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Farag MS, van Campenhout MJH, Sonneveld MJ, Fung S, van Erpecum KJ, Wong DK, Verhey E, de Man R, De Knegt RJ, Brouwer JT, Baak HC, Feld JJ, Liem KS, Boonstra A, Hansen BE, Janssen HLA. Addition of PEG-interferon to long-term nucleos(t)ide analogue therapy enhances HBsAg decline and clearance in HBeAg-negative chronic hepatitis B: Multicentre Randomized Trial (PAS Study). J Viral Hepat 2024; 31:197-207. [PMID: 38243144 DOI: 10.1111/jvh.13918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024]
Abstract
We studied whether 48 weeks of PEG-IFN alfa-2a add-on increases HBsAg-decline and clearance in HBeAg-negative patients on long-term nucleo(s)tide analogue (NA) therapy. In this investigator-initiated, randomized, controlled trial conducted in Europe and Canada, HBeAg-negative patients treated with NA > 12 months, with HBVDNA < 200 IU/mL, were enrolled. Patients were randomized 2:1 to 48 weeks of PEG-IFN alfa-2a add-on (180 μg per week) or continued NA-monotherapy with subsequent follow-up to Week 72. Endpoints were HBsAg decline (≥1 log10 IU/mL) and HBsAg clearance at Week 48. Of the 86 patients in the modified-intention-to-treat analysis, 58 patients received PEG-IFN add-on, and 28 continued NA monotherapy. At Week 48, 16(28%) patients achieved HBsAg decline ≥1 log10 in the add-on arm versus none on NA-monotherapy (p < .001), and HBsAg clearance was observed in 6 (10%) PEG-IFN add-on patients versus 0% NA-monotherapy (p = .01). HBVRNA was only detected in 2% after PEG-IFN treatment versus 19% in NA-monotherapy (p = .002) at Week 48. PEG-IFN add-on therapy was well tolerated in majority of patients. Low baseline HBsAg levels (<10 IU/mL) identified patients most likely to achieve HBsAg loss with PEG-IFN add-on, whereas an HBsAg level > 200 IU/mL at on-treatment Week 12 was highly predictive of non-response (NPV = 100%). Addition of PEG-IFN to long-term NA enhanced HBsAg decline and increased the chance of HBsAg clearance in HBeAg-negative patients on long-term NA. On-treatment HBsAg levels >200 IU/mL identify patients unlikely to benefit from PEG-IFN add-on and could be used as a potential stopping-rule for PEG-IFN therapy. Our findings support further exploration of immune modulation add-on to antiviral therapy, preferably using response-guided strategies, to increase functional cure rates in patients with CHB.
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Affiliation(s)
- Mina S Farag
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Margo J H van Campenhout
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Scott Fung
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Karel J van Erpecum
- Department of Gastroenterology, University Medical Center, Utrecht, The Netherlands
| | - David K Wong
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elke Verhey
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert de Man
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J De Knegt
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johannes T Brouwer
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, The Netherlands
| | - Hubertus C Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - André Boonstra
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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2
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Majeed NA, Alawad AS, Liem KS, Takyar V, Alter H, Feld JJ, Janssen HLA, Ghany MG. Low Rate of Hepatitis B Reactivation Among Patients with Chronic Hepatitis C During Direct Acting Antiviral Therapy. Dig Dis Sci 2023:10.1007/s10620-023-07916-2. [PMID: 37022602 DOI: 10.1007/s10620-023-07916-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/04/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND AND AIMS Hepatitis B virus (HBV) reactivation has been reported in patients co-infected with hepatitis C virus (HCV) during direct acting antiviral (DAA) therapy, leading the United States Food and Drug Administration (U.S. FDA) to issue a black box warning on all DAA drug labels recommending monitoring for HBV reactivation. We conducted a comprehensive evaluation to assess the rate of HBV reactivation among patients with chronic hepatitis C (CHC) during DAA therapy. METHODS Patients with CHC and recovered HBV infection (hepatitis B surface antigen negative (HBsAg)/anti-hepatitis B core positive), treated with DAAs were included if stored sera were available. Samples were tested for HBV DNA, HBsAg, and ALT. HBV reactivation was considered if (1) HBV DNA was undetectable pre-DAA therapy and became detectable post-therapy, or (2) HBV DNA was detectable pre-treatment, but not quantifiable (< 20 IU/mL) and became quantifiable post-treatment. RESULT 79 patients with median age of 62 years were included. 68% were male and Caucasian. Various DAA regimens were administered for 12-24 weeks. Reactivation occurred in 8/79 (10%) of patients and occurred more frequently in men compared to women: 6 during treatment and 2 after treatment. Neither an ALT flare nor HBsAg seroreversion were observed. Detectable HBV DNA was transient in 5/8 and could not be determined in 3/8 but ALT flares were not observed in follow-up of these patients. CONCLUSION The risk of HBV reactivation was low in CHC patients with resolved HBV during DAA therapy. Our data support testing for HBV DNA only in selected patients with ALT flares or failure of ALT normalization during DAA treatment.
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Affiliation(s)
- Nehna Abdul Majeed
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ahmad Samer Alawad
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Canada
| | - Varun Takyar
- Department of Gastroenterology, Alta Bates Summit Medical Center, Oakland, CA, USA
| | - Harvey Alter
- Transfusion Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Canada
- Liver Disease & Transplantation, Erasmus MC, Rotterdam, Netherlands
| | - Marc G Ghany
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
- Liver Diseases Branch, NIDDK, NIH, Bldg 10, Room 9B-16, 10 Center Drive, MSC 1800, Bethesda, MD, 20892-1800, USA.
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Liem KS, Chi H, Fung S, Wong DK, Yim C, Noureldin S, Chen J, de Man RA, Sarowar A, Feld JJ, Hansen BE, Hou J, Peng J, Janssen HLA. Early virologic relapse predicts alanine aminotransferase flares after nucleos(t)ide analogue withdrawal in patients with chronic hepatitis B. J Viral Hepat 2022; 29:986-993. [PMID: 36048970 DOI: 10.1111/jvh.13742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/28/2022] [Accepted: 07/06/2022] [Indexed: 12/09/2022]
Abstract
When patients with chronic hepatitis B (CHB) stop nucleos(t)ide analogue (NA) therapy before achieving HBsAg loss, flares often ensue which are challenging to predict early. We determined the incidence, severity, outcome and predictors of flares after NA withdrawal. Forty-five patients enrolled in an RCT were included; 107 patients from an external, prospective cohort were used for validation. Retreatment criteria were pre-defined. Pre- and post-treatment predictors of alanine aminotransferase (ALT) flare (>5× ULN) were evaluated by Cox proportional-hazards regression. Seventy-two weeks after NA withdrawal, 23/45 (51%) patients had developed >5× ULN and 14 (31%) >20× ULN. Median time to develop ALT >5× ULN was 12 weeks after NA withdrawal. Independent predictors of ALT >5× ULN were male sex (HR [95% CI] 3.2 [1.2-8.9]; p = 0.03) and serum HBV DNA (1.2 [1.0-1.8]; p = 0.03) at Week 6 off-therapy. Specifically, week 6 HBV DNA >10,000 IU/ml predicted ALT >5× ULN (3.4 [1.4-8.4]; p = 0.01), which was externally validated. In conclusion, this study on post-treatment flares revealed a high cumulative incidence in CHB. Week 6 HBV DNA >10,000 IU/ml independently predicted flares. The proposed threshold enables prediction of imminent flares in patients who may benefit from closer monitoring and earlier retreatment.
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Affiliation(s)
- Kin Seng Liem
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Heng Chi
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Scott Fung
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - David K Wong
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Colina Yim
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Seham Noureldin
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Jiayun Chen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arif Sarowar
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,McLaughlin-Rotman Centre for Global Health, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jinlin Hou
- Department of Infectious Diseases, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jie Peng
- Department of Infectious Diseases, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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4
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Johnson Valiente A, Liem KS, Schwarz KB, Rosenthal P, Murray KF, Mogul D, Teckman J, Rodriguez-Baez N, Schwarzenberg SJ, Feld JJ, Wong DK, Lewis-Ximenez LL, Lauer G, Hansen BE, Ling SC, Janssen HLA, Gehring AJ. The Inflammatory Cytokine Profile Associated with Liver Damage is Broader and Stronger in Chronic Hepatitis B Patients Compared to Acute Hepatitis B Patients. J Infect Dis 2021; 225:470-475. [PMID: 34286845 DOI: 10.1093/infdis/jiab373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/20/2021] [Indexed: 11/14/2022] Open
Abstract
Liver damage in hepatitis B is immune driven and correlates with inflammatory markers in patient serum. There is no comparison of these markers to determine if inflammatory profiles are distinct to different types of liver damage across patients at different stages of disease. We measured 25 inflammatory markers in acute hepatitis B, chronic hepatitis B patients with HBeAg seroconversion and chronic patients stopping nucleoside analogue therapy. Myeloid markers dominated the inflammatory profile in all stages of hepatitis B. More inflammatory markers were detectable in chronic patients, including elevated concentrations of cytotoxic effectors Fas ligand, TRAIL and TNF-α.
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Affiliation(s)
- Alexandra Johnson Valiente
- Department of Immunology, University of Toronto, Ontario, Canada.,Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada
| | - Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Kathleen B Schwarz
- Division of Pediatric Gastroenterology, University of California San Diego, San Diego, California, USA.,Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip Rosenthal
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | | | - Douglas Mogul
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffery Teckman
- Department of Pediatrics, Saint Louis University, St. Louis, Missouri, USA
| | | | | | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
| | - David K Wong
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada
| | - Lia L Lewis-Ximenez
- Viral Hepatitis Laboratory, Oswaldo Cruz Institute, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Georg Lauer
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Simon C Ling
- Division of Gastroenterology, Hepatology & Nutrition, the Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Adam J Gehring
- Department of Immunology, University of Toronto, Ontario, Canada.,Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
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Liem KS, Wong DK, Fung S, Zahirieh A, Yim C, Zanjir WR, Feld JJ, Hansen BE, Janssen HLA. Maintained virological suppression and renal function with reduced dose tenofovir disoproxil fumarate in renally impaired chronic hepatitis B patients. J Viral Hepat 2021; 28:51-60. [PMID: 32896948 DOI: 10.1111/jvh.13401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 07/11/2020] [Accepted: 08/15/2020] [Indexed: 01/05/2023]
Abstract
Tenofovir disoproxil fumarate (TDF) effectively suppresses viral replication in chronic hepatitis B (CHB), but occasionally leads to renal impairment. We evaluated the prevalence of viral and biochemical breakthrough and renal function kinetics in renally impaired patients with CHB on reduced and on full-dose TDF. This clinic-based longitudinal cohort study included patients receiving full and reduced dose TDF (due to eGFR [Cockcroft-Gault] <60 mL/min/1.73 m2 ). Viral and biochemical breakthroughs were assessed 1 month after starting full and reduced TDF dose until the end-of-follow-up. Breakthroughs were studied in full and reduced dose TDF, and renal function (MDRD) longitudinally before and after dose reduction within patients starting on full-dose TDF. Of 750 patients on TDF, 78 (10%) had reduced dose and 672 (90%) full dose. At the time of dose reduction, 36 (46%) patients had chronic kidney disease stage G3B. A viral breakthrough occurred in one cirrhotic dialysis-dependent patient (dosed 300 mg weekly) which resolved without signs of decompensation, and in one patient on full dose which resolved spontaneously. One biochemical breakthrough occurred during dose reduction and resolved naturally without viral breakthrough. The MDRD improved within the first year of dose reduction (+3.0 [2.5] mL/min per year; P < .005) and remained stable thereafter. Fifty-three (79%) patients reached an MDRD >50 mL/min during dose reduction. Low dose TDF maintains renal function and viral suppression in most renally impaired patients with CHB, even in those with advanced liver disease. This useful, yet simple strategy could be particularly viable in resource-constrained settings.
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Affiliation(s)
- Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David K Wong
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Scott Fung
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | | | - Colina Yim
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Wayel R Zanjir
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,McLaughlin-Rotman Centre for Global Health, Toronto, ON, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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6
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Liem KS, Fung S, Wong DK, Yim C, Noureldin S, Chen J, Feld JJ, Hansen BE, Janssen HLA. Limited sustained response after stopping nucleos(t)ide analogues in patients with chronic hepatitis B: results from a randomised controlled trial (Toronto STOP study). Gut 2019; 68:2206-2213. [PMID: 31462554 DOI: 10.1136/gutjnl-2019-318981] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/08/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Although most patients with chronic hepatitis B (CHB) reach effective virological suppression with long-term nucleos(t)ide analogues (NA) therapy, some might not need to continue treatment for life. In this randomised, controlled, phase IV trial, we evaluated off-therapy outcomes in patients after discontinuing long-term NA therapy. DESIGN Patients who had received NA therapy for ≥1 year and achieved virological suppression (hepatitis B e antigen (HBeAg) seroconversion combined with undetectable hepatitis B virus (HBV) DNA ≥12 months in HBeAg-positive patients or undetectable HBV DNA ≥36 months in HBeAg-negative patients) were randomised 2:1 to stop or continue NA therapy for 72 weeks. Sustained disease remission (HBeAg negative, HBV DNA <2000 IU/mL and normal alanine aminotransferase (ALT)) was evaluated at 72 weeks after stopping NA therapy. RESULTS Among 67 enrolled patients, sustained disease remission was observed in 13/45 (29%) stop versus 18/22 (82%) continue patients. Hepatitis B surface antigen (HBsAg) loss occurred in two patients (one in each group). The median HBsAg decline from randomisation to week 72 was similar in both groups (0.2 (0.0-0.4) vs 0.1 (0.0-0.2) log IU/mL in stop vs continue patients). Among patients who stopped, 15/45 (33%) had virological or biochemical relapse and 17/45 (38%) were retreated according to predefined criteria. A total of 11/18 (61%) pretreatment HBeAg-positive versus 6/27 (22%) HBeAg-negative patients required retreatment (p=0.01). Fourteen (31%) patients developed ALT >10× upper limit of normal (ULN) and another 7 (16%) had ALT >5× ULN. No patients experienced liver decompensation or died. CONCLUSION The findings of this prospective study suggest limited benefit of stopping NA therapy in chronic hepatitis B. TRIAL REGISTRATION NUMBER NCT01911156.
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Affiliation(s)
- Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Scott Fung
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - David K Wong
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Colina Yim
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Seham Noureldin
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jiayun Chen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Sandra Rotman Centre for Global Health, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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7
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Liem KS, Yim C, Ying TD, Zanjir WR, Fung S, Wong DK, Shah H, Feld JJ, Hansen BE, Janssen HLA. Prevalence and predictors of complementary and alternative medicine modalities in patients with chronic hepatitis B. Liver Int 2019; 39:1418-1427. [PMID: 30912219 DOI: 10.1111/liv.14105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The use of complementary and alternative medicine (CAM) in patients with chronic hepatitis B (CHB) can interact with antiviral treatment or influence health-seeking behaviour. We aimed to study the use of individual CAM modalities in CHB and explore determinants of use, particularly migration-related, socio-economic and clinical factors. METHODS A total of 436 CHB outpatients who attended the Toronto Centre for Liver Disease in 2015-2016 were included in this cross-sectional study. Using the comprehensive I-CAM questionnaire and health records, data were collected on socio-demographic and clinical variables and on usage of 16 CAM modalities in the last year. RESULTS Sixty percent of patients were male, 74% were Asian and 46% were using antiviral treatment. Three-hundred and nine (71%) patients used CAM. Vitamin/mineral preparations (45% of patients) were most commonly used. Overall CAM use and the specific use of potentially injurious CAM, such as green tea extract (9.2%) and St. John's wort (0.2%), were not associated with liver disease severity. Female sex, family history of CHB, lower serum HBV DNA, and higher socio-economic status were independently associated with bio-holistic CAM use, the clinically most-relevant CAM group (P < 0.05); ethnicity, antiviral therapy use and liver disease severity were not. CONCLUSIONS CAM use among CHB patients was extensive, especially use of vitamin and mineral preparations, but without direct influence on liver disease severity. Bio-holistic CAM use appeared to be associated with socio-economic status rather than with ethnicity or liver disease severity. Despite the rare use of hepatotoxins, physicians should actively inquire about it.
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Affiliation(s)
- Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Colina Yim
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Thomas D Ying
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Wayel R Zanjir
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Scott Fung
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - David K Wong
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Hemant Shah
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada.,McLaughlin-Rotman Centre for Global Health, Toronto, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
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Liem KS, Janssen HLA. Editorial: identifying candidates for pegylated interferon add-on to entecavir therapy in patients with HBeAg-positive chronic hepatitis B - authors' reply. Aliment Pharmacol Ther 2019; 49:610-611. [PMID: 30746771 DOI: 10.1111/apt.15155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Liem KS, van Campenhout MJH, Xie Q, Brouwer WP, Chi H, Qi X, Chen L, Tabak F, Hansen BE, Janssen HLA. Low hepatitis B surface antigen and HBV DNA levels predict response to the addition of pegylated interferon to entecavir in hepatitis B e antigen positive chronic hepatitis B. Aliment Pharmacol Ther 2019; 49:448-456. [PMID: 30689258 PMCID: PMC6590282 DOI: 10.1111/apt.15098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 04/23/2018] [Accepted: 11/20/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Various treatment combinations of peginterferon (PEG-IFN) and nucleos(t)ide analogues have been evaluated for chronic hepatitis B (CHB), but the optimal regimen remains unclear. AIMS To study whether PEG-IFN add-on increases response compared to entecavir (ETV) monotherapy, and whether the duration of ETV pretreatment influences response. METHODS Response was evaluated in HBeAg positive patients previously treated in two randomized controlled trials. Patients received ETV pretreatment for at least 24 weeks and were then allocated to 24-48 weeks of ETV+PEG-IFN add-on, or continued ETV monotherapy. Response was defined as HBeAg loss combined with HBV DNA <200 IU/mL 48 weeks after discontinuing PEG-IFN. RESULTS Of 234 patients, 118 were assigned PEG-IFN add-on and 116 continued ETV monotherapy. Response was observed in 38/118 (33%) patients treated with add-on therapy and in 23/116 (20%) with monotherapy (P = 0.03). The highest response to add-on therapy compared to monotherapy was observed in PEG-IFN naive patients with HBsAg levels below 4000 IU/mL and HBV DNA levels below 50 IU/mL at randomization (70% vs 34%; P = 0.01). Above the cut-off levels, response was low and not significantly different between treatment groups. Duration of ETV pretreatment was associated with HBsAg and HBV DNA levels (both P < 0.005), but not with response (P = 0.82). CONCLUSIONS PEG-IFN add-on to ETV therapy was associated with higher response compared to ETV monotherapy in patients with HBeAg positive CHB. Response doubled in PEG-IFN naive patients with HBsAg below 4000 IU/mL and HBV DNA below 50 IU/mL, and therefore identifies them as the best candidates for PEG-IFN add-on (Identifiers: NCT00877760, NCT01532843).
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Affiliation(s)
- Kin Seng Liem
- Toronto Centre for Liver DiseaseToronto General Hospital, University Health NetworkTorontoOntarioCanada,Department of Gastroenterology and HepatologyErasmus University Medical Center RotterdamRotterdamThe Netherlands
| | - Margo J. H. van Campenhout
- Department of Gastroenterology and HepatologyErasmus University Medical Center RotterdamRotterdamThe Netherlands
| | - Qing Xie
- Department of Infectious DiseasesRuijin Hospital, Jiaotong UniversityShanghaiChina
| | - Willem Pieter Brouwer
- Department of Gastroenterology and HepatologyErasmus University Medical Center RotterdamRotterdamThe Netherlands
| | - Heng Chi
- Department of Gastroenterology and HepatologyErasmus University Medical Center RotterdamRotterdamThe Netherlands
| | - Xun Qi
- Department of Hepatitis DiseaseShanghai Public Health Clinical Center, Fudan UniversityShanghaiChina
| | - Liang Chen
- Department of Hepatitis DiseaseShanghai Public Health Clinical Center, Fudan UniversityShanghaiChina
| | | | - Bettina E. Hansen
- Toronto Centre for Liver DiseaseToronto General Hospital, University Health NetworkTorontoOntarioCanada,Department of Gastroenterology and HepatologyErasmus University Medical Center RotterdamRotterdamThe Netherlands,Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntario Canada
| | - Harry L. A. Janssen
- Toronto Centre for Liver DiseaseToronto General Hospital, University Health NetworkTorontoOntarioCanada
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Liem KS. [Lithium, a potentially dangerous drug]. Ned Tijdschr Geneeskd 2005; 149:1017-8; author reply 1018-9. [PMID: 15903046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
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Liem KS. Thrombus in transit. Neth Heart J 2003; 11:89-90. [PMID: 25696186 PMCID: PMC2499871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
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van Winkel AT, Meijs MM, Hesselink EJ, Bendien C, Liem KS. [Boerhaave's syndrome: also in the emergency room]. Ned Tijdschr Geneeskd 2001; 145:449-53. [PMID: 11268904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Two men, aged 52 and 57 years, had vomited and then developed chest pain, dyspnoea and tachypnoea. After a myocardial infarction had been excluded in the cardiac emergency room, further examination revealed a rupture of the oesophagus. This was treated surgically with the ultimate creation of a tubular stomach. Both patients then recovered well. The Boerhaave's syndrome, a 'spontaneous' perforation of the oesophagus, is a rare and potentially lethal condition which should be diagnosed at an early stage. Pain in the chest, dyspnoea and vomiting are frequent symptoms. A cardiac cause is sometimes erroneously suspected. Subcutaneous emphysema is a major indication for a perforation of the oesophagus. The chest X-ray shows also mediastinal emphysema and infiltrative abnormalities; in case of doubt a second X-ray should be made some hours later.
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Affiliation(s)
- A T van Winkel
- Afd. Cardiologie, Gelre Ziekenhuizen, Postbus 9014, 7300 DS Apeldoorn
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Rameis H, Hitzenberger G, Liem KS, Hulkenberg-Tromp D. Comparison of gastrointestinal blood loss induced by cloximate in two formulations and by naproxen. Int J Clin Pharmacol Ther Toxicol 1984; 22:96-8. [PMID: 6365812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
In a double-blind baseline controlled crossover trial gastrointestinal blood loss induced by cloximate in two different formulations (enteric-coated and non-enteric coated) was compared with naproxen. Gastrointestinal blood loss increased more in the naproxen group (0.41 ml/24 h) than in the group treated with non-enteric coated cloximate. The group treated with coated cloximate had a higher mean increase in gastrointestinal blood loss (0.36 ml/24 h) compared with placebo than those treated with non-coated cloximate.
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Liem KS, Sindram MT, van Douveren WA, Fedder G. [Myocardial abscess as complication of infectious endocarditis]. Ned Tijdschr Geneeskd 1979; 123:831-6. [PMID: 440469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Liem KS, van der Does de Willebois JA. [Electrocardiographical changes during lithiumcarbonate therapy]. Ned Tijdschr Geneeskd 1975; 119:1509-12. [PMID: 1178085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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