1
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Woot de Trixhe X, Krzyzanski W, Vermeulen A, Perez‐Ruixo JJ. Multiscale model of hepatitis C virus dynamics in plasma and liver following combination therapy. CPT Pharmacometrics Syst Pharmacol 2021; 10:826-838. [PMID: 34296543 PMCID: PMC8376145 DOI: 10.1002/psp4.12604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/21/2022] [Accepted: 02/01/2022] [Indexed: 12/09/2022] Open
Abstract
This work explores the application of a physiologically structured population (PSP) framework in modeling hepatitis C virus (HCV) kinetics. To do so, a model was developed for the viral RNA load in plasma and liver as observed in 15 patients treated with a combination therapy of pegylated interferon, ribavirin, and telaprevir. By including both intracellular and extracellular processes of the HCV lifecycle, the model provided a description of the treatment effect on the intracellular HCV lifecycle. Combining PSP models with a nonlinear mixed effects approach in a single model permits a natural inclusion of the direct‐acting antiviral effect on intracellular processes, which can then be integrated with the viral kinetics within the host while accounting for the interindividual variability between patients. This should allow an exploration of the treatment effect within the entire chronic HCV‐infected population.
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Affiliation(s)
| | | | - An Vermeulen
- Janssen R&D Division of Janssen Pharmaceutica NVBeerse Belgium
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2
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Balagopal A, Smeaton LM, Quinn J, Venuto CS, Morse GD, Vu V, Alston-Smith B, Cohen DE, Santana-Bagur JL, Anthony DD, Sulkowski MS, Wyles DL, Talal AH. Intrahepatic Viral Kinetics During Direct-Acting Antivirals for Hepatitis C in Human Immunodeficiency Virus Coinfection: The AIDS Clinical Trials Group A5335S Substudy. J Infect Dis 2021; 222:601-610. [PMID: 32201883 DOI: 10.1093/infdis/jiaa126] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Direct-acting antivirals (DAAs) targeting hepatitis C virus (HCV) have revolutionized outcomes in human immunodeficiency virus (HIV) coinfection. METHODS We examined early events in liver and plasma through A5335S, a substudy of trial A5329 (paritaprevir/ritonavir, ombitasvir, dasabuvir, with ribavirin) that enrolled chronic genotype 1a HCV-infected persons coinfected with suppressed HIV: 5 of 6 treatment-naive enrollees completed A5335S. RESULTS Mean baseline plasma HCV ribonucleic acid (RNA) = 6.7 log10 IU/mL and changed by -4.1 log10 IU/mL by Day 7. In liver, laser capture microdissection was used to quantify HCV. At liver biopsy 1, mean %HCV-infected cells = 25.2% (95% confidence interval [CI], 7.4%-42.9%), correlating with plasma HCV RNA (Spearman rank correlation r = 0.9); at biopsy 2 (Day 7 in 4 of 5 participants), mean %HCV-infected cells = 1.0% (95% CI, 0.2%-1.7%) (P < .05 for change), and DAAs were detectable in liver. Plasma C-X-C motif chemokine 10 (CXCL10) concentrations changed by mean = -160 pg/mL per day at 24 hours, but no further after Day 4. CONCLUSIONS We conclude that HCV infection is rapidly cleared from liver with DAA leaving <2% HCV-infected hepatocytes at Day 7. We extrapolate that HCV eradication could occur in these participants by 63 days, although immune activation might persist. Single-cell longitudinal estimates of HCV clearance from liver have never been reported previously and could be applied to estimating the minimum treatment duration required for HCV infection.
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Affiliation(s)
- Ashwin Balagopal
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura M Smeaton
- Harvard T.H. Chan School of Public Health, Boston, Masachussetts, USA
| | - Jeffrey Quinn
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles S Venuto
- Center for Health + Technology, University of Rochester, Rochester, New York, USA
| | - Gene D Morse
- Center for Integrated Global Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Vincent Vu
- Harvard T.H. Chan School of Public Health, Boston, Masachussetts, USA
| | | | | | | | | | - Mark S Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David L Wyles
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Andrew H Talal
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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3
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Gao W, Webber AL, Maxwell J, Anderson M, Caro L, Chung C, Miltenburg AMM, Popa S, Van Dyck K, Wenning L, Mangin E, Fandozzi C, Railkar R, Shire NJ, Fraser I, Howell B, Talal AH, Stoch SA. Fine-Needle Aspiration for the Evaluation of Hepatic Pharmacokinetics of Vaniprevir: A Randomized Trial in Patients With Hepatitis C Virus Infection. Clin Pharmacol Ther 2020; 107:1325-1333. [PMID: 31868916 DOI: 10.1002/cpt.1737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/31/2019] [Indexed: 11/10/2022]
Abstract
Fine-needle aspiration (FNA) for serial hepatic sampling may be an efficient and less invasive alternative to core needle biopsy (CNB), the current standard for liver tissue sampling. In this randomized, open-label trial in 31 participants with hepatitis C virus genotype 1 infection (NCT01678131/Merck protocol PN048), we evaluated the feasibility of using FNA to obtain human liver tissue samples appropriate for measuring hepatic pharmacokinetics (PK), using vaniprevir as a tool compound. The primary end point was successful retrieval of liver tissue specimens with measurable vaniprevir concentrations at two of three specified FNA time points. Twenty-nine patients met the primary end point and, therefore, were included in the PK analyses. Hepatic vaniprevir concentrations obtained with FNA were consistent with known vaniprevir PK properties. The shape of liver FNA and CNB concentration-time profiles were comparable. In conclusion, FNA may be effective for serial tissue sampling to assess hepatic drug exposure in patients with liver disease.
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Affiliation(s)
- Wei Gao
- Merck & Co., Inc, Kenilworth, New Jersey, USA
| | | | | | | | | | - Chris Chung
- Merck & Co., Inc, Kenilworth, New Jersey, USA
| | | | - Serghei Popa
- Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
| | | | | | - Eric Mangin
- Merck & Co., Inc, Kenilworth, New Jersey, USA
| | | | | | | | - Iain Fraser
- Merck & Co., Inc, Kenilworth, New Jersey, USA
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4
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Vranjkovic A, Deonarine F, Kaka S, Angel JB, Cooper CL, Crawley AM. Direct-Acting Antiviral Treatment of HCV Infection Does Not Resolve the Dysfunction of Circulating CD8 + T-Cells in Advanced Liver Disease. Front Immunol 2019; 10:1926. [PMID: 31456810 PMCID: PMC6700371 DOI: 10.3389/fimmu.2019.01926] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/30/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis C virus (HCV) infection disrupts immune functions, including that of cytotoxic CD8+ T-cells which are important mediators of immune response. While HCV cure aims to eliminate long term sequelae of infection, whether direct-acting antiviral (DAA) treatment results in immune reconstitution remains unclear. We and others have reported generalized CD8+ T-cell dysfunction in chronic HCV infection and our research suggests that the degree of liver damage is a factor in this process. Our recent research indicates that liver fibrosis is not readily reversed after DAA-mediated clearance of chronic HCV infection. We therefore examined the function of circulating CD8+ T-cell subsets in chronic HCV infection in the context of liver fibrosis severity, determined by ultrasound elastography and Metavir F-score system. We observed progressive shifts in CD8+ T-cell subset distribution in HCV-infected individuals with advanced liver fibrosis (F4) compared to minimal fibrosis (F0-1) or uninfected controls, and this remained unchanged after viral cure. Impaired CD8+ T-cell function was observed as a reduced proportion of CD107+ and perforin+ late effector memory cells in HCV+(F4) and HCV+(F0-1) individuals, respectively. In HCV+(F4) individuals, nearly all CD8+ T-cell subsets had an elevated proportion of perforin+ cells while naïve cells had increased proportions of IFN-γ+ and CD107+ cells. These exaggerated CD8+ T-cell activities were not resolved when evaluated 24 weeks after completion of DAA therapy and HCV clearance. This was further supported by sustained, high levels of cell proliferation and cytolytic activity. Furthermore, DAA therapy had no effect on elevated concentrations of systemic inflammatory cytokines and decreased levels of inhibitory TGF-β in the plasma of HCV+(F4) individuals, suggesting HCV infection and advanced liver disease result in a long-lasting immune activating microenvironment. These data demonstrate that in chronic HCV infection, liver fibrosis severity is associated with generalized hyperfunctional CD8+ T-cells, particularly with perforin production and cytotoxicity, and this persists after viral clearance. Whether DAA therapy will eliminate other related long-term sequelae in HCV+(F4) individuals remains an important research question.
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Affiliation(s)
- Agatha Vranjkovic
- Chronic Disease Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Felicia Deonarine
- Chronic Disease Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada
| | - Shaima Kaka
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada
| | - Jonathan B Angel
- Chronic Disease Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada.,Division of Infectious Diseases, The Ottawa Hospital, Ottawa, ON, Canada
| | - Curtis L Cooper
- Division of Infectious Diseases, The Ottawa Hospital, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Angela M Crawley
- Chronic Disease Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON, Canada.,Division of Infectious Diseases, The Ottawa Hospital, Ottawa, ON, Canada.,Department of Biology, Carleton University, Ottawa, ON, Canada
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5
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Bons E, Regoes RR. Virus dynamics and phyloanatomy: Merging population dynamic and phylogenetic approaches. Immunol Rev 2019; 285:134-146. [PMID: 30129202 DOI: 10.1111/imr.12688] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In evolutionary biology and epidemiology, phylodynamic methods are widely used to infer population biological characteristics, such as the rates of replication, death, migration, or, in the epidemiological context, pathogen spread. More recently, these methods have been used to elucidate the dynamics of viruses within their hosts. Especially the application of phylogeographic approaches has the potential to shed light on anatomical colonization pathways and the exchange of viruses between distinct anatomical compartments. We and others have termed this phyloanatomy. Here, we review the promise and challenges of phyloanatomy, and compare them to more classical virus dynamics and population genetic approaches. We argue that the extremely strong selection pressures that exist within the host may represent the main obstacle to reliable phyloanatomic analysis.
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Affiliation(s)
- Eva Bons
- Institute of Integrative Biology, ETH Zurich, Zurich, Switzerland
| | - Roland R Regoes
- Institute of Integrative Biology, ETH Zurich, Zurich, Switzerland
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6
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Venuto CS, Talal AH. Intrahepatic Sampling for the Elucidation of Antiviral Clinical Pharmacology. Clin Pharmacol Drug Dev 2018; 6:169-175. [PMID: 28263459 DOI: 10.1002/cpdd.311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 09/15/2016] [Indexed: 12/17/2022]
Abstract
Although the importance of the liver in clinical pharmacology is widely recognized, little is known in humans concerning its function in vivo at the hepatocyte level and how pharmacological functions are altered in the setting of advanced liver disease. Several recent proof-of-principle studies with first-generation DAAs have demonstrated the feasibility of serial liver sampling for pharmacological studies. These studies have begun to describe the liver-to-plasma concentration ratio and how this ratio is altered in the setting of advanced liver disease. These data are particularly relevant to individuals with substance-use disorders because many have advanced liver disease as a consequence of long-standing viral hepatitis infection or continued use of hepatotoxins such as alcohol. Future research should attempt to develop standardized and reproducible methods to assess liver drug concentration, complex drug interactions, and pharmacogenomics in humans to permit elucidation of the clinical pharmacology within the liver.
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Affiliation(s)
- Charles S Venuto
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, NY, USA.,AIDS Clinical Trials Group Pharmacology Specialty Laboratory, New York State Center of Excellence in Bioinformatics and Life Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, Buffalo, NY, USA
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7
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Talal AH, Dumas EO, Bauer B, Rejman RM, Ocque A, Morse GD, Lucic D, Cloherty GA, King J, Zha J, Zhang H, Cohen DE, Shulman N, Pawlotsky JM, Hézode C. Hepatic Pharmacokinetics and Pharmacodynamics With Ombitasvir/Paritaprevir/Ritonavir Plus Dasabuvir Treatment and Variable Ribavirin Dosage. J Infect Dis 2018; 217:474-482. [PMID: 29228392 PMCID: PMC5853515 DOI: 10.1093/infdis/jix495] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 09/14/2017] [Indexed: 12/11/2022] Open
Abstract
Background It is unknown whether ribavirin (RBV) coadministration modifies the early rate of decline of hepatitis C virus (HCV) RNA in the liver versus plasma compartments, specifically. Methods This partially randomized, open-label, phase 2 study enrolled treatment-naive, noncirrhotic patients with HCV genotype 1a. Patients were randomized 1:1 into Arms A and B, and then enrolled in Arm C. Patients received ombitasvir/paritaprevir/ritonavir plus dasabuvir for 12 weeks with either: no RBV for the first 2 weeks followed by weight-based dosing thereafter (Arm A), weight-based RBV for all 12 weeks (Arm B), or low-dose RBV (600 mg) once daily for all 12 weeks. Fine needle aspiration (FNA) was used to determine HCV RNA decline within liver. Results Baseline HCV RNA was higher and declined more rapidly in plasma than liver; however, RBV dosing did not impact either median plasma or liver HCV RNA decline during the first 2 weeks of treatment. Liver-to-plasma drug concentrations were variable over time. The most common adverse event was pain associated with FNA. Conclusions Coadministration of RBV had minimal visible impact on the plasma or liver kinetics of HCV RNA decline during the first 2 weeks of treatment, regardless of RBV dosing.
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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
- INSERM U955
| | - Christophe Hézode
- INSERM U955
- Department of Hepatology, Hôpital Henri Mondor, Université Paris-Est, Créteil, France
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8
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Meissner EG, Kohli A, Higgins J, Lee Y, Prokunina O, Wu D, Orr C, Masur H, Kottilil S. Rapid changes in peripheral lymphocyte concentrations during interferon-free treatment of chronic hepatitis C virus infection. Hepatol Commun 2017; 1:586-594. [PMID: 29202115 PMCID: PMC5703427 DOI: 10.1002/hep4.1074] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/28/2017] [Accepted: 06/30/2017] [Indexed: 01/26/2023] Open
Abstract
Treatment of chronic hepatitis C virus infection with direct acting antivirals results in a rapid decline in viral load and markers of hepatic inflammation, including serum CXCL10 concentration, which is followed in most cases by a sustained virologic response. Whether parallel changes of significance occur in the cellular composition of peripheral blood is relatively unknown. We hypothesized that longitudinal characterization of peripheral blood during treatment would provide insight into cellular migration and immune activation, which would have implications for understanding host immunity both before and after HCV treatment and may relate to HCV clearance. We analyzed longitudinal peripheral innate and adaptive immune cell populations by flow cytometry from 95 subjects enrolled in two direct acting antiviral clinical trials, and examined chemokine receptor expression on T-lymphocytes in 43 patients. Within 1-2 weeks of initiating treatment, significant increases were observed in the concentration of peripheral CD4+ and CD8+ T-lymphocytes, but not monocyte or natural killer cells. In tandem with these changes, the percent of both CD4+ and CD8+ T-lymphocytes with an activated phenotype (HLA-DR+ and CD38+) decreased, and T-lymphocyte surface expression of CXCR3, the chemokine receptor for CXCL10, increased. CONCLUSION Rapid changes in peripheral cellular populations occur during DAA -treatment of HCV infection, which could potentially relate to hepatic efflux of tissue lymphocytes due to altered inflammation and chemokine receptor signaling, providing critical insight into the relationship between host immunity and viral clearance during hepatitis C virus infection.
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Affiliation(s)
- Eric G. Meissner
- Division of Infectious DiseasesDepartment of Microbiology and Immunology, Medical University of South CarolinaCharlestonSC
- Critical Care Medicine DepartmentNIH Clinical CenterBethesdaMD
| | - Anita Kohli
- St. Joseph's Hospital and Medical CenterDepartment of Hepatology, Creighton University School of MedicinePhoenixAZ
| | - Jeanette Higgins
- Applied and Developmental Research DirectorateLeidos Biomedical Research, Inc., Frederick National Laboratory for Cancer ResearchFrederickMD
| | - Yu‐Jin Lee
- Laboratory of ImmunoregulationNational Institute of Allergy and Infectious Diseases, National Institutes of HealthBethesdaMD
| | - Olga Prokunina
- Laboratory of ImmunoregulationNational Institute of Allergy and Infectious Diseases, National Institutes of HealthBethesdaMD
| | - David Wu
- Laboratory of ImmunoregulationNational Institute of Allergy and Infectious Diseases, National Institutes of HealthBethesdaMD
| | - Cody Orr
- Division of Infectious DiseasesDepartment of Microbiology and Immunology, Medical University of South CarolinaCharlestonSC
| | - Henry Masur
- Critical Care Medicine DepartmentNIH Clinical CenterBethesdaMD
| | - Shyam Kottilil
- Laboratory of ImmunoregulationNational Institute of Allergy and Infectious Diseases, National Institutes of HealthBethesdaMD
- Division of Clinical Care and ResearchInstitute of Human Virology, University of MarylandBaltimoreMD
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9
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Paritaprevir and Ritonavir Liver Concentrations in Rats as Assessed by Different Liver Sampling Techniques. Antimicrob Agents Chemother 2017; 61:AAC.02283-16. [PMID: 28264852 DOI: 10.1128/aac.02283-16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/12/2017] [Indexed: 12/28/2022] Open
Abstract
The liver is crucial to pharmacology, yet substantial knowledge gaps exist in the understanding of its basic pharmacologic processes. An improved understanding for humans requires reliable and reproducible liver sampling methods. We compared liver concentrations of paritaprevir and ritonavir in rats by using samples collected by fine-needle aspiration (FNA), core needle biopsy (CNB), and surgical resection. Thirteen Sprague-Dawley rats were evaluated, nine of which received paritaprevir/ritonavir at 30/20 mg/kg of body weight by oral gavage daily for 4 or 5 days. Drug concentrations were measured using liquid chromatography-tandem mass spectrometry on samples collected via FNA (21G needle) with 1, 3, or 5 passes (FNA1, FNA3, and FNA5); via CNB (16G needle); and via surgical resection. Drug concentrations in plasma were also assessed. Analyses included noncompartmental pharmacokinetic analysis and use of Bland-Altman techniques. All liver tissue samples had higher paritaprevir and ritonavir concentrations than those in plasma. Resected samples, considered the benchmark measure, resulted in estimations of the highest values for the pharmacokinetic parameters of exposure (maximum concentration of drug in serum [Cmax] and area under the concentration-time curve from 0 to 24 h [AUC0-24]) for paritaprevir and ritonavir. Bland-Altman analyses showed that the best agreement occurred between tissue resection and CNB, with 15% bias, followed by FNA3 and FNA5, with 18% bias, and FNA1 and FNA3, with a 22% bias for paritaprevir. Paritaprevir and ritonavir are highly concentrated in rat liver. Further research is needed to validate FNA sampling for humans, with the possible derivation and application of correction factors for drug concentration measurements.
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10
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Alqahtani S, Ozaras R, Isakov V, Wyles D, Ferenci P, Feld JJ, Calinas F, Gschwantler M, Gane E, Crawford D, Jacobson IM, Dumas EO, King M, Sulkowski M. Time to viral suppression is not related to achievement of SVR12 in HCV GT1-infected patients treated with ombitasvir/paritaprevir/ritonavir and dasabuvir with or without ribavirin. J Viral Hepat 2017; 24:280-286. [PMID: 27935166 DOI: 10.1111/jvh.12641] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/27/2016] [Indexed: 01/01/2023]
Abstract
High rates of sustained virologic response at post-treatment week 12 (SVR12) were achieved in six phase 3 trials of ombitasvir (OBV, an NS5A inhibitor), paritaprevir (an NS3/4A protease inhibitor) co-dosed with ritonavir (PTV/r) + dasabuvir (DSV, an NS5B RNA polymerase inhibitor) (ie, 3D regimen) with or without ribavirin (RBV) in adults with chronic genotype (GT) 1 hepatitis C virus (HCV) infection. We assessed whether time to first HCV RNA value below the lower limit of quantification in patients with and without cirrhosis was associated with achievement of SVR12. Data were analysed from GT1-infected patients enrolled in six phase 3 studies of 3D ± RBV. Patients who experienced non-virologic failure were excluded from analysis. HCV RNA was determined using the Roche COBAS TaqMan RT-PCR assay (lower limit of quantification, LLOQ =25 IU/mL). SVR12 was analysed by week of first HCV RNA suppression, defined as HCV RNA <LLOQ. The analysis included a total of 2027 patients. Cumulative proportions of subjects with initial HCV RNA suppression <LLOQ at weeks 1, 2, 4 and 6 were 31%, 81%, 99% and 100%, respectively. SVR12 was achieved by 98%, 97%, 98% and 92% of patients with initial suppression at Weeks 1, 2, 4 and 6, respectively (P=.42, trend test). Across six phase 3 trials of 3D ± RBV, most patients achieved viral suppression by week 2. Time to viral suppression was not associated with subsequent achievement of SVR12, suggesting that on-treatment virologic monitoring may not be necessary with this regimen.
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Affiliation(s)
- S Alqahtani
- Johns Hopkins University, Baltimore, MD, USA
| | - R Ozaras
- Cerrahpasa Medical School, Istanbul, Turkey
| | - V Isakov
- Institute of Nutrition, Moscow, Russia
| | - D Wyles
- University of Colorado School of Medicine, Denver, CO, USA
| | - P Ferenci
- Universitaetsklinik fuer Innere Medizin III, Vienna, Austria
| | - J J Feld
- University of Toronto, Toronto, ON, Canada
| | - F Calinas
- Central Lisbon Hospital Centre, Lisbon, Portugal
| | | | - E Gane
- Auckland City Hospital, Auckland, New Zealand
| | - D Crawford
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | | | | | - M King
- AbbVie Inc., North Chicago, IL, USA
| | - M Sulkowski
- Johns Hopkins University, Baltimore, MD, USA
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11
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Abdel-hameed EA, Rouster SD, Zhang X, Chen J, Medvedovic M, Goodman ZD, Sherman KE. Characterization of HCV NS3 Protease Variants in HCV/HIV-Coinfected Patients by Ultra-Deep Sequence Analysis: Relationship with Hepatic Fibrosis. J Acquir Immune Defic Syndr 2017; 74:353-358. [PMID: 27898525 PMCID: PMC5303138 DOI: 10.1097/qai.0000000000001256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Treatment of HCV/HIV coinfection is now largely based on utilization of direct acting agents. Pretreatment viral resistant-associated variants (RAVs) and host liver condition may affect the sustained virological response. In this study, we explored relative prevalence of protease resistance-associated mutations, the evolution of those RAVs after 12 weeks of pegylated interferon alfa exposure, and the role hepatic fibrosis might have on RAV display. METHODS Thirty nonresponder HCV/HIV-coinfected subjects were evaluated before and after 12 weeks of PegIFN treatment. Ultra-deep sequence analysis of NS3 RAVs was performed. Hepatic fibrosis was determined by sensitive computer-assisted histomorphometry determination. RESULTS At baseline, protease inhibitor RAVs were present in 73.3% of patients and expanded to 83.3% of patients after 12 weeks of PegIFN exposure. Q80K showed the highest prevalence before and after treatment at 46.7% and 56.7%, respectively. The presence of Q80K is positively correlated with percent collagen content of the liver tissue. CONCLUSIONS Key RAVs for HCV protease inhibitors are present in a major portion of the HCV/HIV-coinfected population before therapy. Some variants get selected after exposure. Correlation of Q80K with collagen content of the liver suggests that compartmentalization within the liver may contribute to persistence of mutations less fit than wildtype.
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Affiliation(s)
| | - Susan D. Rouster
- University of Cincinnati College of Medicine, Cincinnati, OH
45267
| | - Xiang Zhang
- University of Cincinnati, Department of Environmental Health,
Cincinnati, OH 45267
| | - Jing Chen
- University of Cincinnati, Department of Environmental Health,
Cincinnati, OH 45267
| | - Mario Medvedovic
- University of Cincinnati, Department of Environmental Health,
Cincinnati, OH 45267
| | - Zachary D. Goodman
- Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA
22042
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12
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Nio Y, Hasegawa H, Okamura H, Miyayama Y, Akahori Y, Hijikata M. Liver-specific mono-unsaturated fatty acid synthase-1 inhibitor for anti-hepatitis C treatment. Antiviral Res 2016; 132:262-7. [PMID: 27392483 DOI: 10.1016/j.antiviral.2016.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/01/2016] [Indexed: 11/19/2022]
Abstract
Recently, direct antiviral agents against hepatitis C virus (HCV) infection have been developed as highly effective anti-HCV drugs. However, the appearance of resistant viruses against direct anti-viral agents is an unsolved problem. One of the strategies considered to suppress the emergence of the drug-resistant viruses is to use drugs inhibiting the host factor, which contributes to HCV proliferation, in combination with direct anti-viral agents. The replication complex was reported to be present in the membranous compartment in the cells. Thus, lipid metabolism modulators are good candidates to regulate virus assembly and HCV replication. Recent studies have shown that stearoyl-CoA desaturase (SCD), an enzyme for long-chain mono-unsaturated fatty acid (LCMUFA) synthesis, is a key factor that defines HCV replication efficiency. Systemic exposure to SCD-1 inhibor induces some side effects in the eyes and skin. Thus, systemic SCD-1 inhibitors are considered inappropriate for HCV therapy. To avoid the side effects of systemic SCD-1 inhibitors, the liver-specific SCD-1 inhibitor, MK8245, was synthesized; it showed antidiabetic effects in diabetic model mice with no side effects. In the phase 1 clinical study on measurement of MK8245 tolerability, no significant side effects were reported (ClinicalTrials.gov Identifier: NCT00790556). Therefore, we thought liver-specific SCD-1 inhibitors would be suitable agents for HCV-infected patients. MK8245 was evaluated using recombinant HCV culture systems. Considering current HCV treatments, to avoid the emergence of direct anti-viral agents-resistant viruses, combination therapy with direct anti-viral agents and host-targeted agents would be optimal. With this viewpoint, we confirmed MK8245's additive or synergistic anti-HCV effects on current direct anti-viral agents and interferon-alpha therapy. The results suggest that MK8245 is an option for anti-HCV multi-drug therapy with a low risk of emergence of drug-resistant HCV without significant side effects.
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Affiliation(s)
- Yasunori Nio
- Takeda Pharmaceutical Company Limited, Pharmaceutical Research Division, 26-1, Muraoka-Higashi 2-Chome, Fujisawa, Kanagawa 251-8555, Japan.
| | - Hikari Hasegawa
- Laboratory of Human Tumor Viruses, The Institute for Virus Research, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan; Grad. Sch. of Biostudies, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan
| | - Hitomi Okamura
- Laboratory of Human Tumor Viruses, The Institute for Virus Research, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan; Grad. Sch. of Biostudies, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan
| | - Yohei Miyayama
- Laboratory of Human Tumor Viruses, The Institute for Virus Research, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan; Grad. Sch. of Biostudies, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan
| | - Yuichi Akahori
- Laboratory of Human Tumor Viruses, The Institute for Virus Research, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan; Grad. Sch. of Biostudies, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan
| | - Makoto Hijikata
- Laboratory of Human Tumor Viruses, The Institute for Virus Research, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan; Grad. Sch. of Biostudies, Kyoto University, 53 Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan.
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13
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Townsend K, Meissner EG, Sidharthan S, Sampson M, Remaley AT, Tang L, Kohli A, Osinusi A, Masur H, Kottilil S. Interferon-Free Treatment of Hepatitis C Virus in HIV/Hepatitis C Virus-Coinfected Subjects Results in Increased Serum Low-Density Lipoprotein Concentration. AIDS Res Hum Retroviruses 2016; 32:456-62. [PMID: 26559180 DOI: 10.1089/aid.2015.0170] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Chronic hepatitis C virus (HCV) infection is associated with lower serum concentration of low-density lipoprotein (LDL-C), the primary cholesterol metabolite targeted pharmaceutically to modulate cardiovascular risk. Chronic infection with human immunodeficiency virus (HIV) and treatment with antiretrovirals (ARVs) are associated with dyslipidemia and increased risk of cardiovascular disease. In subjects coinfected with HIV and HCV, lipid abnormalities associated with either infection alone are often attenuated. Treatment of chronic HCV infection in HIV/HCV-coinfected subjects is now possible with interferon (IFN)-free regimens composed of directly acting antivirals (DAAs). We previously observed a marked increase in serum LDL-C in HCV-monoinfected subjects treated with sofosbuvir and ribavirin (SOF/RBV) that correlated with viral decline in serum, suggesting a direct influence of HCV clearance on serum cholesterol. In the present study, we assessed longitudinal changes in cholesterol in HIV/HCV-coinfected subjects during treatment of HCV genotype-1 (GT1) infection with combination DAA therapy. We report a rapid increase in LDL-C and LDL particle size by week 2 of treatment that was sustained during and after treatment in HIV/HCV-coinfected subjects. No change in serum LDL-C was observed at day 3 of treatment, in spite of a marked reduction in serum HCV viral load, suggesting LDL-C increases do not directly reflect HCV clearance as measured in peripheral blood. After effective DAA therapy for HCV, an increase in LDL should be anticipated in HIV/HCV-coinfected subjects.
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Affiliation(s)
- Kerry Townsend
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Eric G. Meissner
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
- Division of Infectious Diseases, Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland
| | - Sreetha Sidharthan
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland
| | - Maureen Sampson
- Clinical Center, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland
| | - Alan T. Remaley
- Lipoprotein Metabolism Section, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Lydia Tang
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland, Baltimore, Maryland
| | - Anita Kohli
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland
- St. Joseph's Hospital and Medical Center, Creighton University School of Medicine, Department of Hepatology, Phoenix, Arizona
| | - Anu Osinusi
- Division of Infectious Diseases, Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland, Baltimore, Maryland
- Gilead Sciences Inc., Foster City, California
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland
| | - Shyam Kottilil
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland, Baltimore, Maryland
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14
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Bartolini B, Selleri M, Garbuglia AR, Giombini E, Taibi C, Lionetti R, D'Offizi G, Capobianchi MR. HCV NS3 quasispecies in liver and plasma and dynamics of telaprevir-resistant variants in breakthrough patients assessed by UDPS: A case study. J Clin Virol 2015; 72:60-5. [PMID: 26418073 DOI: 10.1016/j.jcv.2015.07.310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/20/2015] [Accepted: 07/25/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND The impact of pre-existing variants in hepatitis C virus (HCV) quasispecies, carrying resistance-associated mutations (RAMs), on the outcome of treatment with direct acting antiviral agents (DAA) is debated and it is complicated by the lack of knowledge of quasispecies distribution between the viral reservoir (liver) and the circulating compartment. OBJECTIVE To evaluate NS3 protease heterogeneity and presence of RAMs on baseline plasma and liver biopsy samples. Plasma dynamics were also analyzed during therapy and after its suspension. Study design Ultra-deep pyrosequencing (UDPS) was performed in two HCV genotype 1a patients who received telaprevir (TVR)-based therapy and developed treatment failure due to TVR-resistance. RESULTS In both patients the baseline diversity of NS3 quasispecies in plasma was higher than in liver (183.6×10(-4) vs 47.8×10(-4) and 246.0×10(-4) vs 55.0×10(-4) nt substitution/site, respectively, p<0.0001), but phylogenetic trees did not evidence compartmentalization between the two compartments. At baseline RAMs (i.e. V36A, T54A) were detected very low levels (range: 0.31-0.52%) in both specimen types. However, phylogenetic analyses revealed that the viral variants carrying these mutations at baseline were different from those that became fixed at breakthrough, when combined V36M+R155K, conferring high-level resistance to TVR, were observed. The frequency of resistance-associated variants declined after withdrawal of drug selective pressure. CONCLUSIONS UDPS allowed extensive evaluation of quasispecies compartmentalization and of their dynamics after withdrawal of TVR. Plasma and liver NS3 quasispecies, including low level RAMs, do not show significant difference.
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Affiliation(s)
- Barbara Bartolini
- "L. Spallanzani" National Institute of Infectious Diseases, Via Portuense 292, 00149 Rome, Italy
| | - Marina Selleri
- "L. Spallanzani" National Institute of Infectious Diseases, Via Portuense 292, 00149 Rome, Italy
| | - Anna Rosa Garbuglia
- "L. Spallanzani" National Institute of Infectious Diseases, Via Portuense 292, 00149 Rome, Italy
| | - Emanuela Giombini
- "L. Spallanzani" National Institute of Infectious Diseases, Via Portuense 292, 00149 Rome, Italy
| | - Chiara Taibi
- "L. Spallanzani" National Institute of Infectious Diseases, Via Portuense 292, 00149 Rome, Italy
| | - Raffaella Lionetti
- "L. Spallanzani" National Institute of Infectious Diseases, Via Portuense 292, 00149 Rome, Italy
| | - Gianpiero D'Offizi
- "L. Spallanzani" National Institute of Infectious Diseases, Via Portuense 292, 00149 Rome, Italy
| | - Maria R Capobianchi
- "L. Spallanzani" National Institute of Infectious Diseases, Via Portuense 292, 00149 Rome, Italy.
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15
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Rivero-Juarez A, Camacho A, Rivero A. Pharmacokinetic and pharmacodynamic evaluation of telaprevir for the treatment of hepatitis C. Expert Opin Drug Metab Toxicol 2015; 11:1157-65. [PMID: 26004270 DOI: 10.1517/17425255.2015.1049532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Telaprevir is one of the first direct-acting antiviral drugs approved for the treatment of the hepatitis C virus (HCV) genotype 1. Following its approval in 2011, new data regarding the pharmacokinetics and pharmacodynamics were reported, leading to important clinical applications. AREAS COVERED This article reviews the pharmacokinetic and pharmacodynamic properties of telaprevir for the treatment of the HCV. The areas covered include data regarding the drug's absorption, distribution, metabolism and excretion, in addition to the antiviral activity strategy such as the clinical dose selection and treatment duration. EXPERT OPINION Telaprevir presents several pharmacological properties that could limit its administration such a high-fat, high-calorie meal; the need to be administrated with pegylated IFN plus ribavirin; and the drug-drug interaction profile. As a consequence and considering the new therapeutic arsenal against the HCV, the use of telaprevir as part of HCV therapy will be limited.
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Affiliation(s)
- Antonio Rivero-Juarez
- Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC) , Avda, Menendez Pidal s/n. 14004, Córdoba , Spain +34 9 5701 2421 ; +34 9 5701 1885 ;
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16
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Wright DH, Caro L, Cerra M, Panorchan P, Du L, Anderson M, Potthoff A, Nachbar RB, Wagner J, Manns MP, Talal AH. Liver-to-plasma vaniprevir (MK-7009) concentration ratios in HCV-infected patients. Antivir Ther 2015; 20:843-8. [PMID: 25849338 DOI: 10.3851/imp2958] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Some drugs that are actively taken up into the liver exhibit greater than dose proportional increases in plasma exposure, although human liver-to-plasma concentration ratios have rarely been evaluated. Understanding these relationships has implications for drug concentrations at the target site for certain classes of compounds, such as direct-acting antivirals, targeted towards HCV. METHODS Treatment-experienced, chronic HCV non-cirrhotic patients (n=3) received vaniprevir (600 mg or 300 mg twice daily) on days 1-3 and (600 mg or 300 mg single dose) on day 4. Core needle biopsy was performed at 6 or 12 h post-dose on day 4. Blood samples were collected pre-dose on days 1 and 4, and for 24 h post-dose on day 4. The primary study objective was the hepatic concentration of vaniprevir at 6 and 12 h post-dose. RESULTS Vaniprevir plasma pharmacokinetic parameters increased in a greater than dose-proportional manner between the 300 mg and 600 mg doses, with approximately fivefold increases in AUC0-12 and Cmax associated with a twofold increase in dose (AUC0-12, 10.6 μM/h to 59.5 μM/h; Cmax, 2.60 μM to 13.5 μM). In the 300 mg and 600 mg dose groups, mean liver concentrations of vaniprevir were 84.6 μM and 169 μM at 6 h post-dose, and 29.4 μM and 53.7 μM at 12 h post-dose. Liver concentrations were higher than plasma with liver-to-plasma concentration ratios of approximately 20-280. CONCLUSIONS These data confirm higher vaniprevir concentrations in human liver compared with plasma and demonstrate that measurement of human liver drug concentration using needle biopsy is feasible.
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17
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Zeremski M, Dimova RB, Benjamin S, Penney MS, Botfield MC, Talal AH. Intrahepatic and Peripheral CXCL10 Expression in Hepatitis C Virus-Infected Patients Treated With Telaprevir, Pegylated Interferon, and Ribavirin. J Infect Dis 2014; 211:1795-9. [PMID: 25512630 DOI: 10.1093/infdis/jiu807] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/08/2014] [Indexed: 01/19/2023] Open
Abstract
UNLABELLED We assessed peripheral and liver CXCL10 levels in 15 patients treated with telaprevir/pegylated interferon/ribavirin. Induction of peripheral CXCL10 messenger RNA (mRNA) peaked (mean fold-induction [±SD], 3.1 ± 1.9) between treatment hour 6 and day 2, while induction of intrahepatic CXCL10 mRNA peaked (mean fold-induction [±SD], 1.3 ± 0.54) at hour 10 or day 4. Peripheral CXCL10 levels were higher at treatment hour 10 (P = .032) and day 2 (P = .009) in patients with undetectable virus 2 weeks after treatment initiation. Treatment hour 10 (P = .023) and peak (P = .034) intrahepatic CXCL10 levels were also higher in these patients. CXCL10 did not distinguish treatment responders from nonresponders. In conclusion, CXCL10 identified very rapid virological response in patients treated with a direct-acting antiviral. CLINICAL TRIALS REGISTRATION NCT00892697.
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Affiliation(s)
- Marija Zeremski
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College
| | - Rositsa B Dimova
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine Department of Biostatistics, State University of New York at Buffalo, New York
| | - Samantha Benjamin
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College
| | | | | | - Andrew H Talal
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine
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18
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Moorehead KJ, Burton JR, Everson GT, Zheng JH, Kerr BJ, Bushman LR, Wang M, Ju C, Nydam T, Kiser JJ. Intrahepatic antiviral quantification in a patient undergoing orthotopic cadaveric liver transplantation. J Antimicrob Chemother 2014; 70:315-7. [PMID: 25213274 DOI: 10.1093/jac/dku334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Kaitlyn J Moorehead
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - James R Burton
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gregory T Everson
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jia-Hua Zheng
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Becky Jo Kerr
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Lane R Bushman
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Meng Wang
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Cynthia Ju
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Trevor Nydam
- Division of Transplant Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer J Kiser
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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