Effectiveness, safety and clinical outcomes of direct-acting antiviral therapy in HCV genotype 1 infection: Results from a Spanish real-world cohort

BACKGROUND & AIMS

Clinical trials evaluating second-generation direct-acting antiviral agents (DAAs) have shown excellent rates of sustained virologic response (SVR) and good safety profiles in patients with chronic hepatitis C virus (HCV) genotype 1 infection. We aimed to investigate the effectiveness and safety of two oral DAA combination regimens, ombitasvir/paritaprevir/ritonavir plus dasabuvir (OMV/PTV/r+DSV) and ledipasvir/sofosbuvir (LDV/SOF), in a real-world clinical practice.

METHODS

Data from HCV genotype 1 patients treated with either OMV/PTV/r+DSV±ribavirin (RBV) (n=1567) or LDV/SOF±RBV (n=1758) in 35 centers across Spain between April 1, 2015 and February 28, 2016 were recorded in a large national database. Demographic, clinical and virological data were analyzed. Details of serious adverse events (SAEs) were recorded.

RESULTS

The two cohorts were not matched with respect to baseline characteristics and could not be compared directly. The SVR12 rate was 96.8% with OMV/PTVr/DSV±RBV and 95.8% with LDV/SOF±RBV. No significant differences were observed in SVR according to HCV subgenotype (p=0.321 [OMV/PTV/r+DSV±RBV] and p=0.174 [LDV/SOF]) or degree of fibrosis (c0.548 [OMV/PTV/r/DSV±RBV] and p=0.085 [LDV/SOF]). Only baseline albumin level was significantly associated with failure to achieve SVR (p<0.05) on multivariate analysis. Rates of SAEs and SAE-associated treatment discontinuation were 5.4% and 1.7%, in the OMV/PTV/r+DSV subcohort and 5.5% and 1.5% in the LDV/SOF subcohort, respectively. Hepatocellular carcinoma (HCC) recurred in 30% of patients with a complete response to therapy for previous HCC. Incident HCC was reported in 0.93%.

CONCLUSIONS

In this large cohort of patients managed in the real-world setting in Spain, OMV/PTV/r+DSV and LDV/SOF achieved high rates of SVR12, comparable to those observed in randomized controlled trials, with similarly good safety profiles.

LAY SUMMARY

In clinical trials, second-generation direct-acting antiviral agents (DAAs) have been shown to cure over 90% of patients chronically infected with the genotype 1 hepatitis C virus and have been better tolerated than previous treatment regimens. However, patients enrolled in clinical trials do not reflect the real patient population encountered in routine practice. The current study, which includes almost 4,000 patients, demonstrates comparable rates of cure with two increasingly used DAA combinations as those observed in the clinical trial environment, confirming that clinical trial findings with DAAs translate into the real-world setting, where patient populations are more diverse and complex.

[Epidemiology of chronic inflammatory bowel disease in Gijón, Asturias]

AIMS

To determine several aspects of the epidemiology of chronic inflammatory bowel disease (IBD), including distribution of the various forms of IBD, sex, age at diagnosis considering lag-time to diagnosis, criteria used in the diagnosis, the relationship between educational level and activity, familial aggregation, phenotype (site and clinical type), number of admissions and mean hospital stay/year, surgical requirements and mortality.

PATIENTS AND METHODS

We carried out a retrospective (1954-1993) and prospective (1994-97) descriptive epidemiologic population study, in the fifth health district of Gijón in Asturias (Spain), with 225,798 inhabitants. A total of 595 patients diagnosed with chronic IBD according to the diagnostic criteria described by Lennard-Jones and Truelove for Crohn's disease (CD) and ulcerative colitis (UC) and according to Ashley B. Price's criteria for indeterminate colitis (IC) were studied. In all patients a complete clinical follow-up was performed.

RESULTS

During the study period, we diagnosed 595 patients with IBD [305 patients with UC (51.3%), 272 (45.7%) patients with CD and 18 (3%) with IC]. Sex distribution was 287 females (48.2%) and 308 males (51.8%), with a male/female ratio of 1.07. Mean age at presentation was 38.79 +/- 17.44 years (UC: 43.37 +/- 17.55; CD: 33.98 +/- 16.16; IC: 33.73 +/- 13.48), p = 0.000. Age at onset prior to diagnosis was as follows: UC: 42.03; CD: 30.47; IC: 30.99 (p = 0.000). Diagnostic criteria used in UC was symptomatic in 99.01% (p = ns), endoscopic in 95.04% (p = 0.000), and pathologic in 87.21% (p = 0.000); in CD diagnostic criteria used was radiologic in 85.29% (p = 0.000). A total of 29.1% of patients with UC and 66.7% of those with CD had higher education (p = 0.0005). Family history was found in 9.8%. Anatomical site was as follows: in UC: rectum 21%, 28.2% rectum and sigmoid, 22.3% left colitis, 4.2% distal to hepatic flexure and 24% pancolitis; in CD: 32.72% terminal ileum, 19.11% colon, 37.13% ileo-colon, 11.02% extensive intestinal and 3.67% gastro-duodenal. A total of 8.37% of patients with UC and 14.51% of those with CD had been hospitalized during the previous 4 years; mean hospital stay was 1.63 days in UC and 2.27 days in CD. The mean surgical requirements were 0.54 +/- 1.08 (31.59%); UC: 0.11 +/- 0.36 (10.2%); CD: 1.04 +/- 1.38 (56.25%), p = 0.000. The mortality rate was 48.73 deaths/1,000 inhabitants (UC: T = 65.57; CD: T = 33.08; IC:T= 0) p = ns. The standardized mortality ratio was 4.83 (UC: 6.51; CD: 3.28).

CONCLUSIONS

We highlight the uniformity of the distribution of IBD in relation to types of disease and sex. Patients with CD had a higher level of education. Genetic components play an important role in these diseases and familial aggregation was high, especially in CD. Complicated situations are infrequent in this group of patients. Morbidity was higher in patients with CD as reflected by surgical requirements and hospital stay. Mortality was lower in CD than in UC.

[Incidence and prevalence of inflammatory bowel disease in Gijon, Asturias, Spain]

AIM

To determine the incidence and prevalence of inflammatory bowel disease in our area and to compare our results with those of other series from Spain and other parts of the world.

PATIENTS AND METHODS

Descriptive epidemiologic population study, retrospective (1954-1993) and prospective (1994-1997) in health district V of Gijón in Asturias (Spain) with 225,798 inhabitants. Diagnostic criteria used were those described by Lennard-Jones and Truelove for Crohn's disease and ulcerative colitis and those described by Ashley B. Price for indeterminate colitis. Annual incidence was expressed per 100,000 inhabitants. Prevalence was calculated excluding cured patients: proctocolectomized in ulcerative colitis (10 cases) and deaths (29 cases).

RESULTS

During the period studied, 595 patients were diagnosed with bowel disease (305 patients with ulcerative colitis, 272 with Crohn's disease and 18 with indeterminate colitis). Mean annual incidence (1954-1997) was 6.128 (95% CI: 2.90-9.36). In the 4-year prospective study the incidence was 15.49 (95% CI: 11.19-21.79), 9.36 for ulcerative colitis, 6.08 for Crohn's disease and 0.77 for indeterminate colitis (UC/CD: 1.58). Prevalence was 246.23 (95% CI: 225.6-226.70, 212.79 for ulcerative colitis, 116.47 for Crohn's disease and 7.97 for indeterminate colitis.

CONCLUSIONS

Incidence and prevalence obtained in our environment were higher than those described in other areas of Spain and were similar to those found in areas of Europe and other parts of the world with a higher incidence. Incidence and prevalence have increased since 1980, probably due to the widespread use of endoscopy as a diagnostic technique. Rates were higher in the prospective study than in the retrospective one.

[Campylobacter fetus, an infrequent microbe, as a cause of spontaneous bacterial peritonitis in cirrhosis]

Campylobacter fetus has been implicated in the etiology of sepsis and bacteriemias in immunosupressed subjects. In a few cases, it has also been reported to be responsible for spontaneous bacterial peritonitis in cirrhotic patients. We describe the clinical picture of a woman with terminal liver cirrhosis who had bacteriemia and spontaneous bacterial peritonitis caused by this agent. We argue about the history of cleansing enemas and their probable role in the development of the infection. We stress the excellent response to the antibiotic treatment.

Antibody to hepatitis C virus in acute, self-limited, type B hepatitis

Sera from 104 patients with self-limited, acute type B hepatitis were tested for the presence of anti-HCV antibodies. The results show that especially drug users with acute type B (and occasionally coinfected with type D) hepatitis commonly are infected with HCV. Furthermore, HCV infection may have preceded infection with the other agents and may be responsible for high ALT levels.

Prevalence of antibody to hepatitis C virus in acute non-A, non-B hepatitis in patients from different epidemiological categories

The prevalence of antibodies to hepatitis C virus (HCV) was determined in 65 patients with acute non-A, non-B hepatitis (NANBH). The results suggest that HCV is the most common causative agent in posttransfusion NANBH and in drug-related hepatitis. Detection of HCV antibodies does not appear to be a particularly useful diagnostic criterion due to the kinetics of the immune response in the course of the disease.

Prevalence of antibody to hepatitis C virus in chronic HBsAg carriers

The presence of the anti-HCV antibody was investigated in sera from 102 chronic HBsAg carriers. The subjects varied as to the characteristics of the clinical states. It was found that HCV coinfection was more common in HBsAg positive intravenous drug addicts than in other parenteral risk groups. It also appears that HCV may be the causative agent of chronic liver disease in HBsAg carriers with undetectable HBV (and possibly HDV) replication.