Hepatitis C in children in times of change

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.

Progress and Barriers Towards Elimination of Chronic Hepatitis C in Children

Chronic hepatitis C (CHC) is a global health burden. Mother-to-child transmission (MTCT) accounts for most HCV infections in pediatric patients. Spontaneous viral clearance may occur in early childhood but is uncommon thereafter. Infection is usually asymptomatic during childhood, although without an effective treatment, vertically infected children may develop serious liver complications including cirrhosis and hepatocellular carcinoma in adulthood. Despite the lack of vaccine against hepatitis C and effective post-exposure methods of prevention of MTCT, treatment with direct-acting antiviral agents (DAAs) raised the prospect of eliminating HCV on a population level. Highly effective, well-tolerated, oral, and interferon-free regimens of short duration have revolutionized treatment of CHC. However, access to these therapies might be limited because of its high cost. In this review, we provide the current state of knowledge on the epidemiology, testing, monitoring and treating of HCV in children. We outline the remaining gaps in therapy and barriers to disease eradication.

Cost-effectiveness of Oral Regimens for Adolescents With Chronic Hepatitis C Virus Infection

BACKGROUND

Novel oral regimes have been approved for treating hepatitis C virus (HCV) infection in adolescents due to their superior effectiveness and safety. However, its economic outcome is still unclear in this population. The current analysis investigates the cost-effectiveness of novel oral regimens compared with that of pegylated interferon α with ribavirin (PR) therapies in adolescents in the context of the United States and China.

METHODS

A Markov model was developed to measure the economic and health outcomes of ledipasvir/sofosbuvir (LS) for genotypes 1 and 4, sofosbuvir/ribavirin (SR) for genotype 2, and ledipasvir/sofosbuvir/ribavirin (LSR) for genotype 3 HCV infection compared with the outcomes of PR treatment. Clinical costs and utility inputs were gathered from published sources. Lifetime discounted quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) were measured. The uncertainty was facilitated by 1-way and probabilistic sensitivity analyses.

RESULTS

In the United States, the ICERs of LS strategy were $14,699 and $14,946/QALY for genotypes 1 and 4 HCV infection, respectively; the ICER of SR strategy for genotype 2 was $42,472/QALY; and the ICER of LSR for genotype 3 was $49,409/QALY in comparison with the PR strategy. In Chinese adolescents, LS for genotypes 1 and 4, SR for genotype 2, and LSR for genotype 3 were the dominant alternatives to the PR strategy. The results were robust to sensitivity analyses.

CONCLUSIONS

Novel oral regimes for adolescents with HCV infection are likely to be cost-effective in the context of the United States and China.

Clinical utility of ledipasvir/sofosbuvir in the treatment of adolescents and children with hepatitis C

Chronic infection with hepatitis C virus (HCV) affects an estimated 0.1%–2% of the pediatric population in the United States. While the clinical course in young children is indolent, adolescents who contract HCV have a disease course similar to adults, with a 26-fold increased risk of chronic liver disease-associated mortality, hepatocellular carcinoma, and need for curative liver transplantation. Furthermore, adolescent patients are entering childbearing age and carry a risk of passing HCV to their offspring via vertical transmission. Pegylated-interferon (PEG-IFN) with ribavirin was previously the only treatment option for pediatric patients with chronic hepatitis C (CHC), but the high likelihood of adverse reactions and subcutaneous route of administration limited its use and efficacy. Recently, the direct-acting antivirals (DAAs) ledipasvir (LDV) and sofosbuvir (SOF) were approved for adolescents with CHC. This review discusses the natural history of CHC in pediatric patients, data supporting LDV/SOF in adolescents, and ongoing studies evaluating DAAs in pediatric patients.

The effectiveness and safety of ledipasvir plus sofosbuvir in adolescents with chronic hepatitis C virus genotype 4 infection: a real-world experience

BACKGROUND

The combination of ledipasvir plus sofosbuvir was recently approved for treatment of adolescent (12-17 years) HCV genotype 1, 4, 5 & 6 patients. However, few clinical trials have been performed in genotype 1 patients.

AIM

To investigate the effectiveness and safety of ledipasvir plus sofosbuvir in chronic HCV adolescent patients with genotype 4 in the real world.

METHODS

This prospective multicentre (six centres) open-label study included 144 adolescent chronic HCV patients with genotype 4 (mean age 14 ± 2, 69% males). All patients received a combination tablet containing 400 mg sofosbuvir and 90 mg ledipasvir once daily for 12 weeks. Laboratory and virological markers were evaluated at baseline, week 4, week 8 and week 12 (EOT), and 12 weeks after end of treatment (SVR12).

RESULTS

SVR12 was observed in 142/144 patients (99%). The relapsers occurred in previous naïve patients (n = 2/128, 2%), while the experienced patients showed 100% SVR12. SVR12 was 98% in F0/F1 patients in comparison to 100% in F2 patients (P = 0.552). No serious side effects were observed, nor was treatment discontinuation or death. Headache was the most common side effect in all patients (20%). In experienced patients, pruritus (31%, P = 0.007), diarrhoea (44%, P < 0.001) and skin rash (19%, P = 0.002) were higher than in naïve patients.

CONCLUSIONS

A ledipasvir plus sofosbuvir regimen is well tolerated and effective, and can be used safely in treating adolescent patients with chronic hepatitis C genotype 4.

The Role of Direct-acting Antivirals in the Treatment of Children with Chronic Hepatitis C

In the United States, chronic infection with the hepatitis C virus (HCV) affects an estimated 0.1-2% of the pediatric population, who are consequently at risk for major complications, including cirrhosis, hepatocellular carcinoma, and death. The current standard of treatment for chronic hepatitis C (CHC) in children is pegylated-interferon-alpha (PEG-IFN) in combination with ribavirin. PEG-IFN/ribavirin therapy is approved for children ages 3 and older; however, it is often held from use until adulthood because of its extensive list of potential side effects and high likelihood of causing adverse symptoms. While CHC is usually indolent in children and adolescents, immediately treating and curbing the spread of HCV before adulthood is important, as there can be transmission to other individuals via sexual activity and infected females can later vertically transmit the infection during pregnancy, the latter representing the most common means of transmission for children in the United States. The recent development of direct-acting antivirals has shown promising results in clinical trials for use in children and has dramatically increased the rates of sustained virological response in adults while improving side effect profiles as compared to interferon-based treatments. Given the usually indolent course of CHC in children, significant side effects of the currently-approved PEG-IFN/ribavirin therapy, and likely availability of all-oral interferon-free regimens for children within a few years, deferring treatment in clinically-stable children with CHC in anticipation of upcoming superior treatment modalities may be justified.

New prospects for the treatment and prevention of hepatitis C in children

PURPOSE OF REVIEW

Combined pegylated interferon-α and ribavirin remains the standard therapy for pediatric hepatitis C virus (HCV) infections in 2016, but direct-acting antivirals (DAAs) with greatly improved efficacy and safety are now approved for adults. Here we review the major classes of DAAs and their anticipated use for treatment and potentially prevention of HCV in children.

RECENT FINDINGS

Currently approved DAAs target the viral protease, polymerase, and NS5A, a protein involved in viral replication and assembly. In combination, DAAs have lifted sustained virologic response rates in adults to more than 90% for multiple HCV genotypes, and the rich DAA pipeline promises further improvements. Clinical trials of interferon-free DAA regimens have been initiated for children ages 3-17 years. In 2016, the first efficacy trial of a preventive HCV vaccine is also underway. While awaiting a vaccine, there is hope that increased DAA utilization may prevent pediatric HCV infections by shrinking the pool of infectious persons.

SUMMARY

Interferon-free DAA regimens have revolutionized therapy for HCV-infected adults and, pending results of pediatric trials, will likely do the same for HCV-infected children. If widely deployed, DAA therapies may also help to reduce the number of new vertically and horizontally acquired pediatric infections.