Adefovir dipivoxil alone or in combination with ongoing lamivudine in patients with decompensated liver disease and lamivudine-resistant hepatitis B virus

Evidence-based clinical practice guidelines for liver cirrhosis 2015

The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding are the endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.

Meta-analysis: oral anti-viral agents in adults with decompensated hepatitis B virus cirrhosis

BACKGROUND

The optimal oral anti-viral agent to use in patients with decompensated HBV cirrhosis remains unclear.

AIM

We performed a meta-analysis of the oral nucleos(t)ide analogues in patients with decompensated HBV cirrhosis.

METHODS

One year efficacy and safety outcomes in 22 studies published in English between '95 and 2010 were analysed.

RESULTS

Substantial heterogeneity was noted in the inclusion/exclusion criteria, controls, and sensitivity of the HBV DNA assay used. Pooled 1-year data showed benefit favouring lamivudine (LAM) vs. untreated controls for Child-Turcotte-Pugh (CTP) score improvement by ≥2 (OR: 117 (15 921), P ≤ 0.0001) and transplant-free survival (OR: 3.2 (1.2, 9), P = 0.022). Adefovir (ADV) led to undetectable HBV DNA at 1-year in 41% compared to 83% with LAM and 80% with entecavir (ETV). Overall, 1-year transplant-free survival rates varied from 78% with LAM to 95% and 94% with Tenofovir (TDF) and Telbivudine (TBV), respectively. The 1-year incidence of drug resistant HBV was 0% with ADV, ETV and TDF and 11% with LAM although TBV was associated with a 29% incidence at 2 years. Drug-related adverse events were infrequently reported.

CONCLUSIONS

All the oral anti-viral agents were associated with improved virological, biochemical and clinical parameters at 1-year. However, the efficacy of lamivudine and telbivudine is limited by drug resistance, and adefovir is limited by its potency and slower onset of action. Additional studies of tenofovir and entecavir are needed to determine the optimal agent(s) for treatment naïve patients and in those with drug-resistant decompensated HBV cirrhosis.

Comparative meta-analysis of adefovir dipivoxil monotherapy and combination therapy of adefovir dipivoxil and lamivudine for lamivudine-resistant chronic hepatitis B

OBJECTIVES

The aim of the current study was to compare the effectiveness of adefovir dipivoxil (ADV) monotherapy with that of combination ADV and lamivudine (LAM) therapy in the treatment of LAM-resistant chronic hepatitis B (CHB).

METHODS

Publications on the effectiveness of ADV monotherapy versus the combination of ADV and LAM therapy for the treatment of LAM-resistant CHB were identified by a search (up to year 2010) of the PubMed, HealthStar, ScienceDirect, and VIP databases. Biochemical response data (alanine aminotransferase normalization rate) and virological response data (serum hepatitis B virus DNA undetectable rate) were extracted and combined to obtain an integrated result.

RESULTS

The literature search yielded 11 articles, six of which reported randomized controlled trials; the remaining five reported prospective cohort studies. The summary odds ratio (OR) values of the biochemical response at 3, 6, 12, and >12 months were 1.60 (p=0.06), 1.30 (p=0.18), 1.77 (p=0.008), and 3.35 (p<0.00001), respectively. The summary OR values of the virological response at 3, 6, 12, and >12 months were 1.46 (p=0.21), 1.68 (p=0.04), 1.16 (p=0.54), and 1.87 (p=0.01), respectively.

CONCLUSIONS

The effectiveness of the combination therapy was not obviously predominant over the monotherapy in short duration therapies; however, the combination therapy had a great advantage over monotherapy in both biochemical and virological response when the therapy duration was prolonged to >12 months.

High rate of complete viral suppression with combination therapy in patients with chronic hepatitis B and prior treatment failure

BACKGROUND

Combination therapy for chronic hepatitis B virus (HBV) infection is recommended for patients with antiviral resistance (AVR) or partial response (PR) to earlier antiviral therapy; however, data on outcomes are limited.

GOALS

To determine the rate of complete viral suppression (CVS) with combination therapy and to compare CVS among different indications and treatment regimens.

METHODS

A cohort of 109 consecutive patients with chronic hepatitis B from 3 liver clinics in Northern California was retrospectively studied. All patients started combination therapy between April 2004 and August 2009 for the following indications: AVR (n = 29), PR (n = 60), or others (n = 20). Combination treatments included lamivudine (LAM), adefovir (ADV), telbivudine (LdT), entecavir (ETV), tenofovir (TDF), and emtricitabine (FTC). CVS was defined as undetectable serum HBV DNA <100 IU/mL.

RESULTS

Among the patients, who were nearly all Asian (99%), 73% had ≥ 2 prior treatments and 82% had treatment failure (AVR or PR). Median treatment duration of combination therapy was 21 months (range, 6 to 50 mo). The majority (77%) achieved CVS after 6 months of various combination regimens: 80% for ETV+TDF, 76% for TDF+LAM or FTC or LdT, 75% for ETV+ADV, and 69% for ADV+LAM or LdT (P = 0.86). After 6 months of therapy, CVS was observed in a similar proportion of patients treated for PR and AVR (72% and 74%, respectively).

CONCLUSIONS

Although the majority of 109 treatment-experienced patients had prior treatment failure, high rates of CVS were rapidly achieved and did not significantly differ between indications of AVR and PR or between ETV-based and TDF-based regimens.

Antiviral therapy in patients with hepatitis B virus-related cirrhosis

Antiviral therapy can lead to biochemical remission, histological improvement, and even complete reversibility of liver cirrhosis in patients with hepatitis B virus-related cirrhosis, thereby significantly reducing the incidence of hepatic decompensation, hepatocellular carcinoma and liver disease-related death. Interferon alpha is not contraindicated in compensated cirrhosis and can be used in finite treatment for 6 or 12 months. Long-term treatment with nucleoside/nucleotide analogues is recommended for both compensated and decompensated cirrhosis. Biochemical and virological changes should be carefully monitored during antiviral treatment to promptly find viral breakthrough and prevent hepatitis B recurrence and liver failure. In addition, hepatocellular carcinoma is required to be screened in all cirrhotic patients.

Treatment of chronic hepatitis B with adefovir dipivoxil in combination with lamivudine: an analysis of 32 cases

AIM: To observe the efficacy of adefovir dipivoxil (ADV) in combination with lamivudine (LAM) in the treatment of chronic hepatitis B (CHB).

METHODS: Sixty-two CHB patients were randomly divided into treatment group and control group. The control group was given LAM alone, while the treatment group was treated with ADV in combination with LAM. Serum ALT, AST and HBV DNA load were measured before treatment and at 6 and 12 mo after treatment and then compared between the two groups.

RESULTS: At 6 and 12 mo after treatment, serum ALT and AST levels declined significantly in both groups, significantly lower than pretreatment values (all P < 0.05). The decline in serum ALT and AST levels was more significant in the treatment group than in the control group (all P < 0.05). At 6 mo, ALT normalization rate was higher in the treatment group than in the control group, but showing no statistical difference between the two groups (P > 0.05). At 12 mo, ALT normalization rate was significantly higher in the treatment group than in the control group (P < 0.05). The overall response rate, as revealed by HBV DNA load, was significantly higher in the treatment group than in the control group at 12 mo (P < 0.05).

CONCLUSION: ADV in combination with LAM can increase the response rate and ALT normalization rate in CHB patients.

Treatment of chronic hepatitis B patients harboring YMDD variants

AIM: To evaluate the efficacy and safety of adefovir dipivoxil alone or in combination with lamivudine or entecavir in the treatment of chronic hepatitis B (CHB) patients harboring YMDD variants.

METHODS: One hundred and twenty CHB patients with YMDD variants were randomly divided into four groups: patients receiving adefovir dipivoxil alone for 96 weeks (Group A), those receiving adefovir dipivoxil in combination with lamivudine during the first 12 weeks and adefovir dipivoxil alone for the following 84 weeks (Group B), those receiving adefovir dipivoxil in combination with lamivudine for 96 weeks (Group C), and those receiving entecavir alone for 96 weeks (Group D). Before treatment and at weeks 0, 4, 12, 24, 48, 72 and 96 after treatment, liver function, hepatitis B virus (HBV)-DNA level, HBV serological markers, serum phosphorus and renal function were determined in all patients. HBV YMDD mutation was detected in HBV DNA-positive patients. Sequencing of HBV P gene was performed in patients with a non-virological response or virological breakthrough.

RESULTS: After 96 weeks of treatment, no significant differences were noted in serum alanine aminotransferase (ALT) level and hepatitis B e-antigen (HbeAg) seroconversion rate among the four groups (all P > 0.05). However, significant differences were observed in ALT normalization rate and the percentage of patients with undetectable HBV DNA between the Group A and Group C (χ² = 7.500 and 6.648, respectively; both P < 0.05). The frequencies of drug resistant genotypes in the four groups were16.7% (5/30), 13.3% (4/30), 0 and 13.3% (4/30), respectively. Severe hepatitis occurred in one patient in the Group A.

CONCLUSION: Adefovir dipivoxil in combination with LAM is safe and effective in the treatment of chronic hepatitis B patients with YMDD variants.

Response to adefovir or entecavir in renal allograft recipients with hepatitic flare due to lamivudine-resistant hepatitis B

We studied the effects of adefovir or entecavir in six kidney transplant recipients (mean age 45.7 +/- 7.8 yr) who developed hepatitic flare due to lamivudine-resistant hepatitis B virus (HBV) infection, with 18 months of follow-up. All patients had elevated alanine aminotransferase (ALT) levels and HBV DNA >10(5) copies/mL (median 2.15 x 10(8) copies/mL) at baseline. Serum creatinine and creatinine clearance levels were 137.8 +/- 59.7 mumol/L and 62.6 +/- 18.7 mL/min, respectively. Four patients were treated with adefovir and two with entecavir. Median HBV DNA decreased to 1.99 x 10(5) copies/mL (p = 0.028) after six months, 1.5 x 10(4) copies/mL (p = 0.043) after 12 months, and 7.35 x 10(4) copies/mL (p = 0.068) after 18 months of treatment. There was a corresponding improvement in ALT (34.5 +/- 19.1 U/L after 18 months, p = 0.029 compared with baseline). The rate of HBV DNA suppression was variable, and three patients took over six months for the viral load to decrease to <10(5) copies/mL. After 18 months, HBV DNA was <10(5) copies/mL in four patients and <10(2) copies/mL in one patient. Treatment was well-tolerated and renal function remained stable. We conclude that both adefovir and entecavir are effective in the treatment of lamivudine-resistant HBV in renal allograft recipients, and the reduction of HBV DNA to <10(5) copies/mL could be slow.

Chronic cirrhotic hepatitis B patients with a high incidence of hepatic decompensation after viral breakthrough with lamivudine-resistant mutants and during rescue treatment

OBJECTIVE

To compare the rate of biochemical and hepatic decompensation after viral breakthrough (V-BT) caused by lamivudine (LMV)-resistant HBV mutants and during rescue treatment for patients with liver cirrhosis (LC) and chronic hepatitis B (CHB).

MATERIAL AND METHODS

We reviewed the medical records of 205 CHB patients who developed V-BT with LMV-resistant HBV mutants (134 in the CHB group, 71 in the LC group).

RESULTS

Sixty-five of the 205 patients had an alanine aminotransferase (ALAT) flare-up (32%) and 21 (10%) had hepatic decompensation. The ALAT flare-up among the CHB and LC groups occurred in 43 (32%) and 22 patients (31%), respectively, and there was no significant difference between the two groups. Hepatic decompensation occurred in 5 (4%) and 16 (23%) patients with CHB and LC, respectively, and these differences were significant (p=0.001). A total of 187 patients were treated by rescue therapy (CHB 121, LC 66) and 13 cases with hepatic decompensation occurred only in LC patients during rescue therapy. Among them, 11 patients had serum ALAT levels two times higher than the upper normal limit (UNL) and the HBV-DNA was more than 10(7) copies/ml at the baseline of rescue therapy. In contrast, the cumulative ALAT normalization and viral response rates were reached significantly earlier in patients with a serum HBV-DNA of < or =10(7) copies/ml compared with those with an HBV-DNA >10(7) copies/ml (p=0.0221 and 0.0002, respectively).

CONCLUSION

Earlier rescue therapy for cirrhotic patients with genotypic resistance due to LMV-resistant mutants may improve patient outcome.

Entecavir therapy in a hepatitis B-related decompensated cirrhotic patient

A 58-year-old Arab-American male with HBeAg-negative chronic hepatitis B (HBV), presented with decompensated cirrhosis and a high HBV DNA level. He responded to entecavir with a significant reduction in serum HBV DNA level after 15 weeks of therapy with entecavir. However, he developed a progressive rise in prothrombin time/international normalized ratio (PT/INR) and bilirubin and underwent liver transplantation after receiving 22 weeks of entecavir therapy. Furthermore, with the continued use of combination entecavir and hepatitis B immunoglobulins (HBIG), he showed improvement in his clinical status with a nondetectable serum HBV DNA level 12 weeks after transplantation. He continued to maintain nondetectable serum HBV DNA 2 years following transplantation. To the best of our knowledge, this is the first reported case of a patient with decompensated chronic HBV who responded to entecavir both before and after transplantation without showing any evidence of recurrent HBV. Larger clinical trials are recommended to compare both short-term and long-term efficacy using entecavir among nucleoside-naïve decompensated chronic HBV patients before and after liver transplantation.

New paradigms for the treatment of chronic hepatitis B

The main goals of chronic hepatitis B treatment should be the long-term suppression of viral replication to minimize disease progression and the risk for the development of hepatocellular carcinoma. Treatment end-points, depending on surrogate markers alone, in particular hepatitis B e-antigen seroconversion, may not be ideal for patients who acquire the disease early in life. Currently-available drugs include interferons and oral nucleoside/nucleotide analogs. Although interferon therapy provides a finite treatment period, a significant proportion of patients may not respond, and long-term outcome is inconclusive. Long-term efficacy has been demonstrated for both lamivudine and adefovir. However, prolonged nucleoside/nucleotide analog therapy is associated with the emergence of drug-resistant mutations. Therefore, nucleoside/nucleotide analogs with a high genetic barrier and potent antiviral activity, such as entecavir, should be used to reduce the chance of developing drug-resistant mutations. Drugs with a low genetic barrier, including lamivudine and telbivudine, should be used in conjunction with early testing for antiviral response. This can predict favorable outcomes in the long term. The early detection of drug-resistant mutations should prompt clinicians to either add or switch to another agent with a different drug-resistance profile. There are currently no treatment models in the use of combination or sequential therapy in treatment-naïve patients. To date, long-term treatment appears to be the most effective option. Despite recent advances made with better understanding on the natural history of chronic hepatitis B infection and with newer antiviral drugs available, challenges remain with respect to treatment criteria, treatment end-points, and duration of treatment.

Lamivudine-resistant chronic hepatitis B: an observational study on adefovir in monotherapy or in combination with lamivudine

BACKGROUND/AIMS

In lamivudine-resistant patients with chronic hepatitis B (CHB), we compared efficacy, predictive response factors and changes in viral mutants in two antiviral approaches with adefovir.

METHODS

A prospective cohort study on therapy with adefovir alone (29 patients) or combined with ongoing lamivudine (23 patients) was performed.

RESULTS

A virological response was achieved in 55% of patients treated with adefovir and in 83% of those treated with the combination (p>0.05). This response was directly related to the basal viral load (p<0.0001) and obtained in 10 patients with basal HBV-DNA<17,200 IU/ml using both strategies. In patients with a higher basal viral load, the virological response was more frequent when treated with the combination (p<0.05). Mutation at locus rt181 predicted HBV-DNA persistence during therapy. A virological rebound was observed in 18% of non-responders while on adefovir monotherapy.

CONCLUSIONS

To achieve a complete virological response and reduce the risk of adefovir-resistant mutants in lamivudine-resistant patients, rescue therapy is preferable at early evidence of genotypic resistance. However, in subjects with a significant viral load, combination therapy is more effective. The presence of the rt181 mutation is associated with incomplete response.

Hepatitis B and end-stage liver disease

Hepatitis B virus (HBV) is the most common cause of chronic hepatitis and end-stage liver disease worldwide. Untreated, chronic hepatitis B acquired early in life results in cirrhosis, liver failure, or hepatocellular carcinoma in up to 40% of individuals. Until recently, the options for a patient who had end-stage hepatitis B cirrhosis were severely limited, but during the past 15 years great strides have been made in prevention and treatment of hepatitis B cirrhosis. This article reviews recent advances in the understanding of the natural history, prevention, and medical management of HBV-related end-stage liver disease.

[Long-term use of lamivudine for treating chronic hepatitis B in the State of Mato Grosso]

To assess the results from lamivudine treatment (100 mg or 150 mg) for chronic hepatitis B, 34 patients were followed at a clinic in Cuiabá, Mato Grosso, Central Brazil. Among them, 21 (62%) had liver cirrhosis and 24 (70%) were HBeAg-positive. The viral genotype was determined for 18 patients, among whom genotype A was the most prevalent (12). The median follow-up was 27 months (range from 7 to 64 months). Among the total, 23 (67%) presented a biochemical response after 2 to 24 months of treatment. Among the 24 HBeAg-positive subjects, 13 (54%) became HBeAg-negative during the follow-up. Among the anti-HBe-positive patients, 70% obtained normalization of aminotransferase levels. Fourteen (41%) did not present any initial biochemical or serological response or presented breakthrough. The L180M and M204V mutations were found in six of the non-responders. Four patients died after at least 21 months of lamivudine and three patients with liver cirrhosis developed liver cancer after 24 months. From the third year onwards, complications such as digestive system hemorrhage or liver cancer started to emerge. The present findings suggest that an early response to lamivudine treatment may be associated with better control over chronic hepatitis B.

Chinese medicine Jiangganlong combined with anti-virus medicine in long-term treatment of active liver cirrhosis and its effect on prognosis of patients

AIM: To study the efficacy of Chinese medicine Jiangganlong combined with anti-virus medicine in the treatment of active liver cirrhosis (ALC).

METHODS: A total of 114 ALC patients were divided into treatment group and control group, named A and B, respectively. The patients in group A were treated with Jiangganlong and lamivudine (LAM). Jiangganlong decoction or pills were given a dose every three days, or 4.0 g (tid). LAM was administered 0.1 g per day. After the emergence of YMDD variations, adefovir (ADV) was added. LAM was stopped when HBV DNA YMDD variation became negative. The patients in group B received general and symptomatic treatment. The mean treatment therapeutic time was 36 months.

RESULTS: The rates of negative conversion for the serum HBV DNA were 75.4% (43/57) and 3.5% (2/57) in group A and B, respectively, and there was significant difference between them (P < 0.01). The cumulative rate of YMDD variations among patients of group A was 40.4% (23/57). After the emergence of YMDD variations, 20 patients received ADV treatment, 90% (18/20) of which were found YMDD variation-negative; there were 3 patients who did not receive ADV treatment, and they died of liver failure. The negative conversion rates of HBeAg were 44.4% (16/36), 16.7% (5/30) in group A, B, respectively, and there was marked difference between them (P < 0.05). The total bilirubin (TBIL) and alanine aminotransferase (ALT) returned to the normal level, and the albumin level, Child-Pugh score, and decompensation status were improved in group A. The rate of complications was dramatically lower in group A than that in group B [14.0% (8/57) vs 50.8% (29/57), P < 0.01]. The mortality rate was also decreased in group A as compared with that in group B [7.0% (4/57) vs 29.8% (17/57), P < 0.01], while the survival time was notably prolonged (3.3 ± 2.1 year vs 1.1 ± 1.0 year, P < 0.01).

CONCLUSION: Chinese medicine Jiangganlong combined with anti-virus medicine can inhibit the replication of HBV DNA, ameliorate liver function, decrease the rate of complications, reduce the mortality rate, and prolong the survival time as well as improve the prognosis of ALC patients.