Efficacy and safety of sofosbuvir-based, interferon-free therapy : The Management of rheumatologic extrahepatic manifestations associated with chronic hepatitis C virus infection

Direct-Acting Antiviral Drugs Reduce Fibromyalgia Symptoms in Patients with Chronic Hepatitis C

Background Fibromyalgia (FM) is a complex disorder characterized by chronic widespread pain and significant patient burden. Patients with chronic hepatitis C are reportedly predisposed to the development of FM. Direct-acting antiviral drugs (DAA) achieved a remarkable therapeutic efficacy in CHC patients. We therefore investigated the impact of DAA on FM symptoms in CHC patients. Methods We enrolled consecutive CHC patients who received DAA. FM symptoms were evaluated based on the 2016 American College of Rheumatology (ACR) fibromyalgia scale at baseline and 12 and 24 weeks after cessation of DAA therapy. Logistic regression was performed to determine the influence of HCV on FM at baseline. We also recruited individuals who underwent a health checkup examination as the control group, and calculated the standardized prevalence ratio of FM in CHC patients. Comparisons of fibromyalgia in different time points were undertaken using the Wilcoxon signed-rank test. Results A total of 33 CHC patients (15 males and 18 females) and 402 controls were recruited. All CHC patients achieved sustained virological response. Two (6%) patients and two (0.5%) controls fulfilled the diagnostic criteria for FM, and the standardized prevalence ratio was 23.9 in CHC patients. Logistic regression also showed increased odds for FM in CHC patients after adjusting for age and sex (OR: 14.4; 95%CI: 1.6, 128.0). In addition, their fibromyalgianess scale decreased at 12 and 24 weeks after DAA therapy. In conclusion, CHC patients were more likely to develop FM. Implementation of DAA therapy might improve FM symptoms in these patients.

Impact of direct-acting antiviral regimens on hepatic and extrahepatic manifestations of hepatitis C virus infection

Hepatitis C virus (HCV) is a common cause of liver disease and is associated with various extrahepatic manifestations (EHMs). This mini-review outlines the currently available treatments for HCV infection and their prognostic effect on hepatic manifestations and EHMs. Direct-acting antiviral (DAA) regimens are considered pan-genotypic as they achieve a sustained virological response (SVR) > 85% after 12 wk through all the major HCV genotypes, with high percentages of SVR even in advanced fibrosis and cirrhosis. The risk factors for DAA failure include old males, cirrhosis, and the presence of resistance-associated substitutions (RAS) in the region targeted by the received DAAs. The effectiveness of DAA regimens is reduced in HCV genotype 3 with baseline RAS like A30K, Y93H, and P53del. Moreover, the European Association for the Study of the Liver recommended the identification of baseline RAS for HCV genotype 1a. The higher rate of hepatocellular carcinoma (HCC) after DAA therapy may be related to the fact that DAA regimens are offered to patients with advanced liver fibrosis and cirrhosis, where interferon was contraindicated to those patients. The change in the growth of pre-existing subclinical, undetectable HCC upon DAA treatment might be also a cause. Furthermore, after DAA therapy, the T cell-dependent immune response is much weaker upon HCV clearance, and the down-regulation of TNF-α or the elevated neutrophil to lymphocyte ratio might increase the risk of HCC. DAAs can result in reactivation of hepatitis B virus (HBV) in HCV co-infected patients. DAAs are effective in treating HCV-associated mixed cryoglobulinemia, with clinical and immunological responses, and have rapid and high effectiveness in thrombocytopenia. DAAs improve insulin resistance in 90% of patients, increase glomerular filtration rate, and decrease proteinuria, hematuria and articular manifestations. HCV clearance by DAAs allows a significant improvement in atherosclerosis and metabolic and immunological conditions, with a reduction of major cardiovascular events. They also improve physical function, fatigue, cognitive impairment, and quality of life. Early therapeutic approach with DAAs is recommended as it cure many of the EHMs that are still in a reversible stage and can prevent others that can develop due to delayed treatment.

Rapid improvement of psychiatric stigmata after IFN-free treatment in HCV patients with and without cryoglobulinemic vasculitis

OBJECTIVE

Hepatitis C virus (HCV) causes neuropsychiatric disorders and quality of life impairment, especially in patients with cryoglobulinemic vasculitis (CV). Direct acting antivirals (DAAs) are effective in most extrahepatic HCV diseases, but limited information exists regarding the outcome of psychiatric disorders in patients with and without CV, after therapy. We aimed to evaluate psychiatric outcomes, in HCV-patients with and without CV, before and after successful DAA therapy.

METHODS

We prospectively studied DAA-treated HCV-patients, stratified into presence (CV) or absence of CV (NON-CV). Four psychometric scales were administered to assess depression (HAM-D and MADRS), anxiety (HAM-A), and mania (MRS). Short-Form-36 questionnaires evaluated quality of life.

RESULTS

Seventy-six patients were recruited, and 47 CV and 29 NON-CV were treated with antivirals. At baseline, depression and anxiety, from mild to severe, were frequently shown, with the most advanced cases in thee CV group; no patients achieved the scores for mania. A significant improvement emerged for all the psychometric scales in the entire population and in the subgroups, after viral eradication even in the short-term outcome. The Short-Form-36 summary components showed benefits.

CONCLUSIONS

After HCV eradication, the depression and anxiety scores significantly improved and severity grade generally lowered. DAA-positive effects on mental disorders should be considered part of the therapy outcome, being beneficial especially in CV patients who usually have worse baseline mental scores. Key Points • HCV frequently causes psychiatric disorders and an often-invalidating autoimmune/lymphoproliferative disease called cryoglobulinemic vasculitis. • The new direct acting antivirals (DAAs) are very effective and well tolerated by HCV-patients. • This study shows DAA-induced benefits on depression and anxiety in HCV-patients that are especially evident in CV patients who usually have worse baseline mental scores. • DAA-induced benefits are observed in the short-term post-therapy follow-up, in contrast with data previously obtained in HCV patients treated with IFN-based anti-HCV therapy.

A prospective study in hepatitis C virus treatment-naïve patients showing rheumatologic extra-hepatic manifestations of hepatitis C with associated risk factors: efficacy and safety using sofosbuvir-based direct antiviral therapy

Background

To study the most common rheumatologic manifestations of hepatitis C viral (HCV) infection in Egyptian patients and associated risk factors with assessment the effect of current therapies on these manifestations. A prospective study was carried out to HCV patients attending the tropical medicine department referred to rheumatology department, over a year. A total of 204 hepatitis C virus treatment-naïve patients aged 21–71 years old suffering from rheumatologic manifestations were recruited, and history taking, general and musculoskeletal examination, laboratory and serological investigations, imaging, and liver fibrosis findings were assessed: baseline, end of treatment, and 12 weeks later, either sofosbuvir/ribavirin or sofosbuvir/simeprevir regimens and through three consecutive visits: joint activity and functional scores were taken.

Results

Common observed rheumatologic manifestations were fibromyalgia (74.5%), arthralgia (73.5%), Raynaud’s phenomenon (54.9%), peripheral neuropathy (29.4%),chronic fatigue syndrome and purpura (24.5%), arthritis (16.7%), Sicca symptoms and skin ulcers (9.8%), and vasculitic CNS involvement (5.9%), mostly seen in females. VAS and FAS scales have improved across visits (p value < 0.001) with lowered number and percentage of arthralgia (tender joint counts), arthritis (swollen joint counts), improvement of fibromyalgia, purpura, peripheral neuropathy, anemia, and thrombocytopenia (p < 0.001). Common reported risk factors were barber shaving (52 %), dental procedures (44.1%), and surgical interventions (36.3%). Non-reactive cases shown by HCV-PCR response increased at the end of study reaching 62%. The percent of improvement was significantly higher in patients receiving sofosbuvir/simeprevir regimen (100%) versus sofosbuvir/ribavirin (58.2%).

Conclusion

Direct antiviral drugs seem to improve the rheumatic extra-hepatic manifestations of HCV patients and lowering viremia level especially sofosbuvir/simeprevir regimen in hepatitis C treatment-naïve patients.

The efficacy and safety of direct-acting antiviral drugs in the management of hepatitis C virus-related arthritis

Background

Hepatitis C virus (HCV) infection is a worldwide disease. HCV-related arthritis is one of the extrahepatic manifestations of the disease. The treatment of chronic HCV has been revolutionized with the introduction of oral direct-acting antiviral (DAA) drugs. We aim to determine the outcomes of treatment by the combination of sofosbuvir-daclatasvir with or without ribavirin in patients with HCV-related arthritis.

Results

Post-therapy, all group I patients had sustained viral response. Significant improvement of the outcome parameters was found 12 weeks post-treatment in group I compared to baseline and group II. Complete and partial remission of articular symptoms in group I patients was observed in 80% and 5%, respectively, while 85% of patients in group II showed no remission. Few mild side effects were encountered with therapy.

Conclusion

The combination of sofosbuvir-daclatasvir with or without ribavirin is an effective and safe therapy for eradication of HCV infection and amelioration of HCV-related arthritis.

Uncommon immune-mediated extrahepatic manifestations of HCV infection

INTRODUCTION

Chronic hepatitis C virus (HCV) infection has been associated with myriad extrahepatic manifestations, often resulting from aberrant immune responses. Among the most common immune-mediated manifestations of HCV infection, mixed cryoglobulinemia is the best known extra-hepatic complication. Areas covered: Here we review less common extrahepatic manifestations of HCV infection, with ascertained or presumed immune pathogenesis and the role of the new all oral direct-acting antiviral agents. Rheumatologic, dermatologic, ophthalmologic, renal, pulmonary, hematologic, cardiovascular, and neuropsychiatric manifestations of HCV infection have been considered. Expert commentary: Pathogenesis of HCV-induced aberrant immune responses resulting in peculiar clinical manifestations is not restricted to a single mechanism. A sound approach would therefore consider implementation of an etiologic treatment, through use of antiviral medications, to stop upstream in the pathogenic process all the immune mechanisms leading to hepatic and extrahepatic abnormalities. With the recent introduction of interferon-free, direct antiviral agents, capable of warranting cure for nearly all HCV-infected patients subjected to therapy, both common and uncommon extrahepatic manifestations of chronic hepatitis C are expected to no longer constitute a matter of comorbidity in the course of HCV infection.