Effects of Age on Treatment of Chronic Hepatitis C with Direct Acting Antivirals

INTRODUCTION AND AIM

Data on the efficacy and tolerance of interferon-free treatment in chronic hepatitis C (CHC) in elderly patients are limited in phase II-III trials.

MATERIAL AND METHODS

A prospective cohort of adult patients with CHC treated in French general hospitals.

RESULTS

Data from 1,123 patients, distributed into four age groups, were analyzed. Of these, 278 were > 64 years old (fourth quartile) and 133 were > 73 years old (tenth decile). Elderly patients weighed less, were more frequently treatment-experienced women infected with genotype 1b or 2, while they less frequently had genotype 3 or HIV coinfection, but had more frequent comorbidities and drug consumption. Half of the patients had cirrhosis, whatever their ages. The main treatment regimens were sofosbuvir/ledipasvir (37.8%), sofosbuvir/daclatasvir (31.8%), sofosbuvir/simeprevir (16.9%), sofosbuvir/ribavirin (7.8%); ribavirin was given to 24% of patients. The overall sustained virological response (SVR) rate was 91.0 % (95% CI: 89.292.5%) with no difference according to age. Logistic regression of the independent predictors of SVR were albumin, hepatocellular carcinoma and treatment regimen, but not age. The rate of severe adverse events (66 in 59/1062 [5.6%] patients) tended to be greater in patients older than 64 years of age (21/261,8.1%), but the only independent predictors of SAE by logistic regression were cirrhosis and baseline hemoglobin. Patient-reported overall tolerance was excellent in all age groups, and patient-reported fatigue decreased during and after treatment, independent of age.

CONCLUSIONS

The high efficacy and tolerance of interferon-free regimens is confirmed in elderly patients in real-life conditions.

In routine clinical practice, few physicians use early viral kinetics to guide HCV dual therapy treatment decisions

BACKGROUND & AIMS

PROPHESYS is a large, multinational, non-interventional prospective cohort study of chronic hepatitis C patients treated with peginterferon alfa/ribavirin. This subanalysis assesses rates of premature treatment discontinuation stratified by on-treatment virological response (VR).

METHODS

This PROPHESYS subanalysis is restricted to treatment-naive, hepatitis C virus (HCV) genotype (G)1/2/3 mono-infected patients who received peginterferon alfa-2a (40KD)/ribavirin with intended treatment duration of 48 (G1) or 24 weeks (G2/3). Early virological responses were classified into four mutually exclusive categories [rapid VR (RVR), complete early VR (cEVR), partial EVR (pEVR), no RVR/EVR], using standard criteria.

RESULTS

The likelihood for shortening treatment owing to good efficacy was highest among patients with an RVR and HCV RNA≤400 000 IU/ml (G1 10.0%; G2/3 5.8%) whereas for poor efficacy, it was highest in G1 non-RVR/EVR patients with HCV RNA>400 000 IU/ml (56.6%). Factors significantly associated with early treatment discontinuation as a result of good efficacy in G1 patients included RVR vs. no RVR/EVR and, at baseline, lower HCV RNA, lower FIB-4 score, HCV infection via injection drug use. For G2/3 patients, factors included lower baseline HCV RNA and G2 vs. G3 infection. Most patients started with the recommended peginterferon alfa-2a dose, but a high proportion received a higher-than-recommended ribavirin dose.

CONCLUSIONS

Despite international guidelines, few physicians used early viral kinetics to abbreviate treatment. Therefore, relatively few patients with an RVR and low baseline HCV RNA abbreviated treatment. In addition, there were deviations in ribavirin starting doses, suggesting that physicians tailor treatment according to local guidelines or previous experience.

[Measurement of the quality of life in chronic hepatitis C: validation of a general index and specific index. First French results]

OBJECTIVES

To report the validation of 2 questionnaires of quality of life in chronic hepatitis C and the first results in 100 patients.

METHODS

The questionnaire included 118 items and took 30 to 45 minutes to answer. It included a general index, the Nottingham Health Profile, with 38 items in 6 themes (physical mobility, social isolation, emotional reactions, pain, sleep and energy) and a specific index, the Montpellier Specific Index, with 80 items in 7 themes: symptoms, food, alcohol and tobacco, work, relations with other people, perception of disease.

RESULTS

The questionnaires were self-administered to the 100 first patients with chronic hepatitis C without cirrhosis before treatment; 55 men, 45 women, average age 40 year-old, median Knodell's score 8 and median METAVIR score A2 F1. Reduction in the quality of life was frequent and was not highly correlated with biological, virological and histological parameters; it was associated with psychological disorders, reduced sexuality and apprehension of the future.

CONCLUSION

This study showed the feasibility, validation, sensitivity and agreement of a quality of life questionnaire, which included a general index and a specific index of chronic hepatitis C in France. These initial results must be confirmed in studies during antiviral treatment of patients.

Acute hepatitis after riluzole administration

Riluzole is a new drug representing the first active treatment for amyotrophic lateral sclerosis. We report the cases of two patients who developed acute hepatitis after taking riluzole at the recommended dose (100 mg daily) for 7 and 4 weeks, respectively. In both cases, liver histology showed hepatocellular damage with inflammatory infiltration and microvesicular steatosis without fibrosis. Liver enzymes returned to normal 4 and 8 weeks, respectively, after riluzole withdrawal. In one case, the readministration of riluzole was followed by the relapse of hepatitis. These two observations strongly suggest that riluzole can induce acute hepatitis with associated hepatocellular damage and microvesicular steatosis. They also suggest that liver enzymes should be monitored during treatment with riluzole.

[Extrahepatic cancer in cirrhosis patients. A retrospective clinical study of 164 diagnosed cancers in 2060 cirrhosis patients]

A retrospective study of 2060 inpatients with cirrhosis of the liver identified 164 patients with extrahepatic cancer, a 20-fold increase over the expected number. Gastrointestinal, ENT, pulmonary, and hematologic malignancies predominated. Extrahepatic cancers occur more often and at an earlier age in patients with cirrhosis of the liver than in the population at large.

Cross hepatotoxicity between tricyclic antidepressants and phenothiazines

OBJECTIVE

To describe a case of cross hepatotoxicity between tricyclic antidepressants and phenothiazines.

PATIENT

A woman who developed three episodes of drug-induced hepatitis within 3 years as a result of successive treatment with two tricyclic antidepressants, trimipramine and desipramine, and one neuroleptic derivative, cyamemazine.

INTERVENTIONS

The drugs were withdrawn after the patient experienced liver dysfunction, although bromazepam was later administered with no side effects.

RESULTS

After three episodes of drug-induced hepatitis the patient's serum aspartate aminotransferase and alanine aminotransferase levels returned to normal when the tricyclic antidepressants and cyamemazine were withdrawn.

CONCLUSIONS

Trimipramine, desipramine and cyamemazine are related by their chemical structures which include a tricyclic ring. This suggests that this chemical moiety might be involved in the hepatotoxicity of tricyclic antidepressants and phenothiazine derivatives.

[Amyloidosis of the gallbladder. An unusual localization]

We report a rare case of amyloidosis of the gallbladder in a 60-year-old man. This amyloidosis was associated with hepatic amyloidosis and pancreatic adenocarcinoma. To our knowledge, this is the second case reported in the literature and the first associated with neoplastic pathology.