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Gopalakrishna H, Ghany MG. Perspective on Emerging Therapies to Achieve Functional Cure of Chronic Hepatitis B. Curr Hepatol Rep 2024; 23:241-252. [PMID: 38699562 PMCID: PMC11062629 DOI: 10.1007/s11901-024-00652-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 05/05/2024]
Abstract
Purpose of Review Advancements in our understanding of the hepatitis B viral (HBV) life cycle have paved the way for novel approaches to treat HBV infection. This review summarizes the various strategies being pursued to achieve a functional cure, defined as loss of hepatitis B surface antigen (HBsAg) and absence of viral replication 6 months off-therapy. Recent Findings Direct acting antiviral, host targeting antiviral, and immunological approaches are in various stages of development as treatment for chronic HBV infection. Summary Novel treatments are being developed in pursuit of a cure for HBV. Current evidence suggests a single therapeutic agent alone may be insufficient, necessitating the need for combination therapy targeting HBV and the host immune response. Ongoing research focused on identifying the best therapeutic combination holds promise in achieving functional cure for HBV.
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Affiliation(s)
- Harish Gopalakrishna
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Building 10, Room 9B-16, Bethesda, MD 20892‐1800, USA
| | - Marc G. Ghany
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Building 10, Room 9B-16, Bethesda, MD 20892‐1800, USA
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Di Dato F, Iorio R. Expanding indications for chronic hepatitis B treatment: Is it really desirable to treat everyone? World J Gastroenterol 2024; 30:2294-2297. [DOI: 10.3748/wjg.v30.i17.2294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/08/2024] [Accepted: 04/15/2024] [Indexed: 04/30/2024] Open
Abstract
Chronic viral hepatitis causes an increased risk of progressive liver disease and hepatocellular carcinoma. On the wave of the World Health Organization’s goal to reduce new cases and deaths from hepatitis B and C by 2030, there is an increasing call to expand the indications for treatment of chronic hepatitis B. Currently, the main goal of treatment is to achieve a functional cure due to the inability of current drugs to completely eradicate the virus. There are still many discrepancies between available guidelines in terms of eligibility for treatment as well as an uncertainty about the appropriate treatment duration. This editorial addresses key questions about the topic and whether indications for treatment should be expanded.
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Affiliation(s)
- Fabiola Di Dato
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples 80131, Italy
| | - Raffaele Iorio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples 80131, Italy
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Hirode G, Hansen BE, Chen CH, Su TH, Wong GLH, Seto WK, d'Almeida AF, Papatheodoridi M, Brakenhoff SM, Lens S, Choi HSJ, Chien RN, Feld JJ, Forns X, Sonneveld MJ, Papatheodoridis GV, Vanwolleghem T, Yuen MF, Chan HLY, Kao JH, Hsu YC, Cornberg M, Jeng WJ, Janssen HLA. Limited Sustained Remission After Nucleos(t)ide Analog Withdrawal: Results From a Large, Global, Multiethnic Cohort of Patients With Chronic Hepatitis B (RETRACT-B Study). Am J Gastroenterol 2024:00000434-990000000-01070. [PMID: 38483300 DOI: 10.14309/ajg.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/14/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Complete viral suppression with nucleos(t)ide analogs (NAs) has led to a profound reduction in hepatocellular carcinoma and mortality among patients with chronic hepatitis B. Finite therapy yields higher rates of functional cure; however, initial hepatitis B virus (HBV) DNA and alanine aminotransferase (ALT) elevations are almost certain after treatment interruption. We aimed to analyze off-treatment outcomes beyond 12 months after NA cessation. METHODS Patients with well-suppressed chronic hepatitis B who were hepatitis B e antigen-negative at NA cessation and remained off treatment without hepatitis B surface antigen (HBsAg) loss at 12 months were included (n = 945). HBV DNA and ALT fluctuations were allowed within the first 12 months. We used Kaplan-Meier methods to analyze outcomes beyond 12 months. Sustained remission was defined as HBV DNA <2,000 IU/mL and ALT <2× upper limit of normal (ULN) and an ALT flare as ALT ≥5× ULN. RESULTS Cumulative probability of sustained remission was 29.7%, virological relapse was 65.2% with a mean peak HBV DNA of 5.0 ± 1.5 log 10 IU/mL, an ALT flare was 15.6% with a median peak ALT × ULN of 8.3 (5.7-11.3), HBsAg loss was 9.9% and retreatment was 34.9% at 48 months after NA cessation. A single occurrence of virological relapse or an ALT flare within the first 12 months off-treatment were associated with significantly lower rates of sustained remission beyond 12 months. DISCUSSION Despite allowing for HBV DNA and ALT fluctuations within the first 12 months off-treatment, most patients without HBsAg loss did not maintain a sustained response thereafter. The best candidates for NA withdrawal are patients with low HBsAg levels at NA cessation, and those without profound or recurrent virological and biochemical relapses in the first off-treatment year.
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Affiliation(s)
- Grishma Hirode
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Department of Epidemiology, Biostatistics, Erasmus Medical Center, Rotterdam, Netherlands
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Tung-Hung Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Grace L H Wong
- Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine and State Key Laboratory of Liver Research, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
| | - Arno Furquim d'Almeida
- Viral Hepatitis Research Group, Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | | | - Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sabela Lens
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Linkou, Taiwan
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Xavier Forns
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Thomas Vanwolleghem
- Viral Hepatitis Research Group, Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Man-Fung Yuen
- Department of Medicine and State Key Laboratory of Liver Research, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
| | - Henry L Y Chan
- Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong, China
| | - Jia-Horng Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Chun Hsu
- Center for Liver Diseases, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualized Infection Medicine (CiiM), Hannover, Germany
| | - Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Linkou, Taiwan
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
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Hume SJ, Holmes JA, Thompson AJ. Individualizing the Approach to Stopping Nucleos(t)ide Analogs: Can We Use a Low HBsAg Threshold to Predict a High Chance of Functional Cure and Minimal Risk of Hepatic Decompensation? Am J Gastroenterol 2024:00000434-990000000-01118. [PMID: 38619141 DOI: 10.14309/ajg.0000000000002766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Simon John Hume
- St Vincent's Hospital Melbourne, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital and Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Jacinta Alison Holmes
- St Vincent's Hospital Melbourne, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Alexander James Thompson
- St Vincent's Hospital Melbourne, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
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Peters MG, Yuen MF, Terrault N, Fry J, Lampertico P, Gane E, Hwang C, Stamm LM, Leus M, Maini MK, Mendez P, Lonjon-Domanec I, Berg T, Wang S, Mishra P, Donaldson E, Buchholz S, Miller V, Lenz O. Chronic Hepatitis B Finite Treatment: Similar and Different Concerns With New Drug Classes. Clin Infect Dis 2024; 78:983-990. [PMID: 37633256 PMCID: PMC11006103 DOI: 10.1093/cid/ciad506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 08/28/2023] Open
Abstract
Chronic hepatitis B, a major cause of liver disease and cancer, affects >250 million people worldwide. Currently there is no cure, only suppressive therapies. Efforts to develop finite curative hepatitis B virus (HBV) therapies are underway, consisting of combinations of multiple novel agents with or without nucleos(t)ide reverse-transcriptase inhibitors. The HBV Forum convened a webinar in July 2021, along with subsequent working group discussions to address how and when to stop finite therapy for demonstration of sustained off-treatment efficacy and safety responses. Participants included leading experts in academia, clinical practice, pharmaceutical companies, patient representatives, and regulatory agencies. This Viewpoints article outlines areas of consensus within our multistakeholder group for stopping finite therapies in chronic hepatitis B investigational studies, including trial design, patient selection, outcomes, biomarkers, predefined stopping criteria, predefined retreatment criteria, duration of investigational therapies, and follow-up after stopping therapy. Future research of unmet needs are discussed.
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Affiliation(s)
- Marion G Peters
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine & State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Norah Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John Fry
- Aligos Therapeutics, Clinical Development Consultant, San Francisco, California, USA
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, CRC “A. M. and A. Migliavacca” Center for Liver Disease, University of Milan, Milan, Italy
| | - Ed Gane
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Carey Hwang
- Vir Biotechnology, San Francisco, California, USA
| | - Luisa M Stamm
- Assembly Biosciences, South San Francisco, California, USA
| | - Mitchell Leus
- Forum for Collaborative Research, University of California, Berkeley School of Public Health, Washington, DC, USA
| | - Mala K Maini
- Institute of Immunity and Transplantation, University College London, London, United Kingdom
| | | | | | - Thomas Berg
- Department of Medicine, Leipzig University Medical Center, Leipzig, Germany
| | - Su Wang
- Cooperman Barnabas Medical Center, RWJBarnabas-Rutgers Medical Group, Livingston, New Jersey, USA
| | - Poonam Mishra
- Division of Antivirals, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Eric Donaldson
- Division of Antivirals, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Stephanie Buchholz
- Department 32 Infectiology, Dermatology and Allergology, Federal Institute for Drugs and Medical Devices, Germany
| | - Veronica Miller
- Forum for Collaborative Research, University of California, Berkeley School of Public Health, Washington, DC, USA
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Agarwal K, Buti M, van Bömmel F, Lampertico P, Janczewska E, Bourliere M, Vanwolleghem T, Lenz O, Verbinnen T, Kakuda TN, Mayer C, Jezorwski J, Muenz D, Beumont M, Kalmeijer R, Biermer M, Lonjon-Domanec I. JNJ-73763989 and bersacapavir treatment in nucleos(t)ide analog suppressed patients with chronic hepatitis B: REEF-2. J Hepatol 2024:S0168-8278(24)00231-9. [PMID: 38583491 DOI: 10.1016/j.jhep.2024.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 02/06/2024] [Accepted: 03/21/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND & AIMS Functional cure (FC) for chronic hepatitis B (CHB) requires finite treatment. Two agents under investigation aimed at achieving FC are small interfering RNA JNJ-73763989 (JNJ-3989) and capsid assembly modulator JNJ-56136379 (JNJ-6379; bersacapavir). METHODS REEF-2, a phase 2b, double-blind, placebo-controlled, randomized study (ClinicalTrials.gov Identifier: NCT04129554), enrolled 130 nucleos(t)ide analog (NA)-suppressed hepatitis B e-antigen (HBeAg)-negative CHB patients who received JNJ-3989 (200 mg subcutaneously every 4 weeks)+JNJ-6379 (250 mg oral daily)+NA (oral daily; active arm) or placebos for JNJ-3989 and JNJ-6379 + active NA (control arm) for 48 weeks followed by 48 weeks off-treatment follow-up. RESULTS At Follow-up Week 24, no patients achieved the primary endpoint of FC (off-treatment hepatitis B surface antigen [HBsAg] seroclearance). No patients achieved FC at Follow-up Week 48. There was pronounced on-treatment reduction in mean HBsAg from baseline at Week 48 in the active arm versus no decline in the control arm (1.89 vs 0.06 log10 IU/mL; P = 0.001). At Follow-up Week 48, reductions from baseline were >1 log10 IU/mL in 81.5% versus 12.5% of patients in the active and control arms, respectively, and 38/81 (46.9%) patients in the active arm achieved HBsAg <100 IU/mL versus 6/40 (15.0%) patients in the control arm. Off-treatment HBV DNA relapse and alanine aminotransferase (ALT) increases were less frequent in the active arm with 7/77 (9.1%) and 11/41 (26.8%) patients in the active and control arms, respectively, restarting NA during follow-up. CONCLUSIONS Finite 48-week treatment with JNJ-3989+JNJ-6379+NA resulted in fewer and less severe posttreatment HBV DNA increases and ALT flares, and a higher proportion of patients with off-treatment HBV DNA suppression, with or without HBsAg suppression, but did not result in FC. CLINICALTRIALS GOV IDENTIFIER NCT04129554.
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Affiliation(s)
- Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London, England;.
| | - Maria Buti
- Hospital General Universitari Valle Hebron and CIBER-EHD del Instituto Carlos III, Barcelona, Spain
| | - Florian van Bömmel
- Leipzig University Medical Center, Department of Medicine II, Division of Hepatology, Leipzig, Germany
| | - Pietro Lampertico
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy;; CRC "A.M. and A. Migliavacca" Center for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Ewa Janczewska
- Faculty of Health Sciences, Medical University of Silesia, Katowice, Poland
| | | | - Thomas Vanwolleghem
- Antwerp University Hospital, Edegem, Belgium;; Viral Hepatitis Research Group, Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | | | | | | | | | - John Jezorwski
- Janssen Research & Development, LLC, Titusville, NJ, USA
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Huang CT, Tseng TC. Enhancing off-nucleos(t)ide analogue outcome predictions in chronic hepatitis B with time-varying hepatitis B core-related antigen. Clin Mol Hepatol 2024; 30:154-156. [PMID: 38385197 PMCID: PMC11016483 DOI: 10.3350/cmh.2024.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 02/23/2024] Open
Affiliation(s)
- Chen-Te Huang
- Division of Gastroenterology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tai-Chung Tseng
- Division of Gastroenterology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
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Tsai YN, Wu JL, Hsu YC. Optimizing off-treatment outcome predictions: The potential of time-varying HBcrAg and the need for more research. Clin Mol Hepatol 2024; 30:276-278. [PMID: 38606424 PMCID: PMC11016472 DOI: 10.3350/cmh.2024.0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024] Open
Affiliation(s)
- Ying-Nan Tsai
- Division of Gastroenterology and Hepatology, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Jia-Ling Wu
- Department of Public Health, National Cheng Kung University, College of Medicine, Tainan, Taiwan
| | - Yao-Chun Hsu
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Gastroenterology and Hepatology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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Hin-Man Leung R, Wan-Hin Hui R, Mak LY, Mao X, Sze-Hang Liu K, Ka-Ho Wong D, Fung J, Seto WK, Yuen MF. ALT to qHBsAg ratio predicts long-term HBsAg seroclearance after entecavir cessation in Chinese patients with chronic hepatitis B. J Hepatol 2024:S0168-8278(24)00204-6. [PMID: 38527527 DOI: 10.1016/j.jhep.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 01/30/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Factors predicting HBsAg seroclearance after treatment cessation, irrespective of nucleos(t)ide analogue (NA) resumption, have important clinical implications. We evaluated predictors of long-term HBsAg seroclearance after entecavir cessation. METHODS This study followed up Chinese chronic hepatitis B patients from two previous studies of entecavir cessation. All patients were non-cirrhotic, HBeAg-negative, with undetectable HBV DNA (<20 IU/ml) at end-of-treatment (EOT). They had close monitoring for 48 weeks with regular HBV DNA, qHBsAg and ALT measurements. Entecavir was resumed at HBV DNA >2000 IU/ml, irrespective of ALT levels. After the initial 48 weeks, patients were assessed every six months, regardless of entecavir resumption, to monitor for HBsAg seroclearance. RESULTS 194 patients (63.4% male, mean age 49.9 years, on entecavir for a median of 47.2 months) were recruited. 94 (48.5%) and 158 (81.4%) patients had EOT qHBsAg <100 IU/ml and <1000 IU/ml respectively. 151 (77.8%) patients were eventually resumed on entecavir. After follow-up for a median of 70.7 (51.0-118.2) months, 28 (14.4%) patients had HBsAg seroclearance. qHBsAg levels at weeks 36 and 48 after EOT independently predicted HBsAg seroclearance (both p<0.01), whereas qHBsAg from EOT to week 24 only trended towards statistical significance. The ratio of ALT/qHBsAg at all time points from EOT to week 48 independently predicted HBsAg seroclearance (HR ranging from 1.003-1.028, all p<0.01) with excellent diagnostic performance (Area-under-receiver-operating-characteristics 0.799-0.933, negative-predictive-value >90% at different time points), regardless of whether entecavir was resumed. CONCLUSIONS The ALT/qHBsAg ratio after entecavir cessation predicts HBsAg seroclearance, even in patients who were resumed on treatment. Its use may mitigate the risk of severe hepatitis flares in patients managed by observation without treatment resumption.
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Affiliation(s)
- Ryan Hin-Man Leung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR
| | - Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR
| | - Xianhua Mao
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR
| | - Kevin Sze-Hang Liu
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR
| | - Danny Ka-Ho Wong
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR; Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR.
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10
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Brakenhoff SM, Claassen M, Honkoop P, de Knegt RJ, van der Eijk AA, Boonstra A, de Man RA, Sonneveld MJ. Sustained response and HBsAg loss after nucleo(s)tide analogue discontinuation in chronic hepatitis B patients: the prospective SNAP study. Clin Res Hepatol Gastroenterol 2024; 48:102257. [PMID: 38065523 DOI: 10.1016/j.clinre.2023.102257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/24/2023] [Accepted: 11/30/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND & AIM(S) Current guidelines suggest that nucleos(t)ide analogues (NA) can be discontinued before HBsAg loss in a selected group of chronic hepatitis B (CHB) patients. We aimed to study the safety and off-treatment response after NA cessation. METHODS This is a prospective, multicentre, cohort study in which eligible patients discontinued NA therapy. Adult patients, with a CHB mono-infection, HBeAg-negative, without a (history of) liver cirrhosis, who had achieved long-term viral suppression were eligible. Follow-up visits were planned at week 2-4-8-12-24-36-48-72-96. Re-treatment criteria included severe hepatitis (ALT >10x ULN), signs of imminent liver failure (bilirubin >1.5x ULN or INR >1.5), or at the physician's own discretion. RESULTS In total, 33 patients were enrolled. Patients were predominantly Caucasian (45.5%) and had genotype A/B/C/D/unknown in 3/4/6/10/10 (9.1/12.1/18.2/30.3/30.3%). At week 48, 15 patients (45.5%) achieved a sustained response (HBV DNA <2,000 IU/mL). At week 96, 13 patients (39.4%) achieved a sustained response, 4 (12.1%) achieved HBsAg loss, and 12 (36.4%) were re-treated. Severe hepatitis was the main reason for re-treatment (n=7, 21.2%). One patient with severe hepatitis developed jaundice, without signs of hepatic decompensation. Re-treatment was successful in all patients. CONCLUSION NA therapy can be ceased in a highly selected group of CHB patients if close follow-up can be guaranteed. Treatment cessation may increase the chance of HBsAg loss in selected patients, which is counterbalanced by a significant risk of severe hepatitis.
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Affiliation(s)
- Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Mark Claassen
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Pieter Honkoop
- Department of Gastroenterology and Hepatology, Albert Schweitzer hospital, Dordrecht, The Netherlands
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Annemiek A van der Eijk
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - André Boonstra
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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11
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Tsai YN, Wu JL, Hsu YC. Letter: Estimating the incidence of HBsAg seroclearance after cessation of tenofovir and entecavir - potential influence of censored observation. Aliment Pharmacol Ther 2024; 59:136-137. [PMID: 38085940 DOI: 10.1111/apt.17767] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
LINKED CONTENTThis article is linked to Chen et al papers. To view these articles, visit https://doi.org/10.1111/apt.17602 and https://doi.org/10.1111/apt.17788
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Affiliation(s)
- Ying-Nan Tsai
- Division of Gastroenterology and Hepatology, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Jia-Ling Wu
- Department of Public Health, National Cheng Kung University, College of Medicine, Tainan, Taiwan
| | - Yao-Chun Hsu
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Gastroenterology and Hepatology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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Papatheodoridi M, Papatheodoridis G. Finite therapy of chronic hepatitis B infection: Pros. Clin Liver Dis (Hoboken) 2024; 23:e0148. [PMID: 38707241 PMCID: PMC11068136 DOI: 10.1097/cld.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/09/2024] [Indexed: 05/07/2024] Open
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Lim SG, Tan YC. Additional Measures After Stopping Nucleoside Analogues in HbeAg-Negative Chronic Hepatitis B: Better But Not Enough. Gastroenterology 2024; 166:23-24. [PMID: 37832923 DOI: 10.1053/j.gastro.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Seng Gee Lim
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Yong Chuan Tan
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore
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14
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Hsu YC. Finite therapy of chronic hepatitis B infection: Cons. Clin Liver Dis (Hoboken) 2024; 23:e0146. [PMID: 38707240 PMCID: PMC11068138 DOI: 10.1097/cld.0000000000000146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 05/07/2024] Open
Affiliation(s)
- Yao-Chun Hsu
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan
- Graduate Institute of Medicine and School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Internal Medicine, Fu-Jen Catholic University Hospital, New Taipei, Taiwan
- Institute of Biomedical Informatics, College of Medicine, National Yang-Ming University, Taipei, Taiwan
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15
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Sonneveld MJ, Chiu SM, Park JY, Brakenhoff SM, Kaewdech A, Seto WK, Tanaka Y, Carey I, Papatheodoridi M, Colombatto P, van Bömmel F, Janssen HL, Berg T, Zoulim F, Ahn SH, Dalekos GN, Erler NS, Brunetto M, Wedemeyer H, Cornberg M, Yuen MF, Agarwal K, Boonstra A, Buti M, Piratvisuth T, Papatheodoridis G, Chen CH, Maasoumy B. HBV DNA and HBsAg Levels at 24 Weeks Off-Treatment Predict Clinical Relapse and HBsAg Loss in HBeAg-Negative Patients Who Discontinued Antiviral Therapy. Gastroenterology 2024; 166:168-177.e8. [PMID: 37769952 DOI: 10.1053/j.gastro.2023.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND & AIMS Patients who discontinue nucleo(s)tide analogue therapy are at risk of viral rebound and severe hepatitis flares, necessitating intensive off-treatment follow-up. METHODS We studied the association between hepatitis B surface antigen (HBsAg) and hepatitis B virus (HBV) DNA levels at off-treatment follow-up week 24 (FU W24), with subsequent clinical relapse, and HBsAg loss in a multicenter cohort of hepatitis B e antigen (HBeAg)-negative patients with chronic hepatitis B who discontinued nucleo(s)tide analogue therapy. RESULTS We studied 475 patients, 82% Asian, and 55% treated with entecavir. Patients with higher HBV DNA levels at FU W24 had a higher risk of clinical relapse (hazard ratio [HR], 1.576; P < .001) and a lower chance of HBsAg loss (HR, 0.454; P < .001). Similarly, patients with higher HBsAg levels at FU W24 had a higher risk of clinical relapse (HR, 1.579; P < .001) and a lower chance of HBsAg loss (HR, 0.263; P < .001). A combination of both HBsAg <100 IU/mL and HBV DNA <100 IU/mL at FU W24 identified patients with excellent outcomes (9.9% clinical relapse and 58% HBsAg loss at 216 weeks of follow-up). Conversely, relapse rates were high and HBsAg loss rates negligible among patients with both HBsAg >100 IU/mL and HBV DNA >100 IU/mL (P < .001). CONCLUSIONS Among HBeAg-negative patients with chronic hepatitis B who discontinued antiviral therapy and who did not experience clinical relapse before FU W24, serum levels of HBV DNA and HBsAg at FU W24 can be used to predict subsequent clinical relapse and HBsAg clearance. A combination of HBsAg <100 IU/mL with HBV DNA <100 IU/mL identifies patients with a low risk of relapse and excellent chances of HBsAg loss and could potentially be used as an early surrogate end point for studies aiming at finite therapy in HBV.
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Affiliation(s)
- Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
| | - Shao-Ming Chiu
- Department of Internal Medicine, Koahsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Apichat Kaewdech
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
| | - Wai-Kay Seto
- Department of Medicine, State Key Laboratory for Liver Research, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Yasuhito Tanaka
- Department of Gastroenterology & Hepatology, Kumamoto University, Kumamoto, Japan
| | - Ivana Carey
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Margarita Papatheodoridi
- Department of Gastroenterology, "Laiko" General Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Florian van Bömmel
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Harry L Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Thomas Berg
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - George N Dalekos
- Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Man-Fung Yuen
- Department of Medicine, State Key Laboratory for Liver Research, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Andre Boonstra
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maria Buti
- Liver Unit, Hospital Universitari Vall d'Hebron and Ciberehd del Intituto Carlos III de Barcelona, Barcelona, Spain
| | | | - George Papatheodoridis
- Department of Gastroenterology, "Laiko" General Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Chien-Hung Chen
- Department of Internal Medicine, Koahsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
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16
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Zhang TP, Terrault NA. Peginterferon as Part of a Functional Cure Strategy for Hepatitis B: Is the Juice Worth the Squeeze? J Clin Exp Hepatol 2024; 14:101300. [PMID: 38107185 PMCID: PMC10724687 DOI: 10.1016/j.jceh.2023.10.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/26/2023] [Indexed: 12/19/2023] Open
Affiliation(s)
- Tiange P Zhang
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
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17
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Ray G. Long-term entecavir therapy of chronic hepatitis B in real-life setting-Importance of quantitative HBsAg level. Indian J Gastroenterol 2023:10.1007/s12664-023-01480-3. [PMID: 38158544 DOI: 10.1007/s12664-023-01480-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/26/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The global burden of chronic hepatitis B remains high and the best possible treatment remains long-term viral suppression expecting cure. METHODS Total 154 patients of chronic hepatitis B (48 HBeAg positive, e + ve) treated with oral entecavir (0.5 mg/1 mg per day) were recruited from June 2007 and followed prospectively until December 2022 for persistent HBV DNA negativity, HBeAg and HBsAg loss/seroconversion and other liver and drug-related events in real-life settings. RESULTS The mean duration of therapy was 6.78 (2-14) years with 1364 person-years of follow-up. All patients were HBV DNA negative by 15 months and remained so until the last follow-up. As many as 16.7% lost HBeAg after eight to 13 years of therapy, but not HBsAg. The mean fall in serum HBsAg level per year was 0.158 log IU/mL, being significantly higher in e + ve patients at baseline and until two years of therapy. The decline was significant until six years in e + ve patients compared to two years in e - ve ones. None had biochemical or virological breakthrough (except eight defaulters), flares or any untoward effects. The incidence of liver-related events, hepatocellular carcinoma and death was 10.4%, 1.9% and 14.3%, respectively, and 5.2% deaths were liver-related whose predictors were presence of cirrhosis (log rank 46.5, p > 0.001) and higher HBsAg level > 4 log IU/mL (log rank 18.15, p < 0.001) at baseline. CONCLUSION Long-term entecavir therapy provides additional benefits of continuous reduction of serum HBsAg levels beyond suppression of HBV DNA.
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Affiliation(s)
- Gautam Ray
- B. R. Singh Hospital, Sealdah, Kolkata, 700 014, India.
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18
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Kasianchuk N, Dobrowolska K, Harkava S, Bretcan A, Zarębska-Michaluk D, Jaroszewicz J, Flisiak R, Rzymski P. Gene-Editing and RNA Interference in Treating Hepatitis B: A Review. Viruses 2023; 15:2395. [PMID: 38140636 PMCID: PMC10747710 DOI: 10.3390/v15122395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
The hepatitis B virus (HBV) continues to cause substantial health and economic burdens, and its target of elimination may not be reached in 2030 without further efforts in diagnostics, non-pharmaceutical prevention measures, vaccination, and treatment. Current therapeutic options in chronic HBV, based on interferons and/or nucleos(t)ide analogs, suppress the virus replication but do not eliminate the pathogen and suffer from several constraints. This paper reviews the progress on biotechnological approaches in functional and definitive HBV treatments, including gene-editing tools, i.e., zinc-finger proteins, transcription activator-like effector nucleases, and CRISPR/Cas9, as well as therapeutics based on RNA interference. The advantages and challenges of these approaches are also discussed. Although the safety and efficacy of gene-editing tools in HBV therapies are yet to be demonstrated, they show promise for the revitalization of a much-needed advance in the field and offer viral eradication. Particular hopes are related to CRISPR/Cas9; however, therapeutics employing this system are yet to enter the clinical testing phases. In contrast, a number of candidates based on RNA interference, intending to confer a functional cure, have already been introduced to human studies. However, larger and longer trials are required to assess their efficacy and safety. Considering that prevention is always superior to treatment, it is essential to pursue global efforts in HBV vaccination.
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Affiliation(s)
- Nadiia Kasianchuk
- Faculty of Biology, Adam Mickiewicz University in Poznań, 61-614 Poznań, Poland
| | | | - Sofiia Harkava
- Junior Academy of Sciences of Ukraine, Regional Branch in Dnipro, 49000 Dnipro, Ukraine;
| | - Andreea Bretcan
- National College “Ienăchiță Văcărescu”, 130016 Târgoviște, Romania;
| | - Dorota Zarębska-Michaluk
- Department of Infectious Diseases and Allergology, Jan Kochanowski University, 25-317 Kielce, Poland;
| | - Jerzy Jaroszewicz
- Department of Infectious Diseases and Hepatology, Medical University of Silesia in Katowice, 41-902 Bytom, Poland;
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, 15-540 Białystok, Poland;
| | - Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, 60-806 Poznań, Poland
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You H, Wang F, Li T, Xu X, Sun Y, Nan Y, Wang G, Hou J, Duan Z, Wei L, Jia J, Zhuang H. Guidelines for the Prevention and Treatment of Chronic Hepatitis B (version 2022). J Clin Transl Hepatol 2023; 11:1425-1442. [PMID: 37719965 PMCID: PMC10500285 DOI: 10.14218/jcth.2023.00320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 09/19/2023] Open
Abstract
To facilitate the achieving of the goal of "eliminating viral hepatitis as a major public health threat by 2030" set by the World Health Organization, the Chinese Society of Hepatology together with the Chinese Society of Infectious Diseases (both are branches of the Chinese Medical Association) organized a panel of experts and updated the guidelines for prevention and treatment of chronic hepatitis B in China (version 2022). With the support of available evidence, this revision of the guidelines focuses on active prevention, large scale testing, and expansion of therapeutic indication of chronic hepatitis B with the aim of reducing the hepatitis B related disease burden.
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Affiliation(s)
- Hong You
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Fusheng Wang
- The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Taisheng Li
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoyuan Xu
- Peking University First Hospital, Beijing, China
| | - Yameng Sun
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yuemin Nan
- Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | | | - Jinlin Hou
- Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zhongping Duan
- Beijing You-An Hospital, Capital Medical University, Beijing, China
| | - Lai Wei
- Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Jidong Jia
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hui Zhuang
- Peking University Health Science Center, Beijing, China
| | - Chinese Society of Hepatology, Chinese Medical Association; Chinese Society of Infectious Diseases, Chinese Medical Association
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
- The Fifth Medical Center of PLA General Hospital, Beijing, China
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Peking University First Hospital, Beijing, China
- Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- Beijing You-An Hospital, Capital Medical University, Beijing, China
- Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- Peking University Health Science Center, Beijing, China
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20
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Huang CW, Yang CT, Su PY, Chen YY, Huang SP, Yen HH. Long-Term Hepatitis B Surface Antigen Profile and Seroclearance Following Antiviral Treatment: A Single-Center, Real-World Cohort Study. Biomedicines 2023; 11:2966. [PMID: 38001966 PMCID: PMC10669103 DOI: 10.3390/biomedicines11112966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/04/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023] Open
Abstract
Hepatitis B surface antigen (HBsAg) seroclearance, an indicator of recovery from hepatitis B virus (HBV) infection, is uncommon in long-term nucleos(t)ide analog (NUC) therapy. We compared the incidence of HBsAg seroclearance in patients with and without NUC discontinuation to identify predictors of HBsAg seroclearance. This retrospective study enrolled adult patients with a chronic HBV infection followed for ≥12 months after NUC discontinuation (finite group) and those treated with NUCs for >3 years (non-finite group). Demographic, clinical, and laboratory data were analyzed. The study cohort included 978 patients, including 509 and 469 patients in the finite and non-finite groups, respectively. Cumulative HBsAg seroclearance incidence was significantly higher in the finite group than in the non-finite group (p = 0.006). The 5- and 10-year cumulative HBsAg seroclearance incidence were 6.6% and 18.9% in the finite group and 3% and 14.6% in the non-finite group, respectively. The likelihood of HBsAg seroclearance was higher in those with end of treatment (EOT) HBsAg levels of <100 IU/mL and in those without clinical relapse (CR). The cumulative 3-year CR incidence was 16.8%. The incidence of liver decompensation and hepatocellular carcinoma were 4.1 and 0.4 per 1000 person-years, respectively. The hepatocellular carcinoma incidence did not significantly differ between the finite and non-finite groups (p = 0.941). In conclusion, higher HBsAg seroclearance incidence in patients receiving finite therapy, and the increased likelihood of HBsAg seroclearance in those with EOT HBsAg levels of <100 IU/mL and in those without CR should be considered during decision-making of treatment options.
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Affiliation(s)
- Chih-Wen Huang
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Chen-Ta Yang
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Pei-Yuan Su
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Yang-Yuan Chen
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Siou-Ping Huang
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Hsu-Heng Yen
- Division of Gastroenterology, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
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Gane EJ, Kim W, Lim TH, Tangkijvanich P, Yoon JH, Sievert W, Sukeepaisarnjaroen W, Thompson AJ, Pavlovic V, Surujbally B, Wat C, Brown BD, Achneck HE, Yuen MF. First-in-human randomized study of RNAi therapeutic RG6346 for chronic hepatitis B virus infection. J Hepatol 2023; 79:1139-1149. [PMID: 37524230 DOI: 10.1016/j.jhep.2023.07.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 06/12/2023] [Accepted: 07/09/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND & AIMS RG6346 is an N-acetyl-D-galactosamine (GalNAc)-conjugated, double-stranded RNA interference agent targeting the HBV genome S-region. We investigated the safety, tolerability, pharmacokinetics, and pharmacodynamics of RG6346 in healthy volunteers and patients with chronic HBV infection (CHB). METHODS This first-in-human, adaptive, randomized, double-blinded, phase I study recruited three groups of participants: Group A, 30 healthy volunteers received single-dose RG6346 at 0.1, 1.5, 3.0, 6.0, or 12.0 mg/kg, or placebo; Group B, nucleos(t)ide analogue-naïve participants with CHB received single-dose RG6346 at 3.0 mg/kg (n = 6) or placebo (n = 3); Group C, participants with nucleos(t)ide-suppressed CHB received four doses (every 28 days) of RG6346 at 1.5, 3.0, or 6.0 mg/kg (n = 4 in each cohort) or placebo (n = 6). RESULTS RG6346 treatment for up to 4 months was safe and well tolerated. The most common adverse event was a mild injection site reaction. Several nucleos(t)ide-naïve participants exhibited self-resolving transaminase elevations with preserved liver function. By the end of RG6346 treatment in Group C (Day 112), the mean reduction from baseline in hepatitis B surface antigen (HBsAg) was 1.39, 1.80, and 1.64 log10 IU/ml in the 1.5, 3.0, and 6.0 mg/kg cohorts, respectively. Of the 12 participants in Group C, 11 (91.7%) achieved a ≥1 log10 IU/ml reduction in HBsAg (3 of 11 [27.3%] had the response sustained at conditional follow-up Day 448). No dose-response relationship was apparent between RG6346 and serum HBsAg levels. The RG6346-induced HBsAg response was independent of hepatitis B e antigen status. Moderate-to-marked sustained reductions of hepatitis B core-related antigen, HBV RNA, HBV DNA (in nucleos[t]ide analogue-naïve participants), and hepatitis B e antigen levels were observed. CONCLUSIONS These favorable safety and pharmacodynamic data support the clinical development of RG6346 as the backbone of a finite antiviral treatment regimen, with the goal of sustained HBsAg loss (functional cure) in patients with CHB. CLINICAL TRIAL NUMBER ClinicalTrials.gov NCT03772249. IMPACT AND IMPLICATIONS Currently available therapies for chronic HBV infection are associated with low rates of functional cure and new, more efficacious treatments are needed. This first-in-human study of RG6346, an RNA interference therapy, showed a favorable safety profile as well as marked and durable reductions in hepatitis B surface antigen levels. These results support the continued development of RG6346 as the backbone of a finite treatment regimen targeting high functional cure rates and are important for HBV researchers and physicians.
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Affiliation(s)
- Edward J Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital and University of Auckland, Auckland, New Zealand
| | - Won Kim
- Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Pisit Tangkijvanich
- Center of Excellence in Hepatitis and Liver Cancer, Chulalongkorn University, Bangkok, Thailand
| | | | | | | | | | | | | | - Cynthia Wat
- Roche Products, Welwyn Garden City, United Kingdom
| | - Bob D Brown
- Dicerna Pharmaceuticals Inc., a Novo Nordisk Company, Lexington, Massachusetts, United States
| | - Hardean E Achneck
- Dicerna Pharmaceuticals Inc., a Novo Nordisk Company, Lexington, Massachusetts, United States
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong; State Key Laboratory of Liver Research, School of Clinical Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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22
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Hsu YC, Tseng CH, Kao JH. Safety considerations for withdrawal of nucleos(t)ide analogues in patients with chronic hepatitis B: First, do no harm. Clin Mol Hepatol 2023; 29:869-890. [PMID: 36916171 PMCID: PMC10577354 DOI: 10.3350/cmh.2022.0420] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 02/19/2023] [Accepted: 03/13/2023] [Indexed: 03/16/2023] Open
Abstract
Nucleos(t)ide analogues (NA) are widely used to treat hepatitis B virus (HBV) infection, but they cannot eradicate the virus and treatment duration can be lifelong if the endpoint is set at seroclearance of the hepatitis B surface antigen (HBsAg). As an alternative strategy, finite NA therapy without the prerequisite of HBsAg seroclearance has been proposed to allow treatment cessation in patients with sustained undetectable HBV viremia for two to three years. However, reactivation of viral replication almost always follows NA withdrawal. Whereas HBV reactivation might facilitate HBsAg seroclearance in some, it could lead to serious acute flare-ups in a certain proportion of patients. Occurrence and consequences of NA withdrawal flares are complicated with various factors involving the virus, host, and treatment. Accurate risk prediction for severe flares following NA cessation is essential to ensure patient safety. The risks of life-threatening flares in patients who discontinued NA according to the stopping rules of current guidelines or local reimbursement policies have recently been quantitatively estimated in large-scale studies, which also provided empirical evidence to help identify vulnerable patients at risk of devastating outcomes. Moreover, risk predictors were further explored and validated to hopefully aid in patient selection and management. In this narrative review with a focus on patient safety, we summarize and discuss current literature on the incidence of severe flares following NA cessation, risk stratification for candidate selection, rules of posttreatment monitoring, and indications for treatment resumption. We also share our thoughts on the limitations of existing knowledge and suggestions for future research.
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Affiliation(s)
- Yao-Chun Hsu
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Internal Medicine, Fu-Jen Catholic University Hospital, New Taipei, Taiwan
- Institute of Biomedical Informatics, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Hao Tseng
- School of Medicine College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Division of Gastroenterology and Hepatology, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Jia-Horng Kao
- Department of Internal Medicine and Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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Hirode G, Hansen BE, Chen CH, Su TH, Wong G, Seto WK, Van Hees S, Papatheodoridi M, Brakenhoff SM, Lens S, Choi HSJ, Chien RN, Feld JJ, Forns X, Sonneveld MJ, Papatheodoridis GV, Vanwolleghem T, Yuen MF, Chan HLY, Kao JH, Hsu YC, Cornberg M, Jeng WJ, Janssen HLA. Incidence of Hepatic Decompensation After Nucleos(t)ide Analog Withdrawal: Results From a Large, International, Multiethnic Cohort of Patients With Chronic Hepatitis B (RETRACT-B Study). Am J Gastroenterol 2023; 118:1601-1608. [PMID: 36719174 DOI: 10.14309/ajg.0000000000002203] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/27/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Despite improvements in the management of chronic hepatitis B (CHB), risk of cirrhosis and hepatocellular carcinoma remains. While hepatitis B surface antigen loss is the optimal end point, safe discontinuation of nucleos(t)ide analog (NA) therapy is controversial because of the possibility of severe or fatal reactivation flares. METHODS This is a multicenter cohort study of virally suppressed, end-of-therapy (EOT) hepatitis B e antigen (HBeAg)-negative CHB patients who stopped NA therapy (n = 1,557). Survival analysis techniques were used to analyze off-therapy rates of hepatic decompensation and differences by patient characteristics. We also examined a subgroup of noncirrhotic patients with consolidation therapy of ≥12 months before cessation (n = 1,289). Hepatic decompensation was considered related to therapy cessation if diagnosed off therapy or within 6 months of starting retreatment. RESULTS Among the total cohort (11.8% diagnosed with cirrhosis, 84.2% start-of-therapy HBeAg-negative), 20 developed hepatic decompensation after NA cessation; 10 events were among the subgroup. The cumulative incidence of hepatic decompensation at 60 months off therapy among the total cohort and subgroup was 1.8% and 1.1%, respectively. The hepatic decompensation rate was higher among patients with cirrhosis (hazard ratio [HR] 5.08, P < 0.001) and start-of-therapy HBeAg-positive patients (HR 5.23, P < 0.001). This association between start-of-therapy HBeAg status and hepatic decompensation remained significant even among the subgroup (HR 10.5, P < 0.001). DISCUSSION Patients with cirrhosis and start-of-therapy HBeAg-positive patients should be carefully assessed before stopping NAs to prevent hepatic decompensation. Frequent monitoring of viral and host kinetics after cessation is crucial to determine patient outcome.
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Affiliation(s)
- Grishma Hirode
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
| | - Bettina E Hansen
- Department of Epidemiology, Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Tung-Hung Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Grace Wong
- Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Wai-Kay Seto
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, SAR, China
| | - Stijn Van Hees
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | | | - Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sabela Lens
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
| | - Xavier Forns
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Man-Fung Yuen
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, SAR, China
| | - Henry L Y Chan
- The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Jia-Horng Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Chun Hsu
- E-DaHospital/I-Shou University, Kaohsiung, Taiwan
| | - Markus Cornberg
- Department of Gastroenterology, Hepatolology and Endocrinology, Hannover Medical School, Germany; Centre for Individualized Infection Medicine (CiiM), Hannover, Germany
| | - Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Hsu YC, Wu CY. Editorial: Mitigating the risk of severe hepatitis flare following nucleoside analogue discontinuation-Insights from a real-world study. Authors' reply. Aliment Pharmacol Ther 2023; 58:550-551. [PMID: 37559518 DOI: 10.1111/apt.17644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
LINKED CONTENTThis article is linked to Hsu et al papers. To view these articles, visit https://doi.org/10.1111/apt.17614 and https://doi.org/10.1111/apt.17630
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Affiliation(s)
- Yao-Chun Hsu
- Center for Liver Diseases, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, I-Shou University, Kaohsiung, Taiwan
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Ying Wu
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
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25
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Loglio A, Viganò M. Stopping nucleos(t)ide analogues treatment in non-cirrhotic HBeAg-negative patients: Yes, we can! Dig Liver Dis 2023; 55:1221-1222. [PMID: 37419725 DOI: 10.1016/j.dld.2023.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/09/2023]
Affiliation(s)
- Alessandro Loglio
- Gastroenterology, Hepatology and Transplantation Division, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Mauro Viganò
- Gastroenterology, Hepatology and Transplantation Division, ASST Papa Giovanni XXIII, Bergamo, Italy.
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26
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Lens S, Forns X. More is not always better for novel hepatitis B therapies. Lancet Gastroenterol Hepatol 2023; 8:772-773. [PMID: 37442151 DOI: 10.1016/s2468-1253(23)00162-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/15/2023]
Affiliation(s)
- Sabela Lens
- Liver Unit, Hospital Clínic, Fundació Clínic per a la Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, Spain.
| | - Xavier Forns
- Liver Unit, Hospital Clínic, Fundació Clínic per a la Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, Spain
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27
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Sonneveld MJ, Chiu SM, Park JY, Brakenhoff SM, Kaewdech A, Seto WK, Tanaka Y, Carey I, Papatheodoridi M, Colombatto P, van Bömmel F, Berg T, Zoulim F, Ahn SH, Dalekos GN, Erler NS, Brunetto M, Wedemeyer H, Cornberg M, Yuen MF, Agarwal K, Boonstra A, Buti M, Piratvisuth T, Papatheodoridis G, Chen CH, Maasoumy B. Lower pretreatment HBV DNA levels are associated with better off-treatment outcomes after nucleo(s)tide analogue withdrawal in patients with HBeAg-negative chronic hepatitis B: A multicentre cohort study. JHEP Rep 2023; 5:100790. [PMID: 37484211 PMCID: PMC10362794 DOI: 10.1016/j.jhepr.2023.100790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/21/2023] [Accepted: 05/03/2023] [Indexed: 07/25/2023] Open
Abstract
Background & Aims Pretreatment predictors of finite nucleo(s)tide analogue (NUC) therapy remain elusive. We studied the association between pretreatment HBV DNA levels and outcomes after therapy cessation. Methods Patients with chronic hepatitis B who were HBeAg negative at the start of NUC treatment were enrolled from sites in Asia and Europe. We studied the association between pretreatment HBV DNA levels and (1) clinical relapse (defined as HBV DNA >2,000 IU/ml + alanine aminotransferase >2 × the upper limit of normal or retreatment) and (2) HBsAg loss after NUC withdrawal. Results We enrolled 757 patients, 88% Asian, 57% treated with entecavir, with a median duration of treatment of 159 (IQR 156-262) weeks. Mean pretreatment HBV DNA levels were 5.70 (SD 1.5) log IU/ml and were low (<20,000 IU/ml) in 150 (20%) and high (>20,000 IU/ml) in 607 (80%). The cumulative risk of clinical relapse at 144 weeks after therapy cessation was 22% among patients with pretreatment HBV DNA levels <20,000 IU/ml vs. 60% among patients with pretreatment HBV DNA levels >20,000 IU/ml, whereas the cumulative probabilities of HBsAg loss were 17.5% vs. 5% (p <0.001). In multivariable analysis, pretreatment HBV DNA levels <20,000 IU/ml were independently associated with a reduced likelihood of clinical relapse (adjusted hazard ratio 0.379, p <0.001) and with an increased chance of HBsAg loss (adjusted hazard ratio 2.872, p <0.001). Conclusions Lower pretreatment HBV DNA levels are associated with a lower risk of clinical relapse and a higher chance of HBsAg loss after cessation of NUC therapy, independent of end-of-treatment viral antigen levels. Further studies are needed to confirm these findings in non-Asian populations. Impact and Implications A subgroup of patients with chronic hepatitis B may not require retreatment after stopping antiviral therapy. In this study, comprising 757 patients with chronic hepatitis B from Europe and Asia, we found that higher viral load before initiation of treatment was a risk factor for relapse after stopping treatment. Patients with a low HBV DNA level before starting antiviral therapy had the lowest risk of relapse, and a high chance of HBsAg loss, after stopping treatment. These findings can help select patients for treatment withdrawal and guide intensity of off-treatment monitoring.
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Affiliation(s)
- Milan J. Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Shao-Ming Chiu
- Department of Internal Medicine, Koahsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Sylvia M. Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Apichat Kaewdech
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
| | - Wai-Kay Seto
- Department of Medicine, State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong
| | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Kumamoto University, Kumamoto, Japan
| | - Ivana Carey
- Institute of Liver Studies, King’s College Hospital, London, UK
| | - Margarita Papatheodoridi
- Department of Gastroenterology, ‘Laiko’ General Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Florian van Bömmel
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | | | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - George N. Dalekos
- Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Nicole S. Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany
| | - Man-Fung Yuen
- Department of Medicine, State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong
| | - Kosh Agarwal
- Institute of Liver Studies, King’s College Hospital, London, UK
| | - Andre Boonstra
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maria Buti
- Liver Unit, Hospital Universitari Vall d’Hebron and Ciberehd del Intituto Carlos III de Barcelona, Spain
| | | | - George Papatheodoridis
- Department of Gastroenterology, ‘Laiko’ General Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Chien-Hung Chen
- Department of Internal Medicine, Koahsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Benjamin Maasoumy
- Department of Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany
| | - for the CREATE study group
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Internal Medicine, Koahsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
- Department of Medicine, State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong
- Department of Gastroenterology and Hepatology, Kumamoto University, Kumamoto, Japan
- Institute of Liver Studies, King’s College Hospital, London, UK
- Department of Gastroenterology, ‘Laiko’ General Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
- Hepatology Unit, University Hospital of Pisa, Pisa, Italy
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
- INSERM Unit 1052, Lyon, France
- Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany
- Liver Unit, Hospital Universitari Vall d’Hebron and Ciberehd del Intituto Carlos III de Barcelona, Spain
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28
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Thompson AJ, Jackson K, Bonanzinga S, Hall SA, Hume S, Burns GS, Sundararajan V, Ratnam D, Levy MT, Lubel J, Nicoll AJ, Strasser SI, Sievert W, Desmond PV, Ngu MC, Sinclair M, Meredith C, Matthews G, Revill PA, Littlejohn M, Bowden DS, Canchola JA, Torres J, Siew P, Lau J, La Brot B, Kuchta A, Visvanathan K. Baseline serum HBV RNA is associated with the risk of hepatitis flare after stopping nucleoside analog therapy in HBeAg-negative participants. Hepatol Commun 2023; 7:e0188. [PMID: 37459199 PMCID: PMC10351945 DOI: 10.1097/hc9.0000000000000188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/11/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND AND AIMS HBV RNA in peripheral blood reflects HBV cccDNA transcriptional activity and may predict clinical outcomes. The prospective Melbourne HBV-STOP trial studied nucleot(s)ide analog discontinuation in HBeAg-negative non-cirrhotic participants with long-term virological suppression. Ninety-six weeks after stopping treatment, the proportion of participants with virological relapse (HBV DNA > 2000 IU/mL), biochemical relapse (ALT > 2 × ULN and HBV DNA > 2000 IU/mL), or hepatitis flare (ALT > 5 × ULN and HBV DNA > 2000 IU/mL) was 89%, 58%, and 38%, respectively. We evaluated the ability of serum HBV RNA levels to predict these outcomes. APPROACH RESULTS HBV RNA levels were measured using the Roche cobas 6800/8800 HBV RNA Investigational Assay. Sixty-five participants had baseline and longitudinal off-treatment specimens available for RNA testing. HBV RNA was detectable at baseline in 25% of participants and was associated with a higher risk of biochemical relapse (81% vs. 51%, p value 0.04) and hepatitis flare (63% vs. 31%, p value 0.04). Participants who had undetectable serum HBV RNA as well as HBsAg ≤ 100 IU/mL at baseline were less likely to experience virological relapse (4 of 9, 44%) than participants with detectable HBV RNA and HBsAg level > 100 IU/mL (15/15, 100%; p value 0.0009). Off-treatment levels of HBV RNA were correlated with HBV DNA and were associated with the risk of hepatitis flare. CONCLUSIONS Serum HBV RNA may be a useful biomarker for guiding clinical decision-making before stopping nucleot(s)ide analog therapy. Baseline HBV RNA and HBsAg levels are associated with the risk of clinical relapse, hepatitis flare, and disease remission off-treatment.
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Affiliation(s)
- Alexander J. Thompson
- Department of Gastroenterology, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Immunology Research Centre, Department of Medicine (St Vincent’s Hospital), The University of Melbourne, Melbourne, Victoria, Australia
| | - Kathy Jackson
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital, Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Sara Bonanzinga
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital, Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Sam A.L. Hall
- Department of Gastroenterology, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Immunology Research Centre, Department of Medicine (St Vincent’s Hospital), The University of Melbourne, Melbourne, Victoria, Australia
| | - Simon Hume
- Department of Gastroenterology, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Immunology Research Centre, Department of Medicine (St Vincent’s Hospital), The University of Melbourne, Melbourne, Victoria, Australia
| | - Gareth S. Burns
- Department of Gastroenterology, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
- Immunology Research Centre, Department of Medicine (St Vincent’s Hospital), The University of Melbourne, Melbourne, Victoria, Australia
| | - Vijaya Sundararajan
- Immunology Research Centre, Department of Medicine (St Vincent’s Hospital), The University of Melbourne, Melbourne, Victoria, Australia
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Dilip Ratnam
- Gastroenterology & Hepatology Unit, Monash Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Miriam T. Levy
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, Australia
| | - John Lubel
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - Amanda J. Nicoll
- Gastroenterology Department of Eastern Health, Melbourne, Victoria, Australia
| | - Simone I. Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - William Sievert
- Gastroenterology & Hepatology Unit, Monash Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Paul V. Desmond
- Department of Gastroenterology, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Meng C. Ngu
- Department of Gastroenterology, Concord Repatriation General Hospital, Sydney, Australia
| | - Marie Sinclair
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Victoria, Australia
| | | | - Gail Matthews
- Department of Infectious Disease, St Vincent’s Hospital Sydney, Sydney, Australia
| | - Peter A. Revill
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital, Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Margaret Littlejohn
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital, Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - D. Scott Bowden
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital, Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | | | - Jason Torres
- Roche Molecular Systems, Inc., Pleasanton, California, USA
| | - Philip Siew
- Roche Diagnostics, Pty Ltd, North Ryde, Australia
| | - Jasmin Lau
- Roche Molecular Systems, Inc., Pleasanton, California, USA
| | | | - Alison Kuchta
- Roche Molecular Systems, Inc., Pleasanton, California, USA
| | - Kumar Visvanathan
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital, Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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29
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Lens S, Pérez Del Pulgar S, Forns X. The relevance of finding biomarkers to identify the best candidates for nucleos(t)ide analogue discontinuation in HBeAg-negative chronic hepatitis B. J Hepatol 2023:S0168-8278(23)04994-2. [PMID: 37516200 DOI: 10.1016/j.jhep.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Sabela Lens
- Liver Unit, Hospital Clínic, FCRB-IDIBAPS, University of Barcelona, Barcelona, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain.
| | - Sofía Pérez Del Pulgar
- Liver Unit, Hospital Clínic, FCRB-IDIBAPS, University of Barcelona, Barcelona, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Xavier Forns
- Liver Unit, Hospital Clínic, FCRB-IDIBAPS, University of Barcelona, Barcelona, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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30
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Broquetas T, Carrión JA. Past, present, and future of long-term treatment for hepatitis B virus. World J Gastroenterol 2023; 29:3964-3983. [PMID: 37476586 PMCID: PMC10354584 DOI: 10.3748/wjg.v29.i25.3964] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
The estimated world prevalence of hepatitis B virus (HBV) infection is 316 million. HBV infection was identified in 1963 and nowadays is a major cause of cirrhosis and hepatocellular carcinoma (HCC) despite universal vaccination programs, and effective antiviral therapy. Long-term administration of nucleos(t)ide analogues (NA) has been the treatment of choice for chronic hepatitis B during the last decades. The NA has shown a good safety profile and high efficacy in controlling viral replication, improving histology, and decreasing the HCC incidence, decompensation, and mortality. However, the low probability of HBV surface antigen seroclearance made necessary an indefinite treatment. The knowledge, in recent years, about the different phases of the viral cycle, and the new insights into the role of the immune system have yielded an increase in new therapeutic approaches. Consequently, several clinical trials evaluating combinations of new drugs with different mechanisms of action are ongoing with promising results. This integrative literature review aims to assess the knowledge and major advances from the past of hepatitis B, the present of NA treatment and withdrawal, and the future perspectives with combined molecules to achieve a functional cure.
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Affiliation(s)
- Teresa Broquetas
- Liver Section, Gastroenterology Department, Hospital del Mar, Barcelona 08003, Spain
- Institut Hospital del Mar D’Investigacions Mèdiques, PSMAR, Barcelona 08003, Spain
| | - José A Carrión
- Liver Section, Gastroenterology Department, Hospital del Mar, Barcelona 08003, Spain
- Institut Hospital del Mar D’Investigacions Mèdiques, PSMAR, Barcelona 08003, Spain
- Universitat Pompeu Fabra, Facultat de Ciències de la Salut i de la Vida, Barcelona 08003, Spain
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Feld JJ, Lok AS, Zoulim F. New Perspectives on Development of Curative Strategies for Chronic Hepatitis B. Clin Gastroenterol Hepatol 2023; 21:2040-2050. [PMID: 37080262 DOI: 10.1016/j.cgh.2023.02.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/24/2023] [Accepted: 02/28/2023] [Indexed: 04/22/2023]
Abstract
A functional cure of chronic hepatitis B defined as sustained hepatitis B surface antigen loss after finite course of therapy is rarely achieved with current therapy but is the goal of novel treatments. Understanding the virological and immunological mechanisms of hepatitis B virus persistence has enabled the identification of novel treatment targets, drug discovery, and the evaluation of novel agents in clinical trials. Lessons were learned from early phase 1 and phase 2 trials regarding the antiviral activity and safety profile of these agents. There is a strong rationale to combine agents to reduce viral replication, reduce viral antigen load, invigorate immune responses, and induce specific adaptive immune responses. Nucleos(t)ide analogs will likely remain an essential backbone of future combinations to control viral replication and prevent resistance to antiviral drugs. In this review, we discuss perspectives on approaches to achieving functional cure, with a review of virological and immunological strategies, highlighting challenges and unresolved questions with the various attempts to achieve cure, as well as exploring alternative endpoints such as partial cure and new noninvasive viral and immunological biomarkers to stratify patients and predict/monitor antiviral response.
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Affiliation(s)
- Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Fabien Zoulim
- INSERM Unit 1052 - Cancer Research Center of Lyon, Lyon Hepatology Institute, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
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Feld JJ, Wahed AS, Fried M, Ghany MG, Di Bisceglie AM, Perrillo RP, Khalili M, Yang X, Belle SH, Janssen HL, Terrault N, Lok AS. Withdrawal of Long-Term Nucleotide Analog Therapy in Chronic Hepatitis B: Outcomes From the Withdrawal Phase of the HBRN Immune Active Treatment Trial. Am J Gastroenterol 2023; 118:1226-1236. [PMID: 36728214 PMCID: PMC10298187 DOI: 10.14309/ajg.0000000000002176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/21/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Withdrawal of nucleos(t)ide analog therapy is increasingly being evaluated in chronic hepatitis B infection as a strategy to induce hepatitis B surface antigen (HBsAg) loss. The Hepatitis B Research Network Immune-Active Trial evaluated treatment with tenofovir (TDF) for 4 years ± an initial 6 months of peginterferon-α (PegIFN) (NCT01369212) after which treatment was withdrawn. METHODS Eligible participants (hepatitis B e antigen [HBeAg]-/anti-HBe+, hepatitis B virus [HBV] DNA <10 3 IU/mL, no cirrhosis) who discontinued TDF were followed for at least 1 year with optional follow-up thereafter. Retreatment was based on predefined criteria. RESULTS Among 201 participants who received 4 years of treatment, 97 participants (45 TDF and 52 TDF + PegIFN arm, 79 Asian) discontinued TDF. HBsAg loss occurred in 5 participants, 2 within 25 weeks and 3 within 89-119 weeks postwithdrawal (cumulative rate 4.3% by 2 years). Alanine aminotransferase (ALT) flares (>5× upper limit of normal) after TDF withdrawal occurred in 36 (37.1%) participants and occurred more frequently and earlier in those HBeAg- compared with HBeAg+ at treatment initiation. ALT flares were associated with older age and higher HBV DNA pretreatment and at the visit before the flare. ALT flares were not significantly associated with HBsAg decline or loss but were associated with immune active disease at 1 year (70.6% vs 11.9%, P < 0.0001) and 2 years (66.7% vs 25.9%, P = 0.03) postwithdrawal. Treatment reinitiation was required in 13 (13.4%) participants, and 13 others remained in a sustained inactive carrier state by the end of the study follow-up. No criteria reliably predicted safe treatment withdrawal. DISCUSSION Results from this trial do not support TDF withdrawal as a therapeutic strategy. HBsAg loss was infrequent within 2 years of stopping long-term TDF. If withdrawal is considered, HBV DNA should be carefully monitored with reinitiation of therapy if levels rise above 4 log 10 IU/mL to reduce the risk of ALT flares, as they were not associated with subsequent HBsAg decline or loss.
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Affiliation(s)
- Jordan J. Feld
- Toronto Centre for Liver Disease, University of Toronto University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Abdus S. Wahed
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Fried
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Marc G. Ghany
- Liver Diseases Branch, NIDDK, NIH, Bethesda, Maryland, USA
| | - Adrian M. Di Bisceglie
- Department of Medicine, St. Louis University School of Medicine, St. Louis, Michigan, USA
| | - Robert P. Perrillo
- Department of Medicine, Baylor Scott and White Medical Center, Dallas, Texas, USA
| | - Mandana Khalili
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Xue Yang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven H. Belle
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Harry L.A. Janssen
- Toronto Centre for Liver Disease, University of Toronto University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Norah Terrault
- Department of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anna S. Lok
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Mak LY, Hui RWH, Fung J, Seto WK, Yuen MF. Bepirovirsen (GSK3228836) in chronic hepatitis B infection: an evaluation of phase II progress. Expert Opin Investig Drugs 2023; 32:971-983. [PMID: 37902953 DOI: 10.1080/13543784.2023.2277389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/26/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION Chronic hepatitis B infection is a major global health issue associated with significant liver-related morbidity and mortality. While existing treatments can suppress the virus effectively, they are incapable of inducing functional cure, as defined by hepatitis B surface antigen (HBsAg) seroclearance. Currently, numerous novel compounds are being developed, including bepirovirsen, an antisense oligonucleotide (ASO). AREAS COVERED This review summarizes the mechanism of action, pharmacokinetics, clinical efficacy and safety data collected from phase I and II studies of bepirovirsen. The data were extracted from publications relevant to the pivotal trials of bepirovirsen, in either full manuscript or conference abstracts. EXPERTOPINION Bepirovirsen, a 20-mer ASO, has already entered phase III clinical evaluation using the optimal dosing regimen of 300 mg subcutaneous injection weekly for 24 weeks in nucleoside analogue-treated HBeAg-negative non-cirrhotic patients with low (<3000 IU/mL) baseline HBsAg. The durability and long-term clinical outcomes among Bepirovirsen responders will need to be evaluated. The stop-to-cure approach in those reaching HBsAg < 100 IU/mL should also be explored. In the long run, Bepirovirsen has the potential to facilitate viral hepatitis elimination.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Rex Wan-Hin Hui
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - James Fung
- Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
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Zeng G, Koffas A, Mak LY, Gill US, Kennedy PT. Utility of novel viral and immune markers in predicting HBV treatment endpoints: A systematic review of treatment discontinuation studies. JHEP Rep 2023; 5:100720. [PMID: 37138673 PMCID: PMC10149368 DOI: 10.1016/j.jhepr.2023.100720] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/06/2023] [Indexed: 05/05/2023] Open
Abstract
Background & Aims Antivirals represent the mainstay of chronic hepatitis B treatment given their efficacy and tolerability, but rates of functional cure remain low during long-term therapy. Treatment discontinuation has emerged as a strategy to maintain partial cure and achieve functional cure in select patient groups. We aimed to evaluate how data from treatment discontinuation studies exploring novel viral and/or immune markers could be applied to the functional cure program. Methods Treatment discontinuation studies evaluating novel viral and/or immune markers were identified by a systematic search of the PubMed database through to October 30, 2022. Data extraction focused on information regarding novel markers, including identified cut-off levels, timing of measurement, and associated effect on study outcomes of virological relapse, clinical relapse, and HBsAg seroclearance. Results From a search of 4,492 citations, 33 studies comprising a minimum of 2,986 unique patients met the inclusion criteria. Novel viral markers, HBcrAg and HBV RNA, were demonstrated across most studies to be helpful in predicting off-therapy partial cure, with emerging evidence to support a link with functional cure. From novel immune marker studies, we observed that treatment discontinuation has the potential to trigger immune restoration, which may be associated with a transient virological relapse. To this end, these studies support the combination of virus-directing agents with immunomodulator therapies to induce two key steps underlying functional cure: viral antigen load reduction and restoration of the host immune response. Conclusions Patients with a favourable profile of novel viral and immune markers stand to benefit from a trial of antiviral treatment discontinuation alongside novel virus-directing agents with the aim of achieving functional cure without excessive risk of severe clinical relapse. Impact and implications Select patients with chronic hepatitis B undergoing nucleoside analogue therapy may benefit from a trial of treatment discontinuation, aiming to maintain partial cure and/or achieve functional cure. We propose a profile of novel viral and immune markers to identify patients who are likely to achieve these goals without excessive risk of hepatic decompensation. Furthermore, treatment discontinuation may also be considered as a therapeutic strategy to trigger immune restoration, which may increase the chance of functional cure when used in conjunction with novel virus-directing agents.
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Affiliation(s)
- Georgia Zeng
- Faculty of Medicine, St Vincent’s Clinical School, University of New South Wales, Sydney, Australia
| | - Apostolos Koffas
- Barts Liver Centre, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Lung-Yi Mak
- Barts Liver Centre, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
| | - Upkar S. Gill
- Barts Liver Centre, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Patrick T.F. Kennedy
- Barts Liver Centre, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Corresponding author. Address: Department of Immunobiology, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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van Bömmel F, Stein K, Heyne R, Petersen J, Buggisch P, Berg C, Zeuzem S, Stallmach A, Sprinzl M, Schott E, Pathil-Warth A, von Arnim U, Keitel V, Lohmeyer J, Simon KG, Trautwein C, Trein A, Hüppe D, Cornberg M, Lammert F, Ingiliz P, Zachoval R, Hinrichsen H, Zipprich A, Klinker H, Schulze Zur Wiesch J, Schmiedeknecht A, Brosteanu O, Berg T. A multicenter randomized-controlled trial of nucleos(t)ide analogue cessation in HBeAg-negative chronic hepatitis B. J Hepatol 2023; 78:926-936. [PMID: 37062574 DOI: 10.1016/j.jhep.2022.12.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 04/18/2023]
Abstract
BACKGROUND & AIMS Nucleos(t)ide analogues (NUCs) are the standard and mostly lifelong treatment for chronic HBeAg-negative hepatitis B, as functional cure (loss of HBsAg) is rarely achieved. Discontinuation of NUC treatment may lead to functional cure; however, to date, the evidence for this has been based on small or non-randomized clinical trials. The STOP-NUC trial was designed with the aim of increasing the HBsAg loss rate using a NUC treatment interruption approach. METHODS In this multicenter, randomized-controlled trial, 166 HBeAg-negative patients with chronic hepatitis B on continuous long-term NUC treatment, with HBV DNA <172 IU/ml (1,000 copies/ml) for ≥4 years, were randomized to either stop (Arm A) or continue NUC treatment (Arm B) for a 96-week observation period. In total, 158 patients were available for final analysis, 79 per arm. The primary endpoint was sustained HBsAg loss up to week 96. RESULTS Our study met its primary objective by demonstrating HBsAg loss in eight patients (10.1%, 95% CI 4.8%-19.5%) in Arm A and in no patient in Arm B (p = 0.006). Among patients with baseline HBsAg levels <1,000 IU/ml, seven (28%) achieved HBsAg loss. In Arm A, re-therapy was initiated in 11 (13.9%) patients, whereas 32 (40.5%) patients achieved sustained remission. A decrease of HBsAg >1 log IU/ml was observed in 16 patients (20.3%) in Arm A and in one patient (1.3%) in Arm B. No serious adverse events related to treatment cessation occurred. CONCLUSIONS Cessation of NUC treatment was associated with a significantly higher rate of HBsAg loss than continued NUC treatment, which was largely restricted to patients with end of treatment HBsAg levels <1,000 IU/ml. IMPACT AND IMPLICATIONS As HBeAg-negative patients with chronic hepatitis B on nucleos(t)ide analogues (NUCs) rarely achieve functional cure, treatment is almost always lifelong. The STOP-NUC trial was conducted to investigate whether discontinuing long-term NUC treatment can increase the cure rate. We found that some patients achieved functional cure after stopping NUCs, which was especially pronounced in patients with HBsAg levels <1,000 at the end of NUC treatment, and that many did not need to resume therapy. The results of the Stop-NUC trial provide evidence for the concept of stopping NUC treatment as a therapeutic option that can induce functional cure.
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Affiliation(s)
- Florian van Bömmel
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Liebigstrasse 20, 04103 Leipzig, Germany.
| | - Kerstin Stein
- Praxis Hepatologie - Magdeburg, Breiter Weg 228m, 39104 Magdeburg, Germany
| | - Renate Heyne
- Leberzentrum Checkpoint, Bergmannstraße 5-7, 10961 Berlin, Germany
| | - Jörg Petersen
- Leberzentrum Hamburg an der Asklepios Klinik St. Georg, Lohmühlenstraße 5, 20099 Hamburg, Germany
| | - Peter Buggisch
- Leberzentrum Hamburg an der Asklepios Klinik St. Georg, Lohmühlenstraße 5, 20099 Hamburg, Germany
| | - Christoph Berg
- Universitätsklinikum Tübingen, Medizinische Klinik I, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Stefan Zeuzem
- Universitätsklinikum Frankfurt, Medizinische Klinik 1, Theodor-Stern-Kai, 60590 Frankfurt am Main, Germany
| | - Andreas Stallmach
- Universitätsklinikum Jena, Klinik für Innere Medizin IV, Am Klinikum 1, 07747 Jena, Germany
| | - Martin Sprinzl
- Universitätsmedizin Mainz, I. Medizinische Klinik und Poliklinik. Johannes Gutenberg Universität, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Eckart Schott
- Charité-Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany; Klinik für Innere Medizin II, Helios Klinikum Emil von Behring, Walterhöferstrasse 11, 14165 Berlin, Germany
| | - Anita Pathil-Warth
- Universitätsklinikum Frankfurt, Medizinische Klinik 1, Theodor-Stern-Kai, 60590 Frankfurt am Main, Germany; Universitätsklinikum Heidelberg, Innere Medizin IV, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Ulrike von Arnim
- Universitätsklinikum Magdeburg AöR, Leipziger Str. 44, 39120 Magdeburg, Germany
| | - Verena Keitel
- Universitätsklinikum Magdeburg AöR, Leipziger Str. 44, 39120 Magdeburg, Germany; Universitätsklinikum Düsseldorf, Klinik für Gastroenterologie, Hepatologie und Infektiologie, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Jürgen Lohmeyer
- Universitätsklinikum Gießen, Medizinische Klinik II, Klinikstraße 33, 35385 Gießen, Germany
| | - Karl-Georg Simon
- MVZ Gastroenterologie Leverkusen, Franz-Kail-Str. 2, 51375 Leverkusen, Germany
| | - Christian Trautwein
- Universitätsklinikum RWTH Aachen, Medizinische Klinik III, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Andreas Trein
- Gemeinschaftspraxis Schwabstrasse 59, 70197 Stuttgart, Germany
| | - Dietrich Hüppe
- Gastroenterologische Gemeinschaftspraxis Herne, Wiescherstr. 20, 44623 Herne, Germany
| | - Markus Cornberg
- Medizinische Hochschule Hannover, Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; Centre for Individualised Infection Medicine (CiiM), Hannover, Germany
| | - Frank Lammert
- Medizinische Hochschule Hannover, Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; Universitätsklinikum des Saarlandes, Klinik für Innere Medizin II, Kirrberger Straße 100, 66421 Homburg, Germany
| | - Patrick Ingiliz
- Zentrum für Infektiologie (zibp) Berlin, Driesener Str. 20, 10439 Berlin, Germany; Henri Mondor Universitary Hospital, Hepatology Department, Creteil, France
| | - Reinhart Zachoval
- LMU Klinikum Großhadern, Medizinischen Klinik und Poliklinik II, Marchioninistraße 15, 81377 München, Germany
| | - Holger Hinrichsen
- Gastroenterologisch-Hepatologisches Zentrum Kiel, Goethestr. 11, 24116 Kiel, Germany
| | - Alexander Zipprich
- Universitätsklinikum Jena, Klinik für Innere Medizin IV, Am Klinikum 1, 07747 Jena, Germany; Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, Germany
| | - Hartmuth Klinker
- Universitätsklinikum Würzburg, Medizinische Klinik II, Oberdürrbacher Straße 697080 Würzburg, Germany
| | - Julian Schulze Zur Wiesch
- Universitätsklinikum Hamburg-Eppendorf, I. Medizinische Klinik und Poliklinik, Martinistraße 52, 20246 Hamburg, Germany
| | | | | | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Liebigstrasse 20, 04103 Leipzig, Germany
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Jeng WJ, Lok ASF. What will it take to cure hepatitis B? Hepatol Commun 2023; 7:02009842-202304010-00023. [PMID: 36972391 PMCID: PMC10043561 DOI: 10.1097/hc9.0000000000000084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/02/2022] [Indexed: 03/29/2023] Open
Abstract
The current treatment of chronic HBV infection, pegylated interferon-α (pegIFNα) and nucleos(t)ide analog (NA), can suppress HBV replication, reverse liver inflammation and fibrosis and reduce the risks of cirrhosis, HCC, and HBV-related deaths, but relapse is common when the treatment is stopped before HBsAg loss. There have been major efforts to develop a cure for HBV, defined as sustained HBsAg loss after a finite course of therapy. This requires the suppression of HBV replication and viral protein production and the restoration of immune response to HBV. Direct-acting antivirals targeting virus entry, capsid assembly, viral protein production and secretion are in clinical trials. Immune modulatory therapies to stimulate adaptive or innate immunity and/or to remove immune blockade are being tested. NAs are included in most and pegIFNα in some regimens. Despite the combination of 2 or more therapies, HBsAg loss remains rare in part because HbsAg can be derived not only from the covalently closed circular DNA but also from the integrated HBV DNA. Achievement of a functional HBV cure will require therapies to eliminate or silence covalently closed circular DNA and integrated HBV DNA. In addition, assays to differentiate the source of circulating HBsAg and to determine HBV immune recovery, as well as standardization and improvement of assays for HBV RNA and hepatitis B core-related antigen, surrogate markers for covalently closed circular DNA transcription, are needed to accurately assess response and to target treatments according to patient/disease characteristics. Platform trials will allow the comparison of multiple combinations and channel patients with different characteristics to the treatment that is most likely to succeed. Safety is paramount, given the excellent safety profile of NA therapy.
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Affiliation(s)
- Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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Hui RWH, Mak LY, Seto WK, Yuen MF, Fung J. Chronic hepatitis B - A scoping review on the guidelines for stopping nucleos(t)ide analogue therapy. Expert Rev Gastroenterol Hepatol 2023; 17:443-450. [PMID: 36972516 DOI: 10.1080/17474124.2023.2196405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Nucleos(t)ide analogues (NAs) are effective in suppressing the replication of the hepatitis B virus. However, NAs cannot effectively induce hepatitis B surface antigen (HBsAg) seroclearance, which represents the optimal treatment endpoint in chronic hepatitis B (CHB). Hence, most CHB patients are advised for indefinite NA therapy, but recent data has supported the concept of finite NA therapy before HBsAg seroclearance. AREAS COVERED This article covered the latest evidence on stopping NAs in CHB, with focused analysis on international guidelines. Articles were retrieved by a literature search on PubMed with the keywords "chronic hepatitis B", "antiviral therapy", "nucleos(t)ide analogue", "cessation", "stopping" and "finite". Studies up till 1 December 2022 were included. EXPERT OPINION Finite NA therapy in CHB has potential in enhancing HBsAg seroclearance, however it also carries rare but potentially severe risks. NA cessation before HBsAg seroclearance is only suitable for a highly-selected group of patients, whereas the majority of CHB patients should be treated indefinitely or until HBsAg seroclearance. Current guidelines have provided recommendations on stopping NAs, but further research is required to optimize the monitoring and retreatment protocol after stopping NAs.
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Affiliation(s)
- Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
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Mak LY, Hui RWH, Cheung KS, Fung J, Seto WK, Yuen MF. Advances in determining new treatments for hepatitis B infection by utilizing existing and novel biomarkers. Expert Opin Drug Discov 2023; 18:401-416. [PMID: 36943183 DOI: 10.1080/17460441.2023.2192920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Chronic hepatitis B (CHB) infection is a major global health threat and accounts for significant liver-related morbidity and mortality. An improved understanding of how hepatitis B virus (HBV) interacts with the host immune system allows the discovery of novel biomarkers and new treatment options. Viral biomarkers including hepatitis B surface antigen (HBsAg) and newer ones like HBV RNA and hepatitis B core-related antigen appear to be useful to select patients who are likely to benefit from cessation of long-term antiviral therapy. These markers can also help to confirm target engagement for novel compounds, and efficacy in HBsAg reduction and seroclearance is deemed essential as this is how the current treatment endpoint of functional cure is defined. AREAS COVERED In this review, the authors discuss the current standard of care and the gaps between such standard and the ideal goals for treatment in CHB. The authors highlight novel viral and immunological biomarkers that are potentially useful to evaluate treatment response. Novel treatment approaches in relation to these novel biomarkers are also evaluated. EXPERT OPINION Novel serum viral biomarkers and immunological markers are indispensable in the HBV functional cure program. These will likely become part of standard monitoring soon.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
| | - Ka-Shing Cheung
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
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Choi J. Quantitative Hepatitis B Surface Antigen, the Trustworthy Biomarker for Functional Cure of Chronic Hepatitis B. Gut Liver 2023; 17:179-180. [PMID: 36918269 PMCID: PMC10018298 DOI: 10.5009/gnl230070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Affiliation(s)
- Jonggi Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Chang ML, Liaw YF. Emerging Therapies for Chronic Hepatitis B and the Potential for a Functional Cure. Drugs 2023. [PMID: 36906663 DOI: 10.1007/s40265-023-01843-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 03/13/2023]
Abstract
Worldwide, an estimated 296 million people are living with chronic hepatitis B virus (HBV) infection, with a significant risk of morbidity and mortality. Current therapy with pegylated interferon (Peg-IFN) and indefinite or finite therapy with nucleoside/nucleotide analogues (Nucs) are effective in HBV suppression, hepatitis resolution, and prevention of disease progression. However, few achieve hepatitis B surface antigen (HBsAg) loss (functional cure), and relapse often occurs after the end of therapy (EOT) because these agents have no direct effect on durable template: covalently closed circular DNA (cccDNA) and integrated HBV DNA. Hepatitis B surface antigen loss rate increases slightly by adding or switching to Peg-IFN in Nuc-treated patients and this loss rate greatly increases up to 39% in 5 years with finite Nuc therapy with currently available Nuc(s). For this, great effort has been made to develop novel direct-acting antivirals (DAAs) and immunomodulators. Among the DAAs, entry inhibitors and capsid assembly modulators have little effect on reducing HBsAg levels; small interfering RNA, antisense oligonucleotides, and nucleic acid polymers in combination with Peg-IFN and Nuc may reduce HBsAg levels significantly, even a rate of HBsAg loss sustained for > 24 weeks after EOT up to 40%. Novel immunomodulators, including T-cell receptor agonists, check-point inhibitors, therapeutic vaccines, and monoclonal antibodies may restore HBV-specific T-cell response but not sustained HBsAg loss. The safety issues and the durability of HBsAg loss warrant further investigation. Combining agents of different classes has the potential to enhance HBsAg loss. Compounds directly targeting cccDNA would be more effective but are still in the early stage of development. More effort is required to achieve this goal.
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Yu T, Zhang M, Zhang H, Zheng J, Shen C, Jiang N, Zou L, Wang J, Yu Y, Zhang Q, Yu S, Huang Y, Huang Y, Zhang J, Qiu C, Zhang W, Meng Z. Evidence of Residual Ongoing Viral Replication in Chronic Hepatitis B Patients Successfully Treated With Nucleos(t)ide Analogues. J Infect Dis 2023; 227:675-685. [PMID: 36546708 DOI: 10.1093/infdis/jiac493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 11/17/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chronic hepatitis B is usually treated with nucleos(t)ide analogues (NAs). However, a cure is rarely achieved, even with years of treatment. Here, we investigated whether viral replication is completely halted and how long covalently closed circular DNA (cccDNA) persists in patients successfully treated with NAs. METHODS A series of longitudinal serum samples and a collection of cross-sectional liver biopsies were obtained from patients successfully treated with NAs. Viral variants in serum HBV RNA were enumerated by deep sequencing. Viral replication intermediates in hepatocytes were directly visualized by in situ hybridization. The apparent half-life of each cccDNA was estimated. RESULTS Three of 6 successfully treated patients demonstrated clear evidence of a small proportion of virus evolution, although the overwhelming proportion of variants were identical or possessed a similar degree of divergence through time. The apparent half-life of variants was estimated to be from approximately 7.42 weeks to infinite. Hepatocytes remained positive for cytoplasmic nucleocapsids-associated relaxed circular DNA in 4 of 7 liver needle biopsies. CONCLUSIONS We conclude that even after prolonged treatment, a small proportion of the cccDNA reservoir is constantly replenished by continued low-level HBV replication, whereas a large proportion of the cccDNA reservoir persists over time.
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Affiliation(s)
- Tong Yu
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Miaoqu Zhang
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Hanyue Zhang
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Jianming Zheng
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Chuan Shen
- Department of Infectious Disease, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
- Clinical Research Center for Infectious Disease of Hebei Province, Shijiazhuang, China
| | - Ning Jiang
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Zou
- Department of Infectious Disease, Yancheng Second People's Hospital, Yancheng, China
| | - Jing Wang
- Department of Infectious Disease, Jingan District Central Hospital of Shanghai, Shanghai, China
| | - Yiqi Yu
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Qiran Zhang
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Shuili Yu
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Yanfang Huang
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Yuxian Huang
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Jiming Zhang
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Chao Qiu
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Wenhong Zhang
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
| | - Zhefeng Meng
- Minhang Hospital and Institutes of Biomedical Sciences and Huashan Hospital, Fudan University, Shanghai, China
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Yip TCF, Wong VWS, Lai MSM, Lai JCT, Hui VWK, Liang LY, Tse YK, Chan HLY, Wong GLH. Risk of hepatic decompensation but not hepatocellular carcinoma decreases over time in patients with hepatitis B surface antigen loss. J Hepatol 2023; 78:524-533. [PMID: 36463985 DOI: 10.1016/j.jhep.2022.11.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/23/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND & AIMS We examined the long-term incidence of hepatocellular carcinoma (HCC) and hepatic decompensation among chronic hepatitis B (CHB) patients who have achieved hepatitis B surface antigen (HBsAg) seroclearance. METHODS All adult CHB-monoinfected patients who cleared HBsAg between January 2000 and December 2020 were identified using a territory-wide database in Hong Kong. Patients who underwent liver transplantation and/or developed HCC before HBsAg seroclearance or less than 6 months follow-up were excluded. The primary and secondary endpoints were HCC and hepatic decompensation respectively. RESULTS We identified 9,769 patients with CHB who achieved HBsAg seroclearance (mean age 57 years, 60.0% male, 13.2% cirrhosis); most had compensated liver function at HBsAg loss. At a median (25th-75th percentile) follow-up of 4.6 (2.2-8.4) years, 106 (1.1%) patients developed HCC. Patients who developed HCC were older, more likely to be male and have cirrhosis, and had higher alanine aminotransferase and lower platelets at the time of HBsAg loss than patients without HCC. The cumulative incidence of HCC remained steady 0-7 and 8-12 years after HBsAg loss (p = 0.898) (crude annual incidence drop: -0.04%, 95% CI -0.13% to 0.04%, p = 0.265). Moreover, 124/9,640 (1.3%) patients developed hepatic decompensation. The growth in cumulative incidence of hepatic decompensation decelerated 8-12 years after HBsAg loss (p = 0.009) (crude annual incidence drop: -0.23%, 95% CI -0.40% to -0.06%, p = 0.012). In multivariable analysis, HBsAg loss for over 7 years was associated with a reduced risk of hepatic decompensation (adjusted subdistribution hazard ratio [aSHR] 0.55, 95% CI 0.31-0.97, p = 0.039) but not HCC (aSHR 1.35, 95% CI 0.83-2.19, p = 0.230). CONCLUSION HCC risk persists in patients after HBsAg loss, whereas the risk of hepatic decompensation decreases over time. IMPACT AND IMPLICATIONS Patients with chronic hepatitis B (CHB) still have a non-negligible risk of hepatocellular carcinoma (HCC) after 12 years of HBsAg seroclearance, especially among those with cirrhosis. The risk of developing hepatic decompensation decreases over time after HBsAg seroclearance. In clinical practice, although patients with CHB who cleared HBsAg have a more favourable clinical outcome than those who remain chronically infected, long-term HCC surveillance would still be necessary for patients with cirrhosis and other high-risk subgroups after HBsAg seroclearance.
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Affiliation(s)
- Terry Cheuk-Fung Yip
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Mandy Sze-Man Lai
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong
| | - Jimmy Che-To Lai
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Vicki Wing-Ki Hui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong
| | - Lilian Yan Liang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong
| | - Yee-Kit Tse
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Henry Lik-Yuen Chan
- Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong; Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong; Department of Internal Medicine, Union Hospital, Hong Kong
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong; Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong; Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong.
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Lim SG, Baumert TF, Boni C, Gane E, Levrero M, Lok AS, Maini MK, Terrault NA, Zoulim F. The scientific basis of combination therapy for chronic hepatitis B functional cure. Nat Rev Gastroenterol Hepatol 2023. [PMID: 36631717 DOI: 10.1038/s41575-022-00724-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 01/13/2023]
Abstract
Functional cure of chronic hepatitis B (CHB) - or hepatitis B surface antigen (HBsAg) loss after 24 weeks off therapy - is now the goal of treatment, but is rarely achieved with current therapy. Understanding the hepatitis B virus (HBV) life cycle and immunological defects that lead to persistence can identify targets for novel therapy. Broadly, treatments fall into three categories: those that reduce viral replication, those that reduce antigen load and immunotherapies. Profound viral suppression alone does not achieve quantitative (q)HBsAg reduction or HBsAg loss. Combining nucleos(t)ide analogues and immunotherapy reduces qHBsAg levels and induces HBsAg loss in some patients, particularly those with low baseline qHBsAg levels. Even agents that are specifically designed to reduce viral antigen load might not be able to achieve sustained HBsAg loss when used alone. Thus, rationale exists for the use of combinations of all three therapy types. Monitoring during therapy is important not just to predict HBsAg loss but also to understand mechanisms of HBsAg loss using viral and immunological biomarkers, and in selected cases intrahepatic sampling. We consider various paths to functional cure of CHB and the need to individualize treatment of this heterogeneous infection until a therapeutic avenue for all patients with CHB is available.
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Yardeni D, Chang KM, Ghany MG. Current Best Practice in Hepatitis B Management and Understanding Long-term Prospects for Cure. Gastroenterology 2023; 164:42-60.e6. [PMID: 36243037 PMCID: PMC9772068 DOI: 10.1053/j.gastro.2022.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/25/2022] [Accepted: 10/04/2022] [Indexed: 02/03/2023]
Abstract
The hepatitis B virus (HBV) is a major cause of cirrhosis and hepatocellular carcinoma worldwide. Despite an effective vaccine, the prevalence of chronic infection remains high. Current therapy is effective at achieving on-treatment, but not off-treatment, viral suppression. Loss of hepatitis B surface antigen, the best surrogate marker of off-treatment viral suppression, is associated with improved clinical outcomes. Unfortunately, this end point is rarely achieved with current therapy because of their lack of effect on covalently closed circular DNA, the template of viral transcription and genome replication. Major advancements in our understanding of HBV virology along with better understanding of immunopathogenesis have led to the development of a multitude of novel therapeutic approaches with the prospect of achieving functional cure (hepatitis B surface antigen loss) and perhaps complete cure (clearance of covalently closed circular DNA and integrated HBV DNA). This review will cover current best practice for managing chronic HBV infection and emerging novel therapies for HBV infection and their prospect for cure.
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Affiliation(s)
- David Yardeni
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Kyong-Mi Chang
- Medical Research, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Marc G Ghany
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland.
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Terrault NA, Lok AS, Wahed AS, Ghany MG, Perrillo RP, Fried MW, Wong DK, Khalili M, Lau DTY, Sterling RK, Di Bisceglie AM, Lisker-Melman M, Cooper SL, Chung RT, Patel K, Roberts LR, Belle SH, Janssen HLA. Randomized Trial of Tenofovir With or Without Peginterferon Alfa Followed by Protocolized Treatment Withdrawal in Adults With Chronic Hepatitis B. Am J Gastroenterol 2022. [PMID: 36599136 DOI: 10.14309/ajg.0000000000002125] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/02/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Hepatitis B surface antigen (HBsAg) loss is associated with improved long-term outcomes of patients with chronic hepatitis B but is infrequently achieved with current monotherapies. We assessed whether combination strategies that included treatment withdrawal enhanced HBsAg loss. METHODS A randomized (1:1) trial of tenofovir disoproxil fumarate (TDF) for 192 weeks with or without peginterferon (PegIFN) alfa-2a for the first 24 weeks, followed by withdrawal of TDF at week 192 with 48 weeks of off-treatment follow-up to week 240. The primary endpoint was HBsAg loss at week 240. RESULTS Of 201 participants (52% HBeAg-positive, 12%/6% genotype A/A2, 7% cirrhosis) randomized to TDF + PegIFN (n = 102) or TDF alone (n = 99) 6 participants had lost HBsAg at the end of the treatment phase (week 192), 5 (5.3%) in the combination group and 1 (1.0%) in the TDF alone group ( P = 0.09). By week 240, 9 participants had cleared HBsAg, 5.3% in combination and 4.1% in monotherapy arms ( P = 0.73). HBsAg decline and loss occurred earlier with TDF + PegIFN than TDF, with a ≥1-logIU/mL qHBsAg decline by week 24 in 28% compared to 6% in TDF ( P = 0.04). HBsAg loss occurred in 7 of 12 (58%) with hepatitis B virus subgenotype A2 (all HBeAg-positive) compared to only 2 of 189 (1%) with other hepatitis B virus genotypes, and in 8 of 93 (8.6%) HBeAg-positive vs 1 of 87 (1.1%) HBeAg-negative. DISCUSSION PegIFN combined TDF followed by protocolized TDF withdrawal led to earlier but not higher percentages of HBsAg clearance. Pre-treatment HBeAg positivity and subgenotype A2 were strongly associated with HBsAg clearance.
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Hudu SA, Jimoh AO, Ibrahim KG, Alshrari AS. Hepatitis B Therapeutic Vaccine: A Patent Review. Pharmaceuticals (Basel) 2022; 15. [PMID: 36558991 DOI: 10.3390/ph15121542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Viral hepatitis has long been underrated as a danger to global health. The UN only recently called for worldwide action to tackle viral hepatitis and lessen the disease burden in its "2030 Agenda for Sustainable Development". Hepatitis B virus (HBV), which causes liver cirrhosis and malignancy, is a main cause of death globally. This review analyses innovative HBV therapeutic vaccine candidates for which a patent was filed between January 2010 and March 2022 and presents future improvement techniques for vaccine efficacy. Although there is a preventative vaccine for HBV infection, over 3% of people worldwide have the disease on a long-term basis and can no longer benefit from it. Most people will have chronic HBV infection for the rest of their lives once it has been diagnosed. Moreover, only a small percentage of treated patients experience a functional cure with persistent hepatitis B surface antigen reduction. A significant proportion of deaths are caused by liver cirrhosis and hepatocellular cancer, which are both caused by chronic hepatitis B infection. Hence, there is an urgent need for novel medications due to the inadequacies of the current therapies.
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Abstract
Hepatitis B virus (HBV) is a hepatotropic virus, which damage to hepatocytes is not direct, but through the immune system. HBV specific CD4+ T cells can induce HBV specific B cells and CD8+ T cells. HBV specific B cells produce antibodies to control HBV infection, while HBV specific CD8+ T cells destroy infected hepatocytes. One of the reasons for the chronicity of HBV infection is that it cannot effectively activate adoptive immunity and the function of virus specific immune cells is exhausted. Among them, virus antigens (including HBV surface antigen, e antigen, core antigen, etc.) can inhibit the function of immune cells and induce immune tolerance. Long term nucleos(t)ide analogues (NAs) treatment and inactive HBsAg carriers with low HBsAg level may "wake up" immune cells with abnormal function due to the decrease of viral antigen level in blood and liver, and the specific immune function of HBV will recover to a certain extent, thus becoming the "dominant population" for functional cure. In turn, the functional cure will further promote the recovery of HBV specific immune function, which is also the theoretical basis for complete cure of hepatitis B. In the future, the complete cure of chronic HBV infection must be the combination of three drugs: inhibiting virus replication, reducing surface antigen levels and specific immune regulation, among which specific immunotherapy is indispensable. Here we review the relationship, mechanism and clinical significance between the cure of hepatitis B and immune system.
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Yao Y, Zhang J, Li X, Zao X, Cao X, Chen G, Ye Y. Systematic review: Clinical outcomes of discontinuation of oral antivirals in hepatitis B-related liver cirrhosis. Front Public Health 2022; 10:1037527. [PMID: 36407996 PMCID: PMC9670108 DOI: 10.3389/fpubh.2022.1037527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
Background Discontinuation of Nucleos(t)ide analogs (NAs) remains one of the most controversial topics in the management of hepatitis B-related liver cirrhosis. However, clinical outcomes after NAs discontinuation have not been studied. Aim The aim of this systematic review is to evaluate existing data on clinical outcomes of NAs withdrawal in chronic hepatitis B (CHB) patients with cirrhosis. Methods A literature search (until May 2022) was performed in order to identify all published studies including hepatitis B-related cirrhotic patients who discontinued NAs in virological remission with off-therapy follow-up >12 months. Results Nineteen studies with 1,287 hepatitis B-related cirrhotic patients were included. Most cirrhotic patients were compensated and achieved complete virological suppression when they stopped the antiviral therapy. The pooled proportions of virological relapse and clinical relapse after NAs discontinuation in cirrhotic patients were 55.23 (95% CI: 40.33-69.67) and 43.56% (95% CI: 26.13-61.85), respectively. HBsAg loss was observed in 56 of 500 (pooled proportion = 13.68%, 95% CI: 5.82-24.18) cirrhotic patients. And the pooled proportions of HCC development, hepatic decompensation and overall mortality were 8.76 (95% CI: 2.25-18.95), 3.63 (95% CI: 1.31-7.03), and 0.85% (95% CI: 0.35-1.57), respectively, after NAs discontinuation in cirrhotic patients. Conclusion In hepatitis B-related compensated cirrhosis, who have achieved complete virological suppression, discontinuation of oral antivirals still carries a high relapse rate, but the incidence of adverse events is generally low and controlled during follow-up of at least 12 months. Of attention is that discontinuation of NAs can achieve a high rate of HBsAg seroclearance. This study may be helpful in the management of NAs in cirrhotic patients. Systematic review registration http://www.crd.york.ac.uk/PROSPERO, identifier: CRD42020170103.
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Affiliation(s)
- Yuhao Yao
- Department of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- First School of Clinical Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Jiaxin Zhang
- Department of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute of Liver Diseases, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoke Li
- Department of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute of Liver Diseases, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaobin Zao
- Department of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute of Liver Diseases, Beijing University of Chinese Medicine, Beijing, China
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xu Cao
- Department of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Guang Chen
- Department of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute of Liver Diseases, Beijing University of Chinese Medicine, Beijing, China
| | - Yong'an Ye
- Department of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute of Liver Diseases, Beijing University of Chinese Medicine, Beijing, China
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Abstract
There is increasing incidence and prevalence of acute and chronic liver diseases (CLDs) all over the world which influence the quality of life and can give rise to life threatening complications. The burden of advanced liver disease due to hepatitis B has been controlled by antivirals but its eradication is difficult soon. Highly effective directly acting antiviral therapy has reduced the burden of hepatitis C but is partially offset by increasing IV drug abuse. Non-alcoholic fatty liver disease pandemic is on and there is recent alarming increase in alcohol related liver disease, both of which have no drug cure apart from control of the risk factors. Genetic factors have been identified in progression of all forms of CLD. Due to better management of complications of CLD, the life span of patients have increased spiking the number of hepatocellular carcinoma (HCC) and patients needing liver transplantation (LT). The present severe acute respiratory syndrome coronavirus pandemic has affected the outcome CLD including LT in addition to causing acute hepatitis. Better diagnostics and therapeutics are available for liver fibrosis, portal hypertension, HCC and post LT management and many drugs are under trial. The present review summarises the current scenario of the epidemiology and the advances in diagnosis and treatment of liver diseases including their complications like portal hypertension, HCC and LT.
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Affiliation(s)
- Gautam Ray
- Gastroenterology Unit, Department of Medicine, B.R.Singh (Railway) Hospital, Kolkata 700014, West Bengal, India
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50
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Sonneveld MJ, Chiu SM, Chen CH, Maasoumy B. Reply to: "Probability of HBsAg loss after nucleos(t)ide analogue withdrawal depends on HBV genotype and viral antigen levels". J Hepatol 2022; 77:1224-1226. [PMID: 35810930 DOI: 10.1016/j.jhep.2022.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Shao-Ming Chiu
- Department of Internal Medicine, Koahsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chien-Hung Chen
- Department of Internal Medicine, Koahsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Benjamin Maasoumy
- Department of Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany
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