B Fülöp

Combined effects of different interleukin‐28B gene variants on the outcome of dual combination therapy in chronic hepatitis C virus type 1 infection

In patients with chronic hepatitis C virus (HCV) infection, several variants of the interleukin‐28B (IL28B) gene have been shown to correlate significantly with a sustained virologic response (SVR). Recent evidence shows that determination of one single IL28B polymorphism, rs12979860, is sufficient for predicting treatment outcome. We examined whether the combined determination of the IL28B single‐nucleotide polymorphisms (SNPs), rs12979860, rs8099917, rs12980275, and rs8103142, might improve the prediction of SVR in patients with HCV. In the study cohort, 54% of 942 patients with chronic HCV type 1 infection had SVR. The IL28B SNPs, rs12979860CC and rs8099917TT, correlated significantly with SVR (68% and 62%). The SNPs, rs12980275 and rs8103142, were in strong linkage disequilibrium with rs12979860 and were not included in further analysis. In homozygous carriers of the rs12979860 responder allele C, additional genotyping of the rs8099917 SNP had no effect on response prediction, whereas in carriers of the rs12979860 nonresponder allele, the rs8099917 SNP improved the response prediction. In heterozygous carriers of the rs12979860 nonresponder T allele, SVR rates were 55% in the presence of the rs8099917TT genotype and 40% in patients carrying the rs8099917 TG or GG genotype. Analysis of an independent confirmation cohort of 377 HCV type 1–infected patients verified the significant difference in SVR rates between the combined genotypes, rs12979860CT/rs8099917TT and rs12979860CT/rs8099917TG (38% versus 21%; P = 0.018). Conclusion: Treatment outcome prediction could not be improved in homozygous carriers of the IL28B rs12979860 C responder allele by the additional determination of the rs8099917 SNP. There is evidence that a significant proportion of heterozygous carriers of the rs12979860 T nonresponder allele can profit with respect to SVR prediction by further determination of the rs8099917 SNP. (HEPATOLOGY 2012;55:1700–1710)

High-dose silibinin rescue treatment for HCV-infected patients showing suboptimal virologic response to standard combination therapy.

Summary.  Incomplete suppression of hepatitis C virus (HCV) replication with persistence of minimal viremia (partial virologic response) leading to treatment failure can be observed in a significant proportion of HCV type 1‐infected patients during antiviral therapy. Recently, high‐dose intravenous silibinin has demonstrated strong antiviral activity against HCV. We were therefore interested in whether patients with partial virologic response can be rescued by the on‐treatment addition of a short‐term course of high‐dose intravenous silibinin infusions. Twenty patients who failed to achieve a complete virologic response to different interferon‐based regimens qualified for the rescue strategy and received 1400 mg/day silibinin infusions on two consecutive days. Complete viral suppression (below the limit of detection <6 IU/mL, TMA assay) could be induced in 13 of 20 patients within the first week after the short‐term silibinin infusion, and all but one of them also remained HCV RNA negative during the subsequent follow‐up period on continued peginterferon plus ribavirin treatment. In the remaining seven patients, no complete suppression could be achieved although four showed a significant HCV RNA reduction in response to silibinin. Silibinin infusions were generally well tolerated, and activation of abdominal peristalsis with nausea, diarrhoea and vomiting were the most prominent side effects. Of the twelve patients who exhibited a durable response to peginterferon and ribavirin treatment, three achieved an SVR, two achieved a week 12 SVR and four suffered a viral relapse. Three patients could not complete the assigned antiviral treatment with peginterferon alpha and ribavirin for nonvirological reasons. Short‐term administration of high‐dose intravenous silibinin might be an interesting approach to rescue patients with ongoing minimal residual viremia while on interferon‐based therapy. These preliminary findings may stimulate further studies to evaluate more refined therapeutic strategies.

Association of IFNL3 rs12979860 and rs8099917 with biochemical predictors of interferon responsiveness in chronic hepatitis C virus infection

Background & Aims Genetic variations near the interferon lambda 3 gene (IFNL3, IL28B) are the most powerful predictors for sustained virologic response (SVR) in patients with chronic hepatitis C virus (HCV) infection, compared to other biochemical or histological baseline parameters. We evaluated whether the interplay of both IFNL3 polymorphisms rs12979860 and rs8099917 together with non-genetic clinical factors contributes to the predictive role of these genetic variants. Methods The cohort comprised 1,402 patients of European descent with chronic HCV type 1 infection. 1,298 patients received interferon-based antiviral therapy, and 719 (55%) achieved SVR. The IFNL3 polymorphisms were genotyped by polymerase chain reaction and melting curve analysis. Results A significant correlation was found between the IFNL3 polymorphisms and biochemical as well as virologic predictors of treatment outcome such as ALT, GGT, cholesterol, and HCV RNA levels. In multivariate regression analysis, IFLN3 SNPs, HCV RNA levels, and the GGT/ALT ratio were independent predictors of SVR. Dependent on the GGT/ALT ratio and on the HCV RNA concentration, significant variations in the likelihood for achieving SVR were observed in both, carriers of the responder as well as non-responder alleles. Conclusions Our data support a clear association between IFNL3 genotypes and baseline parameters known to impact interferon responsiveness. Improved treatment outcome prediction was achieved when these predictors were considered in combination with the IFNL3 genotype.

Polymorphisms in the Toll-like receptor 3 ( TLR3) gene are associated with the natural course of hepatitis B virus infection in Caucasian population

Innate immunity can induce spontaneous hepatitis B surface antigen (HBsAg) seroclearance (SC) of hepatitis B virus (HBV) infection or transition towards an inactive carrier state. Toll-like receptor (TLR) 3 signalling has been linked to these processes. Alterations in the TLR3 gene might impair immune responses against HBV. In our study, we analysed the impact of the TLR3 polymorphisms rs3775291 and rs5743305 on the natural course of HBV infection. In this retrospective study, a Caucasian cohort of 621 patients with chronic HBV infection (CHB), 239 individuals with spontaneous HBsAg SC, and 254 healthy controls were enrolled. In the CHB group, 49% of patients were inactive carriers, and 17% were HBeAg-positive. The TLR3 rs3775291 A allele was associated with a reduced likelihood of spontaneous HBsAg SC and HBeAg SC, and an increased risk of developing chronic hepatitis B. In haplotype analysis, the haplotype including both risk variants rs3775291A and rs5743305A had the lowest likelihood of HBsAg SC. Further research in larger cohorts and functional analyses are needed to shed light on the impact of TLR3 signalling.

Polymorphismen im Toll-like-Rezeptor-3-Gen beeinflussen den Verlauf der Hepatitis-B-Virusinfektion

Einleitung: Die spontane Ausheilung der HBV-Infektion, der Ubergang in ein asymptomatisches Stadium und der HBs-Antigen-(HBsAg)-Verlust im naturlichen und therapieabhangigen Verlauf treten haufig bei HBeAg-positiven Patienten auf und werden wahrscheinlich durch Faktoren des angeborenen Immunsystems beeinflusst. Mehre Studien belegen die essentielle Bedeutung des Toll-like-Rezeptor-3-(TLR3)-vermittelten Signalwegs. Veranderungen im TLR3-Gen konnen die Effizienz der Signaltransduktion beeinflussen. Deshalb haben wir die Pravalenz der Genotypen der TLR3-Polymorphismen (SNPs) an den Positionen c.-976T/A und c.1234G/A und die Assoziation der Varianten mit dem naturlichen und therapieabhangigen Verlauf der HBV-Infektion untersucht. Methoden: Es wurden 476 kaukasische Patienten mit chronischer Hepatitis B (CHB) und 194 Personen mit spontaner HBs-Antigen-Serokonversion (SC) mit anti-HBs- und anti-HBc-Positivitat ohne fruhere Vakzinierung genotypisiert. In der CHB-Gruppe befanden sich 40% inaktive Trager und 23% HBeAg-positive Patienten. Die TLR3-SNPs wurden mittels Polymerasenkettenreaktion und Schmelzkurvenanalyse erfasst. Ergebnisse: Die Patienten mit SC waren signifikant alter als jene mit CHB (p < 0,001). Es kamen signifikant weniger A-Allele von TLR3 c.-976T/A und c.1234G/A in der SC-Gruppe (SC vs. CHB; c.-976A: 55% vs. 67%, p = 0,003; c.1234A: 44% vs. 60%, p = 0,0002). In der multivariaten Regressionsanalyse waren die A-Alle beider SNPs mit einer geringeren Wahrscheinlichkeit der spontanen SC assoziiert (c.-976A: OR = 0,60 [95% CI: 0,41 – 0,88] p = 0,01; c.1234A: OR = 0.56 [95% CI: 0,38 – 0,83] p = 0,004). Bei inaktiven Tragern wurden ebenfalls weniger A-Allele von c.1234G/A detektiert (inaktiv vs. hochviramisch: 57% vs. 70% p = 0,002). In der CHB-Gruppe war der AA-Genotyp von c.-976 mit der HBe-Antigen-Positivitat assoziiert (OR = 0,41 [95% CI: 0,20 – 0,84] p = 0,015). Schlussfolgerung: Die Polymorphismen c.-976T/A und c.1234G/A im TLR3-Gen sind sowohl mit der spontanen HBs-Antigen-Serokonversion, mit dem inaktiven Tragerstatus als auch mit HBe-Antigen-Positivitat bei Patienten mit chronischer Hepatitis B assoziiert. Der Einfluss dieser Varianten des angeborenen Immunsystems auf die Progredienz der CHB muss in groseren Kohorten und in funktionellen Analysen weiter untersucht werden.

Hepatitis C viral dynamics during ribavirin priming differ according to prior treatment response and HCV type.

The mode of action of ribavirin is not completely understood. Ribavirin monotherapy has a measurable antiviral effect, which shows great variability. It might lead to an earlier steady state of plasma concentration and therefore enhance the effect of following combination treatment. The aim of this study was to evaluate the antiviral effect of ribavirin priming and its influence on sustained virologic response after combination treatment in a group of patients with different hepatitis C virus (HCV) types with or without prior treatment experience. Retrospective analysis of 75 patients (37 treatment naïve, 20 prior relapse, 16 prior nonresponse, genotype 1 present in 60 patients) from five centres who received ribavirin priming as part of an individual strategy in order to improve treatment outcome. All patients received ribavirin monotherapy with a mean dose of 14.5 mg kg−1 body weight for a mean of 28 days. After ribavirin priming, dual combination treatment with pegylated interferon alfa and ribavirin was started. The mean HCV RNA decline after ribavirin priming was 0.6 log10 IU mL−1 (P<.001). The initial viral decline depended on HCV type and previous treatment status being highest among prior relapsers (0.8 log10 IU mL−1; P=.002) and HCV type 2/3 (1.2 log10 IU mL−1; P=.05) and lowest among those with prior nonresponse (0.3 log10 IU mL−1, P=.01). IFNL4 (formerly IL28B) genotype for rs12979860 and IFNL3 genotype rs8099917 did not influence the initial viral decline. The study demonstrates a significant variability in the viral dynamics and antiviral efficacy of ribavirin monotherapy, which is mainly influenced by prior treatment status. The fact that the lowest response pattern was observed in prior nonresponder patients to pegylated interferon alfa plus ribavirin combination therapy can be taken as a hint that not only the individual interferon, but also the ribavirin sensitivity contributes significantly to the nonresponsive state.

Improved pharmacodynamics and pharmacokinetics after i.v. application of peginterferon alfa-2a in hepatitis C null responders.

Mechanisms of non‐responsiveness to peginterferon alfa‐2a are not completely understood. Inadequate plasma levels may contribute to reduced response. The aim of this prospective, multicentre, crossover, Phase 1 study was to evaluate the pharmacokinetics and viral kinetics of intravenous vs. subcutaneous peginterferon alfa‐2a in patients with genotype 1 chronic hepatitis C infection who showed null response to previous peginterferon/ribavirin.

259 ANTIVIRAL EFFICACY OF RIBAVIRIN MONOTHERAPY FOLLOWED BY STANDARD COMBINATION TREATMENT IN CHRONIC HEPATITIS C

(IP-10 or CXCL10) level might be a predictive factor for sustained virological response (SVR) to pegylated IFN plus ribavirin (PegIFN/RBV) therapy in patients infected with hepatitis C virus (HCV) genotype 1. We aimed to evaluate association of pretreatment and during treatment serum IP-10 levels with virological response to PegIFN/RBV therapy in genotype 1-infected Japanese patients with chronic hepatitis C (CHC). Methods: A total of 110 patients treated with PegIFN/RBV therapy. Serum IP-10 levels were determined by enzyme linked immunosorbent assay before therapy, after 12 weeks of treatment, and endpoint of therapy. Results: 40 (36.4%) patients obtained SVR and 72 (63.6%) resulted in non-responder (NR). From univariate analysis, age (51.8 vs. 57.8: P = 0.004); IFN treatment (First/Re-treatment) (30/10 vs. 33/37: P = 0.005); Stage (F0–2 vs. F3–4) (29/11 vs. 34/36: P = 0.015); Total volume of PegIFN (3194.8 vs 2494.4: P = 0.005); Total volume of RBV (192.4 vs.161.3: P = 0.004); HCV-RNA levels (1615.7 vs. 2110.0: P = 0.046); AST level (60.1 vs.80.4: P = 0.005); PLT level (17.8 vs.16.5: P = 0.021); g-GTP level (44.2 vs.72.9: P < 0.001); AFP level (6.4 vs. 24.2: P < 0.001); treatment period (weeks) (46.4 vs. 40.1: P = 0.005); pretreatment IP-10 levels (448.9 vs. 590.1: P = 0.008); after 12 weeks of treatment IP-10 levels (243.1 vs. 328.4: P = 0.033); endpoint of therapy IP-10 levels (280.7 vs. 374.8: P = 0.047); Rapid virological response (RVR) (12/28 vs. 1/69: P < 0.001); Early virological response (EVR) (36/4 vs. 14/56: P < 0.001); wild type at amino acid 70 in the HCV core region (30/10 vs. 33/37: P = 0.005). By multivariate analysis, Age (odds ratio (OR) 9.19 (95% confidence interval (CI) 1.52–55.72; P = 0.016), treatment period (OR 153.54 (95%CI 3.44–6860.09; P = 0.009), early virological response (EVR) (OR 126.32 (95%CI 7.87-.2026.60; P < 0.001) and after 12 weeks of treatment (OR 16.14 (95%CI 1.29-.202.13; P = 0.031) were identified as predictive factor of SVR. Conclusions: Our data suggest that pretreatment and after 12 weeks of treatment serum IP-10 levels predict SVR to PegIFN/RBV therapy in CHC genotype 1 infected patients.