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Varley CD, Lowy E, Cartwright EJ, Morgan TR, Ross DB, Rozenberg-Ben-Dror K, Beste LA, Maier MM. Success of the US Veterans Health Administration's Hepatitis C Virus Care Continuum in the Direct-acting Antiviral Era. Clin Infect Dis 2024:ciae025. [PMID: 38279939 DOI: 10.1093/cid/ciae025] [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] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/17/2023] [Accepted: 01/23/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Estimated hepatitis C prevalence within the Veterans Health Administration is higher than the general population and is a risk factor for advanced liver disease and subsequent complications. We describe the hepatitis C care continuum within the Veterans Health Administration January 1, 2014-December 31, 2022. METHODS We included individuals in Veterans Health Administration care 2021-2022 who were eligible for direct-acting antiviral treatment January 1, 2014-December 31, 2022. We evaluated the proportion of Veterans who progressed through each step of the hepatitis C care continuum, and identified factors associated with initiating direct-acting antivirals, achieving sustained virologic response, and repeat hepatitis C viremia. RESULTS We identified 133,732 Veterans with hepatitis C viremia. Hepatitis C treatment was initiated in 107,134 (80.1%), with sustained virologic response achieved in 98,136 (91.6%). In those who achieved sustained virologic response, 1,097 (1.1%) had repeat viremia and 579 (52.8%) were retreated for hepatitis C. Veterans of younger ages were less likely to initiate treatment and achieve sustained virologic response, and more likely to have repeat viremia. Stimulant use and unstable housing were negatively associated with each step of the hepatitis C care continuum. CONCLUSIONS The Veterans Health Administration has treated 80% of Veterans with hepatitis C in care 2021-2022 and achieved sustained virologic response in more than 90% of those treated. Repeat viremia is rare and is associated with younger age, unstable housing, opioid use, and stimulant use. Ongoing efforts are needed to reach younger Veterans, and Veterans with unstable housing or substance use disorders.
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Affiliation(s)
- Cara D Varley
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, OR, USA
- Oregon Health & Science University-Portland State University, School of Public Health, Portland, OR, USA
| | - Elliott Lowy
- Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Emily J Cartwright
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Veteran Affairs Atlanta Health Care System, Atlanta, GA, USA
| | - Timothy R Morgan
- Gastroenterology Section, Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
| | - David B Ross
- Department of Veterans Affairs, HIV, Hepatitis, and Public Health Pathogens Programs, Washington, DC, USA
| | | | - Lauren A Beste
- Division of General Internal Medicine, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Marissa M Maier
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, OR, USA
- Veteran Affairs Portland Health Care System, Portland, OR, USA
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Vergara-Samur H, Martínez-Vernaza S, De la Hoz A, Barahona-Correa J, Ortiz JP, Gualtero-Trujillo S, Rumbo-Romero J, Salazar LM, Suárez Quintero Y, Valderrama-Beltrán S. Comparative outcomes of direct-acting antiviral treatment in patients with HIV-Hepatitis C co-infection: insights from a single center experience in Colombia. Infez Med 2023; 31:374-383. [PMID: 37701377 PMCID: PMC10495049 DOI: 10.53854/liim-3103-11] [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] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/26/2023] [Indexed: 09/14/2023]
Abstract
Background Direct-acting antivirals (DAA) were introduced to Latin America with the aim of eliminating hepatitis C (HCV) in the region. There are scarce data on the outcomes of people living with HIV and HCV treated with these medications in Colombia. This study compares the outcomes of patients with HIV-HCV co-infection and HCV mono-infection treated with DAAs. Methods Retrospective observational study including patients ≥18 years old with HCV infection treated with DAAs from August 2017 to December 2019 in a comprehensive center in Colombia. The main outcome was sustained virologic response (SVR). Secondary outcomes included reinfection, relapse and adverse events. Results We included 223 individuals with HCV treated with DAAs; 142 (63.6%) individuals were mono-infected and 81 (36.3%) co-infected. Genotypes 1b (49.7%) and 4 (33.9%) were the most common. Overall SVR after DAA treatment was 96.8%. Relapse rate was 2.24%, reinfection rate was 6.28% and adverse events occurred in 27.8% of cases. SVR was comparable in patients with co- and mono-infection (95% vs 97.8%, p=0.245). Conclusion DAA were effective in mono-infected (HCV) and co-infected (HCV/HIV) patients and reinfection was high in this last group.
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Affiliation(s)
- Hernán Vergara-Samur
- Grupo de Investigación en Enfermedades Infecciosas, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
| | - Samuel Martínez-Vernaza
- Grupo de Investigación en Enfermedades Infecciosas, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
| | - Alejandro De la Hoz
- Grupo de Investigación en Enfermedades Infecciosas, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
- Department of Internal Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States of America
| | | | - Juan Pablo Ortiz
- Grupo de Investigación en Enfermedades Infecciosas, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
| | - Sandra Gualtero-Trujillo
- Grupo de Investigación en Enfermedades Infecciosas, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
| | - José Rumbo-Romero
- Department of Internal Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Luis Miguel Salazar
- Grupo de Investigación en Enfermedades Infecciosas, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
| | - Yanette Suárez Quintero
- Division of Gastroenterology, Department of Internal Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
| | - Sandra Valderrama-Beltrán
- Grupo de Investigación en Enfermedades Infecciosas, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, Colombia
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Rabell-Bernal A, López-Valle R, Morales-Santiago A, Toro DH. The Impact of a Sustained Virologic Response to Hepatitis C Virus Treatment on Liver Stiffness in the Puerto Rico Veterans Attending Liver Clinics in the Veterans Affairs Caribbean Healthcare System. P R Health Sci J 2022; 41:123-127. [PMID: 36018739] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate the impact of sustained virologic response (SVR) on liver stiffness, as measured by transient elastography (TE), in Hispanic patients treated with direct-acting antivirals (DAAs) in the outpatient clinics in the Veterans Affairs Caribbean Healthcare System. METHODS We included hepatitis C virus (HCV) patients treated with DAA regimens from 11/2017 through 06/2019. Patient demographics and variables such as body mass index, HCV genotype, and treatment regimen were collected. The patients had a TE measurement before treatment initiation, and a repeat study 6 to 9 months after the achievement of SVR. A comparison between pre and post-treatment TE scores was performed via a paired t test. RESULTS Forty-three subjects met all the inclusion criteria and completed a posttreatment TE. Most of the subjects were infected with genotypes 1a or 1b. Six to 9 months post SVR, we measured liver stiffness and found a statistically significant reduction in TE score (P value = .0003). The pretreatment median TE score was 10.2 kPa. On a repeat TE study at 6 to 9 months post-treatment, our subjects had a median score of 7.2 kPa. CONCLUSION The eradication of HCV infection with DAAs is associated with improved TE scores. Fibrosis-stage reduction was more frequent in those who had stage 4 fibrosis prior to treatment. These results suggest that achieving SVR may spare patients from future clinical decompensation and complications. Adequate screening of this potentially deadly chronic infection can lead to early therapy with DAAs and the significant regression of fibrosis in this kind of patient.
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Affiliation(s)
| | - Ricardo López-Valle
- Gastroenterology Section, VA Caribbean Healthcare System, San Juan, Puerto Rico
| | | | - Doris H Toro
- Gastroenterology Section, VA Caribbean Healthcare System, San Juan, Puerto Rico
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Jasso-Baltazar EA, Solís-Galindo FA, Muñoz-Hernández MA, Quintal-Medina IA. [Sustained virologic response in patients with hepatitis C and chronic kidney disease]. Rev Med Inst Mex Seguro Soc 2022; 60:283-288. [PMID: 35763028 PMCID: PMC10395936] [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] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 02/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have a higher prevalence of hepatitis C virus (HCV) infection compared to the general population, and they also present higher morbidity and mortality if they are not treated. Current treatment is based on different direct-acting antiviral (DAA) schemes, which are available in the Mexican health system. However, the efficacy and safety of DAA treatment in patients with CKD on hemodialysis and HCV infection are unknown in Mexican population. OBJECTIVE To determine the efficacy through sustained viral response (SVR) and the safety of DAAs in patients with CKD on hemodialysis and chronic HCV infection in the Mexican population. MATERIAL AND METHODS Real-life cohort study. Patients with CKD on hemodialysis and HCV infection treated with DAAs from a third level hospital were included. Descriptive statistics of the clinical characteristics were performed, efficacy was determined by SVR and safety with the global frequency of adverse effects associated with treatment. RESULTS 25 patients were included. All of them received treatment with glecaprebir/pibrentasvir for 8 weeks. The mean age was 57.8 years and the median time of CKD on hemodialysis was 5 years. 96% of patients had HCV genotype 1B. 100% of the patients presented SVR and the most frequent adverse effects were headache, nausea and fatigue. CONCLUSIONS In the Mexican population studied, patients with HCV and CKD on hemodialysis presented a sustained viral response of 100% with glecaprevir/pibrentasvir with mild adverse effects.
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Affiliation(s)
- Erick Augusto Jasso-Baltazar
- Instituto Mexicano del Seguro Social, Hospital de Especialidades No. 71, Servicio de Medicina Interna. Torreón, Coahuila, México
| | - Francisco Alfonso Solís-Galindo
- Instituto Mexicano del Seguro Social, Hospital de Especialidades No. 71, Servicio de Gastroenterología. Torreón, Coahuila, México
| | - Melisa Alejandra Muñoz-Hernández
- Instituto Mexicano del Seguro Social, Hospital de Especialidades No. 71, Dirección de Educación e Investigación en Salud. Torreón, Coahuila, México
| | - Ismael Antonio Quintal-Medina
- Instituto Mexicano del Seguro Social, Hospital General de Zona No. 2, Servicio de Medicina Interna. Tlalnepantla, Estado de México, México
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Lim DH, Jeong JY, Nam S, Choi J, Kwon HC, Yoon YB, Kim Y, Chin B. Clinical Characteristics and Treatment Outcomes of Patients with Hepatitis C Virus and Human Immunodeficiency Virus Coinfection: Experience at a Single Center in Korea. J Korean Med Sci 2021; 36:e308. [PMID: 34845874 PMCID: PMC8629715 DOI: 10.3346/jkms.2021.36.e308] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/13/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Because of the very low incidence of human immunodeficiency virus (HIV) coinfection in Korea, data on hepatitis C virus (HCV)/HIV coinfection are limited. This study aimed to investigate the clinical characteristics and treatment outcomes of patients with HCV/HIV coinfection in Korea. METHODS We performed a retrospective cohort study of all HCV-monoinfected and HCV/HIV-coinfected patients treated with antivirals at National Medical Center in Seoul, Korea, between January 2009 and March 2020. RESULTS We enrolled 220 HCV-monoinfected and 23 HCV/HIV-coinfected patients treated with antivirals. The HCV/HIV-coinfected patients were younger (HCV vs. HCV/HIV: 57.3 ± 11.3 vs. 40.7 ± 10.1 years, P < 0.001) and had a higher proportion of men (HCV vs. HCV/HIV: 54.5% [n = 120] vs. 91.3% [n = 21], P < 0.001) than the HCV-monoinfected patients. Genotype 1b and 2 were most common in both HCV monoinfection and HCV/HIV coinfection groups. HCV-monoinfected patients had a higher incidence of genotype 1b and 2 than HCV/HIV-coinfected patients (HCV vs. HCV/HIV: 95.4% [n = 210] vs. 73.9% [n = 17], P < 0.001), while the HCV/HIV-coinfected patients had genotype 1a (HCV vs. HCV/HIV: 1.8% [n = 4] vs. 21.7% [n = 5], P < 0.001). The fibrosis-4 index was significantly lower in the HCV/HIV-coinfected patients than in the HCV-monoinfected patients (HCV vs. HCV/HIV: 3.81 ± 3.38 vs. 1.66 ± 1.10, P < 0.001). Among the direct-acting antivirals (DAA)-treated patients, the sustained viral response (SVR) rate did not differ significantly between both groups (HCV vs. HCV/HIV: 94.9% [93/99] vs. 90.9% [10/11], P = 0.480). CONCLUSION In Korea, the HCV/HIV-coinfected patients who received antiviral treatment were younger, had higher proportion of men and incidence of genotype 1a, and had less advanced fibrosis than the HCV-monoinfected patients. In actual clinical settings, HCV/HIV-coinfected patients show excellent SVR to DAA treatment, similar to HCV-monoinfected patients.
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Affiliation(s)
- Dae Hyun Lim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Jae Yoon Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Medical Center, Seoul, Korea.
| | - Seongwoo Nam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Medical Center, Seoul, Korea.
| | - Jongkyoung Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Hyeok Choon Kwon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Yong Bum Yoon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Yeonjae Kim
- Division of Infectious Diseases, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - BumSik Chin
- Division of Infectious Diseases, Department of Internal Medicine, National Medical Center, Seoul, Korea
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Bittermann T, Reddy KR. In the Era of Direct-Acting Antivirals, Liver Transplant Delisting Due to Clinical Improvement for Hepatitis C Remains Infrequent. Clin Gastroenterol Hepatol 2021; 19:2389-2397.e2. [PMID: 32971230 DOI: 10.1016/j.cgh.2020.09.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/28/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND / AIMS Studies have suggested marked increases in transplant delisting due to clinical improvement for patients with hepatitis C virus (HCV) associated cirrhosis in the era of direct acting antivirals (DAAs). This study provides a 'real world' assessment of waitlist dynamics for HCV transplant candidates in the current era. METHODS This was a retrospective cohort study of adults waitlisted for liver transplant (LT) alone between 1/1/2005-12/31/2018 using national US data. The post-DAA era included all listings occurring after 1/1/2013. Temporal trends in waitlisting, patient characteristics and outcomes with decompensated cirrhosis were evaluated. Adjusted competing risks models assessed the interaction of DAA-era and HCV history on (i) waitlist mortality, and (ii) delisting due to clinical improvement. RESULTS Overall listing rates for HCV patients have decreased in the DAA era and particularly with Model for End-stage Liver Disease score ≥15 and ≥30. Rates of refractory ascites and severe encephalopathy at listing have increased. Delisting due to clinical improvement remains low (6.1% for 2013-2017 versus 5.2% for 2009-2012 versus 4% for 2005-2008; p < .001) and, for many, ascites (46.5%) and encephalopathy (30.5%) persist at delisting. Waitlist recovery is more frequent for HCV patients post-DAA (adjusted SHR 1.78 vs pre-DAA, 95% CI: 1.58-2.02; p < .001), while improvements in waitlist mortality by era are similar to non-HCV candidates (adjusted SHR 0.74 [95% CI: 0.7-0.78; p < .001] and 0.77 [95% CI: 0.74-0.8; p < .001], respectively). CONCLUSION Listing rates for decompensated HCV cirrhosis have decreased in the DAA era. Delisting of HCV patients for clinical improvement has increased, but remains infrequent and many continue to experience considerable morbidity.
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Ward KM, Falade-Nwulia O, Moon J, Sutcliffe CG, Brinkley S, Haselhuhn T, Katz S, Herne K, Arteaga L, Mehta SH, Latkin C, Brooner RK, Sulkowski MS. Non-adherence to LDV/SOF did not predict SVR in a randomized controlled trial of HIV/HCV coinfected persons who use drugs. J Infect Dis 2021; 225:903-911. [PMID: 34543417 DOI: 10.1093/infdis/jiab477] [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] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/17/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Eliminating Hepatitis C Virus (HCV) will require effective treatment delivery to persons with substance use disorders (SUDs). We evaluated the relationship between ledipasvir/sofosbuvir treatment persistence (receiving 84 tablets), adherence, and sustained virologic response (SVR) in persons with HIV/HCV coinfection. METHODS Of the 144 participants with HIV/HCV and SUDs, 110 initiated a 12-week treatment course under one of three conditions (usual care, peer mentors, and cash incentives). We used self-report, pharmacy pill counts, and expected date of refill to examine adherence. Persistent participants were categorized as high adherence (taking ≥90% of doses) or low adherence (taking <90% of doses). RESULTS Most participants persisted on treatment after initiation (n=105), with 95% (n=100) achieving SVR. One-third (34%) of participants had moderate/heavy alcohol use by the biomarker phosphatidylethanol (PEth ≥50 ng/mL), and 44% had urine toxicology positive for cocaine or heroin at enrollment. The proportion of persons with high adherence was 72% (n=76) and low adherence, 28%. Although low adherence was associated with moderate/heavy alcohol use by PEth (RR 2.77, 95% CI 1.50-5.12), SVR did not vary according to adherence (p=0.702), and most participants (97%) with low adherence achieved SVR. CONCLUSION Treatment persistence led to high SVR rates among persons with HIV/HCV, despite imperfect adherence and SUDs.
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Affiliation(s)
- Kathleen M Ward
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD, USA
| | | | - Juhi Moon
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Catherine G Sutcliffe
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Sherilyn Brinkley
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Taryn Haselhuhn
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Stephanie Katz
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Kayla Herne
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Lilian Arteaga
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Robert K Brooner
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore MD, USA
| | - Mark S Sulkowski
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore MD, USA
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Hashmi ZY, Zia MQ, Bajwa A, Ahmed M, Anwer N, Raza M, Baqar JB. New drugs and new concerns: Gaining insight through Pharmacovigilance of direct acting Anti-Viral's in chronic HCV patients. Pak J Med Sci 2021; 37:299-304. [PMID: 33679903 PMCID: PMC7931287 DOI: 10.12669/pjms.37.2.3400] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective The study aimed to assess the safety profile of Direct Acting Anti-Viral's (DAAs) among patients with chronic Hepatitis C Virus (HCV). Methods This multicenter, analytical cross-sectional study was conducted in six gastroenterology and Hepatology centers including Liver Center Faisalabad, Allama Iqbal Medical Institute and Liver Center DHQ Hospital Sialkot, Isra Hospital Hyderabad, Allied Hospital Faisalabad and Rehman Medical Institute Peshawar, between May 2018 and May 2019. The data regarding patient demographics, treatment plan and the frequency of Adverse Events (AEs), and their severity was collected using a pre-designed questionnaire and analyzed through SPSS version 20.0. Results A total of 511 HCV patients were enrolled, with an overall male majority. Around 66.3% patients experienced a total of 419 AEs, out of which 61 events were suspected from DAAs while remaining 317 events were associated with Ribavirin. Pyrexia (24.6%) and fatigue (14.8%) were the most commonly reported AEs among patients receiving DAAs. Factors such as Ribavirin-based treatments and the presence of Cirrhosis were more likely to promote AEs occurrence OR [95%CI] i.e. 5.2(2.3-9.1) and 1.9(1.1-3.1) respectively (p < 0.05). Conclusion It is concluded from the study results that DAAs have displayed promising outcomes due to the minimal and minor AEs reported.
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Affiliation(s)
| | - Muhammad Qasim Zia
- Muhammad Qasim Zia, FCPS Allama Iqbal Memorial Teaching Hospital, Sialkot, Pakistan
| | - Akram Bajwa
- Akram Bajwa, Ph.D. Liaquat University of Medical & Health Sciences, Hyderabad, Pakistan
| | - Maqsood Ahmed
- Maqsood Ahmed, FCPS Allied Hospital Faisalabad, Pakistan
| | - Naveed Anwer
- Naveed Anwer, MRCP Rehman Medical Institute Peshawar, Pakistan
| | - Mahwish Raza
- Mahwish Raza, Pharm-D Shaheed Zulfikar Ali Bhutto Institute of Science and Technology, Karachi, Pakistan
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Degasperi E, D'Ambrosio R, Iavarone M, Sangiovanni A, Aghemo A, Soffredini R, Borghi M, Lunghi G, Colombo M, Lampertico P. Factors Associated With Increased Risk of De Novo or Recurrent Hepatocellular Carcinoma in Patients With Cirrhosis Treated With Direct-Acting Antivirals for HCV Infection. Clin Gastroenterol Hepatol 2019; 17:1183-1191.e7. [PMID: 30613002 DOI: 10.1016/j.cgh.2018.10.038] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [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: 03/29/2018] [Revised: 10/09/2018] [Accepted: 10/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis and hepatitis C virus (HCV) infection treated with direct-acting antivirals (DAAs) are still at risk for developing hepatocellular carcinoma (HCC). We aimed to identify features of de novo or recurrent HCCs in these patients, and factors associated with HCC development, in a large cohort of patients with cirrhosis who received treatment with DAAs. METHODS In a retrospective study, we collected data from 565 patients with cirrhosis (median age, 64 years; range, 28-87 years; 60% male, 49% infected with HCV genotype 1; median liver stiffness measurement [LSM], 19.1 kPa; 87% Child-Pugh-Turcotte score A) treated with DAAs at a single center in Italy, from December 2014 through 2016. Cirrhosis was defined based on clinical features, histologic factors (METAVIR F4), or LSM >11.9 kPa. Patients were assessed (complete blood analysis and HCV-RNA quantification) every 4 weeks during treatment; at weeks 4, 12, and 24 afterward; and at 6-month intervals thereafter. HCC surveillance was performed by ultrasound or CT scans every 3-6 months, based on history of HCC. Non-invasive markers of fibrosis, such as ratio of aspartate aminotransferase to platelets, fibrosis-4 (FIB-4) score, and LSMs were assessed. RESULTS During a median 25 months of follow up (range, 3-39 months), HCC developed in 28/505 patients without a history of HCC (de novo HCC); the 3-year estimated cumulative probability for HCC was 6% (95% CI, 4%-9%). Of patients with de novo HCC, 75% had a single tumor and 82% of these were Barcelona liver cancer stage 0-A; the median level of alpha-fetoprotein was 6 ng/mL (range, 1.0-9240 ng/mL). Male sex (hazard ratio [HR], 6.17; 95% CI, 1.44-26.47; P = .01), diabetes (HR, 2.52; 95% CI, 1.08-5.87; P = .03), LSM (HR, 1.03; 95% CI, 1.01-1.06; P = .01), and FIB-4 score (HR, 1.08; 95% CI, 1.01-1.14; P = .01) were independently associated with de novo HCC. HCC developed in 20/60 patients with a history of HCC (HCC recurrence); the 3-year cumulative probability for recurrence was 43% (95% CI, 20%-61%). In the 20 patients with HCC recurrence, 11 had a single tumor and 90% were Child-Pugh-Turcotte score A. Diabetes was independently associated with HCC recurrence (HR, 4.12; 95% CI, 1.55-10.93; P = .004). CONCLUSIONS In a large, single-center cohort of consecutive patients with cirrhosis and who received DAA treatment for HCV infection, most liver tumors were identified at early stages. Male sex, diabetes, and non-invasive markers of liver fibrosis can be used to identify patients at increased risk for HCC following DAAs therapy.
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Affiliation(s)
- Elisabetta Degasperi
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
| | - Roberta D'Ambrosio
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Massimo Iavarone
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Angelo Sangiovanni
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Department of Internal Medicine, Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Roberta Soffredini
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Marta Borghi
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giovanna Lunghi
- Microbiology and Virology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Colombo
- Department of Internal Medicine, Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Pietro Lampertico
- CRC "A. M. e A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Baumert TF, Berg T, Lim JK, Nelson DR. Status of Direct-Acting Antiviral Therapy for Hepatitis C Virus Infection and Remaining Challenges. Gastroenterology 2019; 156:431-445. [PMID: 30342035 PMCID: PMC6446912 DOI: 10.1053/j.gastro.2018.10.024] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [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: 06/26/2018] [Revised: 10/05/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
Abstract
Chronic infection with hepatitis C virus is a major cause of liver disease and hepatocellular carcinoma worldwide. After the discovery of hepatitis C virus 3 decades ago, the identification of the structure of the viral proteins, combined with high-throughput replicon models, enabled the discovery and development of direct-acting antivirals. These agents have revolutionized patient care, with cure rates of more than 90%. We review the status of direct-acting antiviral therapies for hepatitis C virus infection and discuss remaining challenges. We highlight licensed compounds, discuss the potential to shorten therapy even further, and review different options for treatment failure and resistance. We also provide an overview of clinical experience with generic agents and evidence for their efficacy. Finally, we discuss the need for new drugs and outline promising targets for future therapies.
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Affiliation(s)
- Thomas F Baumert
- INSERM, U1110, Institut de Recherche sur les Maladies Virales et Hépatiques, Strasbourg, France; Université de Strasbourg, Strasbourg, France; Pôle Hépato-digestif, Institut Hospitalo-Universitaire, Nouvel Hôpital Civil, Strasbourg, France.
| | - Thomas Berg
- Section of Hepatology, Clinic for Gastroenterology and Rheumatology, University Clinic Leipzig, Leipzig, Germany
| | - Joseph K Lim
- Section of Digestive Diseases and Yale Liver Center, Yale University School of Medicine, New Haven, Connecticut
| | - David R Nelson
- Department of Medicine, University of Florida, Gainesville, Florida.
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11
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Souliotis K, Siakavellas S, Golna C, Manesis E, Papatheodoridis G, Hatzakis A. Real-life cost of managing chronic HCV infection in Greece prior to Direct-Acting Antivirals (DAAs): an undeniable truth of spending more for less. Hippokratia 2018; 22:127-131. [PMID: 31641333 PMCID: PMC6801118] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Chronic hepatitis C virus (HCV) infection is a major public health challenge across the world. Before the introduction of Direct-Acting Antivirals (DAAs), managing and treating the disease and its possible complications (cirrhosis, hepatocellular carcinoma) placed a considerable financial burden on public health resources. This study estimates the financial burden of managing HCV in Greece before the introduction of DAAs. PATIENTS AND METHODS We reviewed the clinical records of 146 consecutive patients with chronic HCV that were regularly followed-up at two tertiary hospitals in Athens. Public health resources utilization was recorded by category for consultations, hospitalizations, medications [for the pre-DAAs: pegylated interferon (PEG-IFN) and ribavirin (RBV) regimens), and laboratory and imaging tests. Overall disease burden was stratified according to fibrosis stage in four categories [F1-F2, F3-F4, decompensated cirrhosis, and hepatocellular carcinoma (HCC) - liver transplantation (LT)]. All cost calculations were based on current prices in the Greek Public Health System. RESULTS The average cost per patient on treatment was €8,629 for F1-F2 patients, €13,302 for F3-F4 patients, €14,678 for patients with decompensated cirrhosis, and €48,152 for patients with HCC or LT. Main cost drivers were medications (75.6 % of total cost), laboratory and imaging tests (12.4 %) and hospitalizations (11.4 %). Hospitalization cost grew significantly as the disease progressed. CONCLUSIONS Chronic hepatitis C places a substantial economic burden on the Greek Public Health System. This burden is expected to increase exponentially as patients move to more advanced disease stages. Robust interventions to deter chronic HCV infection progression should be considered beneficial from a long-term economic perspective. HIPPOKRATIA 2018, 22(3): 127-131.
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Affiliation(s)
- K Souliotis
- Department of Social and Educational Policy, Faculty of Social and Political Sciences, University of Peloponnese, Corinth, Greece
- Health Policy Institute, Laiko General Hospital, Athens, Greece
| | - S Siakavellas
- Department of Gastroenterology, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - C Golna
- Innowth Ltd, Larnaca, Cyprus
| | - E Manesis
- Division of Internal Medicine, Hippokration General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G Papatheodoridis
- Department of Gastroenterology, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - A Hatzakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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12
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Younossi ZM, Stepanova M, Feld J, Zeuzem S, Sulkowski M, Foster GR, Mangia A, Charlton M, O'Leary JG, Curry MP, Nader F, Henry L, Hunt S. Sofosbuvir and Velpatasvir Combination Improves Patient-reported Outcomes for Patients With HCV Infection, Without or With Compensated or Decompensated Cirrhosis. Clin Gastroenterol Hepatol 2017; 15:421-430.e6. [PMID: 27847279 DOI: 10.1016/j.cgh.2016.10.037] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [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: 07/14/2016] [Revised: 10/14/2016] [Accepted: 10/31/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The combination of sofosbuvir and velpatasvir is used to treat patients with hepatitis C virus (HCV) infection of different genotypes. We compared the effects of this treatment regimen, with and without ribavirin, on outcomes reported by patients (patient-reported outcomes [PROs]) with HCV infection, with or without cirrhosis. METHODS We performed a post hoc analysis of data collected from phase 3 clinical trials (ASTRAL-1, -2, -3, and -4) of 1701 patients infected with HCV of different genotypes treated with sofosbuvir and velpatasvir with ribavirin for 12 weeks (n = 87), sofosbuvir with ribavirin for 12 or 24 weeks (n = 401), and ribavirin-free sofosbuvir and velpatasvir for 12 or 24 weeks (n = 1213). In all trials, participants completed 4 PRO questionnaires (while blinded to their HCV RNA levels): the Short Form-36, the Functional Assessment of Chronic Illness Therapy-Fatigue, the Chronic Liver Disease Questionnaire-HCV Version, and the Work Productivity and Activity Impairment: Specific Health Problem, at multiple time points. We compared baseline PROs and changes in PROs following treatment in patients without cirrhosis (n = 1112), with compensated cirrhosis (n = 338), and with decompensated cirrhosis (n = 251). RESULTS Baseline PRO scores were as much as 33.5% lower in patients with decompensated cirrhosis than in patients without cirrhosis (P < .05). Following treatment with ribavirin-containing regimens, changes in PRO scores were similar among patients with compensated and decompensated cirrhosis (all P > .01). Treatment with these regimens increased some PRO scores by as much as 11.8% from baseline (P < .05) and reduced others, by as much as 7.1% (P < .05). Despite this, by 12 weeks after cessation of treatment with ribavirin-containing regimens, all PRO decrements resolved; PRO scores increased by as much as 14.2%, and as much as 17.1% at 24 weeks after treatment, regardless of cirrhosis status (all P > .01 between cirrhosis groups). In contrast, treatment with ribavirin-free sofosbuvir and velpatasvir increased PRO scores for patients with compensated cirrhosis, and even more so in patients with decompensated cirrhosis starting at treatment Week 4; no statistically significant decrement was observed at any time point (all 1-sided P values > .05). In multivariate analysis, compensated cirrhosis was associated with a 2.3% to 5.0% greater increase in PRO scores following treatment with sofosbuvir and velpatasvir (P < .05); decompensated cirrhosis was associated with a 5.5%-9.1% greater increase (P < .002). Clinicaltrials.gov number, NCT02201940, NCT02220998, NCT02201953, NCT02201901. CONCLUSIONS In an analysis of data from 4 phase 3 clinical trials, we found that patients with HCV infection (especially those with decompensated cirrhosis) have significant increases in their PRO scores during treatment with sofosbuvir and velpatasvir and after achieving a sustained virologic response.
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Affiliation(s)
- Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia.
| | - Maria Stepanova
- Center for Outcomes Research, Washington, District of Columbia
| | - Jordan Feld
- Toronto Center for Liver Disease, Toronto, Canada
| | - Stefan Zeuzem
- Johann Wolfgang Goethe University Medical Center, Frankfurt am Main, Germany
| | | | | | - Alessandra Mangia
- Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | | | | | | | - Fatema Nader
- Center for Outcomes Research, Washington, District of Columbia
| | - Linda Henry
- Center for Outcomes Research, Washington, District of Columbia
| | - Sharon Hunt
- Center for Outcomes Research, Washington, District of Columbia
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13
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Maan R, van Tilborg M, Deterding K, Ramji A, van der Meer AJ, Wong F, Fung S, Sherman M, Manns MP, Cornberg M, Hansen BE, Wedemeyer H, Janssen HLA, de Knegt RJ, Feld JJ. Safety and Effectiveness of Direct-Acting Antiviral Agents for Treatment of Patients With Chronic Hepatitis C Virus Infection and Cirrhosis. Clin Gastroenterol Hepatol 2016; 14:1821-1830.e6. [PMID: 27404965 DOI: 10.1016/j.cgh.2016.07.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [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: 06/20/2016] [Accepted: 07/04/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Direct-acting antivirals (DAAs) have revolutionized treatment for patients with chronic hepatitis C virus (HCV) infection, leading to a high rates of sustained virologic response. This study assessed the real-world safety and effectiveness of DAA-based antiviral therapy for the treatment of cirrhotic patients with chronic HCV infection. METHODS This international, multicenter cohort study included all consecutive patients with chronic HCV infection and cirrhosis who underwent antiviral therapy with second-generation DAAs. Data on all patients were analyzed to assess treatment response. Predictors of hepatic decompensation during antiviral therapy were assessed using Cox proportional hazards regression analyses. RESULTS Until June 2015, 433 cirrhotic patients with chronic HCV infection started DAA-based treatment. Their mean age was 57.8 (±8.7) years, 277 (64.0%) patients were male, and 114 (26.3%) had a Child-Pugh (CP) score of B/C cirrhosis. The sustained virologic response rate at 12 weeks was similar among patients with a CP score of A (261 of 304 [85.9%]) and a CP score of B/C (83 of 101 [82.2%]; P = .37). A baseline albumin level less than 35 g/L (hazard ratio [HR], 3.11; 95% confidence interval [CI], 1.23-7.84; P = .005), baseline MELD score of 14 or higher (HR, 1.63; 95% CI, 1.03-2.61; P = .037), and HCV genotype 3 (HR, 2.05; 95% CI, 1.09-3.88; P = .033) were associated independently with hepatic decompensation during antiviral treatment among patients with a CP score of B/C. CONCLUSIONS This large cohort study showed that therapy is safe and effective in patients with compensated (CP score of A) cirrhosis. For patients with decompensated (CP score of B/C) cirrhosis, albumin level less than 35 g/L, MELD score of 14 or greater, and HCV genotype 3 are important risk factors for hepatic decompensation during DAA-based treatment. Therefore, these patients require close monitoring during antiviral therapy or treatment should be deferred until after transplantation.
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Affiliation(s)
- Raoel Maan
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network, University of Toronto, Toronto, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Marjolein van Tilborg
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Katja Deterding
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Alnoor Ramji
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Florence Wong
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Scott Fung
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Morris Sherman
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network, University of Toronto, Toronto, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto Western and General Hospital, University Health Network, University of Toronto, Toronto, Canada
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14
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Sarrazin C, Dvory-Sobol H, Svarovskaia ES, Doehle BP, Pang PS, Chuang SM, Ma J, Ding X, Afdhal NH, Kowdley KV, Gane EJ, Lawitz E, Brainard DM, McHutchison JG, Miller MD, Mo H. Prevalence of Resistance-Associated Substitutions in HCV NS5A, NS5B, or NS3 and Outcomes of Treatment With Ledipasvir and Sofosbuvir. Gastroenterology 2016; 151:501-512.e1. [PMID: 27296509 DOI: 10.1053/j.gastro.2016.06.002] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [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: 09/10/2015] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS We evaluated the effects of baseline hepatitis C virus (HCV) NS5A, NS5B, and NS3 resistance-associated substitutions (RASs) on response to the combination of ledipasvir and sofosbuvir, with or without ribavirin, in patients with HCV genotype 1 infection. METHODS We analyzed data from 2144 participants in phase 2 and 3 studies of patients with HCV genotype 1a or b infection who received the combination of ledipasvir (90 mg) and sofosbuvir (400 mg) (ledipasvir/sofosbuvir) once daily, with or without ribavirin twice daily. Population and/or deep sequence analyses of the HCV NS3, NS5A, and NS5B genes were performed on blood samples collected at baseline. RESULTS Overall, 16.0% of patients had detectable baseline RASs in NS5A. Among patients with HCV genotype 1b infection, there was no significant effect of baseline RASs in NS5A on sustained viral response 12 weeks after the end of treatment (SVR12) with ledipasvir/sofosbuvir and only a small effect in patients with HCV genotype 1a infection. RASs in NS5A that increased the half-maximal effective concentration to ledipasvir by more than 100-fold reduced the rate of SVR12 in treatment-naive patients given ledipasvir/sofosbuvir for 8 weeks (P = .011), but not for 12 weeks. These same baseline NS5A RASs reduced the percentage of treatment-experienced patients who achieved an SVR12 to 12 weeks (but not 24 weeks) ledipasvir/sofosbuvir (P < .001). These RASs had a small effect in patients given ledipasvir/sofosbuvir in combination with ribavirin for 12 weeks. Overall, 2.5% of patients had baseline NS5B nucleotide inhibitor RASs (L159F, N142T, S282G, or L320S) and all achieved an SVR12. Of patients previously treated with protease inhibitors, 53.7% had RASs in NS3 and 96.5% achieved an SVR12. CONCLUSIONS Baseline RASs in NS5A have minimal effects on patient responses to ledipasvir/sofosbuvir therapy. When these RASs do have effects, they could be largely overcome by extending treatment duration or through treatment intensification.
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Affiliation(s)
| | | | | | | | | | | | - Julie Ma
- Gilead Sciences, Inc, Foster City, California
| | - Xiao Ding
- Gilead Sciences, Inc, Foster City, California
| | - Nezam H Afdhal
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Edward J Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Eric Lawitz
- Texas Liver institute, University of Texas Health Science Center, San Antonio, Texas
| | | | | | | | - Hongmei Mo
- Gilead Sciences, Inc, Foster City, California
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15
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Lawitz E, Makara M, Akarca US, Thuluvath PJ, Preotescu LL, Varunok P, Morillas RM, Hall C, Mobashery N, Redman R, Pilot-Matias T, Vilchez RA, Hézode C. Efficacy and Safety of Ombitasvir, Paritaprevir, and Ritonavir in an Open-Label Study of Patients With Genotype 1b Chronic Hepatitis C Virus Infection With and Without Cirrhosis. Gastroenterology 2015; 149:971-80.e1. [PMID: 26170136 DOI: 10.1053/j.gastro.2015.07.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [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: 03/17/2015] [Revised: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Interferon-free treatment options are rapidly evolving for patients with chronic hepatitis C virus (HCV) genotype 1b (GT1b) infection with cirrhosis and for nonresponders to prior pegylated interferon and ribavirin therapy. We performed a phase 2b, open-label trial of the combination of ombitasvir (a NS5A replication complex inhibitor), paritaprevir, and ritonavir (an NS3/4A protease inhibitor)-an interferon- and ribavirin-free regimen-in difficult-to-treat patients, including prior null responders and patients with cirrhosis. METHODS In an international study, 82 patients without cirrhosis (42 treatment-naive and 40 prior null responders) and 99 with cirrhosis (47 treatment-naive and 52 treatment-experienced with prior relapse or a null or partial response) with chronic HCV GT1b infection received ombitasvir (25 mg), paritaprevir (150 mg), and ritonavir (100 mg) once daily for 12 weeks (without cirrhosis) or 24 weeks (with cirrhosis). The primary efficacy endpoint was sustained virologic response 12 weeks after the end of treatment (SVR12). RESULTS In treatment-naive and null responder patients without cirrhosis, rates of SVR12 were 95.2% and 90.0%, respectively. In treatment-naive and treatment-experienced patients with cirrhosis, rates of SVR12 were 97.9% and 96.2%, respectively. No clinically meaningful differences in rates of SVR12 were observed between patients with or without cirrhosis. Virologic relapse occurred in 3 null responders without cirrhosis and 1 with cirrhosis; virologic breakthrough occurred in 1 null responder without cirrhosis. Common adverse events included headache, asthenia, pruritus, and diarrhea. One patient discontinued taking the drugs because of treatment-related adverse events. CONCLUSIONS An interferon- and ribavirin-free regimen of ombitasvir, paritaprevir, and ritonavir, achieved high rates of SVR12 in patients with HCV GT1b infection with and without cirrhosis. This regimen was well tolerated and was associated with low rates of treatment discontinuation. ClinicalTrials.gov no: NCT01685203.
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Affiliation(s)
- Eric Lawitz
- Texas Liver Institute, University of Texas Health Science Center, San Antonio, Texas
| | - Mihály Makara
- Outpatient Clinic, Saint Laszlo Hospital, Budapest, Hungary
| | - Ulus Salih Akarca
- Ege University, Faculty of Medicine, Department of Gastroenterology, Izmir, Turkey
| | - Paul J Thuluvath
- Mercy Medical Center and University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Peter Varunok
- Premier Medical Group, New York Medical College, Poughkeepsie, New York
| | - Rosa Ma Morillas
- Liver Section and CIBERehd, Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Coleen Hall
- Infectious Diseases Clinical Development, AbbVie Inc, North Chicago, Illinois
| | - Niloufar Mobashery
- Infectious Diseases Clinical Development, AbbVie Inc, North Chicago, Illinois
| | - Rebecca Redman
- Infectious Diseases Clinical Development, AbbVie Inc, North Chicago, Illinois
| | - Tami Pilot-Matias
- Infectious Diseases Clinical Development, AbbVie Inc, North Chicago, Illinois
| | - Regis A Vilchez
- Infectious Diseases Clinical Development, AbbVie Inc, North Chicago, Illinois
| | - Christophe Hézode
- Department of Hepatology and Gastroenterology, Hôpital Henri Mondor, AP-HP, Université Paris-Est, INSERM U955, Créteil, France.
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16
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Madan V, Paul D, Lohmann V, Bartenschlager R. Inhibition of HCV replication by cyclophilin antagonists is linked to replication fitness and occurs by inhibition of membranous web formation. Gastroenterology 2014; 146:1361-72.e1-9. [PMID: 24486951 DOI: 10.1053/j.gastro.2014.01.055] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [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: 07/07/2013] [Revised: 01/13/2014] [Accepted: 01/22/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Replication of hepatitis C virus (HCV) requires host cell factors, such as cyclophilin A (CypA). CypA binds to HCV's nonstructural protein (NS)5A to promote replication of viral RNA. CypA antagonists, such as cyclosporines, are potent inhibitors of HCV replication. NS2 modulates sensitivity of HCV to cyclosporines. We investigated why cyclosporines require NS2 to increase their inhibitory effect and how they block HCV replication. METHODS We determined replication fitness and sensitivity of various HCV replicons, containing or lacking NS2, to cyclosporine and other direct-acting antiviral agents. We also analyzed the effects of cyclosporine on membranous web formation by electron microscopy. RESULTS NS2-5B replicons of genotype 2a (JFH1), but not genotype 1b, had increased sensitivity to cyclosporine. This difference was lost with replication-attenuated NS3-5B JFH1 RNAs, showing that cyclosporine sensitivity is linked to reduced replication fitness of NS2-containing HCV RNAs. Fitness also determined sensitivity to a nucleoside analogue and an NS5A inhibitor, but not to telaprevir. Cyclosporine blocked de novo formation of the membranous web, but had little effect on established membranous replication factories. This block was prevented by cyclosporine resistance mutations in NS5A. CONCLUSIONS Cleavage at the NS2/3 junction is a rate-limiting step in replication of particular HCV isolates and determines their sensitivity to CypA inhibitors. These drugs target de novo formation of the membranous web and RNA replication.
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Affiliation(s)
- Vanesa Madan
- Department for Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany; German Center for Infection Research, Heidelberg University, Heidelberg, Germany
| | - David Paul
- Department for Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| | - Volker Lohmann
- Department for Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| | - Ralf Bartenschlager
- Department for Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany; German Center for Infection Research, Heidelberg University, Heidelberg, Germany.
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17
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Abstract
Therapy for hepatitis C is undergoing a revolution. Several new drugs against the hepatitis C virus (HCV) have reached the market and many others, including direct-acting antivirals and host-targeted agents, are in phase II or III clinical development. All-oral, interferon-free combinations of drugs are expected to cure more than 90% of infections. A vast amount of data from clinical trials are presented regularly at international conferences or released to the press before peer-review, creating confusion in the viral hepatitis field. The goal of this review is to clarify the current stage of HCV therapy and drug development. This review describes the different classes of drugs and their mechanisms and properties, as well as treatment strategies in development, including those that are interferon-based and interferon-free. HCV treatment options that will be available in 2014-2015 are presented for each genotype. A number of unanswered questions and challenges remain, such as how to treat special populations, the role of ribavirin in interferon-free regimens, the role of HCV resistance in treatment failures, and how to best re-treat patients who failed on treatment. Strategic choices, cost issues, HCV screening, and improving access to care in resource-constrained areas also are discussed.
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Affiliation(s)
- Jean-Michel Pawlotsky
- National Reference Center for Viral Hepatitis B, C and D, Department of Virology, Hôpital Henri Mondor, Université Paris-Est, Créteil, France; INSERM U955, Créteil, France.
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18
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Zeuzem S, Berg T, Gane E, Ferenci P, Foster GR, Fried MW, Hezode C, Hirschfield GM, Jacobson I, Nikitin I, Pockros PJ, Poordad F, Scott J, Lenz O, Peeters M, Sekar V, De Smedt G, Sinha R, Beumont-Mauviel M. Simeprevir increases rate of sustained virologic response among treatment-experienced patients with HCV genotype-1 infection: a phase IIb trial. Gastroenterology 2014; 146:430-41.e6. [PMID: 24184810 DOI: 10.1053/j.gastro.2013.10.058] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [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: 07/04/2013] [Revised: 10/24/2013] [Accepted: 10/29/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Simeprevir (TMC435) is an oral NS3/4 protease inhibitor in phase III trials for chronic hepatitis C virus (HCV) infection. We performed a phase IIb, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of the combination of simeprevir, peginterferon-α2a (PegIFN), and ribavirin (RBV) in patients with HCV genotype-1 infection previously treated with PegIFN and RBV. METHODS We analyzed data from patients who did not respond (null response), had a partial response, or relapsed after treatment with PegIFN and RBV, randomly assigned to receive simeprevir (100 or 150 mg, once daily) for 12, 24, or 48 weeks plus PegIFN and RBV for 48 weeks (n = 396), or placebo plus PegIFN and RBV for 48 weeks (n = 66). All patients were followed for 24 weeks after planned end of treatment; the primary end point was the proportion of patients with sustained virologic response (SVR; undetectable HCV RNA) at that time point. RESULTS Overall, rates of SVR at 24 weeks were significantly higher in the groups given simeprevir than those given placebo (61%-80% vs 23%; P < .001), regardless of prior response to PegIFN and RBV (simeprevir vs placebo: prior null response, 38%-59% vs 19%; prior partial response, 48%-86% vs 9%; prior relapse, 77%-89% vs 37%). All groups had comparable numbers of adverse events; these led to discontinuation of simeprevir or placebo and/or PegIFN and RBV in 8.8% of patients given simeprevir and 4.5% of those given placebo. CONCLUSIONS In treatment-experienced patients, 12, 24, or 48 weeks simeprevir (100 mg or 150 mg once daily) in combination with 48 weeks PegIFN and RBV significantly increased rates of SVR at 24 weeks compared with patients given placebo, PegIFN, and RBV and was generally well tolerated. ClinicalTrials.gov number: NCT00980330.
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Affiliation(s)
| | | | - Edward Gane
- Auckland Clinical Studies, Auckland, New Zealand
| | - Peter Ferenci
- Universitätsklinik für Innere Medizin III, Wien, Austria
| | | | - Michael W Fried
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Gideon M Hirschfield
- NIHR Biomedical Research Unit, Centre for Liver Research, University of Birmingham, United Kingdom
| | - Ira Jacobson
- Weill Cornell Medical College, New York, New York
| | - Igor Nikitin
- Russian State Medical University, Moscow, Russia
| | | | - Fred Poordad
- The Texas Liver Institute/University of Texas Health Science Center, San Antonio, Texas
| | - Jane Scott
- Janssen Global Services LLC, High Wycombe, Buckinghamshire, United Kingdom
| | - Oliver Lenz
- Janssen Infectious Diseases BVBA, Beerse, Belgium
| | | | - Vanitha Sekar
- Janssen Research & Development, Titusville, New Jersey
| | | | - Rekha Sinha
- Janssen Infectious Diseases BVBA, Beerse, Belgium
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