Experiences on antiviral treatment for chronic viral B and C hepatitis patients in Hungary. 1998–2004

EFFICACY OF TREATMENT WITH PEGYLATED INTERFERON AND RIBAVIRIN IN PATIENTS WITH CHRONIC HCV INFECTION “UNDER REAL LIFE“ CONDITIONS

Objective. To investigate the outcomes of combined therapy of hepatitis C (HCV) patients with peginterferon and ribavirin in ”real life” practice, to compare them with data obtained in randomized clinical trials (RCT) and to evaluate possible predictors of sustained virological response (SVR). Material and methods. The retrospective study of HCV patients routinely examined and treated in the Vilnius University Hospital Santariskiu Klinikos (2003−2009 yrs) was carried out. They had undergone the treatment with combination of peginterferon alfa and ribavirin according to the Lithuanian guide. Overall 203 patients were enrolled. SVR was evaluated in 179 patients. Results. The overall rate of SVR was 43 %: in 51,3 % of naives (genotype 1 − 38,8 %, genotype 2 – 100 %, genotype 3 − 82,6 % cases) and in 28,1 % of experienced patients (genotype 1 – 17 %, and genotype 3 – 64,3 % cases). Significant relations of SVR and HCV genotype was observed: 68,9 % having genotype1 were non-responders, whereas 80 % and 75,7 % ones with genotype 2 and 3 achieved SVR (p 0.005 and p = 0.01, respectively). The inverse relation with the age (p 0.01), degree of fibrosis (p = 0.039) and previous unsuccessful treatment was confirmed by multivariate analysis. Conclusions. Data of SVR obtained „on real life“ conditions are non unambiguous: SVR of naive and experienced patients overall and those with genotype 1 were similar or slightly lower, while for patients with genotype 3 significantly higher than results presented in clinical trials. Genotype 1, previous unsuccessful antiviral treatment, older age, and advanced fibrosis were strongest negative predictors for SVR.

[Clinical correlations of chronic hepatitis C, diabetes mellitus and steatohepatitis]

Subsequent studies have implicated the hepatitis C virus (HCV) core protein in the pathogenesis of hepatic steatosis. Chronic HCV infection may also cause steatosis by impairing fatty acid oxidation. There is relationship between accumulation of fat into the liver and overweight and/or obesity. Another unexpected virus-host interaction is the HCV infection and diabetes. HCV encoded proteins might alter insulin signaling thus explaining impaired insulin sensitivity and the occurrence of glycaemic dysregulation. Some pieces of the puzzle are still not well known; e.g. the factors and the spectrum of disorders associated with insulin resistance, and whether the liver is a trigger or target of metabolic syndrome? In this review article clinical consequence of chronic HCV infection, diabetes mellitus and hepatic steatosis are discussed, as well as their possible effects on antiviral therapy.

[New possibilities on the horizon for the treatment of hepatitis C virus infection: direct-acting antiviral therapy]

Current treatment for chronic hepatitis C virus (HCV) infection results 40-45% sustained virological response (SVR) rates in patients with HCV genotype 1, which is the most prevalent genotype in Europe and in Hungary. This therapy requires long duration, high costs and is associated with side effects. For these reasons, progress needs to develop more effective treatment regimes. In the past 5 years, advances have been made in better knowledge of HCV viral life cycle, and in the researches of HCV-specific directly acting antivirals. Recent data suggest that protease and polymerase inhibitors, in triple combinations with interferon plus ribavirin-based treatment are able to shorten treatment duration and improve SVR rates even in "hard to cure" HCV genotype 1 patients. The aim of this review is to summarize results obtained with novel anti-HCV compounds.

[Hepatitis C virus infection--after 20 years]

The paper is devoted to the two decades of hepatitis C virus related basic researches and clinical experiences, from the discovery of the virus to the newest therapeutic options. Virology, epidemiology, pathology-pathogenesis, the virus-induced immunological and metabolic changes, the diagnosis and advances in antiviral treatment are discussed.

[Successful elimination of hepatitis C virus after hepatic lobectomy in a patient with hepatocellular carcinoma]

Hepatocellular carcinoma develops frequently after chronic hepatitis C and B virus infections. Hepatitis B virus has a direct, while hepatitis C virus an indirect role in hepatocarcinogenesis.

THE AIM OF OUR WORK

To demonstrate a very unique and interesting case where after the elimination of early detected duplex hepatocellular carcinoma with a combined therapy of PEG-interferon and ribavirin, hepatitis C virus could be eliminated.

CASE PRESENTATION

A 53-year-old male patient had chronic hepatitis C infection in his anamnesis. In 1995 histological examination confirmed cirrhosis in his liver. One year later he was non-responder for conventional interferon therapy. In 2002 CT examination confirmed a process with multiple plexus in the liver. With cytologic proof of hepatocellular carcinoma, a resection of the tumor by left-lobectomy of the liver was carried out. Four years after the operation a one-year PEG-interferon-alfa-2a and ribavirin combined therapy was instituted. The patient became virologically negative.

CONCLUSION

In chronic liver diseases carcinoma can develop from multiple center at the same time. PEG-interferon and ribavirin combined therapy can be effective in chronic liver disease, as well as after resection of established hepatocellular carcinoma.

[Clinical aspects of hepatitis C in women of child-bearing age]

It is difficult to define the optimal timing of antiviral treatment in women infected with viral hepatitis C, who have child-bearing potential. Antiviral treatment is strictly contraindicated during pregnancy and the breast-feeding period. Data are conflicting about the question of treatment with modern drugs (peginterferon and ribavirin) before or after pregnancy. The risk of vertical transmission from mother to child is estimated about 5%. The mother's viraemia seems to be the main transmission factor. There is a worse prognosis in nulliparous and postmenopausal women in the natural history of viral hepatitis C. Poor outcome in gestational age, maturity and Apgar score were not associated with hepatitis C virus infection. Combined treatment has frequent gynecological and other side effects. The timing of antiviral therapy in women in child-bearing period is recommended individually.

[Effectiveness of peg-interferon and ribavirin for hepatitis C in a patient with hypertension and diminished kidney function]

The treatment of chronic hepatitis caused by hepatitis C virus (HCV) has got now success only in 40-60 per cent of cases with combined interferon and ribavirin therapy. In patients infected by HCV not only the liver but other organs can have alterations. The treatment should be generally applied in a one-year period, and its administration should be carefully carried out both by the patients and the doctors. It can be accompanied by several complications. Beside these the other diseases of the patient's organs can have some problems.

AIM OF THE STUDY

The demonstration of a patient history with clinical success who had hypertension and renal disease.

CASE REPORT

42-year-old female patient who had hypertension and kidney diseases in her anamnesis. Her complaints started with mild abdominal symptoms in 2000. The biochemical alterations and the positive reaction with HCV-PCR test showed HCV infection. Its genotype was 1b. The patient tolerated the combined peginterferon-alfa-2a and ribavirin treatment well, between August 2006 and August 2007. She became HCV-PCR negative after six-month treatment and also at the end of therapy.

DISCUSSION

The concomitant diseases of the patient made the treatment heavier, but not impossible.

CONCLUSION

The elimination of HCV infection can be possible also in the case of hypertension and decreased renal function.

[Interferon in the treatment of viral hepatitis. The interferon was discovered 50 years ago]

The interferons are heterogenic glycoproteins which are produced on the effect of virus infection, as immune answer, by the living cells. They were discovered half a century ago. They have antineoplastic, antiviral and immunomodulator effect. The names of interferons used in the therapy are nominated with Greek letters. This nomination shows their origins: the interferon-alpha originates from leucocytes, the interferon-beta does from fibroblasts and the interferon-gamma is produced as immune interferon by lymphocytes. In human medicine both natural and recombinant interferons are applied. The connection of polyethyleneglycol to interferons ensures their sustained effect. Nowadays they are applied in the therapy of chronic hepatitis B or C as well as in oncology to inhibit the neoplasm progression.