Interferon-associated retinopathy during the treatment of chronic hepatitis C: a systematic review

A case of successful treatment of a rare retinal disease presented by interferon-induced retinopathy

OBJECTIVE

Aim: To showcase a rare retinal lesion and the results of contemporary diagnostic and treatment of interferon-induced retinopathy.

PATIENTS AND METHODS

Materials and Methods: We describe a case of a 36-year-old patient with interferon-induced retinopathy, with hepatitis C, that received prolonged interferon treatment. Clinical signs, examination and combined laser and pharmacologic treatment were showcased in the study.

RESULTS

Results: As a result of pharmacologic and laser treatment, the patient's visual acuity increased from 0.1 to 1.0 through the duration of 3 months after treatment. The patients` condition remained stable under dynamic observation.

CONCLUSION

Conclusions: Because interferon-induced retinopathy is a rare occurrence in routine ophthalmologic practice, combined laser therapy can be used for treatment of preretinal hemorrhage, which leads to improvement of visual functions and stabilization of the retinal processes. This case is an addition to the few described cases of interferon-induced retinopathy.

The Impact of Systemic Medications on Retinal Function

This study will provide a thorough review of systemic (and select intravitreal) medications, along with illicit drugs that are capable of causing various patterns of retinal toxicity. The diagnosis is established by taking a thorough medication and drug history, and then by pattern recognition of the clinical retinal changes and multimodal imaging features. Examples of all of these types of toxicity will be thoroughly reviewed, including agents that cause retinal pigment epithelial disruption (hydroxychloroquine, thioridazine, pentosan polysulfate sodium, dideoxyinosine), retinal vascular occlusion (quinine, oral contraceptives), cystoid macular edema/retinal edema (nicotinic acid, sulfa-containing medications, taxels, glitazones), crystalline deposition (tamoxifen, canthaxanthin, methoxyflurane), uveitis, miscellaneous, and subjective visual symptoms (digoxin, sildenafil). The impact of newer chemotherapeutics and immunotherapeutics (tyrosine kinase inhibitor, mitogen-activated protein kinase kinase, checkpoint, anaplastic lymphoma kinase, extracellular signal-regulated kinase inhibitors, and others), will also be thoroughly reviewed. The mechanism of action will be explored in detail when known. When applicable, preventive measures will be discussed, and treatment will be reviewed. Illicit drugs (cannabinoids, cocaine, heroin, methamphetamine, alkyl nitrite), will also be reviewed in terms of the potential impact on retinal function.

Role of Serum Vitamin D, Interleukin 13, and microRNA-135a in Hepatocellular Carcinoma and Treatment Failure in Egyptian HCV-Infected Patients Receiving Direct Antiviral Agents

Direct-acting antivirals (DAAs) are used for hepatitis C virus (HCV) treatment. However, treatment failure and hepatocellular carcinoma (HCC) development following treatment was reported. In this study, we assessed the role of serum vitamin D, interleukin 13 (IL-13), and microRNA-135a in the prediction of treatment failure with DAA and HCC development among Egyptian HCV-infected patients. A total of 950 patients with HCV-related chronic liver disease underwent DAA treatment. Before DAAs, serum vitamin D and IL-13 were determined by ELISA, and gene expression of miRNA-135a was assessed in serum by real-time PCR. The predictive abilities of these markers were determined using the receiver operating characteristic (ROC) curve. Sustained virological response (SVR) was achieved in 92.6% of HCV-infected patients (responders). High viral load, IL-13, miRNA-135a, and low vitamin D levels were associated with treatment failure and HCC development. HCC development was recorded in non-responders, but not in the responders (35.7% vs. 0% p < 0.001). In conclusion: serum IL-13, Vitamin D, and miRNA-135a could be potential biomarkers in monitoring DAA treatment and HCC prediction. DAAs-induced SVR may decrease the incidence of HCC.

Unilateral retinopathy post perilesional interferon α2b injections for ocular surface squamous cell carcinoma

Purpose

To describe the clinical course of a patient presenting with unilateral retinopathy after perilesional interferon alpha injections for treatment of ocular surface squamous cell carcinoma.

Observations

A patient, who was being treated with interferon alpha for ocular squamous cell carcinoma, presented with new onset decreased vision in her left eye. Upon examination, she was found to have cotton wool spots and retinal hemorrhages in the affected eye.

Conclusions and Importance

Retinopathy is a well-documented side effect of systemic usage of interferon alpha. However, retinopathy has not been well discussed in the scenario of perilesional injections of interferon. It is important for clinicians to monitor for such pathology when using interferon alpha not only systemically, but also locally.

Analysis of Different Types of Interferon-Associated Retinopathy in Patients with Chronic Hepatitis C Virus Infection Treated with Pegylated Interferon Plus Ribavirin

This retrospective cohort study aims to investigate interferon (IFN)-associated retinopathy incidence in patients with chronic hepatitis C virus (HCV) infection treated with pegylated interferon (PegIFN) plus ribavirin (RBV). We selected 1688 patients undergoing PegIFN/RBV therapy for HCV (HCV-treated cohort), 3376 patients not receiving HCV treatment (HCV-untreated cohort) and 16,880 controls without HCV (non-HCV cohort) from the Taiwan Longitudinal Health Insurance Database. The patients were frequency-matched by age, sex, and index date at a 1:2:10 ratio, and followed up until the end of 2013. Cox proportional hazard regression models were used to compare the incidences of any retinal vascular events, including subtypes, among the three cohorts. Compared with the non-HCV cohort, the HCV-treated cohort had a significantly increased risk of retinopathy (hazard ratio (HR) = 4.98, 95% confidence interval (CI): 2.02–12.3). The risk was particularly prominent for retinal hemorrhage (HR = 12.7, 95% CI: 3.78–42.9). When the HCV-untreated cohort was used as the reference, the aforementioned HRs increased to 9.02 (95% CI: 3.04–26.8) and 32.3 (95% CI: 3.94–265), respectively. This study suggested that PegIFN/RBV therapy significantly increased the risk of retinal hemorrhage but not retinal vascular occlusions in the HCV-treated cohort.

Retinal vasculitis: A framework and proposal for a classification system

Retinal vasculitis, a poorly understood process involving inflammation or ischemia of the retinal vessel wall, may occur in association with a systemic process, although it can also be isolated to the retina. Because of the limited ability to perform histopathological studies on retinal vessels, there is no gold standard for diagnosis. Thus, there is utility in creating a classification system for retinal vasculitis and improving diagnostic strategies for this disease. We provide a framework for understanding retinal vasculitis based on size, location, and etiology. We hope that this information can be implemented in the clinical setting to provide some diagnostic strategies for this often confusing entity.

Ocular comorbidities with direct-acting antiviral treatment for chronic hepatitis C virus (HCV) patients

PURPOSE

The aim of this study is to detect the incidence and nature of ocular complications encountered in chronic hepatitis C virus (HCV) patients treated with direct-acting antiviral drugs.

METHODS

This study is a prospective follow-up study on 200 chronic HCV patients attending the Outpatient Hepatology Clinic of National Liver Institute who were indicated for direct-acting antiviral treatment (sofosbuvir, daclatasvir and ribavirin) in the period between January 2017 and December 2017 and referred to the Department of Ophthalmology of Menoufia University hospitals where full ophthalmological examinations were done at the first visit before the treatment, the second visit at the end of the treatment (3 months) and the third visit 3 months later (6 months). Follow-up for those patients was done by slit-lamp examination, IOP measurement by applanation tonometer, colored fundus photographs, fluorescein fundus angiography (FFA), optical coherence tomography.

RESULTS

Patients who received direct-acting antiviral therapy showed no ocular complications throughout the 6-month period of follow-up. Besides, BCVA and C/D ratio did not show any changes with no statistically significant differences between three visits. No signs of uveitis appeared in patients prescribed to the therapy protocols. Also, FFA did not show any retinal vascular changes. However, two cases of subconjunctival hemorrhage were observed with triple therapy.

CONCLUSION

Direct-acting antiviral treatment including sofosbuvir, daclatasvir and ribavirin appears to be safe and shows no detectable intraocular complications in the six-month follow-up period, and routine ophthalmic follow-up seems to be less required than in older anti-HCV medications.

Transitioning from interferon-based to direct antiviral treatment options: A potential shift in barriers and facilitators of treatment initiation among people who use drugs?

BACKGROUND

Multiple barriers for accessing hepatitis C virus (HCV) treatment were identified during the interferon-based (IFN) treatment era for people who inject drugs (PWID). Whether these barriers persist since the introduction of IFN-free direct-acting antiviral (DAA) agents in Canada remains to be documented. This study examined temporal trends in HCV treatment initiation and associated factors during the transition from INF-based to all-oral DAA regimens.

METHODS

The study population was drawn from a prospective cohort of PWID in Montreal, Canada. At three-month/one-year intervals between 2011 and 2017, participants with chronic HCV infection completed an interviewer-administered questionnaire on socio-demographic characteristics, drug use and health service utilisation, including HCV treatment. Time-updated Cox multivariate regression models, stratified by DAA + INF (2011-2013) and all-oral DAA (2014-2017) availability periods, were conducted to examine associations between time to HCV treatment initiation and associated barriers and facilitators.

RESULTS

Of 308 participants (85% male, median age 42 [IQR: 33, 50]), 80 (26%) initiated HCV treatment during 915 person-years (PY). Incidence rates increased from 1.6 /100 PY (95%CI:0.9-2.6) in 2011 to 12.7 (10.6-15.1) in 2017 (p-trend = 0.0012). In multivariate analyses, visiting a primary care physician (2011-2013: aHR = 3.63[1.21-10.9]; 2014-2017: 2.52[1.10-5.77]) and frequent injection (0.23[0.05-0.99] and 0.49[0.24-0.99]) were consistently associated with treatment initiation. Participants aged >40 (2.27[1.24-4.13]), receiving opioid agonist therapy (OAT) (2.17[1.19-3.94]), and reporting prior HCV treatment (3.00[1.75-5.15]) were more likely to initiate treatment in the all-oral DAA period.

CONCLUSION

Treatment initiation increased between 2011 and 2017, but still remains low among PWID. Primary care visiting was a key facilitator regardless of the period, while engagement in OAT and health services, indicated by prior HCV treatment, increased the likelihood of treatment initiation in the DAA era. These findings suggest that access to health services is essential but not enough to scale up treatment in this population.

Optical Coherence Tomography Angiography in the Multimodal Imaging Evaluation of Interferon-Associated Retinopathy: A Case Report

The authors present the case of a 59-year-old woman in treatment with interferon alfa-2b for stage IV melanoma and widespread metastases who presented with interferon-associated retinopathy. An ocular examination revealed multiple retinal cotton-wool spots and hard exudates. Interferon treatment was suspended. The patient was followed up for 5 months following the baseline visit by means of en face optical coherence tomography (OCT), spectral-domain OCT, and OCT angiography. Multimodal imaging was useful in the follow-up of this condition, permitting the characterization of all the lesions hallmarking the interferon-retinopathy and showing that this illness was related to a reduction of the retinal vascular perfusion. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:498-504.].

Unusual course of interferon-related retinopathy in chronic hepatitis C

Interferon Alfa retinopathy usually presents as cotton wool spots, superficial hemorrhages and macular edema. We describe a rare case of severe retinopathy involving hard exudates at macula that lead to permanent visual loss in one eye. Elderly male presented with diminution of vision in right eye of 8 month duration. He was a diagnosed case of compensated chronic hepatitis C and had received interferon Alfa therapy before. Fundus examination of both eye showed multiple hard exudates at macula with a plaque involving the foveal center in right eye. OCT and FFA confirmed the findings seen clinically. Patient was advised regular follow up and on 3 months follow up his clinical picture was same. Ours is the first case report where patient had significant visual loss secondary to hard exudate plaque at center of fovea and ischemic fovea in right eye. Presence of hard exudates at any stage of therapy of hepatitis C could be an indicator of the severity of retinopathy with possible indication for stopping the drug.

Drug-induced Raynaud's phenomenon: beyond β-adrenoceptor blockers

AIM

Drug-induced Raynaud's phenomenon (RP) has long been associated with the use of different drugs, including cancer chemotherapy or β-adrenoceptor blockers. However, sources report extremely variable prevalence and the level of evidence for each class is heterogeneous. Moreover, new signals are emerging from case reports and small series. Our objective was therefore to review available evidence about this adverse drug effect and to propose a mechanistic approach of drug-induced RP.

METHODS

A systematic review of English and French language articles was performed through Medline (1946-2015) and Embase (1974-2015). Further relevant papers were identified from the reference lists of retrieved articles.

RESULTS

We identified 12 classes of drugs responsible for RP, with a variety of underlying mechanisms such as increased sympathetic activation, endothelial dysfunction, neurotoxicity or decreased red blood cell deformability. Cisplatin and bleomycin were associated with the highest risk, followed by β-adrenoceptor blockers. Recent data suggest a possible involvement of tyrosine kinase inhibitors (TKI), through an unknown mechanism.

CONCLUSION

Drug-induced RP is a probably underestimated adverse drug event, with limited available evidence regarding its prevalence. Although rare, serious complications like critical digital ischaemia have been reported. When these treatments are started in patients with a history of RP, careful monitoring must be made and, if possible, alternative therapies that do not alter peripheral blood flow should be considered.

Interferon-β Inhibits Neurotrophin 3 Signalling and Pro-Survival Activity by Upregulating the Expression of Truncated TrkC-T1 Receptor

Although clinically useful for the treatment of various diseases, type I interferons (IFNs) have been implicated as causative factors of a number of neuroinflammatory disorders characterized by neuronal damage and altered CNS functions. As neurotrophin 3 (NT3) plays a critical role in neuroprotection, we examined the effects of IFN-β on the signalling and functional activity of the NT3/TrkC system. We found that prolonged exposure of differentiated human SH-SY5Y neuroblastoma cells to IFN-β impaired the ability of NT3 to induce transphosphorylation of the full-length TrkC receptor (TrkC-FL) and the phosphorylation of downstream signalling molecules, including PLCγ1, Akt, GSK-3β and ERK1/2. NT3 was effective in protecting the cells against apoptosis triggered by serum withdrawal or thapsigargin but not IFN-β. Prolonged exposure to the cytokine had little effects on TrkC-FL levels but markedly enhanced the messenger RNA (mRNA) and protein levels of the truncated isoform TrkC-T1, a dominant-negative receptor that inhibits TrkC-FL activity. Cell depletion of TrkC-T1 by small interfering RNA (siRNA) treatment enhanced NT3 signalling through TrkC-FL and allowed the neurotrophin to counteract IFN-β-induced apoptosis. Furthermore, the upregulation of TrkC-T1 by IFN-β was associated with the inhibition of NT3-induced recruitment of the scaffold protein tamalin to TrkC-T1 and tamalin tyrosine phosphorylation. These data indicate that IFN-β exerts a negative control on NT3 pro-survival signalling through a novel mechanism involving the upregulation of TrkC-T1.

A comparative study of serum lipid contents in pre and post IFN-alpha treated acute hepatitis C patients

BACKGROUND

To study the effect of Interferon (INF) alpha-2b therapy on the serum lipids and fatty acid (FA) level in pre and post treated hepatitis C (HCV) patients.

METHODS

Fifty samples were collected from pre and post treated patients along with age and gender matched controls. After separating serum, lipid contents were analyzed by microlab and gas chromatography.

RESULTS

The hepatitis C infection results in hypolipidemia with reduced level of triglyceride (113 mg/dl), high density lipoprotein (37.1 mg/dl), low density lipoprotein (74.3 mg/dl), cholesterol (149.9 mg/dl) that increase the infection resolution and after the IFN treatment, the lipid profile of the patients were increased. The myristic (2.8 g/100 g) and palmitic acids (26.6 g/100 g) were significantly higher while linoleic acid (20.94 g/100 g) was significantly lower in HCV patients. The higher oleic: stearic (1.4) and palmitoleic: palmitic acid (0.2) ratios were detected in HCV patients, showing enhanced stearoyl-CoA desaturase activity. The levels of serum saturated (44.9 g/100 g) and monounsaturated FA's (26.98 g/100 g) were higher while polyunsaturated FA's (25.9 g/100 g) were found lower in HCV patients in comparison of controls (40.1; 25.01; 33.44 g/100 g respectively). An inverse correlation was found HCV RNA viral load and PUFA (R(2) = 0.4555). Elevated levels of serum saturated free FA (45.7 g/100 g) in HCV patients indicates stimulated lipoapoptosis.

CONCLUSION

The present study conclude that serum PUFA level was lower in HCV patients, hence PUFA may provide synergistic antiviral effects when given as a food supplement during the INF based anti- HCV therapy.

Retinopathy during interferon-β treatment for multiple sclerosis: case report and review of the literature

The onset of new visual symptoms in patients with multiple sclerosis is often associated with a neuro-ophthalmologic manifestation of the disease. However, other possible differential diagnoses need to be ruled out, including drug-induced retinal side effects. Although uncommon, retinal side effects of interferon-beta formulations may occur, and need to be promptly recognized and treated by neurologists. In this manuscript, we report the case of a 37-year-old woman affected by multiple sclerosis diagnosed with interferon beta-associated retinopathy and we review the literature with regard to the epidemiology, clinical presentation, management and follow-up of interferon beta-associated retinopathy. Interferon-beta induced retinopathy seems to be an uncommon and a dose-related side effect in multiple sclerosis patients. Retinopathy tends to completely resolve after treatment discontinuation. Neurologists must be aware that immune-modulatory drugs, in particular interferon beta, have been reported to cause retinal side effects. In multiple sclerosis patients complaining of new visual symptoms during interferon-beta treatment, it is thus advisable to perform an ophthalmological assessment to rule out and properly manage retinopathy.

Association between interferon use and reduced metabolic and vascular complications among patients with hepatitis C

We examined whether interferon treatment is associated with reduced metabolic/vascular complications in hepatitis C virus patients. The study had historical prospective cohort design using Maryland Medicaid administrative data (2006-2009). The end point was the incidence rate of mild, severe and combined mild/severe events from the Diabetes Complications Severity Index (DCSI). Interferon-treated and -untreated hepatitis C virus patients were matched on baseline covariates. Using multivariate counting process Cox regressions, we modeled the association between interferon receipt of at least 24 weeks and DCSI events incidence rate. Treated whites had similar rate of mild DCSI events, significantly 64% (p < 0.01) lower rate of severe DCSI events, and overall 29% (p = 0.14) lower rate of mild/severe DCSI events, compared with untreated whites. Compared with untreated blacks, treated blacks had a similar rate of DSCI events. Future studies should confirm our findings and should include important clinical variables such as viral genotype, virologic count and achieving sustained virologic response.

Overview and recent trends of systematic reviews and meta-analyses in hepatology

A systematic review (SR) is a research methodology that involves a comprehensive search for and analysis of relevant studies on a specific topic. A strict and objective research process is conducted that comprises a systematic and comprehensive literature search in accordance with predetermined inclusion/exclusion criteria, and an assessment of the risk of bias of the selected literature. SRs require a multidisciplinary approach that necessitates cooperation with clinical experts, methodologists, other experts, and statisticians. A meta-analysis (MA) is a statistical method of quantitatively synthesizing data, where possible, from the primary literature selected for the SR. Review articles differ from SRs in that they lack a systematic methodology such as a literature search, selection of studies according to strict criteria, assessment of risk bias, and synthesis of the study results. The importance of evidence-based medicine (EBM) in the decision-making for public policy has recently been increasing thanks to the realization that it should be based on scientific research data. SRs and MAs are essential for EBM strategy and evidence-based clinical practice guidelines. This review addresses the current trends in SRs and MAs in the field of hepatology via a search of recently published articles in the Cochrane Library and Ovid-MEDLINE.