Lamivudine and interferon versus lamivudine monotherapy for HBeAg-positive hepatitis B treatment: a meta-analysis of randomized, controlled trials

Mixed treatment comparison meta-analysis evaluating the relative efficacy of nucleos(t)ides for treatment of nucleos(t)ide-naive patients with chronic hepatitis B

BACKGROUND/AIMS

Five nucleoside/nucleotide treatments are now available for chronic hepatitis B (CHB). This meta-analysis aimed to assess the relative efficacy of adefovir, entecavir, lamivudine, telbivudine, tenofovir disoproxil fumarate (TDF), and nucleos(t)ide combinations in the treatment of CHB.

METHODS

A systematic review of MEDLINE and the Cochrane library was conducted to identify all studies evaluating these nucleos(t)ides in adults with CHB. Randomized controlled trials were included in the meta-analysis if they reported the proportion of patients with undetectable hepatitis B virus (HBV) DNA or hepatitis B e antigen (HBeAg) loss/seroconversion at 1 year. Bayesian mixed treatment comparison meta-analyses were conducted in WinBUGS to assess relative efficacy.

RESULTS

A random-effects meta-analysis of trials on treatment-naive patients with HBeAg-positive CHB demonstrated that 94% of patients will achieve HBV DNA < 300 copies/ml after 1 year with TDF, compared with 73% for entecavir, 50% for adefovir, and 38% for lamivudine. There was a 97.7% probability that TDF enabled a greater proportion of patients to achieve HBV DNA < 300 copies/ml at 1 year than all other treatments considered in the analysis. TDF was significantly superior to all nucleos(t)ides for this outcome at the 0.05 level. There were no statistically significant differences between nucleos(t)ides in HBeAg seroconversion at 1 year, based on a fixed-effects meta-analysis in the same population. More trials on HBeAg-negative and drug-resistant patients are required to facilitate meta-analyses for these subgroups.

CONCLUSIONS

In nucleos(t)ide-naive patients with HBeAg-positive CHB, TDF is associated with the highest probability of achieving undetectable HBV DNA at 1 year of all nucleos(t)ides considered.

Pharmacology, clinical efficacy and safety of lamivudine in hepatitis B virus infection

Lamivudine was the first nucleoside analog for the treatment of chronic hepatitis B (CHB). It is well-tolerated and induces a decrease in serum HBV DNA levels associated with normalization of serum alanine aminotransferase levels. However, a sustained response with hepatitis B 'e' antigen to anti-hepatitis B e seroconversion is obtained in a smaller proportion of patients and hepatitis B surface antigen loss is exceptional. The response is maintained during therapy, and needs to be continued indefinitely in the majority of patients since withdrawal of treatment is generally followed by a rapid reappearance of the virus. However, mutations can be induced in long-term treatment.

Systematic review: combination therapies for treatment-naïve chronic hepatitis B

BACKGROUND

There is a renewed interest in use of combination therapies in treatment-naïve chronic hepatitis B (CHB) because of limitations of monotherapies.

AIM

To discuss the current status of combination therapies in treatment-naïve CHB.

METHODS

PubMed search was done using 'combination', 'sequential' and 'chronic hepatitis B' as the search terms.

RESULTS

The two most popular combination therapies include 'combination of nucleos(t)ide analogues' and 'combination of interferons and nucleos(t)ide analogues'. Combination therapies using two nucleos(t)ide analogues do not lead to higher long-term efficacy. However, addition of a nucleos(t)ide analogue with a good resistance profile to a nucleos(t)ide analogue with a lower genetic barrier to resistance decreases the risk of emergent resistance to the latter. Greater sustained virological, biochemical and seroconversion rates are observed with addition of lamivudine to conventional interferon, but pegylated-interferon monotherapy is equally effective as combination with lamivudine. Again, resistance to lamivudine is lower with its combination with interferons.

CONCLUSIONS

The answer to the question whether hepatitis B can be treated better with combination or monotherapy remains largely unknown. Additional trials are warranted of combination therapies of peginterferon and potent nucleos(t)ide analogues or therapies with the combined use of nucleos(t)ide analogues or immunomodulators.