Managing chronic hepatitis C in the difficult-to-treat patient

Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, United States
Liver international: official journal of the International Association for the Study of the Liver (Impact Factor: 4.85). 01/2008; 27(10):1297-310. DOI: 10.1111/j.1478-3231.2007.01613.x
Source: PubMed


Patients with chronic hepatitis C virus (HCV) infection and disease-related complications - among them cirrhosis and liver failure - pose a particular management challenge. Some of these patients may fail to respond to current therapy (non-responders), and some are affected so severely that treatment puts them at an unacceptable risk for complications. Treatment with pegylated interferon (peg-IFN) plus ribavirin improves hepatic enzyme levels and eradicates the virus in approximately 50% of patients; however, a significant number of patients do not respond to therapy or relapse following treatment discontinuation. Several viral, hepatic and patient-related factors influence response to IFN therapy; many of these factors cannot be modified to improve long-term outcomes. Identifying risk factors and measuring viral load early in the treatment can help to predict response to IFN therapy and determine the need to modify or discontinue treatment. Retreatment options for patients who have failed therapy are limited. Retreatment with peg-IFN has been successful in some patients who exhibit an inadequate response to conventional IFN treatment, particularly those who have relapsed. Consensus IFN, another option in treatment-resistant patients, has demonstrated efficacy in the retreatment of non-responders and relapsers. Although the optimal duration of retreatment and the benefits and safety of maintenance therapy have not been determined, an extended duration is likely needed. This article reviews the risk factors for HCV treatment resistance and discusses the assessment and management of difficult-to-treat patients.

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    • "Clinical studies show that CIFN is effective for HCV infection [15,16]. Furthermore, several large multi-centre studies showed that patients with hepatitis C who do not respond to ordinary IFN-alpha therapy may benefit from re-administration of CIFN [17,18]. However, none of the the large clinical trials currently underway with CIFN for chronic hepatitis B have yet been reported. "
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    ABSTRACT: Consensus interferon (CIFN) is a newly developed type I interferon. This multicentre, controlled trial was conducted to determine the efficacy of CIFN and to compare it with alpha-1b-interferon (IFN-alpha1b) in the treatment of patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B. 144 Patients were randomly assigned to receive 9 microg CIFN (CIFN group) or 50 microg INF-alpha1b (IFN-alpha group) subcutaneously 3 times weekly for 24 weeks, followed by 24 weeks of observation. Efficacy was assessed by normalization of serum alanine transaminase (ALT) levels and the non-detectability of serum hepatitis B virus DNA or HBeAg at the end of treatment and 24 weeks after stopping treatment. There was no statistically significant difference in the serological, virological and biochemical parameters between CIFN and IFN-alpha1b groups at the end of the therapy and follow-up period (p > 0.05). Overall, at the end of treatment, 7.0% (5/71) and 35.2% (25/71) of patients in the CIFN group showed a complete or partial response compared with 7.4% (5/68) and 33.8% (23/68) of the IFN-alpha group (p = 0.10). At 24 weeks after stopping treatment, 6.9% (5/72) and 37.5% (27/72) of patients in the CIFN group showed complete response or partial response compared with 7.1% (5/70) and 34.3% (24/70) of the IFN-alpha group (p = 0.10). These findings suggest that 9 microg CIFN is effective in the treatment of patients with HBeAg-positive chronic hepatitis B. It can gradually induce ALT normalization and HBV DNA clearance and HBeAg loss or HBeAg/HBeAb seroconversion.
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    ABSTRACT: Specific antibodies against poly(ethylene glycol) (anti-PEG) were induced in animals following exposure to PEG-conjugated proteins and particles, resulting in rapid clearance of PEG-conjugated agents. In humans, induction of anti-PEG was observed following exposure to a PEG-conjugated drug, and pre-existing anti-PEG was identified in over 25% the healthy population. In clinical studies, the presence of anti-PEG was strongly associated with rapid clearance of PEG-asparaginase and PEG-uricase. PEGylation of therapeutic agents will continue to be of significant value in medicine to reduce immunogenicity, antigenicity and toxicity as well as markedly reducing renal clearance, while maintaining drug efficacy. It is important to recognize that PEG itself may possess antigenic and immunogenic properties. Further comprehensive studies are warranted to fully elucidate the effect of anti-PEG on PEG-conjugated agents and if confirmed in a prospective trial, patients should be screened and monitored for anti-PEG, and strategies developed to overcome the potential negative effect of anti-PEG on drug clearance to improve the effectiveness of therapy.
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    ABSTRACT: Early viral load decline following pegylated interferon-alpha2a and ribavirin therapy is an important predictor of the treatment responses in chronic hepatitis C (CHC) patients, thus, it is essential to evaluate the influence of host and viral factors on early viral load decline. Clinical and serial virological data were collected from 145 consecutive Asian CHC patients with pegylated interferon-alpha2a plus ribavirin therapy. A dose of pegylated interferon-alpha2a was administered at week 1 and then weekly with daily oral ribavirin for 24 or 48 weeks. Genotyping and quantification of hepatitis C virus (HCV) RNA were done using molecular methods. A total of 81 patients were infected with HCV genotype 1,61 with genotype 2 and 3 with both genotypes 1 and 2. At the end of follow-up, 110 patients attained sustained virological response (SVR). In multivariate analyses, body mass index (BMI) and genotype were related to viral load decline at day 2, baseline viral load and high-density lipoprotein (HDL) cholesterol levels were correlated with viral load decline between days 2 and 28. Genotype, baseline viral load, alanine aminotransferase (ALT) levels and BMI independently predicted rapid virological response, whereas only genotype 2, lower baseline viral load and more substantial viral load decline at day 28 predicted a higher SVR. HCV genotype, baseline viral load, pretreatment BMI, HDL and ALT levels have a significant effect on early viral load decline of Asian CHC patients with interferon-based therapy. Only HCV genotype, baseline viral load and viral load decline at day 28 can independently predict SVR.
    Antiviral therapy 02/2009; 14(1):45-54. · 3.02 Impact Factor
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