RNA editing blood biomarkers for predicting mood alterations in HCV patients

Treatment-emergent depression is a common complication in patients with chronic hepatitis C virus (HCV) infection undergoing antiviral combination therapy with IFN-α and ribavirin. It has recently been shown that changes in A-to-I RNA editing rates are associated with various pathologies such as inflammatory disorders, depression and suicide. Interestingly, IFN-α induces gene expression of the RNA editing enzyme ADAR1-1 (ADAR1a-p150) and alters overall RNA editing activity. In this study, we took advantage of the high prevalence of pharmacologically induced depression in patients treated with IFN-α and ribavirin to test the interest of RNA editing–related biomarkers in white blood cells of patients. In this 16-week longitudinal study, a small cohort of patients was clinically evaluated using standard assessment methods prior to and during antiviral therapy and blood samples were collected to analyse RNA editing modifications. A-I RNA editing activity on the phosphodiesterase 8A (PDE8A) gene, a previously identified RNA editing hotspot in the context of lupus erythematosus, was quantified by using an ultra-deep next-generation sequencing approach. We also monitored gene expression levels of the ADAR enzymes and the PDE8A gene during treatment by qPCR. As expected, psychiatric evaluation could track treatment-emergent depression, which occurred in 30% of HCV patients. We show that PDE8A RNA editing is increased in all patients following interferon treatment, but differently in 30% of patients. This effect was mimicked in a cellular model using SHSY-5Y neuroblastoma cells. By combining the data of A-I RNA editing and gene expression, we generated an algorithm that allowed discrimination between the group of patients who developed a treatment-emergent depression and those who did not. The current model of drug-induced depression identified A-I RNA editing biomarkers as useful tools for the identification of individuals at risk of developing depression in an objective, quantifiable biological blood test.

[Benefits of a preventive psychiatric accompaniment in patients Hepatitis C Virus seropositive (HCV): prospective study concerning 39 patients]

Hepatitis C represents a major public health challenge due to its chronic evolution and major complications (eg liver tumor and cirrhosis). New treatment strategies (interferon pégylé +/- ribavirine) have recently improved the prognosis except in case of poor compliance. Psychiatric comorbidity, especially affective disorders, is commonly associated with hepatitis C and constitutes the main cause of poor compliance, therapeutic discontinuations and treatment contra-indication. At this moment of new therapeutic protocols and the possibility of curing HCV infections, it is of utmost importance to widen antiviral treatment in many indications, to upgrade compliance, and to limit therapeutic discontinuations. In this context, where anxious and depressive disorders are the main reasons for failure in curing, it is necessary to anticipate the appearance of these troubles within an earlier multidisciplinary taking in charge. The primary aim of our study is to emphasize the utility of a multi-disciplinary approach including psychiatric evaluation, preventive follow-up and preventive treatment. The secondary objective is to show that a previous story of depression or use of drugs should not be considered as an insuperable contra-indication provoding the implementation of a specific follow-up. Thirty nine interferon treated patients were included in a prospective study. Our data confirm the high rate (28%) of Major Depressive Disorders among the population of hepatitis C treated patients in a preventive follow-up. A previous story of alcoholism, of suicide attempt or break off treatment with Major Depressive disorders might be predictive of such a complication. According to the subjective feeling of these patients with previous break'off treatment associated, specific psychiatric follow-up may improve tolerance for the treatment.

METHODS AND OBJECTIVES

39 patients (17 men and 22 women) accepted, on (or after) the non-systematic proposal of their hepatologist, to consult the psychiatrist of the network, prior to any therapeutic decision. The first objectives of the consultations were to inform the patient (and, with his agreement, his -relatives), about the risk of depressive disorders while under treatment by interferon, as well as their potential consequences. Moreover, the psychiatrist answers their questions concerning this issue, and proposes him a long-term psychotherapeutic follow up (up to several months after the antiviral treatment end) including availability in emergency if necessary and preventive antidepressive treatment. In this framework, we assessed in a prospective way the frequency, the intensity and the time (or moments) when major depressive episode (MDE) (according to the DSM IV) appeared under interferon alpha, the predictive factors for these MDE, the interest and the quality of a preventive antidepressive treatment prescription and the psycho-social benefits of this taking in charge for the patient.

RESULTS

Among these 39 patients -regularly followed during and after the antiviral therapy, 11 (28%) had a MDE while under treatment. These MDE, except for 2 (5%) of them which led to an hospitalization, were mild to moderate. They mainly appeared within the 2 first quarters of treatment without significant difference. Patients with antecedents of suicide attempt (80%), drug addiction (50%) or alcohol addiction (50%) are more likely to have a MDE under interferon alpha than other patients, but these risk factors are not a contra-indication for treatment because 95% of the patients ended their treatment and the 2 antiviral treatment discontinuations observed were secon-dary to (or following) an acute psychotic episode (hospitalization) and a maniac episode in a schizophrenic patient (outpatient care). The existence of antecedents of antiviral treatment discontinuations due to MDE (33%) does not seem to be a risk factor anymore when preventive care is provided. It is interesting to point out the existence of a certain male fragility, men are more psychologically sensitive to interferon alpha than women. About 90% of patients chose to take an antidepressant. The latter was mainly a treatment with sertraline (45% out of cases), with citalopram (40% out of cases), and for 15% of them antidepressive treatment previously prescribed and non modified because they were well-tolerated and efficient. 86% of the first prescriptions were not changed during the follow up. 75% of patients already treated by a previous antiviral treatment with interferon alpha estimated that an earlier psychiatric accompaniment was very beneficial for them, in terms of compliance and socio-professional insertion.

CONCLUSION

A specialized psychiatric accompaniment within a coherent multidisciplinary network provides a major benefit to the patients in terms of compliance and safe care (even for population considered as having higher risks) although it is not possible to define accurately the influence of the preventive prescription of a antidepressant (which is not prejudicial anyway). a previous story of depressive disorder should not be considered as a contra-indication, but should imply a specific psychiatric follow-up especially when alcoholism, previous story of suicidal attempt and previous break'off treatment are reported.

[Reflections on the treatment of EDM in hepatitis C virus patients treated with interferon alpha from a retrospective survey concerning 29 patients]

At this moment of new therapeutic protocols and the possibility of curing HCV infections, it is of utmost importance to widen antiviral treatment in many indications, to upgrade compliance, and to limit therapeutic discontinuations. Depressive disorders are probably the main reason for failure of this treatment. The lack of knowledge about depressive disorders and the little specialized psychiatric accompaniment in this field are obviously not beneficial for the patient and his disease (no access to interferon alpha therapy, poor compliance, frequent discontinuations of treatment.);

METHODS AND OBJECTIVES

24 patients (15 men and 9 women) treated by interferon alpha and having a major depressive episode (MDE) (according to the DSM IV) and who were about to discontinue their treatment, had a emergency consultation with the psychiatrist of the network who took them immediately in charge in the most adapted way (psychotropic therapy, psychotherapy, hospitalization.) as well as a long term specialized follow up (up to several months after the treatment was discontinued). From this follow up and based on a retrospective questionnaire proposed to the patients, we have thought about the existence and the relevance of the risk factors of the appearance of MDE under interferon alpha (personal antecedents of depression, of suicide attempts, of antiviral treatment discontinuations, of the drug addiction-induced contamination.) and about the major interest of a psychiatric accompaniment within an organized network.

RESULTS

Among the 29 patients regularly followed during and after the antiviral therapy, 23 (79.3%) received a psychotropic treatment adapted to the clinical situation (82.6% of initially prescribed antidepressants have not been modified) associated the the psychotherapy, 4 (13.7%) were hospitalized in the psychiatric ward where the network psychiatrist works, one attempted to commit suicide without associated depression disorders (hospitalization, no discontinuation of antiviral therapy). More than 90% of patients were able to complete treatment. However, 7 patients (24,1%) had a MDE within the 3 months following treatments (5 patients consulted after their treatment discontinuations even though this treatment was well tolerated and efficient). The frequency of MDE under interferon alpha in patients with personal antecedents of MDE (10 patients, 41.7%) was not significantly different from that found in patients without antecedents of MDE (14 patients, 58.3%). The frequency of MDE under interferon alpha in patients assuming that they had been obviously contaminated by a risky use of drugs (13 patients, 54%) is not significantly different from that found in patients assuming that they had been obviously contaminated by another risky situation (11 patients, 46%). We can wonder, despite of the poor recruitment, about the potential involvement of driving under the influence of alcohol, antecedents of MDE induced-discontinuation of a last treatment by interferon alpha or antecedents of suicide attempt, in the appearance of MDE under interferon alpha. The results are similar in women and men although almost twice as many men had an emergency consultation; 78.5% (11 patients) of already interferon alpha-treated patients in the past (14 patients) considered that the psychiatric accompaniment was extremely beneficial for their psycho-social well-being.

CONCLUSION

The antecedents of MDE and drug addiction are not predictive of the appearance of MDE under interferon alpha and should not be considered as a contra-indication of this treatment. A psychiatric accompaniment within a multidisciplinary network provides a major benefit to the patients in terms of compliance and safe care. It is essential to follow up the patients in the months following the end of antiviral treatment, above all if this latter was well-tolerated.

[Apropos of atypical melancholia with Sustiva (efavirenz)]

The treatment of HIV infection has changed dramatically in recent years as a result of the development of new drugs which allows a variety of multitherapy combinations more adapted to patients' needs and thereby improving compliance. Efavirenz is a non-nucleoside reverse transcriptase inhibitor. In addition to a potent antiretroviral activity, efavirenz is an easy-to-take drug with once-daily dosing and is usually well tolerated. Efavirenz, however, may induce psychic alterations which are variable and atypical in both their clinical presentation and severity. As early as the first days of treatment, efavirenz may provoke surprising phenomena such as nightmares, vivid dreams, hallucinations or illusions, and twilight states. Depersonalization and derealization episodes, personality alterations, stream of thought troubles and unusual thought contents, atypical depression and cognitive disorders have also been observed. These phenomena may occur either early or later on treatment. The prevalence of severe psychic disorders is less than 5%, but they are often responsible for harmful treatment discontinuations. Psychiatric side effects are heterogeneous and probably not related to pre-existing psychologic weakness. We do not have enough data to evaluate these side effects and their etiopathogeny. The drug could act directly on the central nervous system since it crosses the blood-brain barrier, on the serotoninergic and dopaminergic systems. Some authors have compared efavirenz-induced psychic effects to those associated with LSD and found structural similarities between the two molecules. However, the heterogeneity and low prevalence of the psychiatric side effects of efavirenz suggest and individual sensitivity. In order to improve patient care, a better clinical approach, neuropsychological evaluation, and functional brain imagery should be used to progress in the analysis and comprehension of these disorders. We discuss in this paper the case of Mister H. This HIV-infected person presented with two severe melancholic episodes associated with marked cognitive disorders which resisted two successive antidepressant treatments (viloxazine and citalopram, respectively) prescribed at effective doses and for sufficient time duration. Mister H. had no personal or family psychiatric antecedent. His psychic condition improved only when efavirenz was discontinued. However, drug discontinuation may not be an obligatory step to improve the patient's condition since antidepressant treatment has been found effective in some similar situations. Actually, each case should be discussed with the clinicians taking care of the patient.

Comparison of the effects of iodine and iodide on thyroid function in humans

Concerns have been raised over the use of iodine for disinfecting drinking water on extended space flights. Most fears revolve around effects of iodide on thyroid function. iodine (I2) is the form used in drinking-water disinfection. Risk assessments have treated the various forms of iodine as if they were toxicologically equivalent. Recent experiments conducted in rats found that administration of iodine as I- (iodide) versus I2 had opposite effects on plasma thyroid hormone levels. I2-treated animals displayed elevated thyroxine (T4) and thyroxine/triiodothyronine (T/T3) ratios, whereas those treated with I- displayed no change or reduced plasma concentrations of T4 at concentrations in drinking water of 30 or 100 mg/L. The study herein was designed to assess whether similar effects would be seen in humans as were observed in rats. A 14-d repeated-dose study utilizing total doses of iodine in the two forms at either 0.3 or 1 mg/kg body weight was conducted with 33 male volunteers. Thyroid hormones evaluated included T4, T3, and thyroid-stimulating hormone (TSH). TSH was significantly increased by the high dose of both I2 and I-, as compared to the control. Decreases in T4 were observed with dose schedules with I- and I2, but none were statistically significant compared to each other, or compared to the control. This human experiment failed to confirm the differential effect of I2 on maintenance of serum T4 concentrations relative to the effect of I- that was observed in prior experiments in rats. However, based on the elevations in TSH, there should be some concern over the potential impacts of chronic consumption of iodine in drinking water.