M. Melis

Multiclass HCV resistance to direct-acting antiviral failure in real-life patients advocates for tailored second-line therapies

Despite the excellent efficacy of direct‐acting antivirals (DAA) reported in clinical trials, virological failures can occur, often associated with the development of resistance‐associated substitutions (RASs). This study aimed to characterize the presence of clinically relevant RASs to all classes in real‐life DAA failures.

Improvement of ALT decay kinetics by all-oral HCV treatment: Role of NS5A inhibitors and differences with IFN-based regimens

Background Intracellular HCV-RNA reduction is a proposed mechanism of action of direct-acting antivirals (DAAs), alternative to hepatocytes elimination by pegylated-interferon plus ribavirin (PR). We modeled ALT and HCV-RNA kinetics in cirrhotic patients treated with currently-used all-DAA combinations to evaluate their mode of action and cytotoxicity compared with telaprevir (TVR)+PR. Study design Mathematical modeling of ALT and HCV-RNA kinetics was performed in 111 HCV-1 cirrhotic patients, 81 treated with all-DAA regimens and 30 with TVR+PR. Kinetic-models and Cox-analysis were used to assess determinants of ALT-decay and normalization. Results HCV-RNA kinetics was biphasic, reflecting a mean effectiveness in blocking viral production >99.8%. The first-phase of viral-decline was faster in patients receiving NS5A-inhibitors compared to TVR+PR or sofosbuvir+simeprevir (p<0.001), reflecting higher efficacy in blocking assembly/secretion. The second-phase, noted δ and attributed to infected-cell loss, was faster in patients receiving TVR+PR or sofosbuvir+simeprevir compared to NS5A-inhibitors (0.27 vs 0.21 d-1, respectively, p = 0.0012). In contrast the rate of ALT-normalization, noted λ, was slower in patients receiving TVR+PR or sofosbuvir+simeprevir compared to NS5A-inhibitors (0.17 vs 0.27 d-1, respectively, p<0.001). There was no significant association between the second-phase of viral-decline and ALT normalization rate and, for a given level of viral reduction, ALT-normalization was more profound in patients receiving DAA, and NS5A in particular, than TVR+PR. Conclusions Our data support a process of HCV-clearance by all-DAA regimens potentiated by NS5A-inhibitor, and less relying upon hepatocyte death than IFN-containing regimens. This may underline a process of “cell-cure” by DAAs, leading to a fast improvement of liver homeostasis.

Frequent NS5A and multiclass resistance in almost all HCV genotypes at DAA failures: what are the chances for second-line regimens?

Velia Chiara Di Maio, Valeria Cento, Marianna Aragri, Stefania Paolucci, Teresa Pollicino, Nicola Coppola, Bianca Bruzzone, Valeria Ghisetti, Maurizio Zazzi, Maurizia Brunetto, Ada Bertoli, Silvia Barbaliscia, Silvia Galli, William Gennari, Fausto Baldanti, Giovanni Raimondo, Carlo Federico Perno, Francesca Ceccherini-Silberstein, on behalf of treatment team of the HCV Virology Italian Resistance Network (VIRONET-C),

DNMT1 modulation in Chronic Hepatitis B patients and hypothetic influence on Mitochondrial DNA methylation status during long-term Nucleo(t)side Analogues Therapy.

Inhibition of viral replication is the most important goal in patients with Hepatitis B virus chronic infection (CHB). Currently, five oral nucleo(t)side analogs (NAs), including Lamivudine, Adefovir, Telbivudine, Entecavir, and Tenofovir, have been approved for treatment. The widespread use of NAs has also been linked with a progressive growth of unlikely anomaly attributable to mitochondrial dysfunctions, not previously recognized. Here, we explore the hypothesis that NAs may cause persistent epigenetic changes during prolonged NAs therapy in CHB patients. We obtained peripheral blood mononuclear cells (PBMC) from whole blood samples of consecutive patients with chronic HBV infection, 18 receiving NAs and 20 untreated patients. All patients were Caucasian and Italians. Epigenetic analysis was performed by Bisulphite sequencing PCR to search the existence of methylated cytosine residues in the Light (L)‐strands of mitochondrial DNA control region (D‐loop). Gene expression analysis of DNA methyltransferases 1 was performed by a quantitative relative Real‐Time Polymerase Chain Reaction (PCR). DNMT1 expression was significantly (P < 000001) higher in NA treated patients (4.09, IQR 3.52‐5.15) when compared with HBV naives (0.61, IQR 0.34‐0.82). Besides, DNMT1 expression was significantly correlated with NA therapy duration (Spearman Rho = 0.67; P < 0.05). Furthermore, NA therapy duration was the only significant predictor of DNMT1 expression at multivariate analysis (Beta = 0.95, P < 0.0000001). Bisulphite PCR sequencing showed that methylation of cytosine residues occurred in a higher percentage in patients treated with NAs in comparison with untreated patients and healthy controls. Our data showed a DNMT1 overexpression significantly correlated to NA therapy duration and an higher regional mtDNA hypermethylation. This might suggest an epigenetic alteration that could be involved in one of the possible mechanisms of mitochondrial gene regulation during NAs therapy.

L’impatto della terapia antiretrovirale sulla densità minerale ossea@@@The impact of Antiretroviral therapy on bone mineral density

Riassunto Il miglioramento della terapia antiretrovirale ha portato ad un aumento dell’età media nella popolazione HIV positiva con incremento delle co-morbidità. La co-morbidità ossea in corso di infezione da HIV ed i suoi rapporti con la terapia antiretrovirale sono oggetto di numerosi studi. L’inizio della HAART determina un rimodellamento osseo con incremento degli osteoclasti e riduzione di BMD (bone mineral density) sia a livello lombare che femorale. Tale turnover, massimo nei primi 3 mesi, raggiunge un equilibrio a 12 mesi dall’inizio della terapia determinando una stabilizzazione della perdita di massa ossea. Il tenofovir (TDF), rispetto ad altri farmaci, si associa ad una aumentata riduzione di BMD sia nel paziente naive che negli switch. La classe degli inibitori delle proteasi, da tempo considerata responsabile del decremento di BMD in particolare nel distretto lombare, vede oggi ridimensionato il suo ruolo per il possibile bias nell’interpretazione della DEXA a causa dell’aumento del grasso viscerale indotto dalla classe. Tra gli inibitori dell’integrasi, il raltegravir rappresenta l’unico farmaco con un buon impatto dimostrato sull’osso. La possibilità di limitare con l’uso dei bifosfonati l’altrimenti inevitabile perdita di massa ossea associata alla HAART suggerisce come specifici interventi possano ridurre l’impatto dei farmaci. Considerato l’invecchiamento della popolazione con infezione da HIV, si rende sempre più necessaria una personalizzazione della terapia antiretrovirale sin dal primo regime terapeutico. review