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Efficacy of 8 weeks elbasvir/grazoprevir regimen for naïve-genotype 1b, HCV infected patients with or without glucose abnormalities: Results of the EGG18 study. Dig Liver Dis 2022; 54:1117-1121. [PMID: 34593348 DOI: 10.1016/j.dld.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/11/2021] [Accepted: 09/10/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Direct Acting Antivirals(DAAs) achieve the highest rate of sustained viral response(SVR) in patients with genotype-1b(G1b) Hepatitis C virus(HCV) infection. Reducing treatment duration can simplify the management and improve adherence of therapy. PATIENTS AND METHODS The study evaluates the efficacy of 8 weeks of elbasvir/grazoprevir regimen in 75 treatment-naïve(TN), G1b patients with mild-moderate fibrosis(Liver Stiffness by Fibroscan® <9.0 kPa). Viral load(VL) has been evaluated by Roche TaqMan RT-PCR(LLOQ<15 IU/ml). RESULTS Mean age was 61.0 ± 14.2 years, 44% were male, mean LS by Fibroscan® was 6.1 ± 1.8 kPa. Twenty-eight patients(37.3%) had an HOMA>2.5. Two patients were excluded from analysis(one dropped out and the other one had diagnosed genotype 2c at genotyping by sequencing performed after relapse). At 8 weeks(EOT), 71 out of 73 patients(97.3%) had undetectable HCV-RNA, while in two cases HCV-RNA was detectable but with VL<15 IU/ml. Both of them achieved SVR. Two G1b patients relapsed at 12 weeks of follow-up, both with baseline VL>800,000 IU/ml and HOMA score 1.3 and 3.8 respectively. Both had undetectable HCV VL at 4th week and at the EOT. Modified intention-to-treat SVR12 for G1b patients was 71/73(97.3%). CONCLUSION In naïve, genotype-1b HCV-infected patients with mild/moderate liver fibrosis, short course of 8 weeks of EBR/GZR appears to achieve high efficacy regardless of features of insulin resistance.
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Li J, Li G, Wang J, Zhao R, He J, Wang L, Zhang L. Efficacy and safety of elbasvir/grazoprevir treatment for Chinese patients with hepatitis C virus genotype 1b: a retrospective study. Am J Transl Res 2022; 14:3995-4005. [PMID: 35836873 PMCID: PMC9274559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/11/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To determine the efficacy and safety of elbasvir/grazoprevir (EBR/GZR) treatment in Chinese patients with GT1b chronic hepatitis virus C (HCV) infections. METHODS In this retrospective study, 49 treatment-naive patients with chronic GT1b HCV infection were treated with GZR (100 mg) plus EBR (50 mg) for 12 weeks. The viral response was the primary endpoint and fibrosis stage changes during and after treatment, as well as the incidence of treatment-emergent adverse events (TEAE) were secondary endpoints. RESULTS After 2-week EBR/GZR treatment, the virologic response rate was 85.1% (80/94) and reached 100% (94/94) after 8 and 12 weeks of therapy. Sustained virologic response (SVR) rates were 100% at the 12, 24 and 48-week follow-ups. Multivariate analysis revealed that the baseline viral load of HCV RNA may affect the rapid 2-week virologic response (OR: 0.36, 95% CI: 0.14-0.92, P=0.034), but did not influence efficacy during further treatment or follow-ups. Fifteen patients with ≥1 TEAE (16.0%) were observed and 7 (7.4%) and 8 (8.5%) patients had mild ALT or AST elevations (1.1-2.5× BL), but no serious drug-related AEs occurred. Liver stiffness measurement (LSM), the AST to platelet ratio index (APRI) and the fibrosis index based on 4 factor (FIB4) scores were consistently reduced, especially in patients with high baseline assessments after 12 weeks' treatment and during follow-ups. CONCLUSIONS A 12-week EBR/GZR regimen shows high efficacy and safety in Chinese patients with GT1b HCV infections.
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Affiliation(s)
- Juan Li
- Department of Hepatology, Lanzhou University Second Hospital No. 82 Cuiying Gate, Chengguan District, Lanzhou 730000, Gansu, China
| | - Guangming Li
- Department of Hepatology, Lanzhou University Second Hospital No. 82 Cuiying Gate, Chengguan District, Lanzhou 730000, Gansu, China
| | - Juanxia Wang
- Department of Hepatology, Lanzhou University Second Hospital No. 82 Cuiying Gate, Chengguan District, Lanzhou 730000, Gansu, China
| | - Rui Zhao
- Department of Hepatology, Lanzhou University Second Hospital No. 82 Cuiying Gate, Chengguan District, Lanzhou 730000, Gansu, China
| | - Jingjing He
- Department of Hepatology, Lanzhou University Second Hospital No. 82 Cuiying Gate, Chengguan District, Lanzhou 730000, Gansu, China
| | - Liang Wang
- Department of Hepatology, Lanzhou University Second Hospital No. 82 Cuiying Gate, Chengguan District, Lanzhou 730000, Gansu, China
| | - Lingyi Zhang
- Department of Hepatology, Lanzhou University Second Hospital No. 82 Cuiying Gate, Chengguan District, Lanzhou 730000, Gansu, China
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Abergel A, Asselah T, Mallat A, Chanteranne B, Faure F, Larrey D, Gournay J, Loustaud-Ratti V, Di Martino V, Fouchard-Hubert I, Pol S, Bailly F, Samuel D, Tran A, Dodel M, Andant N, Lamblin G, Muti L, Reymond M, Teilhet C, Pereira B, Buchard B. Phase 3, Multicenter Open-Label study to investigate the efficacy of elbasvir and grazoprevir fixed-dose combination for 8 weeks in treatment-naïve, HCV GT1b-infected patients, with non-severe fibrosis. Liver Int 2020; 40:1853-1859. [PMID: 32383275 DOI: 10.1111/liv.14502] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/08/2020] [Accepted: 04/26/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Genotype 1b is the most common HCV genotype worldwide, accounting for the largest proportion of infections in Europe, Russia, Latin America and Asia. Reducing treatment duration can improve adherence, reduce drug exposure and cost. Accordingly, we evaluated the efficacy of 8 weeks fixed-dose combination of grazoprevir-elbasvir in treatment-naïve patients, with non-severe fibrosis. METHODS HCV mono-infected and treatment naïve patients with non-severe fibrosis (Fibroscan® <9.5 kPa and Fibrotest® < 0.59) were enrolled in a study which included 117 patients. Genotyping by sequencing identified five patients with non-1b genotype (two GT1a, one GT1h, one GT1e and one GT1l). Thus, we included in the final analysis 112 GT1b patients. The primary end point was the proportion of patients with HCVRNA below the lower limit of quantification 12 weeks after treatment (SVR12). FINDINGS Mean age was 54 ± 13 years, 31% were men and viral load was higher than 800.000 IU/mL in 70 of 112 patients (63%). Using Fibroscan® , 100 had F0-1 fibrosis score. FIB-4 lower than 1.45 and APRI less than 1 was found in 74/112 (66%) and 107/112 (95%) patients respectively. Relapse occurred in three patients by week 12. These three patients had a viral load higher than 6 million IU/mL and NS5A Y93H RAS (resistance-associated substitution). Then, modified intention-to-treat SVR12 for patients with genotype 1b was 109/112 (97%). By week 24; five relapses were observed and all had the Y93H RAS at relapse. SVR12 was achieved in 100% of patients with a baseline viral load below 6 million and decreased to 98% (98/100) by follow-up week 24. INTERPRETATION Naïve patients with genotype 1b and non-severe fibrosis can achieve an SVR12 of 97% and an SVR24 of 95%. Then, these patients can be treated with grazoprevir-elbasvir for 8 weeks.
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Affiliation(s)
- Armand Abergel
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France.,UMR 6602 CNRS-Sigma-Université Clermont Auvergne, Clermont-Ferrand, France
| | - Tarik Asselah
- Department of Hepatology, Université Paris Diderot, Sorbonne Paris Cité, CRI, UMR 1149, Inserm, Paris, France.,Department of Hepatology, AP-HP Hôpital Beaujon, Clichy, France
| | - Arianne Mallat
- Department of Hepatology and Gastroenterology, Hôpital Henri Mondor, AP-HP, INSERM, Créteil, France.,Faculté de Médecine, Université Paris-Est, Créteil, France
| | - Brigitte Chanteranne
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France
| | - Frederic Faure
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France
| | - Dominique Larrey
- Department of Hepatology, Hôpital Saint Eloi, INSERM1183, Montpellier University, Montpellier, France
| | - Jerome Gournay
- Gastroenterology and Hepatology Department, Institut des Maladies de l'Appareil Digestif, University Hospital Nantes, Nantes, France
| | - Veronique Loustaud-Ratti
- Department of Hepatology and Gastroenterology, CHU Limoges, INSERM U1248, Université de Limoges, Limoges, France
| | - Vincent Di Martino
- Service d'Hépatologie, CHRU Jean Minjoz and Université de Franche-Comté, Besançon, France
| | - Isabelle Fouchard-Hubert
- Hepato-Gastroenterology Department, Angers University Hospital, Angers, France.,HIFIH Laboratory, UPRES 3859, SFR 4208, Angers University, Angers, France
| | - Stanislas Pol
- Department of Hepatology, APHP Hôpital Cochin, Université Paris Descartes/INSERM U1223, Institut Pasteur, Paris, France
| | - Francois Bailly
- Service d'Hépatologie et Gastroentérologie, Hôpital de la Croix-Rousse, Lyon, France.,INSERM U1052, Centre de Recherche en Cancérologie de Lyon, Lyon, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Université Paris-Sud, UMR-S1193, Université Paris-Saclay, and Hepatinov, Villejuif, France
| | - Albert Tran
- Department of Gastroenterology, Université Côte d'Azur, CHU de Nice, INSERM, Centre Digestif, Nice, France
| | - Marie Dodel
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France
| | - Nicolas Andant
- Biostatistics Unit, Délégation Recherche Clinique & Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Geraldine Lamblin
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France
| | - Leon Muti
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France
| | - Maud Reymond
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France
| | - Camille Teilhet
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Délégation Recherche Clinique & Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Benjamin Buchard
- Service de médecine digestive et hépato-biliaire CHU Estaing, Clermont-Ferrand, France
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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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5
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Guaraldi G, Maurice JB, Marzolini C, Monteith K, Milic J, Tsochatzis E, Bhagani S, Morse CG, Price JC, Ingiliz P, Lemoine M, Sebastiani G. New Drugs for NASH and HIV Infection: Great Expectations for a Great Need. Hepatology 2020; 71:1831-1844. [PMID: 32052857 DOI: 10.1002/hep.31177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/28/2020] [Indexed: 12/14/2022]
Abstract
In recent years, there has been an increasing number of clinical trials for the treatment of nonalcoholic steatohepatitis (NASH). People living with human immunodeficiency virus (PLWH) are commonly excluded from these studies, usually due to concerns over drug-drug interactions associated with antiretroviral therapy. The Steatohepatitis in HIV Emerging Research Network, a group of international experts in hepatology and infectious diseases, discusses our current understanding on the interaction between human immunodeficiency virus and NASH, and the issues related to the inclusion of PLWH in NASH clinical trials. Recent trials addressing NASH treatment in PLWH are discussed. The risk of drug-drug interactions between antiretroviral therapy and aramchol, cenicriviroc, elafibranor, obeticholic acid and resmetirom (MGL-3196), which are currently in phase 3 trials for the treatment of NASH, are reviewed. A model for trial design to include PLWH is proposed, strongly advocating for the scientific community to include this group as a subpopulation within studies.
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Affiliation(s)
- Giovanni Guaraldi
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - James B Maurice
- Hepatology Unit, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Catia Marzolini
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Kenneth Monteith
- Coalition des Organismes Communautaires Québécois de Lutte Contre le Sida, Montréal, QC, Canada
| | - Jovana Milic
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, University College London, London, United Kingdom
| | - Sanjay Bhagani
- Royal Free London, NHS Foundation Trust, London, United Kingdom
| | - Caryn G Morse
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Jennifer C Price
- Department of Medicine, University of California, San Francisco, CA
| | - Patrick Ingiliz
- Center for Infectiology, Berlin, Germany.,Department of Gastroenterology and Hepatology, Charité University Medical Center, Berlin, Germany
| | - Maud Lemoine
- Department of Surgery and Cancer, Liver Unit, St Mary's Hospital, Imperial College London, London, United Kingdom
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Royal Victoria Hospital - Site Glen, Montréal, QC, Canada.,Division of Infectious Diseases, McGill University Health Center, Royal Victoria Hospital-Site Glen, Montréal, QC, Canada
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6
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Tsai TC, Deng ST, Hsu CW. The efficacy and safety of elbasvir/grazoprevir treatment in HCV genotype 1 patients in Taiwan. J Med Virol 2019; 92:219-226. [PMID: 31599455 PMCID: PMC6916308 DOI: 10.1002/jmv.25605] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/30/2019] [Indexed: 12/31/2022]
Abstract
Background Elbasvir/grazoprevir (EBR/GZR) is a new generation, fixed‐dose, combination antiviral drug used in chronic hepatitis C virus (HCV) genotype (GT) 1 or 4 infection. Our study evaluates the clinical efficacy and safety of EBR/GZR after its launch in Taiwan. Methods This is a retrospective observational study. Patients who had received EBR/GZR for chronic HCV GT 1 between June 2017 and April 2018 were recruited. Patients’ age, sex, HCV GT, changes in HCV RNA level before and after treatment, sustained virologic response 12 weeks (SVR12) after the cessation of drug administration, side effects, and interaction effects were used to evaluate the clinical efficacy and safety. Results A total of 149 patients were recruited. Of them, 145 (97.3%) had HCV GT 1b, and the rest had HCV GT 1a; most of the EBR/GZR‐related side effects in this study were mild. Three participants were discontinued because their alanine transaminase levels were elevated to over 10 times the upper limit of normal. The therapeutic effect analyses revealed a rapid virologic response rate of 95.3% and an SVR12 rate of 98%. Subgroup analyses performed using SVR12 as the outcome variable revealed three demographic factors HCV GT 1, hepatocellular carcinoma medical history, and noncirrhosis plus HCV RNA level. Conclusions This study confirmed that EBR/GZR is safe and effective for treating patients with HCV GT 1 and exhibited excellent overall clinical efficacy in Taiwan. The therapeutic effects are unrelated to factors such as sex, HCV RNA level before treatment, and history of liver cirrhosis. EBR/GZR is safe and effective for HCV GT 1 in Taiwan. SVR rate is high and compare with western country. Medication related side effect is mild and tolerable. There are no significant statistic difference in renal function in each group during the period of treatment and follow‐up.
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Affiliation(s)
- Tzu-Cheng Tsai
- Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Long Term Care, Hsin Sheng College of Medical Care and Management, Taoyuan, Taiwan
| | - Shin-Tarng Deng
- Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chao-Wei Hsu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Chang Gung University College of Medicine, Taoyuan, Taiwan
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