costs than those without HCV treatment before liver transplant. Introduction of newer all-oral direct-acting antiviral regimens, with higher acquisition costs, will require further research to more accurately assess medication adherence and its relationship with transplantation, as well as with total health care costs.

DISCLOSURES

No outside funding supported this research. Ems, Worley, Racsa, Gregory, Anderson, and Holt are employees of Humana. Brill has participated in a physician advisory board at Humana. The authors have no other financial disclosures to report. Study concept and design were contributed by Ems, Racsa, Worley, and Anderson, along with Gregory, Brill, and Holt. Racsa took the lead in data collection, along with Ems and Worley. All authors participated in data interpretation. Anderson, along with the other authors, wrote the manuscript, which was revised by Brill and Holt, with assistance from the other authors.

Once-daily dose regimen of ribavirin is interchangeable with a twice-daily dose regimen: randomized open clinical trial

Background

The combination of ribavirin (RBV) and pegylated interferon (PEG-IFN) is effective in the treatment of chronic hepatitis C infection. Reducing the frequency of RBV intake from twice to once a day will improve compliance and opens up the opportunity to combine RBV with new and more specific direct-acting agents in one pill. Therefore, the purpose of this study was to evaluate the pharmacokinetic profile of RBV in a once-daily to twice-daily regimen. The secondary aim was to determine tolerability as well as the severity and differences in side effects of both treatment regimens.

Methods

In this randomized open-label crossover study, twelve patients with chronic type 1 hepatitis C infection and weighing more than 75 kg were treated with 180 µg of PEG-IFN weekly and 1,200 mg RBV daily for 24 weeks. The patients received RBV dosed as 1,200 mg once-daily for 12 weeks followed by RBV dosed as 600 mg twice-daily for 12 weeks, or vice versa. In addition to the pharmacokinetic profile, the hematological profile and side effects were recorded. The RBV concentrations in plasma were determined using liquid chromatography-tandem mass spectrometry.

Results

Eight of twelve patients completed the study. Neither the time taken for RBV to reach peak plasma concentration nor the AUC_0-last (adjusted for difference in dose) was significantly different between the two groups (P>0.05). Furthermore, the once-daily regimen did not give more side effects than the twice-daily regimen (P>0.05). No significant differences in the hematological profile were observed (P>0.05).

Conclusion

The standard twice-daily RBV regimen is interchangeable with the once-daily regimen. The once-daily regimen will improve compliance and opens the opportunity to combine RBV with other drugs dosed once a day, in a single pill.

Rational Design and Adaptive Management of Combination Therapies for Hepatitis C Virus Infection

Recent discoveries of direct acting antivirals against Hepatitis C virus (HCV) have raised hopes of effective treatment via combination therapies. Yet rapid evolution and high diversity of HCV populations, combined with the reality of suboptimal treatment adherence, make drug resistance a clinical and public health concern. We develop a general model incorporating viral dynamics and pharmacokinetics/ pharmacodynamics to assess how suboptimal adherence affects resistance development and clinical outcomes. We derive design principles and adaptive treatment strategies, identifying a high-risk period when missing doses is particularly risky for de novo resistance, and quantifying the number of additional doses needed to compensate when doses are missed. Using data from large-scale resistance assays, we demonstrate that the risk of resistance can be reduced substantially by applying these principles to a combination therapy of daclatasvir and asunaprevir. By providing a mechanistic framework to link patient characteristics to the risk of resistance, these findings show the potential of rational treatment design.

Compliance with once-daily versus twice or thrice-daily administration of antibiotic regimens: a meta-analysis of randomized controlled trials

Objective

To investigate whether compliance of patients to antibiotic treatment is better when antibiotics are administered once than multiple times daily.

Methods

We performed a systematic search in PubMed and Scopus databases. Only randomized controlled trials were considered eligible for inclusion. Compliance to antibiotic treatment was the outcome of the meta-analysis.

Results

Twenty-six studies including 8246 patients with upper respiratory tract infections in the vast majority met the inclusion criteria. In total, higher compliance was found among patients treated with once-daily treatment than those receiving treatment twice, thrice or four times daily [5011 patients, RR=1.22 (95% CI, 1.11, 1.34]. Adults receiving an antibiotic once-daily were more compliant than those receiving the same antibiotic multiple times daily [380 patients, RR=1.09 (95% CI, 1.02, 1.16)]. Likewise, children that received an antibiotic twice-daily were more compliant than those receiving the same antibiotic thrice-daily [2118 patients, RR=1.10 (95% CI, 1.02, 1.19)]. Higher compliance was also found among patients receiving an antibiotic once compared to those receiving an antibiotic of different class thrice or four times daily [395 patients, RR=1.20 (95% CI, 1.12, 1.28)]. The finding of better compliance with lower frequency daily was consistent regardless of the study design, and treatment duration.

Conclusion

This meta-analysis showed that compliance to antibiotic treatment might be associated with higher when an antibiotic is administered once than multiple times daily for the treatment of specific infections and for specific classes of antibiotics.

Self-efficacy and adherence to antiviral treatment for chronic hepatitis C

GOALS

To investigate the role of self-efficacy (SE) during hepatitis C virus (HCV) treatment.

BACKGROUND

Adherence to chronic HCV treatment is critical. SE is an important predictor of medication adherence in a number of chronic disease populations and medication regimens, but its role during HCV treatment remains unknown.

STUDY

Data from the prospective Virahep-C study were analyzed to examine relationships between SE and patient-driven deviations (ie, missed doses measured using electronic pill caps, and nonpersistence) from adherence to HCV antiviral treatment. SE was measured using the 17-item HCV Treatment Self-Efficacy scale. This measure provides a global estimate of a patient's confidence to undergo and adhere to HCV treatment, and can estimate SE in 4 underlying domains: communication SE (ie, confidence to communicate with health care provider), physical coping SE (ie, confidence to cope with physical side effects), psychological coping SE (ie, confidence to cope with psychiatric side effects), and treatment adherence SE (ie, confidence to take all medications as prescribed and attend doctor visits). Generalized estimating equations and Cox proportional hazards models were used to assess associations between SE and missed doses and nonpersistence, respectively.

RESULTS

SE was associated with being in a relationship, educated, privately insured, and less depressed. Higher communication SE at TW24 reduced the risk of missed doses between TW24 and TW48. Higher baseline treatment adherence SE reduced the likelihood of nonpersistence between baseline and TW24.

CONCLUSIONS

SE's relationship to HCV treatment adherence has promising clinical and research implications.

Adherence during antiviral treatment regimens for chronic hepatitis C: a qualitative study of patient-reported facilitators and barriers

GOALS

To understand patients' perceptions of factors which facilitate and hinder adherence to inform adherence-enhancing interventions.

BACKGROUND

Adherence to antiviral therapy for hepatitis C viral infection is critical to achieving a sustained virological response. However, persistence with and adherence to antiviral regimens can pose challenges for patients that interfere with sustained virological response.

STUDY

A qualitative analysis of 21 semistructured patient interviews using open-ended questions and specific follow-up probes was conducted. Interviews were audio-recorded, transcribed, and content-analyzed iteratively to determine frequent and salient themes.

RESULTS

Three broad themes emerged: (1) missing doses and dose-timing errors; (2) facilitators of adherence; and (3) barriers to adherence. Open-ended questioning revealed few dose-timing deviations, but more specific probes uncovered several more occurrences of delays in dosing. Facilitators of adherence fell into 2 broad categories: (a) patient knowledge and motivation; and (b) practical behavioral strategies and routines. Facilitators were noted post hoc to be consistent with the Information-Motivation-Behavioral Skills Model of Adherence. Barriers to adherence involved changes in daily routine, being preoccupied with family or work responsibilities, and sleeping through dosing times. A few patients reported skipping doses due to side effects. Patients with previous hepatitis C virus treatment experience may have fewer dose-timing errors. Finally, a high level of anxiety among some patients was discovered regarding dosing errors. Emotional and informational support from clinical and research staff was key to assuaging patient fears.

CONCLUSION

This qualitative study improves our understanding of patients' perspectives regarding adhering to hepatitis C treatment and can lead to the development of adherence-enhancing interventions.

Pegylated interferon pharmacokinetics and self-reported depressive symptoms during antiviral treatment for chronic hepatitis C

BACKGROUND

Pegylated interferon-2a (PegIFN-2a)+ribavirin treatment for chronic hepatitis C is often associated with depressive symptoms. Previous studies have failed to explore whether PegIFN-2a pharmacokinetic variability plays an etiologic role in PegIFN-2a-induced mood disorders. The objective of this investigation was to evaluate the association between trough PegIFN-2a concentration at treatment week 4 ("PegIFN-2a Cmin4") and an increase in depressive symptoms.

METHODS

Using data from Virahep-C, the association between PegIFN-2a Cmin4 and the following depression outcomes were evaluated using the Center for Epidemiological Studies-Depression scale (CES-D): (1) change in CES-D score from baseline to week 12; (2) greatest difference in CES-D score between baseline and weeks 4, 12, or 24; and (3) occurrence of severe depressive symptoms (CES-D greater than 23) at weeks 4, 12, or 24. One post-hoc analysis examined whether PegIFN-2a exposure during the first week of treatment was associated with change in CES-D score from baseline to week 4.

RESULTS

No significant associations between PegIFN-2a Cmin4 and the depression outcomes were observed (p>0.05). Exploratory analyses suggest a possible relationship between PegIFN-2a exposure during the first week of therapy and CES-D score change from baseline to week 4 (p=0.03).

CONCLUSIONS

PegIFN-2a concentration levels from baseline to week 4 do not predict the onset and severity of depressive symptoms during 24 weeks of antiviral therapy; however PegIFN-2a levels during the first week of treatment may predict depressive symptoms in the first 4 weeks, earlier than anticipated and warrants further exploration.

Patient-reported outcomes assessment in chronic hepatitis C treated with sofosbuvir and ribavirin: the VALENCE study

BACKGROUND & AIM

Interferon (IFN) negatively impacts patients' well-being and patient-reported outcomes (PROs). Our aim was to assess PROs during treatment with an IFN-free regimen [sofosbuvir (SOF)+ribavirin (RBV)].

METHODS

Four PRO questionnaires [Short Form-36 (SF-36), Chronic Liver Disease Questionnaire-HCV (CLDQ-HCV), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Work Productivity and Activity Index: Specific Health Problem (WPAI:SHP)] were administered at baseline, end-of-treatment and post-treatment to 334 HCV genotype 2 and 3 patients (naïve or treatment-experienced) enrolled in the VALENCE study. Of these, 250 genotype 3 patients were treated for 24 weeks while 73 genotype 2 and 11 genotype 3 patients received 12 weeks of treatment.

RESULTS

Baseline PRO scores were similar between the two arms of the study. Throughout and after treatment, patients receiving 12 or 24 weeks had similar FACIT-F, CLDQ-HCV, SF-36 and WPAI:SHP scores (all p>0.05). Compared to their own baseline scores, patients receiving SOF+RBV experienced modest declines in some aspects of SF-36, CLDQ-HCV, fatigue and WPAI:SHP scores (p = 0.04 to <0.0001). By follow-up week 12, all PRO scores returned to the pre-treatment levels (p>0.05). In patients achieving SVR-12 (regardless of the regimen), significant improvements were noted in general health (p = 0.0004), CLDQ-HCV (p<0.0001), fatigue (p = 0.005), emotional well-being (p<0.0001) and physical component summary score of SF-36 (p = 0.0022). In multivariate analysis, baseline depression, fatigue, insomnia, cirrhosis, and treatment-related adverse events were the most consistent predictors of PRO impairment (all p<0.05).

CONCLUSIONS

PROs are minimally impacted by SOF+RBV regimens. An additional 12 weeks of treatment does not substantially add to the PRO burden.

Factors influencing adherence in Hepatitis-C infected patients: a systematic review

BACKGROUND

Adherence is a crucial point for the successful treatment of a hepatitis-C virus infection. Studies have shown that especially adherence to ribavirin is important.The objective of this systematic review was to identify factors that influence adherence in hepatitis-C infected patients taking regimes that containing ribavirin.

METHODS

A systematic literature search was performed in Medline and Embase in March 2014 without limits for publication date. Titles and abstracts and in case of relevance, full-texts were screened according to predefined inclusion criteria. The risk of bias was assessed. Both process steps were carried out independently by two reviewers. Relevant data on study characteristics and results were extracted in standardized tables by one reviewer and checked by a second. Data were synthesized in a narrative way using a standardized procedure.

RESULTS

Nine relevant studies were identified. The number of analyzed patients ranged between 12 and 5706 patients. The study quality was moderate. Especially the risk of bias regarding the measurement of influencing factors was mostly unclear."Psychiatric disorders" (N = 5) and having to take "higher doses of ribavirin" (N = 3) showed a negative influence on adherence. In contrast, a "HIV co-infection" (N = 2) and the "hemoglobin level" (N = 2) were associated with a positive influence on adherence. Furthermore, there is the tendency that male patients are more adherent than female patients (N = 6). "Alcohol consumption" (N = 2), "education", "employment status", "ethnic group","hepatitis-C virus RNA" (N = 4), "genotype" (N = 5), "metavir activity" (N = 1) and "weight" (N = 3) showed mostly no effect on adherence. Although, some studies showed statistically significant results for "age", "drug use" , "genotype", "medication dose interferon", and "treatment experience" the effect is unclear because effect directions were partly conflicting.The other factors were heterogeneous regarding the effect direction and/or statistical significance.

CONCLUSION

There are some factors that seem to show an influence on adherence. However, due to the heterogeneity (e.g. patient characteristics, regimes, settings, countries) no general conclusions can be made. The results should rather be considered as indications for factors that can have an influence on adherence in hepatitis-C infected patients taking regimes that containing ribavirin.

Electronic monitoring of medication adherence in a 1-year clinical study of 2 dosing regimens of mesalazine for adults in remission with ulcerative colitis

BACKGROUND

Adherence to medication is an issue of great importance for patients with ulcerative colitis. Once daily mesalazine seems to be no worse than divided doses in preventing relapse in remitting patients. Although this has been attributed to improved adherence, detailed measures of adherence have been lacking from previous studies.

METHODS

A 1-year substudy was conducted alongside a trial that compared 2 different dosing regimens (once daily versus three times daily) of mesalazine for patients in remission with ulcerative colitis. Participants in the substudy had their adherence monitored electronically using the medication event monitoring system, self-report, and tablet counts. We compared measures, determined factors associated with adherence and associations between adherence and relapse, modeled adherence over time, and explored behavioral aspects.

RESULTS

We included 58 participants. Adherence was high across all measures (89.3% self-report, 96.7% tablet counts, and 89.2% medication event monitoring system). Agreement between the measures was poor at times. Adherence according to the medication event monitoring system best distinguished between the participants who relapsed (71.4%) and those who remained in remission (93.4%), although this difference was not statistically discernible at the 5% level. Adherence deteriorated over the study period, with three times daily participants generally less adherent than once-daily participants (odds ratio, 0.03; 95% confidence interval, 0.01-0.08). Adherence was higher on weekdays (odds ratio, 1.47; 95% confidence interval, 1.31-1.65) and around clinic visit dates (odds ratio, 1.43; 95% confidence interval, 1.18-1.72).

CONCLUSIONS

Simple dosing regimens are preferable to multiple daily dosing regimens. Electronic monitoring of adherence should be used more often in clinical studies. Self-reported adherence and tablet counts may underestimate adherence. Adherence declined over time, and adherence was generally lower and more varied for those allocated to the three times daily regimen.

Patient adherence issues in the treatment of hepatitis C

The current standard-of-care treatments for chronic hepatitis C, based on a bitherapy that combines peginterferon alpha-2a or -2b and ribavirin for all genotypes, and on a triple therapy with the addition of an antiprotease specifically for genotype 1, are associated with a limited adherence that decreases their efficacy. The main factors limiting adherence are difficulties in taking the treatment and side effects that worsen the quality of life of the patients. Programs of therapeutic education are essential to improve adherence, quality of life, likelihood of viral suppression, improvement of liver disease, and decrease of late complications. Therapeutic education should be understood as an acquisition of decisional, technical, and social competency with the purpose of making the patient able to make health choices, realize their own life plans, and use health care resources in the best manner. The patient should be placed in the center of an organization, comprising various care workers who include social service professionals and medical staff. For hepatitis C, therapeutic education may be separated into three phases: a first phase corresponding to the educative diagnosis; a second phase corresponding to support during treatment; and the third phase corresponding to support after treatment. Therapeutic education is performed using various instruments and methods specifically adapted to the needs and expectations of individual patients. Upcoming treatments for hepatitis C, with evidence for high efficacy, few side effects, and shorter duration, will certainly change the landscape of adherence and the management of therapeutic education.