Sequential therapy with entecavir and pegylated interferon in a cohort of young patients affected by chronic hepatitis B.

The treatment of patients affected by active chronic hepatitis B (CHB) could be performed using a finite-time therapy with pegylated-interferon alpha (PEG-IFN) or indefinite time treatment with nucleos(t)ide analogues (NAs). Current practice guidelines do not provide the combined use of PEG-IFN and NAs, but some studies analyzed various combined approach with NAs and PEG-IFN with encouraging result. In this perspective study, we have treated 39 patients with different hepatitis B virus (HBV) genotypes, hepatitis B "e" antigen (HBeAg)-positive/negative using a sequential therapy with entecavir (ETV) 0.5 mg/day monotherapy for 12 weeks followed by combination of ETV and PEG-IFN α-2a 180 µg/week for 12 weeks, then PEG-IFN monotherapy for 36 weeks. HBeAg seroconversion rate was 68.2%; HBsAg loss was 33.3%; sustained virological response (SVR) was 64.1%; primary non-response was observed in eight patients (20.5%) after 12 weeks of PEG-IFN therapy; virological relapse was reported in six (15.3%) patients. Viral genotype and hepatitis B surface antigen (HBsAg) decline were the most important predictive factor for PEG-IFN response. The stopping rule after 12 weeks of PEG-IFN therapy is useful for identify the non-responders. Our study offers interesting and promising results using a sequential combined therapy with ETV and PEG-IFN in a cohort of young patient with active CHB. These results, however, should not be generalized and further investigations are required for the confirmation of advantage of this combination approach. J. Med. Virol. 88:1953-1959, 2016. © 2016 Wiley Periodicals, Inc.

Role of IL28B genotyping in patients with hepatitis C virus-associated mixed cryoglobulinemia and response to PEG-IFN and ribavirin treatment.

The role of interleukin (IL) 28B in the treatment of chronic hepatitis C (CHC) has recently been examined in many studies, while a possible relationship between IL28B and the presence of mixed cryoglobulinemia (MC) remains to be clarified. In this study, we analyzed the influence of IL28B rs8099917/rs12979860 on the presence of MC and the role in treatment with PEG-IFN. We retrospectively examined 541 patients affected by CHC who were treated with pegylated interferon (PEG-IFN) and ribavirin from 2003 to 2012. We included all treatment-naïve patients without other viral co-infections or major contraindications to the PEG-IFN and ribavirin standard of care. One hundred seventy-five patients (32.3 %) had MC; 49 of these (33.3 %) had symptomatic MC. The IL28B rs8099917/rs12979860 TT/CC genotype was the most frequent in MC-positive patients with sustained virological response (SVR) (p < 0.001), while the TG/TC genotype was most frequent in non-SVR (p < 0.001). The TT/CC genotype was found to be the main positive predictive factor of MC in HCV patients (OR = 11.914; IQR = 7.092-18.776; p < 0.001); HCV genotype 2/3 was the strongest positive predictive factor of SVR (OR = 10.448; IQR = 8.352-21.561; p < 0.001); IL28B rs8099917/rs12979860 TT/CC was a better predictive factor than rs12979860 CC alone (OR = 9.829 vs. 2.663). Negative predictive factors were Metavir score F3-F4 (OR = 0.625; IQR = 0.416-0.779; p = 0.008), insulin-resistance (OR = 0.315; IQR = 0.224-0.585; p < 0.001) and presence of symptoms (OR = 0.716; IQR = 0.492-0.855; p < 0.001). IL28B rs8099917/rs12979860 is useful in the treatment of MC-positive HCV patients with PEG-IFN and ribavirin; the TT/CC genotype is associated with SVR, the TG/TC with non-SVR; TT/CC is also predictive of MC in HCV patients.

Development and In-House Validation of an Enzyme-Linked Immunosorbent Assay and a Lateral Flow Immunoassay for the Dosage of Tenofovir in Human Saliva.

Highly active antiretroviral therapy (HAART) includes very potent drugs that are often characterized by high toxicity. Tenofovir (TFV) is a widely used drug prescribed mainly for pre-exposure prophylaxis (PreP) and the treatment of human immunodeficiency virus (HIV). The therapeutic range of TFV is narrow, and adverse effects occur with both underdose and overdose. The main factor contributing to therapeutic failure is the improper management of TFV, which may be caused by low compliance or patient variability. An important tool to prevent inappropriate administration is therapeutic drug monitoring (TDM) of compliance-relevant concentrations (ARCs) of TFV. TDM is performed routinely using time-consuming and expensive chromatographic methods coupled with mass spectrometry. Immunoassays, such as enzyme-linked immunosorbent assays (ELISAs) and lateral flow immunoassays (LFIAs), are based on antibody-antigen specific recognition and represent key tools for real-time quantitative and qualitative screening for point-of-care testing (POCT). Since saliva is a non-invasive and non-infectious biological sample, it is well-suited for TDM. However, saliva is expected to have a very low ARC for TFV, so tests with high sensitivity are required. Here, we have developed and validated a highly sensitive ELISA (IC50 1.2 ng/mL, dynamic range 0.4-10 ng/mL) that allows the quantification of TFV in saliva at ARCs and an extremely sensitive LFIA (visual LOD 0.5 ng/mL) that is able to distinguish between optimal and suboptimal ARCs of TFV in untreated saliva.

Negative predictive value of IL28B, SLC28A2, and CYP27B1 SNPs and low RBV plasma exposure for therapeutic response to PEG/IFN-RBV treatment.

OBJECTIVES: The response rate to treatment of chronic hepatitis C virus-genotype 1 and 4 infections was recently found to be strongly influenced by many polymorphisms. The aim of our study was to carry out an integrated analysis of the effects of polymorphisms and ribavirin (RBV) plasma exposure on outcome. METHODS: The retrospective analysis included 174 patients. IL28B, CYP27B1, SLC29A1, SLC28A3, and SLC28A2 polymorphisms were genotyped and tested for association with sustained virological response. The impact of RBV plasma exposure during the first 3 months of therapy on outcome was also investigated. RESULTS: Considering patients infected by hepatitis C virus-1/4, 3 polymorphisms (IL28B rs8099917TT, CYP27B1 rs4646536TT, and CNT2 rs11854484TT) were associated with sustained virological response. The number of negative variant allele and low RBV exposure were correlated to percentage increasing to therapy failure, suggesting some degree of cumulative effect of the 4 factors. A cutoff of 2.5 µg/mL of RBV was found to be associated with outcome (area under ROC [AUROC] curve = 0.64, sensitivity = 55.0%, and specificity = 71.2%, P = 0.020). In multivariate logistic regression analyses, each variant allele and RBV plasma exposure cutoff were independently associated with outcome. CONCLUSIONS: In this study, we found that additional polymorphisms and RBV plasma exposure are also able to influence the achievement of response. Regardless of the magnitude of RBV pharmacokinetic exposure, the negative predictive value of the polymorphisms here investigated is much stronger than the positive one.

Treatment with PEG-IFN and ribavirin in patients with chronic hepatitis C, low grade of hepatic fibrosis, genotype 1 and 4 and favorable IFNL3 genotype: A pharmacogenetic prospective study.

The new direct-acting antivirals agents (DAAs) rapidly changed the treatment approach in chronic hepatitis C (CHC); however, the interferon (IFN)-free therapies availability is currently different in some countries, due to higher costs of these drugs. Naïve treated patients, who are not eligible for IFN-free therapies, could be selected for standard dual treatment with pegylated (PEG)-IFN and ribavirin (RBV), through IFN lambda 3 gene polymorphisms and fibrosis stage evaluation. Inclusion criteria were: naïve treated CHC patients with GT1 or GT4, without major contraindication to PEG-IFN or RBV, with fibrosis stage F0-F2 and IFNL3 rs8099917/rs12979860 TT/CC genotypes. 65 patients were included in the study. Overall SVR was observed in 50 patients (76.9%); SVR rates among different genotypes were as follows: 15 with GT1a (71.4%), 27 with GT1b (79.4%) and 8 for GT4 (80%). The RBV cutoff at 2weeks of 1800ng/mL, predictor of RVR, was determined (p=0.003; sensibility=60.4%, specificity=88.2%, positive predictive value=88.9%, negative predictive value=100%). In multivariate analysis, factors significantly associated with treatment failure were living alone condition (OR=4.302; 95%IC=1.254-16.257; p=0.034) and RBV plasma level <1800ng/mL at 2weeks (OR=4.970; 95%IC=1.405-17.565; p=0.009). Considering a pharmacogenetic-guided approach, dual therapy with PEG-IFN and RBV can be considered a reliable option for patients ineligible for IFN-free treatments, who are motivated and well informed about all the aspects related to PEG-IFN administration.

Role of HBsAg decline in patients with chronic hepatitis B HBeAg-negative and E genotype treated with pegylated-interferon.

Treatment options for patients with chronic hepatitis B (CHB) and hepatitis B e antigen (HBeAg)-negative are pegylated interferon alfa-2a (PEG-IFN) for 48 weeks or nucleos(t)ide analogues (NAs). The choice of patients with higher chance of sustained response (SR) to PEG-IFN can be made with pre-treatment and on-treatment factors; recent studies evidenced the role of early drop of serum hepatitis B surface antigen (HBsAg) as predictor of SR. The aim of this study was the evaluation of early decrease of HBsAg on the SR in HBeAg-negative patients with E genotype. A retrospective analysis was performed on 72 patients affected by HBeAg-negative CHB with E genotype, treated for 48 weeks with PEG-IFN. HBsAg and HBV-DNA kinetics were evaluated. Decline of HBsAg (>0.5 logIU/mL) and HBV-DNA (≥2 logIU/mL) at 12 weeks was described according to observed chance of SR. After 96 weeks of follow-up, SR was observed in 10 patients (13.9%); HBsAg loss 6 (8.3%), HBsAg seroconversion in 3 (4.2%). No patients with HBsAg decline ≤0.5 log IU/mL and HBV-DNA<2 logIU/mL achieved SR (negative predictive value, NPV 100%). In multivariate analysis were significantly associated with SR the combined decline of HBsAg and HBV-DNA at 12 weeks (OR = 35.336; 95% CI: 4.668-112.226; p < 0.001) and the HBsAg≤7500 IU/mL at 24 weeks (OR = 51.824; 95% CI: 9.692-134.144; p < 0.001). Combining the HBsAg and HBV-DNA decline at 12 weeks we can identify patients without chance of SR who may stop PEG-IFN treatment. Stopping rule at 24 weeks using HBsAg≤7500 IU/mL is strong predictor of SR in HBeAg-negative patients with E genotype.

Physical and Chemical Stability of Urapidil in 0.9% Sodium Chloride in Elastomeric Infusion Pump.

Urapidil is an antihypertensive agent, usually administered through intravenous bolus injection, slow-intravenous infusion, or continuous-drug infusion by perfusor. Since to date no evidences are available on drug stability in elastomeric pumps, patients have to be hospitalized. The purpose of this study was to validate an ultra-performance liquid chromatographic method to evaluate urapidil stability in an elastomeric infusion pump, in order to allow continuous infusion as home-care treatment. Analyses were conducted by diluting urapidil in an elastomeric pump. Two concentrations were evaluated: 1.6 mg/mL and 3.3 mg/mL. For the analyses, a reverse-phase ultra-performance liquid chromatographic- photodiode array detection instrument was used. Stressed degradation, pH changes, and visual clarity were used as stability indicators up to 10 days after urapidil solution preparation. The drug showed no more than 5% degradation during the test period at room temperature. No pH changes and no evidences of incompatibility were observed. Stress tests resulted in appreciable observation of degradation products. Considering the observed mean values, urapidil hydrochloride in sodium chloride 0.9% in elastomeric infusion pumps is stable for at least 10 days. These results indicate that this treatment could be administered at home for a prolonged duration (at least 7 days) with a satisfactory response.

Treatment optimization of naïve HCV-1 patients using IL28B, RVR and fibrosis stage.

The treatment of patients with HCV genotype 1 is quickly changing. The clinician could optimize the selection of patients who may benefit from standard therapy with pegylated-interferon and ribavirin instead of more expensive new combinations with the directly acting antivirals. We retrospectively examined in our cohort of 232 patients with genotype 1 infection the role of interleukin 28B (both rs8099917 and rs12979860), fibrosis stage and rapid virological response. Global SVR in TT/CC patients was 88.3% (98% in F0-F1, 80% in F2-F3); in TT/TC was 68.2 (85% in F0-F1, 71.4% in F2-F3). Rapid virological response was related to rs12979860 CC genotype but is not useful to predict the virological response in TG/GG patients at rs8099917. The standard dual therapy may be successfully administered in all TT/CC and TT/TC patients without F4 fibrosis score. Conversely, patients with TG/CC or GG/CC genotypes should be treated with other therapeutic options.

Role of IL28-B polymorphisms in the treatment of chronic hepatitis B HBeAg-negative patients with peginterferon.

Interleukin (IL)28-B polymorphism has been related to interferon response in the treatment of hepatitis C, but its role in chronic hepatitis B (CHB) therapy is still poorly understood. We aimed to investigate the effect of IL28-B polymorphisms in the treatment with pegylated-interferon (PEG-IFN) of patients with CHB. We retrospectively analyzed 190 patients with chronic hepatitis B e antigen (HBeAg) negative, genotype A (22%), B (12%), C (10%), D (33%), E (20%), treated with PEG-IFN alfa-2a for 48weeks; genotype analysis was performed for IL28-B polymorphisms rs12979860, rs8099917 and rs12980275 according to virological, serological and biochemical response. During 2years of follow-up 12 patients (6.3%) cleared hepatitis B surface antigen (HBsAg) with seroconversion, 40 (21%) obtained a negative viral load and 104 (54.7%) gained a biochemical response. We found a difference of distribution of rs12979860 CC genotype among different ethnicity (p=0.013). Rs12979860 CC genotype was significantly associated with serological and virological response (p<0.001); rs8099917 TT and rs12980275 AA genotypes were mostly related with virological response (p<0.001). In multivariate logistic analysis rs12979860 CC was predictive of virological response (OR=4.290; CI=1.589-11.580, p=0.004) and serological response (OR=10.129; CI=2.440-42.044; p<0.001). Rs8099917 TT was predictive only of virological response (OR=3.746, CI=1.235-11.355; p=0.020). The E genotype was a negative predictive factor of virological response (OR=0.057; CI=0.014-0.238; p<0.001). IL28-B polymorphisms are related to different response in the treatment of CHB HBeAg-negative with PEG-IFN, and the E genotype is a novel negative predictive factor.