Experiencia en práctica clínica real con los nuevos antivirales de acción directa en hepatitis crónica C / Experience in real clinical practice with new direct acting antivirals in chronic hepatitis C

Introducción y objetivo: La inclusión en práctica real de los antivirales de acción directa en pacientes con hepatitis crónica por VHC ha supuesto un hito histórico en Medicina. Pacientes y métodos: Estudio analítico, prospectivo que incluyó 126 pacientes con hepatitis crónica por VHC tratados con antivirales de acción directa. Evaluamos la eficacia y seguridad del tratamiento y factores asociados a fracaso terapéutico. Resultados: Edad 54±10 años. Varón (70%). Cirrosis (60%). Distribución según genotipos: G1a (31%), G1b (42%); G3 (14%); G4 (13%). Child-Pugh B y C (n=15). Naïve (56%). Tasa RVS fue (87,3%): Child-A (91%), Child-B (75%) y Child-C (60%). Las mejores tasas de curación se alcanzaron con las combinaciones Combo 3D/2D±ribavirina (RVS=97,4%; n=39) y sofosbuvir/ledipasvir±ribavirina (RVS=93,1%; n=29). Tasas<90% se registraron con: sofosbuvir+simeprevir±ribavirina (RVS=88%; n=25), simeprevir+daclatasvir±ribavirina (RVS=78%; n=18) y sofosbuvir+daclatasvir±ribavirina (RVS=73,3%; n=15). La adicción de ribavirina a estas 3 últimas opciones terapéuticas (n=19) mejoraba las tasas de curación (RVS=94,7%; 18/19) frente a su ausencia (n=39; RVS=77%). Mejoría MELD (40%). Salida lista trasplante (20%). Sustituciones asociadas a resistencias NS3: G1a (posiciones 80K; n=5); G1b y G4 (posición 168 y 36; n=4), mientras para NS5a: G1a (posición 30; n=2) y G1b y G3 (posición 93; n=3). Variables asociadas al fracaso en análisis multivariante (p<0,05): presencia de ascitis, G3 y dosis de ribavirina<600mg/día. Discusión: La presencia de genotipo 3, ascitis o dosis de ribavirina<600mg/día se asoció a mayores tasas de fracasos. Sería recomendable el uso de ribavirina≥600mg/día en cirróticos G1 o G3, que vayan a ser tratados con sofosbuvir+simeprevir o daclatasvir, si no hubiese disponibilidad de un test de resistencia basal (AU)

Introduction and objective: Inclusion of direct-acting antivirals into clinical practice in patients with chronic HCV (CHC) has been a milestone in medicine. Patients and methods: Analytical, prospective study, involving 126 patients with chronic HCV treated with direct-acting antivirals. Efficacy and safety of treatment and factors associated with failure treatment were evaluated. Results: Age 54±10. Male (70%). Cirrhosis (60%). Distribution according to genotypes: G1a (31%), G1b (42%); G3 (14%); G4 (13%). Child-Pugh B and C (n=15). Naïve (56%). SVR rate was (87.3%): Child-A (91%), Child-B (75%) and Child-C (60%). The best cure rates were achieved with a 3D/2D±ribavirin (SVR=97.4%;n=39) and sofosbuvir/ledipasvir±ribavirin (RVS=93.1%; n=29) combination. An SVR rate of <90% was achieved with sofosbuvir+simeprevir±ribavirin (SVR=88%, n=25), simeprevir+daclatasvir±ribavirin 73%, n=15). The association of ribavirin to these last three therapeutic options (n=19) improved cure rates (SVR=94.7%, 18/19) compared to its absence (n=39;SVR=77%). Improvement in MELD (40%). Output transplant list (20%). Substitutions associated with resistors NS3: G1a (positions 80K; n=5); G1b and G4 (position 168 and 36; n=4), while for NS5a: G1a (position 30; n=2) and G1b and G3 (position 93; n=3). Variables associated with failure in multivariate analysis (p<0.05): presence of ascites, G3 and ribavirin dosage<600mg/day. Discussion: The presence of genotype 3, ascites or dosage of ribavirin<600mg/day were associated with higher failure rates. The use of ribavirin>600mg/day in cirrhotic G1 or G3, who will be treated with sofosbuvir+simeprevir or daclatasvir is recommended where no baseline resistance test is available (AU)

Experience in real clinical practice with new direct acting antivirals in chronic hepatitis C. / Experiencia en práctica clínica real con los nuevos antivirales de acción directa en hepatitis crónica C.

INTRODUCTION AND OBJECTIVE: Inclusion of direct-acting antivirals into clinical practice in patients with chronic HCV (CHC) has been a milestone in medicine. PATIENTS AND METHODS: Analytical, prospective study, involving 126 patients with chronic HCV treated with direct-acting antivirals. Efficacy and safety of treatment and factors associated with failure treatment were evaluated. RESULTS: Age 54±10. Male (70%). Cirrhosis (60%). Distribution according to genotypes: G1a (31%), G1b (42%); G3 (14%); G4 (13%). Child-Pugh B and C (n=15). Naïve (56%). SVR rate was (87.3%): Child-A (91%), Child-B (75%) and Child-C (60%). The best cure rates were achieved with a 3D/2D±ribavirin (SVR=97.4%;n=39) and sofosbuvir/ledipasvir±ribavirin (RVS=93.1%; n=29) combination. An SVR rate of <90% was achieved with sofosbuvir+simeprevir±ribavirin (SVR=88%, n=25), simeprevir+daclatasvir±ribavirin 73%, n=15). The association of ribavirin to these last three therapeutic options (n=19) improved cure rates (SVR=94.7%, 18/19) compared to its absence (n=39;SVR=77%). Improvement in MELD (40%). Output transplant list (20%). Substitutions associated with resistors NS3: G1a (positions 80K; n=5); G1b and G4 (position 168 and 36; n=4), while for NS5a: G1a (position 30; n=2) and G1b and G3 (position 93; n=3). Variables associated with failure in multivariate analysis (p<0.05): presence of ascites, G3 and ribavirin dosage<600mg/day. DISCUSSION: The presence of genotype 3, ascites or dosage of ribavirin<600mg/day were associated with higher failure rates. The use of ribavirin>600mg/day in cirrhotic G1 or G3, who will be treated with sofosbuvir+simeprevir or daclatasvir is recommended where no baseline resistance test is available.

¿Son útiles los antisecretores en el manejo de la hemorragia digestiva alta no varicosa? / Are anti-secretory drugs useful for the management of non-variceal upper gastrointestinal haemorrhage?

La hemorragia digestiva alta no varicosa supone la causa más importante de sangrado digestivo, siendo una consulta frecuente en los servicios de urgencias hospitalarios. El tratamiento médico basado en el uso de inhibidores de la bomba de protones (IBP), junto con el tratamiento endoscópico, ha demostrado disminuir de manera significativa las tasas de resangrado, mejorando la supervivencia de estos pacientes. Después de dos décadas desde la comercialización de los (IBP), a día de hoy sigue existiendo controversia en cuanto a su dosificación y forma de administración en los pacientes con hemorragia digestiva de origen péptico (AU)

Non-variceal upper gastrointestinal haemorrhage, is the most frequent cause of gastrointestinal bleeding and is a common presentation in emergency departments. Medical treatment based on the use of proton pump inhibitors (PPIs), together with endoscopic therapy, has been shown to significantly lower rates of rebleeding and improve survival in these patients. Two decades after the marketing of PPIs there is still controversy as to dosage and method of administration for patients with gastrointestinal bleeding of peptic origin (AU)