Introduction
At present, for refractory chronic hepatitis C,
interferon (IFN)-based triple-agent combination therapy with
second-generation direct-acting antivirals (DAAs) has been
established as the standard treatment method. In IFN-based therapy,
negative conversion of hepatitis C virus (HCV) RNA in the early
phase following treatment initiation is considered an important
factor for predicting treatment outcomes (1–4).
Recently, HCV-RNA measuring systems that are more
sensitive compared to conventional HCV-RNA qualitative assays have
been developed and reported to be clinically useful (5,6).
The AccuGENE m-HCV RNA quantitative assay [Abbott
RealTime HCV (ART) assay], which was developed as a highly
sensitive HCV RNA quantitative assay by Abbott Laboratories (Abbott
Park, IL, USA), has a minimum detection sensitivity of 12 IU/ml and
enables the quantification and detection of lower viral loads
compared to that allowed by the conventional Cobas TaqMan HCV
quantitative assay [Cobas AmpliPrep/Cobas TaqMan (CAP/CTM) assay],
developed by Roche Diagnostics (Basel, Switzerland).
In the present study, these two highly sensitive
HCV-RNA quantitative assays were compared and analyzed for their
ability to predict therapeutic outcomes in patients with relapse
following triple-agent combination therapy with pegylated
interferon (PEG-IFN), ribavirin (RBV) and simeprevir (SMV).
Subjects and methods
Study design
Between December 2013 and October 2015, patients
received 100 mg/day SMV per os (Sovriad; Janssen
Pharmaceutical K.K., Tokyo, Japan), combined with weekly
subcutaneous injections of 1.5 µg/kg of PEG-IFN α2b (Peg-Intron
with weekly subcutaneous and per os administration of
600–1,000 mg/day of RBV (Rebetol; MSD) in accordance with the
prescribing information for 12 weeks followed by PEG-IFN α2b and
RBV between weeks 12 and 24.
Dose reductions or discontinuation of SMV, PEG-IFN
and RBV were according to the judgment of the treating physicians.
Patients were followed up for ≥24 weeks after the final treatment
administration to assess the sustained virological response
(SVR).
SVR24 was defined as undetectable serum HCV RNA
levels at 24 weeks after the end-of-treatment (EOT).
Patients
The present study included 6 patients with genotype
1 chronic hepatitis C with a high viral load who achieved an EOT
response (ETR) but subsequently experienced a relapse.
Assays
The CAP/CTM assay, which is the first-generation
COBAS® assay developed by Roche Diagnostics, and the ART
assay, developed by Abbott Laboratories, were used for the
measurements, following the manufacturer's protocols.
Viral kinetics in the HCV-RNA loads detected by
these two assays were compared and analyzed at each measurement
point on treatment weeks 2, 4, 8, 12, 16, 20 and 24, at EOT and at
24 weeks after EOT. A negative response signifies no detection of
HCV RNA.
Results
Patient characteristics
The patient clinical characteristics are shown in
Table I. The mean age was 73.8±6.5
years, and 3 patients (50%) were male and 3 (50%) were female. The
interleukin-28B major allele was present in 1 patient, and the
minor allele was present in the others.
 | Table I.Clinical characteristics. |
Table I.
Clinical characteristics.
| Case no. | Age, years | Gender | IL-28B allele | Previous type of
response |
|---|
| 1 | 72 | Male | Major | SOC relapse |
| 2 | 66 | Male | Minor | SOC null
response |
| 3 | 77 | Female | Minor | SOC relapse |
| 4 | 85 | Female | Minor | SOC relapse |
| 5 | 71 | Female | Minor | Naïve |
| 6 | 72 | Male | Minor | SOC relapse |
Assay diagnosis
At 4 weeks after treatment initiation, 4 of the 6
patients were diagnosed as negative by the CAP/CTM assay, whereas 2
of these 4 patients were not found to be negative by the ART assay.
Of the 2 patients, one was signal-positive with an HCV RNA load
<1.08 Log IU/ml, and the other patient had a viral load of 1.12
Log IU/ml. At 8 weeks after treatment initiation, 1 patient was
found to be negative by the CAP/CTM assay, but signal-positive with
a viral load <1.08 Log IU/ml by the ART assay of one patient.
From 4 to 8 weeks after treatment initiation, 3 of the 6 patients
appeared to be discrepant cases (Table
II).
| Table II.Comparison of the viral kinetics
between the ART and CAP/CTM assays. |
Table II.
Comparison of the viral kinetics
between the ART and CAP/CTM assays.
|
|
| Viral kinetics value,
Log IU/ml |
|---|
|
|
|
|
|---|
| Case no. | Assay | Pre-treatment | 4 weeks | 8 weeks |
|---|
| 1 | ART | 6.3 | ND | ND |
|
| CAP/CTM | 6.2 | ND | ND |
| 2 | ART | 6.2 | <1.08 | ND |
|
| CAP/CTM | 6.2 | <1.2 | ND |
| 3 | ART | 5.9 | 1.37 | <1.08 |
|
| CAP/CTM | 6.1 | <1.2 | ND |
| 4 | ART | 6.1 | 1.12 | ND |
|
| CAP/CTM | 6.1 | ND | ND |
| 5 | ART | 6.3 | <1.08 | ND |
|
| CAP/CTM | 6.2 | ND | ND |
| 6 | ART | 7.1 | ND | ND |
|
| CAP/CTM | 7.2 | ND | ND |
Discussion
Antiviral therapy for chronic hepatitis C was
initiated with IFN alone in the 1990s. Until recently, standard
treatment for chronic HCV genotype 1 infection was PEG-IFN in
combination with RBV (7,8).
A combination therapy with PEG-IFN and RBV was
subsequently applied to patients with genotype 1 chronic hepatitis
C with a high viral load.
Novel drug classes, including inhibitors of the
NS3/S4 protease of HCV polyprotein (protease inhibitors), have
recently become available (9–11).
Of these, telaprevir (TVR) was the first to be
approved in Japan for the treatment of chronic hepatitis C. In a
clinical trial of TVR triple combination therapy (TVR, PEG-IFN and
RBV) for 24 weeks in Japan, rapid reductions in the serum HCV RNA
levels were observed with an SVR rate of ~70% (12,13).
Subsequently, SMV, a second-generation protease
inhibitor, was included in the standard treatment regimen.
SMV is a second-generation NS3/NS4 protease
inhibitor (14). The QUEST 1 and QUEST
2 phase 3 clinical trials demonstrated SVRs of 80 and 81%,
respectively, in patients treated with SMV triple combination
therapy (SMV, PEG-IFN, and RBV). Similar results have been reported
in phase 3 clinical trials conducted in Japan (15–17).
As the factors determining the effects of
PEG-IFN/RBV combination therapy, which is the standard treatment
strategy for refractory chronic hepatitis C, the time required for
the negative conversion of HCV RNA has attracted attention.
Serial measurement of HCV-RNA loads and assessment
of the rates of decrease in viral loads enable clinicians to make
decisions regarding changes in treatment duration or to predict
therapeutic outcomes.
It is essential to predict therapeutic outcomes in
order to more accurately determine the time required for viral
clearance or to more precisely understand viral kinetics in the
treatment of chronic hepatitis C.
In the present study, HCV-RNA loads were serially
measured following treatment initiation by 2 types of quantitative
polymerase chain reaction assays in patients with chronic hepatitis
C who received PEG-IFN/RBV/SMV triple-agent combination therapy,
and the results of the two assays were compared and analyzed.
At 4 weeks after treatment initiation, 4 of the 6
patients were diagnosed as negative by the CAP/CTM assay, whereas 2
of these 4 patients were not found to be negative by the ART assay;
1 was signal-positive with an HCV-RNA load <1.08 Log IU/ml and
the second had a viral load of 1.12 Log IU/ml. At 8 weeks after
treatment initiation, one patient was found to be negative by the
CAP/CTM assay, but signal-positive with a viral load <1.08 Log
IU/ml by the ART assay. From 4 to 8 weeks after treatment
initiation, 3 of the 6 patients appeared to be discrepant cases. Of
the 6 patients who achieved an ETR, 4 were determined to have
achieved a rapid virological response (RVR) by the CAP/CTM assay
but may not have actually become negative.
As aforementioned, in patients who achieved an RVR
but were found to have an extremely low HCV-RNA load during
subsequent treatment, it is assumed that the HCV-RNA loads may
serve as a predictive factor for relapse.
A recent study showed that in patients who become
negative for HCV RNA at or after 12 weeks of treatment, the rate of
complete response can be improved by the use of PEG-IFN/RBV
combination therapy for 72 weeks (18). Although further studies with a larger
sample size are required, the use of the highly sensitive HCV-RNA
quantitative assay may improve the prediction of therapeutic
outcomes. In discrepant cases showing slightly delayed negative
conversion as determined by this assay, the patients should be
regarded as late responders; the continuation of the PEG-IFN/RBV
combination therapy may lead to further improvement of the
therapeutic effects in such cases.
Although therapeutic outcomes have recently been
improved, more accurate test methods are required to predict these
therapeutic outcomes.
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