Cost‐effectiveness of elbasvir/grazoprevir use in treatment‐naive and treatment‐experienced patients with hepatitis C virus genotype 1 infection and chronic kidney disease in the United States

Among patients with chronic kidney disease (CKD) in the United States, HCV infection causes significant morbidity and mortality and results in substantial healthcare costs. A once‐daily oral regimen of elbasvir/grazoprevir (EBR/GZR) for 12 weeks was found to be a safe and efficacious treatment for HCV in patients with CKD. We evaluated the cost‐effectiveness of EBR/GZR in treatment‐naïve and treatment‐experienced CKD patients compared with no treatment (NoTx) and pegylated interferon plus ribavirin (peg‐IFN/RBV) using a computer‐based model of the natural history of chronic HCV genotype 1 infection, CKD and liver disease. Data on baseline characteristics of the simulated patients were obtained from NHANES, 2000–2010. Model inputs were estimated from published studies. Cost of treatment with EBR/GZR and peg‐INF/RBV were based on wholesale acquisition cost. All costs were from a third‐party payer perspective and were expressed in 2015 U.S. dollars. We estimated lifetime incidence of liver‐related complications, liver transplantation, kidney transplantation, end‐stage live disease mortality and end‐stage renal disease mortality; lifetime quality‐adjusted life years (QALY); and incremental cost‐utility ratios (ICUR). The model predicted that EBR/GZR will significantly reduce the incidence of liver‐related complications and prolong life in patients with chronic HCV genotype 1 infection and CKD compared with NoTx or use of peg‐IFN/RBV. EBR/GZR‐based regimens resulted in higher average remaining QALYs and higher costs (11.5716, $191 242) compared with NoTx (8.9199, $156 236) or peg‐INF/RBV (10.2857, $186 701). Peg‐IFN/RBV is not cost‐effective, and the ICUR of EBR/GZR compared with NoTx was $13 200/QALY. Treatment of a patient on haemodialysis with EBR/GZR resulted in a higher ICUR ($217 000/QALY). Assuming a threshold of $100 000 per QALY gained for cost‐effectiveness, use of elbasvir/grazoprevir to treat an average patient with CKD can be considered cost‐effective in the United States.     

More improvement than progression of liver fibrosis following antiretroviral therapy in a longitudinal cohort of HIV‐infected patients with or without HBV and HCV co‐infections

We examined the effect of combination antiretroviral therapy (cART) on liver fibrosis among HIV‐infected patients with or without hepatitis B (HBV) or C virus (HCV) co‐infection. This was a retrospective cohort study of HIV‐infected patients receiving cART during 2004‐2016. Liver fibrosis was assessed using Fibrosis‐4 (FIB‐4) score with three classifications: Class 1, <1.45; Class 2, 1.45‐3.25; Class 3, >3.25. Of 3900 participants, 68.6% were HIV mono‐infected, 5.3% were HIV/HBV co‐infected, 23.8% were HIV/HCV co‐infected and 2.3% were HIV/HBV/HCV co‐infected. Participants received follow‐up treatment (median was 3.3 years). Improvement to a lower class was observed in Class 2 (52.6%) and Class 3 (74.2%), respectively. Progression to a higher class was observed in 12.8% and 5.0% in Class 1 and Class 2, respectively, and with a median time of 5.7 months. For improvement to lower classes, older age, male, Dai ethnicity, injection drug use, HCV co‐infection and tenofovir for treatment were negative predictors, but in Class 3 of FIB‐4 and time‐updated increases in CD4 count from baseline were positive predictors. For progression to higher classes, older age, male, Jingpo ethnicity and HCV co‐infection were positive predictors, while baseline CD4 count and in Class 2 of FIB‐4 were negative predictors. Improvement to lower class linked with decreased mortality risk among patients in Class 3. Early cART initiation for HIV‐infected patients with and without hepatitis co‐infections may mitigate or slow down some of liver fibrosis, but special attention should be given to those who are older, male, co‐infected with HCV.     

Effect of hepatitis C virus on immunological and virological responses in HIV‐infected patients initiating highly active antiretroviral therapy: a meta‐analysis

Co‐infection of human immunodeficiency virus (HIV) with hepatitis C virus (HCV) is rather common. In the era of highly active antiretroviral therapy (HAART), viral hepatitis could result in adverse outcomes in HIV+ patients. The current meta‐analysis aims to evaluate the impact of HCV on immunological and virological responses after HAART initiation in HIV/HCV co‐infected individuals by synthesizing the existing scientific evidence. A comprehensive search of electronic databases was performed. Eligible studies were analysed using univariate and multivariate meta‐analytic methods. Totally, 21 studies involving 22533 individuals were eligible. The estimated summary difference in CD4 cell counts increase between HIV and HIV/HCV co‐infected subjects after 3–12 months on HAART was 34.86 cells/mm³ [95% confidence interval (CI): 16.82–52.89]. The difference was more prominent in patients with baseline CD4 counts below 350 cells/mm³ (38.97, 95% CI: 20.00–57.93) and attenuated 2 years later (13.43, 95% CI: 0.83–26.04). The analysis of ratio measures yielded similar findings. The virological control remained unaffected by the presence of HCV (adjusted Hazard Ratio for co‐infected patients vs those with HIV alone: 0.99, 95% CI: 0.91–1.07). The bivariate meta‐analytic method confirmed the results of the univariate approaches. This meta‐analysis supports the adverse effect of HCV on immune recovery of HIV+ patients initiating HAART, especially of those with initially impaired immunologic status. Although this effect diminishes over time, early administration of HAART in the setting of co‐infection seems to be justified.     

HCV E1E2‐MF59 vaccine in chronic hepatitis C patients treated with PEG‐IFNα2a and Ribavirin: a randomized controlled trial

Hepatitis C virus (HCV) vaccines may be able to increase viral clearance in combination with antiviral therapy. We analysed viral dynamics and HCV‐specific immune response during retreatment for experienced patients in a phase Ib study with E1E2MF59 vaccine. Seventy‐eight genotype 1a/1b patients [relapsers (30), partial responders (16) and nonresponders (32) to interferon‐(IFN)/ribavirin‐(RBV)] were randomly assigned to vaccine (V:23), Peg‐IFNα2a‐180‐ug/qw and ribavirin 1000–1200‐mg/qd for 48 weeks (P/R:25), or their combination (P/R + V:30). Vaccine (100 μg/0.5 mL) was administered intramuscularly at week 0‐4‐8‐12‐24‐28‐32‐36. Neutralizing of binding (NOB) antibodies and lymphocyte proliferation assay (LPA) for E1E2‐specific‐CD4 + T cells were performed at week 0‐12‐16‐48. Viral kinetics were analysed up to week 16. The vaccine was safe, and a sustained virological response (SVR) was achieved in 4 P/R + V and 2 P/R patients. Higher SVR rates were observed in prior relapsers (P/R + V = 27.3%; P/R = 12.5%). Higher NOB titres and LPA indexes were found at week 12 and 16 in P/R + V as compared to P/R patients (P = 0.023 and 0.025, P = 0.019 and <0.001, respectively). Among the 22 patients with the strongest direct antiviral effects of IFN (ε ≥ 0.800), those treated with P/R + V (10) reached lower HCV‐RNA levels (P = 0.026) at week 16. HCV E1E2MF59 vaccine in combination with Peg‐IFNα2a + RBV was safe and elicited E1E2 neutralizing antibodies and specific CD4 + T cell proliferation. Upon early response to IFN, vaccinations were associated with an enhanced second phase viral load decline. These results prompt phase II trials in combination with new antiviral therapies.     

Acute and chronic immune biomarker changes during interferon/ribavirin treatment in HIV/HCV co‐infected patients

Chronic viral infections lead to persistent immune activation, which is alleviated by eradicating or suppressing the infection. To understand the effects of interferon treatment on immune system activation by chronic infections, we evaluated kinetic patterns of a broad spectrum of serum biomarkers during HCV treatment in HIV/HCV co‐infected patients. HCV viral load and 50 biomarkers were analysed at baseline and 27 time points during pegylated interferon‐alpha and ribavirin (IFN/RBV) treatment of 12 HIV/HCV co‐infected patients. We evaluated biomarker changes from baseline for each time point and biomarker correlations with clinical parameters, treatment response and liver histopathology. IL‐1α, IL‐12p40, IL‐1RA, IP‐10, MIG, MIP‐1α/1β, HGF, sCD40L, TRAIL and leptin increased in the first day. IL‐12p70, IL‐17A, IL‐10, GROα, IL‐8, MCP‐3, IL‐4 and M‐CSF peaked later during week 1. IL‐1α, HGF, IP‐10, MIP‐1α, TRAIL, sCD40L, IL‐10, IL‐12p70, MCP‐3, FGFb, ENA‐78, TGF‐β, IL‐2, IFN‐γ, IL‐6, IL‐15, IL‐7 and PDGF‐BB decreased below baseline over the course of treatment. Higher BMI, baseline HCV viral load and leptin levels were associated with lack of sustained virologic response. ENA‐78 was associated with sustained viral response. Positive correlations were found between liver inflammation and baseline CD4 count, sVCAM and HGF; fibrosis stage and HGF; liver steatosis, BMI and leptin. Our findings suggest IFN/RBV treatment initially increases levels of several biomarkers, but eventually leads to a decline in many immune markers. These findings shed light on the relationship between IFN treatment and immune activation by chronic viral infections, such as HCV.     

ITPA genetic variants influence efficacy of PEG‐IFN/RBV therapy in older patients infected with HCV genotype 1 and favourable IL28B type

Inosine triphosphatase (ITPA) genetic variants are strongly associated with ribavirin (RBV)‐induced anaemia during pegylated interferon (PEG‐IFN) plus RBV therapy. However, the treatment efficacy of ITPA genetic variants has not been fully explored. We enrolled 309 individuals infected with hepatitis C virus genotype 1, who were treated with PEG‐IFN plus RBV for 48 weeks. The ITPA SNP: rs1127354 and IL28B SNP: rs8099917 were genotyped. We examined the risk factors for severe anaemia up to week 12 after the start of treatment and treatment efficacy. The incidence of severe anaemia, ≥3 g/dL reduction or <10 g/dL of haemoglobin (Hb) up to week 12, was more frequent in patients with CC at rs1127354 [65% (145/224), 33% (73/224)] than in those with CA/AA [25% (21/85), 6% (8/85)] (P < 0.0001). ITPA genotype, pretreatment Hb level and age were independent predictive factors for severe anaemia: Hb < 10 g/dL. In IL28B favourable type, the sustained virologic response rate was higher in ≥60‐year‐old patients with CA/AA than in those with CC [71% (22/31) vs 40% (26/65), P = 0.005], although there was no significant difference in treatment efficacy according to ITPA genetic variants in the <60‐year‐old patients. The proportion of patients administered ≥80% of the dosage of RBV was significantly higher in the patients with CA/AA than in those with CC (P = 0.025), resulting in a lower relapse rate. In conclusion, ITPA genetic variants were associated with severe RBV‐induced anaemia and could influence the efficacy of PEG‐IFN plus RBV treatment among elderly patients with IL28B favourable type.     

Regression of fibrosis and portal hypertension in HCV‐associated cirrhosis and sustained virologic response after interferon‐free antiviral therapy

It is still controversial, whether and to what amount cirrhosis and portal hypertension are reversible in patients with hepatitis C virus (HCV)‐associated cirrhosis and sustained virologic response (SVR) after interferon‐free antiviral therapy. In this study, we prospectively evaluated dynamics of liver and spleen stiffness in HCV‐infected patients with advanced liver disease and SVR after interferon‐free treatment. A total of 54 patients with HCV‐associated cirrhosis and SVR were included. Liver and spleen stiffness was measured at therapy baseline (BL), end of treatment (EOT) and 24 weeks after EOT (FU24) by transient liver elastography (L‐TE) as well as by acoustic radiation force impulse of the liver (L‐ARFI) and spleen (S‐ARFI), as well as biochemical, virologic and clinical data. Improvement of liver and spleen stiffness was found in 44 of 50 (88%), 31 of 54 (57%) and 25 of 54 (46%) of patients assessed by L‐TE, L‐ARFI and S‐ARFI between baseline and FU24. Liver stiffness assessed by L‐TE improved between BL [median (range), 32.5 (9.1–75) kPa] and EOT [median (range), 21.3 (6.7–73.5) kPa; (P<.0001)], and between BL and FU24 [median (range), 21.2 (5.4–70) kPa; (P<.0001)]. Liver stiffness assessed by L‐ARFI improved between BL [median (range), 2.7 (1.2–4.1) m/s] and FU24 [median (range), 2.4 (1.2–3.9) m/s; P=.002), while spleen stiffness remained unchanged. Our data suggest that improvement of liver stiffness may be rather due to reduced necroinflammation and may be due to a less extent to regression of cirrhosis, as dynamics of liver stiffness improvement was more pronounced between BL and EOT than BL and FU24.     

Hypovitaminosis D and osteopenia/osteoporosis in a haemophilia population: a study in HCV/HIV or HCV infected patients

Recent reports show a correlation between haemophilia and osteoporosis. HIV, HCV and their treatments are independently associated with an increased risk of osteoporosis. Vitamin D plays a pivotal role in bone mineralization. The aim of our study was to compare Vitamin D levels, bone metabolism markers and bone mineral density (BMD) in patients with haemophilia with or without co‐infections. Seventy‐eight adult patients with severe or moderate haemophilia A or B were subdivided into three groups of 26 patients each (HIV‐HCV co‐infected, HCV mono‐infected and uninfected). The BMD was measured by dual energy X‐ray absorptiometry (DXA) at both the femoral area (F) and lumbar spine (L). This was correlated to laboratory values and haemophilic arthropathy was assessed using validated clinical and radiological scores. The DXA showed a homogeneous F‐BMD reduction in all the three groups, whereas L‐BMD was significantly lower in co‐infected patients (P < 0.05). The clinical score was higher in co‐infected (P < 0.002) and mono‐infected (P < 0.006). The radiological score was higher in mono‐infected than in the other two groups (P < 0.001). Overall 25‐hydroxyvitamin D (25‐OH Vit D) was reduced (87%). Bone‐specific alkaline phosphatase (b‐ALP) and telopeptide were increased in co‐infected (P < 0.001 and P < 0.01) and mono‐infected (P < 0.001 and P < 0.02). The result of the homogeneous F‐BMD reduction in all groups could be explained by the pivotal role of arthropathy; the lower L‐BMD in co‐infected and the increase of b‐ALP and telopeptide in co‐infected and mono‐infected groups suggest faster bone metabolism in case of infections.     

Serum microRNAs as predictors for liver fibrosis staging in hepatitis C virus‐associated chronic liver disease patients

Accurate staging of liver fibrosis is important for clinical decision making and personalized management. Liver fibrosis is influenced by patients’ genomics, including IFNL3 genotype and microRNA expression. However, incorporating microRNAs into fibrosis prediction algorithms has not been investigated. We examined the potential of eight selected serum microRNAs; miR‐122, miR‐126, miR‐129, miR‐199a, miR‐155, miR‐203a, miR‐221, and miR‐223 as non‐invasive biomarkers to stage liver fibrosis in HCV‐associated chronic liver disease (HCV‐CLD). 145 Egyptian HCV‐CLD patients were divided according to Metavir fibrosis scores. MicroRNAs and IFNL3 rs12979860 genotype were assayed by RT‐qPCR and allelic discrimination techniques, respectively. Serum miR‐122 was downregulated, whereas miR‐203a and miR‐223 were upregulated in significant fibrosis (≥F2) compared with no/mild fibrosis (F0‐F1). Serum miR‐126, miR‐129, miR‐203a, and miR‐223 were upregulated in severe fibrosis (≥F3) and cirrhosis (F4) compared with F0‐F2 and F0‐F3, respectively. miR‐221 was upregulated in ≥F3, but unchanged in F4. miR‐155, miR‐199a, and IFNL3 rs12979860 genotype were not significantly different in all comparisons. Differentially expressed serum microRNAs discriminated ≥F2, ≥F3, and F4 by receiver‐operating‐characteristic analysis. Multivariate logistic analysis revealed a model combining miR‐129, miR‐223, AST, and platelet count with high diagnostic accuracy for ≥F3 (AUC=0.91). The model also discriminated F4 (AUC=0.96) and ≥F2 (AUC=0.783), and was superior to APRI and FIB‐4 in discriminating ≥F3 and F4, but not ≥F2. In conclusion, combining serum microRNAs with baseline predictors could serve as a new non‐invasive algorithm for staging HCV‐associated liver fibrosis. Additional studies are required to confirm this model and test its significance in liver fibrosis of other etiologies.