The impact of sofosbuvir/velpatasvir/voxilaprevir treatment on serum hyperglycemia in hepatitis C virus infections: a systematic review and meta-analysis

BACKGROUND

The combination of Sofosbuvir (SOF), velpatasvir (VEL), and voxilaprevir (VOX) is an effective, safe rescue therapy for patients with previous treatment failure. Direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) infection in diabetics with a history of hypoglycemia could improve insulin resistance due to HCV clearance. However, some studies have shown that SOF/VEL/VOX causes grade 3 hyperglycemia and other adverse events, which contradicts the findings of other DAA studies.

AIM

To analyze the incidence of grade 3 hyperglycemia of SOF/VEL/VOX for chronic HCV infection.

METHODS

We searched electronic databases from the inception of each database until October 2021. A random-effects model was employed to pool data. The study was conducted according to the PRISMA guidelines, and quality assessment was performed by using the Cochrane risk-of-bias tool for randomized controlled trials (RCTs). The study protocol was registered on the INPLASY database (Registration No. 2021120109).

RESULTS

Five RCTs were included in this review. Overall, 49 of 2315 patients had grade 3 hyperglycemia with a risk ratio of 0.015 (95% confidence interval, 0.010-0.020; p < .001), and the incidence risk ratio (IRR) for cirrhosis compared to without cirrhosis was 12.000 (95% confidence interval: 0.727-198.160), the HCV genotype 3-genotype 1 IRR was 4.13 (95% confidence interval: 1.52-11.22) in subgroup analysis. No significant differences were found within the other subgroups, in prior DAA treatment experience, and in treatment duration.

CONCLUSION

Although the incidence of hyperglycemia was rare in diabetic patients with HCV, it is recommended that glucose levels be closely monitored during the first 3 months of therapy and that diabetes medication be modified if necessary.

A randomized controlled trial of SOF/VEL/VOX with or without ribavirin for retreatment of chronic hepatitis C

BACKGROUND & AIMS

The combination of sofosbuvir, velpatasvir and voxilaprevir (SOF/VEL/VOX) is recommended retreatment for patients with hepatitis C virus (HCV) infection who failed previous direct-acting antiviral (DAA) treatment. However, whether ribavirin further increases the therapeutic efficacy of SOF/VEL/VOX retreatment remains unclear. We aimed to test this hypothesis by a randomized controlled trial.

METHODS

We randomly assigned 315 patients with DAA treatment failure from 5 Egyptian sites into two groups. Group A (n=158) received SOF/VEL/VOX for 12 weeks, and group B (n=157) received SOF/VEL/VOX + weight-based ribavirin for 12 weeks. Therapeutic efficacy was defined as SVR12 (undetectable HCV RNA 12 weeks after treatment completion). Safety and tolerability were evaluated by monitoring treatment-related adverse events (AEs) and laboratory abnormalities.

RESULTS

Seventeen patients in each group were lost to follow-up. SVR12 rates by intention-to-treat (ITT) were 87.3% (138/158), and by per-protocol analysis, 97.8% (138/141) in group A; and 87.9% (138/157) and 98.5% (138/140) in group B (p=NS for ITT and PP). Males comprised 53.9% of group A, and 57.1% in group B (p=0.58), with mean ages of 51.8 and 47.3 years in group A and B, respectively. Both regimens were well-tolerated, with no deaths and only one serious AE (anemia) in group B requiring ribavirin discontinuation. Fifty-five patients in group A vs. 77 in group B experienced any adverse events (p=0.002).

CONCLUSION

This randomized controlled trial showed equal, high efficacy of both regiments in retreating previous DAA failures, although ribavirin was associated with more adverse events. Therefore SOF/VEL/VOX monotherapy should be the preferred retreatment strategy.

IMPACT AND IMPLICATIONS

HCV treatment guidelines recommend retreating DAA treatment failures with the combination of sofosbuvir, velpatasvir and voxilaprevir (SOF/VEL/VOX) for 12 weeks. However, whether ribavirin exerts an additional/synergistic effect remains unclear. The present study confirmed that SOF/VEL/VOX without ribavirin is the best regimen for retreating DAA treatment failures, and thus will help clinicians caring for patients who are not cured with a first course of DAA therapy. CLINCIALTRIALS.

GOV NUMBER

NCT04695769.