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Bar N, Bensoussan N, Rabinowich L, Levi S, Houri I, Ben-Ami Shor D, Shibolet O, Mor O, Weitzman E, Turner D, Katchman H. Barriers and Facilitators of Hepatitis C Care in Persons Coinfected with Human Immunodeficiency Virus. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15237. [PMID: 36429957 PMCID: PMC9690547 DOI: 10.3390/ijerph192215237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/09/2022] [Accepted: 11/13/2022] [Indexed: 06/16/2023]
Abstract
Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are often co-transmitted. Viral coinfection results in worse outcomes. Persons who inject drugs (PWIDs) face barriers to medical treatment, but HCV treatment is indicated and effective even with ongoing active drug use. We aimed to assess access to HCV care and treatment results in patients coinfected with HIV-HCV. This is a real-world retrospective single-center study of patients followed in the HIV clinic between 2002 and 2018. Linkage to care was defined as achieving care cascade steps: (1) hepatology clinic visit, (2) receiving prescription of anti-HCV treatment, and (3) documentation of sustained virologic response (SVR). Of 1660 patients with HIV, 254 with HIV-HCV coinfection were included. Only 39% of them achieved SVR. The rate limiting step was the engagement into hepatology care. Being a PWID was associated with ~50% reduced odds of achieving study outcomes, active drug use was associated with ~90% reduced odds. Older age was found to facilitate treatment success. Once treated, the rate of SVR was high in all populations. HCV is undertreated in coinfected young PWIDs. Further efforts should be directed to improve access to care in this marginalized population.
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Affiliation(s)
- Nir Bar
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
| | - Noa Bensoussan
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
| | - Liane Rabinowich
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
| | - Sharon Levi
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
| | - Inbal Houri
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
| | - Dana Ben-Ami Shor
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
| | - Oren Shibolet
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
| | - Orna Mor
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Ramat Gan 5262000, Israel
- Department of Epidemiology, School of public health, Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
| | - Ella Weitzman
- Center for Liver Disease, Rambam Healthcare Campus, Rappaport Faculty of Medicine, Technion, Haifa 3109601, Israel
| | - Dan Turner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
- Crusaid Kobler AIDS Center, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Helena Katchman
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6195001, Israel
- Department of Gastroenterology and Hepatology, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
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El Ghany SA, El Husseiny NM, Roshdy M, Moustafa H, Atallah MT, Fathy A, El Demellawy HH, Abdelhameed AM, El Demerdash DM. Impact of different anti-HCV regimens on platelet count during treatment in Egyptian patients. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-00054-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Side effects of antiviral therapies for hepatitis C, especially hematologic abnormalities, may decrease both therapeutic adherence and therapeutic success rate. Adherence to therapy is essential to achieve an early viral response (EVR), and this is vital for attaining a sustained viral response (SVR). Discontinuation of anti-viral therapy is the only way to prevent progressive thrombocytopenia; however, discontinuation of therapy may reduce the rate of viral clearance and SVR. Our aim is to study effects of antiviral therapy for HCV on platelet count. One hundred sixty eight adult patients with chronic hepatitis C were enrolled in this study and subcategorized into 3 groups: group (1) contains 56 patients receiving IFN, ribavirin and sofosbuvir (triple therapy); group (2) contains 55 patients receiving ribavirin and sofosbuvir (SOF/RBV); and group (3) contains 57 patients receiving simeprevir and sofosbuvir (SIM/SOF). HCV RNA by PCR were checked basically for all studied patients. Follow-up platelet count was done weekly during the first month then monthly till end of treatment. Follow-up of platelet count decrement was assessed at the 2nd week, 4th week and end of antiviral therapy for all studied groups.
Results
We found that in the 2nd week and 4th week, most of patients (76.2%, 71.4%) showed platelet count decrement during antiviral therapy. The decrement of platelet at the 2nd week, 4th week and at end of treatment was much noticed with the SOF/RBV antiviral therapy studied group. None of the patients developed severe thrombocytopenia; none of the patients needed to stop antiviral therapy due to thrombocytopenia, only 6 patients needed dose modification, most of them were from the triple therapy group.
Conclusion
We concluded that thrombocytopenia in chronic HCV infection has a multifactorial pathophysiology and remains a major problem. The recent change in direct-acting antiviral therapy (DAA) without IFN, as the frontline therapy for HCV, permit to avoid the dilemmas associated with initiating or maintaining IFN-based antiviral therapy. DAAs, with high SVR and few haematological adverse effects, have been shown to improve thrombocytopenia associated with HCV infection as well as advanced hepatic disease.
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Saleh MI, Hindi NN. A population pharmacodynamic model characterizing neutropenia associated with pegylated interferon alpha 2-a therapy in patients with chronic hepatitis C viral infection. Naunyn Schmiedebergs Arch Pharmacol 2018; 391:953-963. [PMID: 29872876 DOI: 10.1007/s00210-018-1517-1] [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: 12/01/2017] [Accepted: 05/22/2018] [Indexed: 12/24/2022]
Abstract
Neutropenia is a hematologic disorder commonly reported in patients with chronic hepatitis C viral (HCV) infection. The objective of the present analysis is to describe the change in neutrophil count resulting from peglated interferon alpha 2-a (PEG-IFN α-2a) therapy in HCV-infected patients. A population pharmacodynamic model will be developed. We also plan to identify patient characteristics that contribute to the development of PEG-IFN α-2a-induced neutropenia in hepatitis C patients. A population pharmacodynamic modeling approach was applied to a cohort of patients (n = 292) with chronic HCV infection. Modeling was performed using NONMEM 6. Data was obtained from two phases III studies sponsored by Hoffmann-La Roche. Covariate screening was applied to evaluate various demographic and clinical characteristics as possible predictors of pharmacodynamic parameter during model development. A total of 4517 neutrophil counts from 292 subjects were analyzed by the proposed population pharmacodynamic model. A constant residual error model was used to the log-transformed neutrophil count. Platelet baseline count and uric acid level were identified as predictors of neutrophil pharmacodynamic model. Increased baseline platelet count is expected to result in higher neutrophil baseline. A higher neutrophil baseline is also expected in patients with increased uric acid level. In conclusion, a mechanistic pharmacodynamic model was developed. The effect of various covariates was included in the model. This allows the prediction of neutrophil count following antiviral therapy in patients with hepatitis C infection. Clinical studies: NV15942 and NV15801.
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Affiliation(s)
- Mohammad I Saleh
- School of Pharmacy, The University of Jordan, Amman, 11942, Jordan.
| | - Nagham N Hindi
- School of Pharmacy, The University of Jordan, Amman, 11942, Jordan
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Ribavirin. MEYLER'S SIDE EFFECTS OF DRUGS 2016. [PMCID: PMC7151912 DOI: 10.1016/b978-0-444-53717-1.01403-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pontali E, Angeli E, Cattelan AM, Maida I, Nasta P, Verucchi G, Caputo A, Iannacone C, Puoti M. Cytopenias during treatment of HIV-HCV-coinfection with pegylated interferon and ribavirin: safety analysis of the OPERA study. Antivir Ther 2014; 20:39-48. [PMID: 24831457 DOI: 10.3851/imp2781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Until recently, recommendations for HCV treatment in HIV-coinfected patients have been combination therapy with pegylated interferon (PEG-IFN) and ribavirin (RBV). However, this treatment is often accompanied with cytopenias which lead to drug-dose reduction/discontinuation, therefore influencing sustained virological response (SVR). This study aimed at evaluating incidence and predictors of cytopenias and to define their impact on SVR in Italian HIV-HCV-coinfected patients undergoing PEG-IFN/RBV treatment. METHODS OPERA was a multicentric, observational study conducted in 98 Italian centres. Patients with HIV-HCV coinfection were administered with PEG-IFN/RBV combination treatment for 48 weeks. Incidence and time of onset of cytopenias and multiple bone marrow toxicity (mBMT) was monitored. Logistic regression analysis assessed factors associated with SVR, anaemia, neutropenia, thrombocytopenia and mBMT. RESULTS Between 2005 and 2011, 1,523 patients were enrolled. Anaemia (haemoglobin <10 g/dl) occurred in 197 (12.9%) patients and a haemoglobin drop ≥3 g/dl was recorded in 796 (52.3%). Anaemia did not impact on SVR, its rate being 42.1% and 38.1%, respectively, in patients with and without anaemia (P=0.31). Therapy discontinuation due to anaemia occurred in 47 patients (3.1%). Neutropenia (<1,000 neutrophils/mm(3)) occurred in 652 (42.8%) patients, and SVR was higher (P<0.001) for patients with neutropenia (44.8%) compared to without neutropenia (34%). Patients developing neutropenia did not have an increased risk of developing infections. Thrombocytopenia (<100,000 platelets/mm(3)) occurred in 595 (39.1%) patients, SVR was not influenced by it (38.2% versus 38.9% in patients with and without thrombocytopenia, respectively; P=0.79), and 16 patients (1.1%) discontinued therapy due to it. Cirrhosis was found in 148/734 evaluated patients (20.2%) and was significantly associated with thrombocytopenia (P<0.0001). mBMT was found in 417 patients (27.4%). CONCLUSIONS Cytopenias are frequent side effects of PEG-IFN/RBV combination therapy in HIV-HCV-coinfected patients. However, SVR is not negatively affected by their presence, nor is there an increased risk of infections in patients developing neutropenia. Several predicting factors for the onset of cytopenias have been unravelled, which will help to identify early those patients at high risk of developing cytopenia.
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Affiliation(s)
- Emanuele Pontali
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy.
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6
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Hermos JA, Quach L, Gagnon DR, Weber HC, Altincatal A, Cho K, Lawler EV, Grotzinger KM. Incident severe thrombocytopenia in veterans treated with pegylated interferon plus ribavirin for chronic hepatitis C infection. Pharmacoepidemiol Drug Saf 2014; 23:480-8. [PMID: 24677630 DOI: 10.1002/pds.3585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 12/30/2013] [Accepted: 01/14/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE We sought to determine the incidence and risks for severe thrombocytopenia (platelets < 50,000/μL) in United States Veteran patients treated with pegylated interferon (PEG-IFN) plus ribavirin for hepatitis C virus-positive (HCV) chronic liver disease (CLD). METHODS Using a retrospective, observational cohort study design to analyze databases from the New England Veterans Healthcare System, we identified 979 patients diagnosed with HCV-positive CLD treated solely with PEG-IFN plus ribavirin. The cohort was stratified by pre-treatment platelet counts of 50,000-100,000/μL (N = 90), >100,000-150,000/μL (N = 162), and >150,000μL (N = 727). The cumulative incidence of severe thrombocytopenia and major bleeding events were determined for each baseline platelet group for 48 weeks following treatment initiation. Multivariable Cox regression was used to identify risk factors for incident severe thrombocytopenia. RESULTS Overall, severe thrombocytopenia occurred in 6.1% (N = 60), but in 41.1% of patients with pre-treatment platelet counts 50, 000-100,000/μL compared with 11.7% (p < 0.001) and 0.55% (p < 0.001) in the two higher pre-treatment platelet groups. Most episodes occurred within the first 12 weeks of treatment. Median nadir count for these 60 patients was 35,000/μL (inter-quartile range 28,000, 44,000). Baseline platelet counts of 50,000-100,000/μL [adjusted hazard ratio (HR) = 3.81; 95%CI = 2.07-7.00] and hemoglobin <10 g/dL (adjusted HR = 3.39; 95%CI = 1.45-7.960) associated with severe thrombocytopenia. Major bleeding events during the 48-week observation period were rare (N = 5, 0.51%). CONCLUSIONS The incidence of severe thrombocytopenia in a large, observational cohort of veteran patients with HCV CLD treated with PEG-IFN plus ribavirin was 6.1%. Low pre-treatment platelet counts and hemoglobin levels associated with early, incident severe thrombocytopenia.
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Affiliation(s)
- John A Hermos
- VA Cooperative Studies Program, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA, USA; Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Noncompliance with guidelines for the treatment of hepatitis C is frequent in daily practice. Eur J Gastroenterol Hepatol 2014; 26:65-73. [PMID: 23751351 DOI: 10.1097/meg.0b013e328362dd03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE In trials of pegylated interferons (PEG-IFNs), the lack of an early virological response (EVR) was associated with sustained virological response (SVR) rates of only 0-3%. The rates were similarly low when hepatitis C virus (HCV)-RNA was positive at week 24. Treatment guidelines therefore recommend 'stop rules' on the basis of HCV-RNA levels at weeks 12 and 24 of treatment. We analyzed the use of these rules under 'real-life' conditions. PATIENTS AND METHODS This was a prospective, community-based cohort study involving 467 physicians from institutions throughout Germany, including 4727 treatment-naive genotype-1 patients who received a full course of treatment with PEG-IFN α-2a plus ribavirin between 2003 and 2009. RESULTS The overall SVR rate was 43.1%. Failure to determine EVR decreased from 20% in 2003-2004 to 10% in 2006-2007. Unexpectedly, treatment was continued in 86.1% of patients without an EVR and in those who had an EVR but were HCV-RNA positive at week 24 (67.5%), resulting in SVR rates of 15.7 and 40.9%, respectively. Between 77.5 and 95.3% of physicians did not follow prescribed recommendations to reduce PEG-IFN or ribavirin in cases of hematological abnormalities. CONCLUSION Although recommendations to assess EVR and HCV-RNA at week 24 were increasingly observed in daily practice, the corresponding 'stop rules' in nonresponders were neglected. The subsequent SVR was 5-10 times higher than that reported in controlled trials. This may partly be because of the fact that reductions in PEG-IFN or ribavirin dose were not performed despite recommendations. The issue of stop rules will gain even more interest since the first HCV protease inhibitors have been approved. Prolongation of treatment beyond the new stop rules is associated with risks of resistant HCV variants. Thus, the new stop rules are to be observed more strictly when compared with previous therapy with interferons and ribavirin.
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8
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Lashin AH, Shaheen YA, Metwally MA, El-Feky HM, Hegab MF, Abbas SM. Incidence and predictors of hematological side effects in chronic HCV Egyptian patients treated with PEGylated interferon and ribavirin. Indian J Gastroenterol 2013; 32:316-23. [PMID: 23715642 DOI: 10.1007/s12664-013-0336-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 04/13/2013] [Indexed: 02/04/2023]
Abstract
AIM The aim of this paper was to study the incidence and predictors of hematological abnormalities during treatment of chronic hepatitis C virus (HCV) patients with interferon and ribavirin. METHODS One thousand and eighty-one chronic HCV patients who were treated with PEGylated interferon α-2a 180 μg (n = 536) or α-2b 1.5 μg/kg (n = 545) plus ribavirin for 48 weeks were included. Baseline demographic, laboratory, and histopathological data and, during treatment, hematological data were collected and analyzed using univariate and multivariate analyses to identify independent predictors of hematological side effects. RESULTS During therapy, 168 of 1,018 (15.5 %) had moderate anemia (Hb <10 and ≥8.5 g/dL) and 88 (8.1 %) had severe anemia (Hb <8.5 g/dL). Two hundred and six patients (19.1 %) had moderate neutropenia (absolute neutrophil count (ANC) <750 and ≥500/mm(3)); only 55 (5.1 %) had severe neutropenia (ANC <500/mm(3)). Forty-three patients (4 %) had moderate (platelet <50,000 and ≥25,000/mm(3)) and 5 (1.4 %) had severe thrombocytopenia (platelet <25,000/mm(3)). Fibrosis stage, week 4 Hb level, and week 2 and 4 reduction level in Hb were independent predictors of moderate and severe anemia (p < 0.001). Fibrosis stage and ANC at weeks 2 and 4 were predictors of neutropenia (p < 0.001, 0.001, and 0.004, respectively). Fibrosis stage and platelet count at weeks 2 and 4 were predictors of thrombocytopenia (p < 0.001, <0.001, and 0.005, respectively). There was no association between interferon type and anemia (p = 0.57), neutropenia (p = 0.6), or thrombocytopenia (p = 0.79). CONCLUSIONS Fibrosis stage and week 2 and 4 hematological parameter reduction levels were independent predictors of hematological side effects, which are not related to interferon type.
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Affiliation(s)
- A H Lashin
- Hepatology, Gastroenterology, and Infectious Diseases Department, Benha University, Benha, PO Box 31518, Qualubia, Egypt
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Erqou S, Mohanty A, McGinnis KA, Vanasse G, Freiberg MS, Sherman KE, Butt AA. Hepatitis C virus treatment and survival in patients with hepatitis C and human immunodeficiency virus co-infection and baseline anaemia. J Viral Hepat 2013; 20:463-9. [PMID: 23730839 DOI: 10.1111/jvh.12107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 03/02/2013] [Indexed: 12/24/2022]
Abstract
The impact of pretreatment anaemia on survival in individuals with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection is not known. Moreover, HCV treatment is offered less frequently to individuals with anaemia, due to haematological side effects of the treatment regimen. This study aimed to determine the effect of HCV treatment on survival among HCV/HIV co-infected individuals with pretreatment anaemia using the Electronically Retrieved Cohort of HCV-Infected Veterans (ERCHIVES). Individuals with HCV/HIV co-infection were included in current analyses. Participants were considered treated if they were prescribed ≥ 4 weeks of HCV treatment. All-cause mortality data were obtained using record linkage. Survival analyses were performed using Cox proportional hazard models. Among 5000 HCV/HIV co-infected individuals, 1671 (33.4%) had pretreatment anaemia. In a follow-up period of up to 7 years (19,500 person-years), individuals with anaemia had significantly higher mortality rate compared with those without anaemia [144.2 (95% CI: 134.5-154.7) vs 47.5 (44.0-51.2) per 1000 person-years, respectively]. Among individuals with anaemia, HCV treatment was associated with significantly lower mortality rate [66.6 (44.3-100.2) vs 149.6 (139.2-160.5) per 1000 person-years, for treated vs untreated, respectively]. Treatment remained associated with substantial survival benefit after taking into account the effect of multiple comorbidities (hazards ratio: 0.34, 95% CI: 0.21-0.62). These data suggest that HCV/HIV co-infected individuals with pretreatment anaemia have significantly higher mortality compared with those without anaemia. HCV treatment is associated with substantial survival benefit in this group. Additional studies are needed to determine strategies to improve HCV treatment rates among this group.
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Affiliation(s)
- S Erqou
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Pugi A, Bonaiuti R, Maggini V, Moschini M, Tuccori M, Leone R, Rossi M, Motola D, Piccinni C, Ferrazin F, Sottosanti L, Mugelli A, Vannacci A, Lapi F. Safety profile of antiviral medications: A pharmacovigilance study using the Italian spontaneous-reporting database. Am J Health Syst Pharm 2013; 70:1039-46. [DOI: 10.2146/ajhp120665] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Alessandra Pugi
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Roberto Bonaiuti
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Valentina Maggini
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Martina Moschini
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Marco Tuccori
- PCTC, and Interdepartmental Center for Research in Clinical Pharmacology and Experimental Therapeutics, University of Pisa, Pisa, Italy
| | - Roberto Leone
- Clinical Pharmacology Unit, University of Verona, Verona, Italy
| | - Marco Rossi
- PCTC, and University Hospital of Siena, Siena, Italy
| | - Domenico Motola
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Piccinni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fernanda Ferrazin
- National Pharmacovigilance Office, Pharmacovigilance Unit, Italian Medicines Agency, Rome
| | - Laura Sottosanti
- National Pharmacovigilance Office, Pharmacovigilance Unit, Italian Medicines Agency, Rome
| | - Alessandro Mugelli
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, and PCTC
| | - Alfredo Vannacci
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, and PCTC
| | - Francesco Lapi
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, PCTC, and the Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Mohanty A, Erqou S, McGinnis KA, Vanasse G, Freiberg MS, Sherman KE, Butt AA. Therapy for hepatitis C virus infection increases survival of patients with pretreatment anemia. Clin Gastroenterol Hepatol 2013; 11:741-7.e3. [PMID: 23376794 DOI: 10.1016/j.cgh.2013.01.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 01/12/2013] [Accepted: 01/18/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Individuals with chronic hepatitis C virus (HCV) infection and pretreatment anemia are less likely to begin and complete a full course of treatment for HCV. However, among those who are treated for HCV infection, the effect of treatment on mortality is not clear. METHODS We performed a retrospective analysis of 200,139 HCV-infected veterans using data from the Electronically Retrieved Cohort of Hepatitis C-Infected veterans (2001-2008). The effects of treatment and treatment duration on survival were compared based on data from 1820 treated and 27,690 untreated anemic HCV-infected veterans. The association between HCV treatment and mortality was estimated using the Cox proportional hazard models, with adjustments for potential confounders. The main outcome was all-cause mortality. RESULTS In multivariable analysis, pretreatment anemia was associated significantly with African American race (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.95-2.11), chronic kidney disease (OR, 3.36; 95% CI, 3.23-3.51), and decompensated liver disease (OR, 3.69; 95% CI, 3.53-3.86). All-cause mortality for treated, anemic, HCV-infected veterans was lower (54.2 per 1000 person-years; 95% CI, 49.2-59.7 per 1000 person years) than for untreated, anemic HCV-infected veterans (146.8 per 1000 person-years; 95% CI, 144.2-149.4 per 1000 person-years). The adjusted hazard ratio for treatment of HCV in anemic veterans was 0.45 (95% CI, 0.39-0.51), which was reduced after exclusion of comorbidities (hazard ratio, 0.28; 95% CI, 0.22-0.37). CONCLUSIONS Based on a retrospective analysis of a veterans database, HCV therapy increases survival rates of individuals with pretreatment anemia. Additional studies are needed to determine strategies to increase rates of HCV therapy for this group.
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Affiliation(s)
- Arpan Mohanty
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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12
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Gara N, Ghany MG. What the infectious disease physician needs to know about pegylated interferon and ribavirin. Clin Infect Dis 2013; 56:1629-36. [PMID: 23429551 DOI: 10.1093/cid/cit074] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The treatment of chronic hepatitis C is rapidly evolving from triple therapy to regimens that do not require interferon or even ribavirin. However, pegylated interferon and ribavirin will remain the backbone of hepatitis C therapy for the time being. This review summarizes the pharmacokinetics of peginterferon and ribavirin with a particular emphasis on their side-effect profile and management. Finally, the continued role of peginterferon and ribavirin in future therapies will be discussed.
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Affiliation(s)
- Naveen Gara
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892-1800, USA
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Hermos JA, Altincatal A, Weber HC, Grotzinger K, Smoot KJ, Cho K, Gagnon DR, Lawler EV. Thrombocytopenia and bleeding in veterans with non-hepatitis C-related chronic liver disease. Dig Dis Sci 2013; 58:562-73. [PMID: 23010745 DOI: 10.1007/s10620-012-2404-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 08/31/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND Thrombocytopenia in chronic liver disease (CLD) typically reflects disease severity and may indicate an increased risk for bleeding. AIMS To describe the longitudinal course of thrombocytopenia and risks for bleeding in veteran patients with non-hepatitis C-related CLD. METHODS We identified 2,349 patients with non-hepatitis C-related CLD from databases of the New England Veterans Healthcare System between 1999 and 2008. The cohort was stratified by baseline platelet counts of <50,000, 50-100,000, > 100,000-150,000, and >150,000/μl. Primary outcomes were the incidence and hazard rates for bleeding episodes requiring hospitalization and incident severe thrombocytopenia (<50,000/μl). RESULTS Over a median follow-up of 3.3 years (IQR 1.2, 6.3), incident major bleeds, predominantly gastrointestinal, occurred in 254 patients (10.8 % of the cohort) and in 19.9 % of those with baseline platelets <50,000/μl. Incident severe thrombocytopenia occurred in 315 patients (13.4 % of cohort) and in 40.7 % of those with baseline platelet counts between 50,000 and 100,000/μl. Baseline platelet counts between 50,000 and 100,000/μl independently predicted bleeding [adjusted HR 2.89 (1.76, 4.73) p < 0.001] as did esophageal varices, hemoglobin ≤ 9.9 g %, and INR 1.4-2.0. Incident severe thrombocytopenia and minimum platelet counts <25,000/μl each associated with bleeding episodes, but the average of minimum platelet counts recorded for those who bled was 76,000/μl. CONCLUSIONS Among veteran patients with non-hepatitis C-related CLD, baseline platelet counts of 50,000 to 100,000/μl increased subsequent risks for both incident severe thrombocytopenia and major bleeding events. Whereas associations between severe thrombocytopenia and bleeding most likely reflect CLD severity, liver-related coagulopathies, and co-morbid bleeding risks, interventions to enhance platelet production may be beneficial for such patients.
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Affiliation(s)
- John A Hermos
- VA Cooperative Studies Program, Massachusetts Veterans Epidemiologic Research and Information Center (MAVERIC), VA Boston Healthcare System (151MAV), 150 S. Huntington Ave, Boston, MA 02130, USA.
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Genetic variants at the ITPA locus protect against ribavirin-induced hemolytic anemia and dose reduction in an HCV G2/G3 cohort. Eur J Gastroenterol Hepatol 2012; 24:890-6. [PMID: 22584257 DOI: 10.1097/meg.0b013e3283546efd] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Two functional genetic variants in the inosine triphosphatase (ITPA) gene have been shown to be strongly associated with protection from ribavirin (RBV)-induced hemolysis. We aimed at evaluating this finding in a chronic hepatitis C genotype 2/3 cohort with a predominance of genotype 3 patients where available data are scarce. A second objective was to determine whether a protective association translated into the need for RBV reduction and hence a possible impact on treatment response. METHODS Overall, 457 patients were recruited from two trials of genotype 2/3 patients treated with pegylated interferon α-2b and weight-based RBV. rs1127354 and rs7270101 were genotyped and a composite ITPAase deficiency variable was graded according to the two single nucleotide polymorphisms. The primary endpoints were hemoglobin (Hb) decline from baseline and Hb decline of more than 3 g/dl at week 4. RESULTS Both single nucleotide polymorphisms and the composite ITPAase deficiency variable were strongly and independently associated with protection from a decline in Hb at week 4 in multivariate linear regression models (Prs1127354=7.0×10, Prs7270101=0.0036, PITPase deficiency variable =6.3×10). Patients with any degree of reduced ITPAase activity were less likely to have their RBV dose reduced (odds ratio 0.39, 95% confidence interval 0.16-0.96, P=0.040), although this did not translate into increased rapid viral response or sustained viral response (Prvr=0.93, Psvr=0.22). CONCLUSION We have confirmed a strong association between functional ITPA variants and RBV-induced hemolysis and showed protection from RBV dose reduction, although this did not translate into increased rapid viral response or sustained viral response.
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Lin KH, Hsu PI, Yu HC, Lin CK, Tsai WL, Chen WC, Chan HH, Lai KH. Factors linked to severe thrombocytopenia during antiviral therapy in patients with chronic hepatitis c and pretreatment low platelet counts. BMC Gastroenterol 2012; 12:7. [PMID: 22257364 PMCID: PMC3275508 DOI: 10.1186/1471-230x-12-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 01/18/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Baseline low platelet count (< 150,000/μL) increases the risk of on-treatment severe thrombocytopenia (platelet count < 50,000/μL) in patients with chronic hepatitis C (CHC) undergoing antiviral therapy, which may interrupt treatment. The purpose of this study was to identify risk factors for severe thrombocytopenia during treatment for CHC in patients with baseline thrombocytopenia. METHODS Medical records were reviewed for 125 patients with CHC treated with antiviral therapy according to the standard of care, with regular follow-up examinations. Early platelet decline was defined as platelet decrease during the first 2 weeks of therapy. RESULTS Severe thrombocytopenia developed in 12.8% of patients with baseline thrombocytopenia, and predicted a higher therapeutic dropout rate. Multivariate analysis revealed baseline platelet count < 100,000/μL and rapid early platelet decline (> 30% decline in the first 2 weeks) were significantly associated with severe thrombocytopenia (P < 0.001 and 0.003, odds ratios, 179.22 and 45.74, respectively). In these patients, baseline PLT ≥ 100,000/μL and lack of rapid early platelet decline predicted absence of severe thrombocytopenia (negative predictive values were 95.1% and 96.6%, respectively). In contrast, baseline platelet count < 100,000/μL combined with rapid early platelet decline predicted severe thrombocytopenia (positive predictive value was 100%). CONCLUSIONS For patients with CHC on antiviral therapy, baseline platelet counts < 100,000/μL and rapid early platelet decline can identify patients at high risk of developing on-treatment severe thrombocytopenia.
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Affiliation(s)
- Kung-Hung Lin
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Division of Internal Medicine, Kaohsiung Veterans General Hospital, Pingtung Branch, Taiwan
| | - Ping-I Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of General Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Chung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Ku Lin
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wei-Lun Tsai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hoi-Hung Chan
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Kwok-Hung Lai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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