Real-world Experience with Sofosbuvir-based Regimens for Chronic Hepatitis C, Including Patients with Factors Previously Associated with Inferior Treatment Response

The introduction of sofosbuvir, a direct acting antiviral, has revolutionized the treatment of chronic hepatitis C virus (HCV). Phase 3 clinical trials have demonstrated the efficacy, simplicity, and tolerability of sofosbuvir-based regimens and report high rates of sustained virological response (SVR) rates. The purpose of this study was to assess whether clinical trial findings translate into a real-world setting, particularly with treatment of chronic HCV in our diverse, multiethnic population of Hawai'i. Retrospective analysis was performed for 113 patients with genotype 1-6 HCV infection being treated at the Queen's Liver Center between January 2014 and March 2015. SVR rates for our cohort were slightly lower than the rates published by the clinical trials. Data analysis also suggested that most baseline characteristics previously associated with inferior response might not be as significant for sofosbuvir-based regimens; in our cohort, male gender was the only factor significantly related to increased risk of virologic relapse. Pacific Islanders also had higher rate of relapse compared to other ethnic groups, but the small number of patients treated in this subgroup make it difficult to validate this finding. While newer all-oral treatment regimens have been introduced since this study, we highlight the importance of comparing real-world versus clinical trial results for new treatments, and provide data analyses for treatment of chronic HCV in Hawai'i.

Autoimmune Hepatitis in Hawai'i

Autoimmune Hepatitis (AIH) is a poorly understood disease. There has been a paucity of reports on the epidemiology and clinical course of AIH in multiethnic populations. The aim of this study is to examine the clinical and serologic features of AIH in the multiethnic population of Hawai'i. This was a retrospective, cross-sectional study of a cohort of patients seen between 2010-2013 in a tertiary referral center in Hawai'i. All 32 patients were diagnosed according to International Autoimmune Hepatitis Group (IAIHG) criteria. The mean (SD) age of diagnosis was 49.4 (17.5) years, 75% of patients were female, 72% were Asian, 19% were Caucasian, 6% were Pacific Islander, and 3% were African American. When compared to Caucasians, Asians had lower transaminase levels and international normalized ratio (INR), and were more likely to have anti-nuclear antibody (ANA) seropositivity at presentation. Asians were also older at diagnosis and more likely to achieve complete or partial remission. Patients diagnosed before the age of 40 had higher levels of total bilirubin at presentation compared to those diagnosed after the age of 40. No significant differences were observed between genders. Asian patients with type I AIH present later in life with more favorable laboratory values, and have a superior treatment response compared to Caucasians. Diagnosis before the age of 40 is associated with less favorable laboratory values at diagnosis. Further studies are necessary to validate these findings and determine the reason for the ethnic differences.

New triple therapy for chronic hepatitis C: real life clinical experience in a community setting

Recent advances in treatment of chronic hepatitis C virus have improved significantly due to the introduction of two new protease inhibitors-telaprevir and boceprevir. In combination with the previous standard of care, peginterferon and ribavirin, telaprevir and boceprevir have demonstrated improved sustained virologic response rates for HCV genotype 1 patients by approximately 30%. The purpose of this study was to assess the validity of large clinical trial data with respect to efficacy and side effects in a community setting in Honolulu, Hawai'i. This retrospective study was performed by reviewing the charts of 59 chronic HCV patients who were started on triple therapy from July 1, 2011 to July 7, 2012. Sustained virologic response was attained by 73% of patients treated with telaprevir and 46% of patients treated with boceprevir respectively. Our clinical experience with telaprevir demonstrates that SVR rates are compatible with published literature values. Rates of SVR in our cohort were also similar to those reported in cirrhotic patients - about 50%. Due to small number of patients treated with a boceprevir-based regimen, it is difficult to compare our experience with pivotal trial experience. The side effect profiles for the two protease inhibitors were similar to the literature values except for more rectal irritation and a higher incidence and severity of anemia on telaprevir therapy in the clinical setting. While not intended to be conclusive, our study demonstrates that clinical trial data are largely compatible with the outcomes obtained in our community setting.

Trial and error: investigational drug induced liver injury, a case series report

This is a case report series of four patients who exhibited signs and symptoms of acute liver dysfunction during participation in a Phase I trial of a novel non-steroidal anti-inflammatory drug (NSAID) designed to inhibit microsomal prostaglandin synthase 1 (MPGES1). Within one month of trial initiation, all four patients presented with epigastric pain, fatigue, nausea, and increasing liver function tests (LFTs). Two out of four patients required hospitalization, underwent liver biopsies, and were treated with N-acetylcysteine. The remaining two patients were managed as outpatients. Liver biopsies were consistent with drug induced liver injury (DILI). Within three months of stopping the investigational drug, symptoms subsided and LFTs normalized in all patients. This case report series signifies the importance of NSAIDs and novel drug agents in general as potentially hepatotoxic substances, the need for a high level of suspicion of DILI when considering possible etiologies of acute liver failure, and the need for prompt withdrawal of the causative agent in management of patients presenting with DILI.

Comparison of practice patterns of hospitalists and community physicians in the care of patients with congestive heart failure

OBJECTIVE

The objective of the present study was to compare the practice patterns of hospitalists and community physicians in the care of patients with congestive heart failure.

DESIGN/PARTICIPANTS/SETTING

The study was a retrospective chart review of 342 patients treated for congestive heart failure at a community-based teaching hospital.

MEASUREMENTS

Use of established therapeutic modalities for congestive heart failure and utilization of resources by hospitalists and nonhospitalists were compared. Outcome measures were adjusted length of stay (LOS), costs per case, in-hospital mortality, acute renal failure rate, and readmission rate.

RESULTS

The patients of hospitalist were more likely to receive ACE-I or ARB therapy within 24 hours of admission (86% vs. 72%; P = .003), intravenous diuretics (90% vs. 73%; P < .001), and social work consultation (48% vs. 29%; P < .001). They were less likely to have had serial chest radiographs (4% vs. 13%; P = .01) and multiple consultants (8% vs. 16%; P = .03). Hospitalists' patients with an illness whose severity was categorized as minor had a 40% reduction in LOS, those with a moderately severe illness had a 20% reduction, and those with an extremely severe illness had a 13% reduction (P = .002). Costs per case were reduced by $1000-$3100 across all severity categories (P < .001). Rates of acute renal failure and readmission were similar between the groups.

CONCLUSIONS

Early use of ACE-I/ARB, aggressive approach to diuresis, greater involvement of social work services and decreased use of chest radiographs and medical consultants were identified as distinct practices of hospitalists in this medical center. These practices may have led to a shorter LOS and lower costs while preserving quality of care and possibly improving clinical outcomes.