Peginterferon alpha-2b and ribavirin for the treatment of chronic hepatitis C in Japanese pediatric and young adult patients: a survey of the Japan Society of Pediatric Hepatology

Natural history and clinical features of hepatitis C virus infection during childhood: A nationwide, observational survey in Japan

AIM

Few data on spontaneous clearance rates of cases of mother-to-child transmission of hepatitis C viral (HCV) infection are available in Japan. Furthermore, the treatment courses of interferon-based and direct-acting antiviral agent (DAA) therapies for children are also unclear. Our aim was thus to clarify the long-term natural progression of HCV infection and the treatment outcomes of children in Japan.

METHODS

We conducted a combined multicenter, observational survey involving 65 pediatric institutions in Japan. Pediatric HCV infection cases with patients born between 1973 and 2021 were collected over the 11-year period from 2012 to 2022. A total of 563 patients were enrolled, with 190 excluded for having insufficient laboratory data or treatment information, resulting in 373 eligible cases.

RESULTS

Of 328 cases of mother-to-child infection, 34 (10.4%) had spontaneous clearance, with a median time to spontaneous clearance of 3.1 years (range 0.9-7.2 years). Of the total 373 eligible cases, 190 received antiviral therapy (interferon-based therapy, 158; DAA therapy, 32). Sustained virologic response rates after first-line treatment were 75.3% (119/158) and 100% (32/32) for interferon-based therapy and DAA therapy, respectively, with the DAA group showing a shorter time from therapy initiation to viral negativity (2.7 vs. 1.0 months; p = 0.0031).

CONCLUSIONS

Approximately 10% of Japanese children infected by mother-to-child transmission achieve spontaneous resolution of HCV infection. Our findings indicate that DAA therapy is safe and highly effective in Japanese children, achieving higher sustained virologic response rates and shorter time to clearance of the virus compared with interferon-based therapy.

Clinical practice guidelines for the management of children with mother-to-child transmitted hepatitis C virus infection

BACKGROUND

The first guidelines for care of pregnant women carrying the hepatitis C virus (HCV) and their infants were published in 2005 in Japan. Since then, evidence has gradually accumulated worldwide regarding the natural course and treatment of this condition and, especially in recent years, treatment for chronic hepatitis C in adult patients has made great progress. However, the clinical practice policy for children has not been standardized, and new clinical practice guidelines for children with mother-to-child (MTC) transmitted HCV infection have become necessary.

METHODS

In the development of the current guideline, we requested cooperation from The Japanese Society for Pediatric Infectious Diseases, The Japan Society of Hepatology, and the Japan Society of Obstetrics and Gynecology. The committee members were recommended and approved by each society to participate in developing the guidelines. The guideline was also created in accordance with the Minds Guide for Practice Guideline Development. The statements were prepared by consensus-building using the Delphi method, based on the comprehensively searched academic papers and guidelines. These articles were retrieved through searching the PubMed, Cochrane Library, and the Igaku Chuo Zasshi databases.

RESULTS

Eight clinical questions (CQs) with clinical statements were developed regarding etiology (CQs 1-3), diagnosis (CQs 4 and 5), and treatment (two CQs 6 and 7). In each statement, the consensus rate, evidence level, and recommendation level were determined.

CONCLUSION

The guidelines will be helpful in the management of children with hepatitis C MTC transmission.

High SVR12 With 8-Week Course of Direct-Acting Antivirals in Adolescents and Children With Chronic Hepatitis C: A Comprehensive Analysis

Direct-acting antiviral (DAA) treatment for 8 weeks has a sustained virological response rate in adults with chronic hepatitis C. We have conducted a systematic review and meta-analysis to compare the efficacy and safety of the 8-week vs. 12/24-week DAA treatment in adolescents and children with CHC. The PubMed, Web of Science, and Cochrane databases were searched for the relevant articles from January 1, 2017 to August 28, 2020 and further screened for literature reviews on April 1, 2021. Pool proportions with 95% CIs for SVR12 were summarized with fixed/random effects models using Freeman-Tukey double arcsine transformation. Subgroup analysis was used to explore the source of heterogeneity. Thirty-six relevant publications were identified. For adolescents aged 12-17 years old, the pooled SVR12 and AE rate were 99.4% (95% CI: 98.7-99.9) and 34.7% (95% CI: 31.9-37.6). No one discontinued treatment due to drug intolerance. In addition, the SVR12 adolescents treated for 12 and 8/24 weeks were 99.3% (95% CI: 98.4-99.9) and 100%, respectively. The pooled SVR12 rate, AEs, and SAEs for children younger than 12 years were 98.9% (95% CI: 97.3-99.8), 51.6% (95% CI: 47.0-56.2), and 1.1% (95% CI: 0.4-2.5), respectively. The most common AE was fatigue (28.4%). The SVR12 was 98.8% (95% CI: 97.1-99.8) and 100% for the pediatric patients treated for 12 weeks and 8/24 weeks, respectively. Taken together, DAAs are generally effective against CHC and well-tolerated by the adolescents and children. A treatment duration of 8 weeks is equally effective and safe as 12/24 weeks in this demographic group.

Transient Hypothyroidism and Autoimmune Thyroiditis in Children With Chronic Hepatitis C Treated With Pegylated-interferon-α-2b and Ribavirin

BACKGROUND

Autoimmune thyroid disease and thyroid dysfunction are common in adults receiving interferon (IFN)-based treatment for chronic hepatitis C (CHC). Few data are available in children with CHC. This study is aimed to evaluate the appearance and timing of thyroid dysfunction and antithyroid autoimmunity in children with CHC treated with pegylated IFN-α-2b and ribavirin (RBV).

METHODS

Sixty-one otherwise healthy children with CHC, 3-17 years of age, infected perinatally and treatment naïve, receiving therapy with pegylated IFN-α-2b and RBV and 183 age- and sex-matched controls were included in a multicenter, prospective, case-control study. Thyroid-stimulating hormone, free thyroxine, antithyroglobulin antibodies and antithyroid peroxidase antibodies were assessed before, during and 24 weeks after the end of treatment.

RESULTS

From baseline to the end of treatment, subclinical hypothyroidism and autoimmune thyroiditis were diagnosed in 17 of 61 (27.94%) and in 4 of 61 (6.6%) of the children treated, respectively, and in 5 of 183 (2.7%) and in none of the controls (P < 0.0001, relative risk: 10.2, 95% confidence interval: 3.9-26.5; P = 0.03, relative risk: 26.8, 95% confidence interval: 1.5-489.1, respectively). Twenty-four weeks after the end of treatment, subclinical hypothyroidism persisted in only 4 of 61 (6.6%). Autoimmune thyroiditis persisted in 3 of 4 (75%) of the cases.

CONCLUSIONS

Subclinical hypothyroidism is common in children with CHC receiving treatment with pegylated IFN-α-2b and RBV, but in most cases is transient. Autoimmune thyroiditis, which is less common, generally persists after treatment completion. Thyroid function should be carefully monitored in patients presenting with antithyroid autoantibodies and thyroid dysfunction during and after pegylated IFN-α-based treatment.

Peginterferon Therapy in Children With Chronic Hepatitis C: A Nationwide, Multicenter Study in Japan, 2004-2013

OBJECTIVES

The aim of the present study was to review the medical treatment of Japanese children and adolescents with chronic hepatitis C in the past 10 years.

METHODS

This nationwide, multicenter study evaluated patients who were younger than 18 years of age when diagnosed with chronic hepatitis C virus (HCV) infection and were treated with pegylated interferon (PEG-IFN) monotherapy or PEG-IFN/ribavirin (RBV) combination therapy between 2004 and 2013. The subjects' median age was 10 (3-18) years, with a male to female ratio of 52:50 and a genotype-1 to genotype-2 ratio of 45:57. Among the 102 patients, 18 received PEG-IFN monotherapy and 84 received PEG-IFN/RBV combination therapy. The IL28B genotype polymorphism was analyzed in patients infected with genotype-1.

RESULTS

In patients with HCV genotype-1 infections, sustained virological response (SVR) rates obtained by PEG-IFN monotherapy and by PEG-IFN/RBV combination therapy were 100% (2/2) and 72% (31/43), respectively. In patients with HCV genotype-2 infections, SVRs were 75% (12/16) and 100% (41/41), respectively. In 32 genotype-1 patients available for the IL28B genotype (rs8099917), SVR was achieved in more patients in the IL28B major allele group than in the minor allele group (15/17 vs 7/15, P = 0.021) after PEG-IFN/RBV combination therapy. The frequencies of adverse events were similar between the treatment regimens.

CONCLUSIONS

Overall, both therapies showed encouraging results, and were reasonably safe in children and adolescents with chronic hepatitis C. The IL28B genotype was useful for predicting the treatment response to PEG-IFN/RBV combination therapy in this cohort.

Outcomes in pediatric hepatitis C transplant recipients: analysis of the UNOS database

HCV may lead to the development of ESLD in late childhood and, consequently, contributes to the need for liver transplantation. The aim of this study was to examine post-transplant outcomes in HCV-positive pediatric patients with ESLD from any cause and to determine the impact of the PELD scoring system, introduced in February 2002, on post-transplant patient and graft survival. A retrospective analysis of the UNOS database from 1994 to 2010 was performed to assess graft and patient survival in pediatric HCV-seropositive liver transplant recipients. Graft survival and patient survival comparing subjects in the pre-PELD era and post-PELD era were analyzed using Kaplan-Meier statistics. Factors associated with survival were identified using Cox regression analysis. Of 120 pediatric HCV transplant recipients, 80 were transplanted in the pre-PELD era and 40 were transplanted post-PELD. Median serum total bilirubin, INR, and creatinine were 4.8 mg/dL, 1.6, and 0.7 mg/dL in the pre-PELD era vs. 5.5 mg/dL, 1.7, and 0.6 mg/mL, respectively, in the post-PELD era (p NS). One-yr graft survival in the pre-PELD vs. post-PELD era was 65.0% and 89.7%, respectively (p < 0.01); corresponding three-yr graft survival was 57.3% vs. 76.2% (p = 0.04). One-yr patient survival in the pre-PELD vs. post-PELD era was 79.0% and 97.5%, respectively (p < 0.01); corresponding three-yr survival was 79.0% vs. 89.4% (p = 0.17). Twenty-eight patients (23.3%) were retransplanted: 24 (30%) in the pre-PELD era (median time to retransplant 272 days) and four (10%) in the post-PELD era (median time to retransplant 586 days). Early follow-up demonstrates a trend toward improved pediatric HCV liver transplant graft and patient survival in the post-PELD era. Superior outcomes may be attributed to pretransplant factors, improved surgical technique and better treatment options for HCV infection.

Association of IL28B polymorphisms with virological response to peginterferon and ribavirin therapy in children and adolescents with chronic hepatitis C

AIM

The objective of the current study was to find baseline predictive factors of response to therapy with pegylated interferon and ribavirin (PEG-IFN/RBV therapy) in children and adolescents with chronic hepatitis C.

METHODS

IL28B genotype and mutations in the core of hepatitis C virus (HCV) were analyzed in 30 patients treated with PEG-IFN/RBV for HCV infection. The initial rate of decrease in the viral load was assessed during the first 2 weeks of treatment.

RESULTS

IL28B major allele was seen more frequently in patients with sustained virologic response (SVR) than in non-SVR patients (P < 0.001). There was no difference between these two groups in frequency of Core 70 mutation. Among patients with genotype-1, SVR was achieved in more patients (P = 0.007) in the IL28B major allele group than in those in the minor allele group. The early decrements in the viral load (log/2 weeks) were 3.80 ± 0.86 in the genotype-2 major allele group, 1.82 ± 0.84 in the genotype-1 major allele group, and 0.41 ± 0.33 in the genotype-1 minor allele group.

CONCLUSIONS

Among pediatric patients with HCV infection the effectiveness of PEG-IFN/RBV therapy may be lower in the group with genotype-1 IL28B minor alleles than in other groups with IL28B major allele. Treatment strategy should be carefully implemented in patients with IL28B unfavorable type.

Effects of pegylated interferon-α-2a monotherapy on growth in Japanese children with chronic hepatitis C

AIM

The relationship between pegylated interferon (PEG IFN)-α-2a and growth of children with chronic hepatitis C (CHC) remains unclear. This study was to evaluate the effects of PEG IFN-α-2a on growth.

METHODS

From 2003-2012, we prospectively analyzed the data of children with CHC through mother-to-infant transmission. They were all treatment naive and were treated with PEG IFN-α-2a monotherapy.

RESULTS

Among 31 children (19 boys, 12 girls; median age, 6 years) treated with monotherapy during the study period, 21 children (13 boys, eight girls; median age, 7 years) were statistically analyzed. The median treatment period of the 21 children was 48 weeks (range, 48-72). Z-scores of height and weight before treatment, at the end of treatment and 1 year after treatment were -0.05, -0.24 and -0.12 (height), and +0.11, -0.23 and -0.05 (weight). Both Z-scores were significantly decreased at the end of the treatment. One year after treatment, Z-scores of height and bodyweight were significantly improved compared with that of end of treatment but were still lower than those before treatment, with statistical significance. Z-scores of height growth velocity was significantly increased after the treatment (+0.71), compared with that during treatment (-2.25).

CONCLUSION

PEG IFN-α-2a has an inhibitory effect on children's growth, and Z-scores of height and bodyweight were decreased at the end of treatment. Although Z-scores improved after the treatment, they had not returned to the baseline level 1 year after the treatment.

Association between an IL-28B genetic polymorphism and the efficacy of the response-guided pegylated interferon therapy in children with chronic hepatic C infection

AIM

The relation between interleukin-28B (IL-28B) genotypes and treatment-induced hepatitis C virus (HCV) clearance in children is unknown. This was a retrospective study to evaluate the association between an IL-28B genotype (rs8099917) and pegylated (PEG) interferon (IFN) response.

METHODS

Sixty-three children (median age, 7 years; range, 3-17 years; 22 with HCV genotype 1 and 41 with genotype non-1) with chronic HCV infection who were treated with response-guided PEG IFN on the basis of viral load were evaluated.

RESULTS

The duration of treatment with PEG IFN was 24 weeks in one child (2%), 36 weeks in eight children (13%), 48 weeks in 36 children (57%), 60 weeks in 11 children (17%) and 72 weeks in seven children (11%). Of the total 63 children, 54 (86%) were initially treated with PEG IFN-α-2a monotherapy. The remaining nine (14%) received PEG IFN plus ribavirin as the initial therapy. Of the 54 children initially treated with monotherapy, 35 (65%) continued receiving monotherapy until the end of treatment. In the remaining 19 (35%), monotherapy was changed to PEG IFN plus ribavirin at 12 or 24 weeks of treatment. Of the total 63 children, 54 (86%) achieved a sustained virological response (SVR). In univariate analysis, rs8099917 genotype TT (P = 0.075) showed a weak association with SVR. However, the multivariate analysis revealed no predictive factors which had a significant association with SVR.

CONCLUSION

The IL-28B genotype was not a strong pretreatment predictor for SVR in a mixed genotype cohort of children treated with response-guided PEG IFN therapy.

Efficacy and safety of pegylated interferon alfa-2a or alfa-2b plus ribavirin for the treatment of chronic hepatitis C in children and adolescents: a systematic review and meta-analysis

BACKGROUND

A systematic review and meta-analysis were conducted to examine the efficacy and safety of pegylated interferon (peg-IFN) alfa-2a and peg-IFN alfa-2b plus ribavirin (RBV) in children and adolescents with chronic hepatitis C virus (HCV).

METHODS

Medline, Embase, and Cochrane Central Register of Controlled Trials were searched. Clinical trials examining peg-IFN alfa-2a or peg-IFN alfa-2b plus RBV among persons ages 3-18 years with HCV were included. Data were abstracted for complete early virologic response (EVR), sustained virologic response (SVR), relapse, treatment discontinuations, hematologic and dermatologic adverse events, and growth inhibition.

RESULTS

Eight trials met the inclusion criteria. Results indicate that 70% of subjects (95% confidence interval [CI], 58%-81%) achieved EVR, and 58% (95% CI, 53%-64%) achieved SVR. EVR and SVR were higher for those with HCV genotypes 2/3 than 1/4. Discontinuation due to adverse events and discontinuation due to viral breakthrough were each 4%, discontinuation due to a lack of response was 15%, and relapse was 7%. Anemia, neutropenia, leukopenia, and thrombcytopenia were 11%, 32%, 52%, and 5%, respectively. Alopecia, injection site erythema, and pruritus were 13%, 27%, and 10%, respectively. Small growth inhibitions were observed during treatment.

CONCLUSION

The results of this meta-analysis indicate that peg-IFN/RBV combination treatment is effective and safe in treating children and adolescents with HCV.

Prophylaxis for ribavirin-related anemia using eicosapentaenoic acid in chronic hepatitis C patients

BACKGROUND

Ribavirin-related anemia is a serious side-effect of the pegylated interferon and ribavirin therapy used for hepatitis C, and may be cause for a reduction in ribavirin dose or even cessation of treatment. The aim of this study was to evaluate the prophylactic effects of oral eicosapentaenoic acid (EPA) supplementation on ribavirin-induced hemolytic anemia in pediatric and young adult patients.

METHODS

Twelve chronic hepatitis C patients ranging in age from 3 to 21 years (mean, 13.9 ± 5.1 years) who received pegylated interferon α-2b and ribavirin combination therapy were randomized to either the control group (n = 6) or EPA group (n = 6). Blood samples were collected before, and at 4, 8, and 16 weeks after treatment to measure clinical laboratory parameters.

RESULTS

The reduction in hemoglobin levels of the EPA group was significantly ameliorated at 8 and 16 weeks when compared to the control group (P < 0.05). There was no significant difference in plasma ribavirin concentrations between the two groups during the treatment. However, one patient in the control group had a reduction in ribavirin dose.

CONCLUSION

EPA supplementation prevented ribavirin-induced hemolytic anemia during combination therapy with pegylated interferon α-2b and ribavirin in pediatric and young adult patients.

Current treatment options and response rates in children with chronic hepatitis C

Vertical transmission has become the most common mode of transmission of hepatitis C virus (HCV) in children. The rate of perinatal transmission from an HCV-infected mother to her child ranges from 2% to 5% and the prevalence of HCV in children in developed countries ranges between 0.1% and 0.4%. Spontaneous viral clearance seems to be dependent on the genotype and has been reported between 2.4%-25%. For chronically infected patients, treatment with recombinant polyethylene glycol (PEG)-interferon α-2b and daily ribavirin has now been approved as standard treatment for children 2-17 years of age. In five large prospective studies, a total of 318 children and adolescents aged 3-17 years were treated either with subcutaneous PEG-interferon α-2b at a dose of 1-1.5 μg/kg or 60 μg/m² once a week in combination with oral ribavirin (15 mg/kg per day) or PEG-interferon α-2a with ribavirin. Subjects with genotype 1 and 4 received the medication for 48 wk and individuals with genotype 2 and 3 mainly for 24 wk. Overall sustained viral response (SVR) was achieved in 193/318 (60.7%) of treated patients. Stratified for genotype; 120/234 (51%) with genotype 1, 68/73 (93%) with genotype 2/3, and 6/11 (55%) with genotype 4 showed SVR. Relapse rate was between 7.7% and 17%. Overall, treatment was well tolerated; however, notable side effects were present in approximately 20%. According to recent experiences in the treatment of chronic hepatitis C in children and adolescents, a combination of PEG-interferon α with ribavirin has been found to be well tolerated and highly efficacious, particularly in individuals with genotype 2/3. Thus, this treatment can be recommended as standard of care until more effective treatment options will become available for genotype 1 patients.

Efficacy of pegylated interferon-α2a monotherapy in Japanese children with chronic hepatitis C

AIM

  There is little information available on the efficacy of pegylated interferon (PEG IFN) therapy for children with chronic hepatitis C. The aim of this study was to evaluate the efficacy and tolerability of PEG IFN-α2a monotherapy for children infected by chronic hepatitis C virus (HCV).

METHODS

  From 2004-2006, we conducted a prospective, open-label, multicenter study of 22 patients aged 4-18 years, including eight with genotype 1 and 14 with genotype 2. None had previously received IFN. The patients were treated with s.c. PEG IFN-α2a at a dose of 3 µg/kg once a week for 48 weeks. Rapid virological response (RVR) was defined as: undetectable serum HCV RNA at week 4; early viral response (EVR) as a 2 or more log reduction or undetectable serum HCV RNA at week 12; and sustained viral response (SVR) as undetectable serum HCV RNA at 24 weeks after the cessation of treatment.

RESULTS

  SVR was achieved in 10 (45%) of the 22 patients (three with genotype 1, seven with genotype 2). Retrospectively, the patients with SVR included five with RVR (one with genotype 1, four with genotype 2) and five with EVR (two with genotype 1, three with genotype 2). PEG IFN-α2a monotherapy was well tolerated, except in one patient in whom alanine aminotransferase activity flared (>500 IU/L) during treatment.

CONCLUSION

  The efficacy of PEG IFN-α2a monotherapy in children is similar to that for adults, while tolerability seems to be better in children than in adults.

Chronic hepatitis C virus infection in children and adolescents: Epidemiology, natural history, and assessment of the safety and efficacy of combination therapy

Hepatitis C virus (HCV) is the most common cause of chronic liver disease of infectious etiology in children. Most of the children infected with HCV are asymptomatic, and only a few of them develop signs and symptoms of end-stage liver disease early in life. It is not possible to predict either in which patients HCV infection will have a bad outcome or the critical time in early adulthood when disease progression will accelerate. The experiences with therapy in children with chronic hepatitis C are based on earlier and continuing data from adult trials. The currently recommended treatment for chronic HCV infection in adults is the combination of peginterferon-á and ribavirin. The choice of this regimen is based on the results of randomized clinical trials that demonstrated the superiority of this combination treatment over standard interferon-á and ribavirin. Recently, results of pivotal, multicenter, interventional open-label studies on combined treatment with peginterferon-á and ribavirin in children have been published, and the US Food and Drug Administration and the European Medicines Agency have approved the combination therapy in those older than 3 years. The aim of this review is to evaluate critically the available data regarding the safety and efficacy of combination treatment with peginterferon-á and ribavirin in children.