Treatment

 

870. Higher Levels of HBV-DNA in Genotypes B and C Compared to Genotypes A and D

H. Krarup; P. Madsen; A. Bentzen-Petersen; J. M. Mller; N. Weis

 

Hepatitis B viral factors such as viral load and HBV genotype have been suggested to influence progression of chronic hepatitis B.

 

Aim:

To explore relations between 1) genotype and viral load, 2) gender and viral load, 3) gender and genotype and 4) genotype and country of origin.
Material: Samples from 802 consecutive HBV-
DNA positive patients in Denmark were genotyped if possible. In house real-time PCR based methods were used. HBV-DNA levels were in the range of 10(2) 10(10) IU/mL. Genotypes were determined using genotype specific primer pairs selected from the pre-S region of the genome.

 

Results:

Male/female ratio 427 to 375, age given as median (25;75 percentiles) was for males 37 (27;46) and females 30 (24;38) years. In total 195 samples could not be genotyped; 106 due to lack of sufficient amount of material and 89 due to various reasons, mostly too low viral load. Of 607 samples 11.2% were genotype A, 14.3% B, 19.4% C, 50.3% D, 2.3% E, 0.5% F and 1.5% genotype G, 0.8% had more than one genotype.

 

1) A significant difference was observed in viral load in genotype A compared to B and C (p values <0.008) and genotype D compared to B and C (p values <0.007), but no difference was observed in viral load between A and D or B and C. The viral loads in genotypes A to D were 1.2 x 10(5) (4.4 x 10(3); 3.8 x 10(7)) IU/mL, 1.4 x 10(7) (2.9 x 10(4); 1.4 x 10(8)) IU/mL, 1.4 x 10(7) (8.5 x 10(4); 1.4 x 10(8)) IU/mL and 1.0 x 10(5) (4.0 x 10(3); 5.9 x 10(7)) IU/mL respectively.

 

2) No difference in viral load among gender was observed either overall or in different genotypes.

 

3) A significant difference in distribution of gender over the 4 dominant genotypes was observed: more women had genotypes B or C while more men had genotypes A or D (p values <0.001). Women were significantly younger than men, 30 years versus 41 years (p value <0.001) and 30 years versus 35 years (p value <0.004) in genotypes B and D respectively, whereas no significant age difference was observed in genotypes A or C, men 32 years versus 35 years and 29 years versus 31 years respectively.

 

4) More than 65% of patients with genotype A originated from Africa.73% and 95% of patients with genotypes B and C originated from South East Asia, while 75% of patients with genotype D originated from the Middle East, Afghanistan or India.

 

Conclusion:

We found the median of serum HBV-DNA levels 100 times higher in genotypes B and C compared to genotypes A and D. More women, than men, had genotypes B or C, as opposed to genotypes A or D. The distribution of genotypes was as expected from ethnic origin of the patients.

 


Treatment Adefovir

 

890. Durability of Adefovir Dipivoxil-Induced HBeAg Loss Following Long-term Additional Therapy in Patients with YMDD Mutants of Hepatitis B Virus

S. Kim; Y. Chung; J. A. Kim; Y. Lee; D. Lee; S. Lee; D. Seo; J. Shin; N. Park; K. Kim; H. Lee; Y. Lee; D. Suh

 

Backgrounds/Aims:

Adefovir dipivoxil (ADV) has been widely used in patients with YMDD mutants as well as in those with wild type of hepatitis B virus (HBV). However, the optimal duration of ADV administration remains to be determined due to frequent relapse after cessation of the therapy, especially in endemic areas of HBV. In this study we intended to examine the durability of ADV-induced HBeAg loss following long-term additional therapy in patients with YMDD mutants of HBV.

 

Methods:

Among 318 chronic hepatitis B (CHB) patients with YMDD mutants of HBV who had been treated with ADV at a dose of 10 mg once daily for a median 27 months (range: 9-59), 100 patients (31%) lost their serum HBeAg as well as HBV-DNA (by real-time PCR) at a median 18 months (range: 1-53) after initiation of ADV therapy. Out of them, 35 patients whose serum HBeAg and HBV-DNA had been negative persistently for 24 months discontinued ADV administration and followed for a median 9 months (range: 2-31). The median duration of ADV therapy in these patients was 31 months (range: 25-47). During the treatment and follow-up periods, serum ALT, HBV-DNA levels and HBeAg/anti-HBe were monitored at every visit per 1 to 3 months. Genotypes of HBV were determined by restriction fragment length polymorphism (RFLP) following PCR.

 

Results:

All the 318 patients [Median age: 45 years (range: 15-81); male: 266 (84%)] enrolled in this study had HBV of genotype C. YIDD variants of HBV were determined in 196 (62%); YVDD in 103 (32%) and both in 19 (6%). In 13 (37%) and 14 (40%) out of 35 patients whose serum HBeAg and HBV-DNA had been negative persistently for 24 months, serum HBeAg reappeared at 6 and 12 months after stopping ADV therapy, respectively; serum HBV-DNA became detectable by real-time PCR again in 20 (57%) and 20 (60%), respectively. At 6 and 12 months after cessation of ADV therapy, the cumulative rates of serum HBeAg reversion were 49% and 56%; those of ALT re-elevation were 65% and 73%, respectively. Between relapsers and sustained responders, there was no difference in age, gender, initial serum ALT, HBV-DNA level, the presence of anti-HBe, the proportion of YMDD variants and the association of liver cirrhosis.

 

Conclusion:

Our data suggest that serum HBeAg loss induced by ADV therapy may not be durable even following long-term additional administration of ADV for 24 months.

 


Treatment

 

952. HBeAg Seroconversion Induced by Nucleos(t)ide Analogues in Chronic Hepatitis B Is Not Durable in a Majority of Cases

M. Perquin; J. G. Reijnders; N. Zhang; H. L. Janssen

 

Background and Aim:

Seroconversion of HBeAg indicates the probable attainment of sustained response in chronic hepatitis B (CHB) patients, currently justifying discontinuation of antiviral therapy after a consolidation period. Yet, long-term durability of HBeAg seroconversion achieved under treatment with nucleos(t)ide analogues (NA) is unclear.

 

Methods:

In this single center cohort study, all HBeAg positive CHB patients who received more than six months of treatment with any NA were included. Measurement of virologic parameters was done every 3 to 6 months. Seroconversion was defined as loss of HBeAg with appearance of anti-HBe. Relapse of seroconversion was defined as either reappearance of HBeAg or loss of anti-HBe.

 

Results:

In this study 131 patients were included (69 treated with Lamivudine(LAM), 35 Adefovir(ADV), 18 Entecavir(ETV), 6 Tenofovir(TDF), 1 ADV+LAM, 2 TDF+LAM). Baseline characteristics: mean age 3518 years; m/f 97/34; mean ALT 4.86.4 xULN ; mean HBV DNA 8.11.6log10 copies/mL. During a median follow up of 98 (24-507) weeks HBeAg seroconversion was observed in 44 (34%) patients (27 induced by LAM, 12 ADV, 3 ETV, 2 TDF). In 4 cases there was no follow-up after HBeAg seroconversion and, therefore, these subjects were excluded from further analysis. Median duration of therapy until HBeAg seroconversion was 28 (7-211) weeks. In multivariate analysis, independent baseline predictors of HBeAg seroconversion were high ALT (OR 1.25, CI 1.11-1.41, P<0.001) and low HBV DNA (OR 0.62, CI 0.45-0.85, P=0.003). Relapse after HBeAg seroconversion occurred in 26 (65%) patients (LAM 19/26 (73%), ADV 6/10 (60%), ETV 1/2 (50%), TDF 0/2 (0%)). Twenty-three (88%) HBeAg relapses occurred during therapy under which seroconversion was achieved. Fifteen (58%) patients experienced relapse more than 6 months after HBeAg seroconversion, 8 (31%) more than 1 year after HBeAg seroconversion. Relapse was associated with antiviral drug resistance in 11 (42%) cases. Of 9 patients who stopped therapy after a consolidation therapy of at least 6 months (median duration 67 (25-198) weeks), 3 (33%) experienced off-therapy relapse, 2 (22%) restarted with NA therapy (due to increasing viral load) and 4 (45%) remained HBeAg-negative, anti-HBe positive in absence of therapy.

 

Conclusion:

NA induced HBeAg seroconversion was followed by relapse in a majority of cases, often during treatment. Consolidation treatment of more than 6 months did not induce remission of disease in the majority of cases. Therefore, long-term continuation of treatment with NA after HBeAg seroconversion appears necessary, irrespective of the occurrence of HBeAg seroconversion.

 


Treatment Antiviral Resistance

 

897. High Risk of Renal Impairment and Arterial Hypertension During Long-term Adefovir and Lamivudine Combination Therapy in Patients with Lamivudine-resistant Chronic Hepatitis B

M. Vigan; P. Lampertico; M. Iavarone; G. Tontini; F. Facchetti; M. Colombo

 

Background and Aim:

Add-on treatment with adefovir (ADV) is recommended for lamivudine (LMV)-resistant patients with chronic hepatitis B, but the long-term safety of this approach is unknown.

 

Material and Methods:

271 LMV-resistant patients with chronic hepatitis B treated with ADV+LMV (213 males, 55 yr, 184 Child-Pugh score A/B cirrhotics, median creatinine 0.8 mg/dL, median creatinine clearance 87 mL/min), with normal renal function at baseline and more than 6 month treatment were followed for 7-77 months (median 32). Patients were followed every three months with laboratory, clinical exams and arterial blood pressure measurement. Renal impairment was the increase of serum creatinine of ≥ 0.5 mg/dL compared to baseline and led to ADV dose reduction from 10 mg daily to 10 mg on the other day. Arterial hypertension was diagnosed according to the current guidelines. Results. 31 (11%) patients showed renal impairment after a median of 23 months (range: 7-60), requiring ADV dose reduction. Six months (range 1-30) after dose adjustment, serum creatinine significantly declined from 1.60.3 to 1.30.2, (p<0.001), no patient had further renal deterioration.

 

One patient had >1 log10 rebound of viremia but no rtN236T or rtA181T/V mutations were identified, whereas all the others maintained either undetectable or stable serum HBV DNA levels. Twenty-five of 221 patients (11%) without arterial hypertension at baseline developed mild-moderate hypertension (≥ 140-90 mmHg) after a median of 15 (range:3-47) months of treatment, requiring specific treatment. Five patients had both adverse events with arterial hypertension preceeding in all cases renal impairment occurrence. The 4-year cumulative rates of renal impairment and arterial hypertension development was 18% for both.

 

Conclusions:

Patients on long-term treatment with ADV+LMV should be carefully monitored for the development of renal impairment and arterial hypertension.

 


Treatment Entecavir

 

969. Entecavir Induced HBV DNA Suppression at 12 Weeks in Treatment-Navie Patients with Chronic Hepatitis B is a Good Predictive Factor for Virological Response at 48 Weeks

H. Lee; H. Kim; M. Kim; K. Kim; J. Lee; H. Sul; S. Chung; S. Hwang; C. Choi; J. Kim; J. Do; J. Kim; S. Chang; S. Park

 

Background/Aims:

Entecavir (ETV) is a potent, selective inhibitor of HBV DNA polymerase. ETV had superior virological and biochemical efficacy to lamivudine in treatment-nave patients with chronic hepatitis B (CHB). The aims of our study are to evaluate the efficacy of ETV and to explore useful predictors for efficacy of ETV treatment in treatment-nave patients with CHB.

 

Methods:

A total of 112 treatment-nave patients with CHB, who visited Chung-Ang University Hospital and Ilsan Paik Hospital in Korea between January 2007 and October 2007, were enrolled in this study (79 males and 66 HBeAg positive). Mean age, baseline serum ALT level and serum HBV DNA level were 46 years (range, 23-69), 190.2 IU/L (range, 43-724) and 7.3 log10 copies/ml (range, 5.4-9.9), respectively. They were treated with ETV 0.5 mg/d. The mean duration of treatment was 11 months (range, 6-15). All patients were assessed for virological response (HBV DNA<140 copies/mL), biochemical response (ALT<40IU/mL), and HBeAg seroconversion. Serum HBV DNA was quantified using the real time PCR assay (Artus HBV LC PCR Kit, Roche Diagnositcs, lower limit of quantification, 140 copies/mL). The definition of good response was undetectable HBV-DNA and normalization of serum ALT at 48 weeks.

 

Results:

The rates of virological response were 48.2% (53/110) and 66.1% (39/59) at week 24 and 48. The rates of biochemical response were 76.4% (84/110) and 84.7% (50/59) at week 24 and 48. In addition, the rates of composite virological and biochemical response were 38.2% (42/110) and 61.0% (36/59) at week 24 and 48. Mean reduction of baseline HBV DNA was -5.7, and -6.5 log10 copies/mL at 24 and 48 weeks. Through 48 weeks, HBeAg seroconversion occurred in 5.7% (3/53). There was no virologic breakthrough, primary non-response, and other adverse event. In multivariate analysis, the rapid decline in HBV DNA (≥5 log10 copies/mL) at week 12 was clinically important predictive factors for good response at week 48 (odds ratio [OR], 6.659; 95% confidence interval [CI], 1.444-30.705; P = 0.015).

 

Conclusions:

In patients with treatment-nave CHB, ETV provides potent viral load reduction, and ALT normalization free from adverse event. In addition, the rapid decline in HBV DNA (≥5 log10 copies/mL) at week 12 may be used as a good predictor of long-term outcome.

 


Treatment Clevudine

 

911. Clevudine Was Superior to Lamivudine in the Patients with HBeAg(+) Chronic Hepatitis B

G. K. Lau; N. Leung; C. K. Hui; A. Kwok; A. Wong; R. Chan; H. W. Yoo

 

Background:

Clevudine is a pyrimidine analogue with potent anti-HBV activity in vitro. In the pivotal phase III clinical trials, clevudine 30 mg for 24 weeks showed profound viral suppression with normalization of serum ALT levels.

 

Methods:

The aim of this study is to compare the efficacy and safety of clevudine versus lamivudine for 48 weeks in chronic hepatitis B (CHB) patients in a randomized and blinded way. The study is ongoing in Hong Kong. Eligible patients were treatment-nave HBeAg(+) CHB patients with HBV DNA levels≥3,000,000 copies/mL and 1.0 ≤ALT<10 times of the upper limit of the normal range. HBV DNA was quantified by Amplicor PCR assay with a lower limit of detection (LOD) of 300 copies/mL. Preliminary results from the 55 patients (29 in the clevudine group and 26 in the lamivudine group) who have completed 48-week dosing period are presented here. After completion of 48-week treatment period, an optional 48 weeks extension treatment period are planned. During the 48 weeks optional extension phase, open-labelled clevudine treatment was provided to eligible subjects with their consents. The interim data of 21 patients who continue the extension study is also presented here.

 

Results:

The clevudine group demonstrated greater viral suppression at Week 48 when compared with the lamivudine group [median reduction (range) 4.7 (3.3-6.2) vs. 3.2 (-0.2~5.7) log copies/ml at Week 48, respectively, p < 0.01]. Serum HBV DNA level was below 300 copies/mL in 59% and 32% at week 32 and in 72% (N=29) and 46% (N=26) at week 48 in the clevudine and lamivudine groups, respectively. HBeAg seroconversion occurred in 17% of patients in the clevudine group while as 8% of patients in the lamivudine group at week 48. Lamivudine-resistant mutations were detected in 9 patients in the lamivudine group, who showed viral rebound during lamivudine therapy but no mutation was found in clevudine group during 48-week treatment period.

 

At week 72, 82% of patients (N=11) in the clevudine group had HBV DNA below LOD. At week 24 after switching to clevudine from lamivudine (at week 72), viral level in the previous lamivudine group was more decreased (viral decrease from baseline : 4.2 log copies/ml) and 80% of patients had HBV DNA below LOD after switching to clevudine from lamivudine.

 

Conclusions:

A 48-week dosing with clevudine 30mg showed superior viral suppression to lamivudine 100mg without the emergence of viral breakthrough in HBeAg(+) CHB patients, while 31% of patients in the lamivudine group showed lamivudine-related resistance during 48 weeks. The extension study with clevudine demonstrated that clevudine is a promising drug for the long-term treatment.

 


Treatment Antiviral Resistance

 

884. Primary Resistance Mutations Against Nucleos(t)ide Analogues in Treatment-nave Patients with HBV-infection

A. D. Ludwig; T. Goebel; O. Adams; N. Baumann; K. Hauck; H. Fey; H. Hengel; D. Haussinger; A. Erhardt

 

Background:

Little is known about the frequency of primary resistance mutations in treatment naive patients with acute or chronic hepatitis B infection. The occurence of primary resistance mutations and the association of these mutations with viral genotypes was investigated.

 

Methods:

Direct sequencing of the HBV polymerase gene and overlapping S-gene was performed with an ABI 310 system and data of 288 patients with treatment nave hepatitis B virus infection. Sequence alignments and phylogenetic analysis together with detection of resistance mutations were accomplished with the ABI program SeqScapev2.5. Additionally, genotyping of viral strains and detection of resistance mutations were performed with an open access strain matching system (http://www.hiv-grade.de/cms/grade/hbv-tool.html).

 

Results:

Distribution of hepatitis B genotypes in the investigated patients was as follows: 56.9% D, 28.8% A, 5.6% C, 2.7% B, 4.2% E and 0,7% G. Primary resistance mutations were observed in 9.3% (exclusive polymorphisms at nt 215 and 217; table) and in 34.7% of patients (inclusive polymorphisms at nt 215 and 217) respectively. Primary resistance mutations (not including polymorphisms at nt 215 and 217) were detected at a rate of 8.2% in genotype A, 20.8 % in genotype B/C, 10.4 % in genotype D and 0% in genotype E. Polymorphisms at nt 217 were highly associated with genotype A, and polymorphisms at nt 215 with genotype D. Patients with primary resistance mutations were less frequent HBeAg-positive (25%) compared to patients without primary resistance mutations (44%; p<0.008) but did not differ in ALT-levels and viral load.

 

Conclusions:

In the present investigation, which is among the first to study the prevalence resistance mutations in nave patients, about 10% of all patients were diagnosed with primary resistance mutations against lamivudine, telbivudine, adefovir and possibly entecavir and tenofovir. Since these findings have an impact on therapeutic decisions, newly diagnosed patients with hepatitis B infection should receive a primary resistance testing. The clinical significance of polymorphisms at nt 215 and 217 warrants further study.

 

V173L/M

L180M

A181S/V/T

T184I

A194G/T

M204I

M204V

I233V/K/R

N236D

n

1

3

3

1

3

2

2

11

1

[%]

0.3

1.0

1.0

0.3

1.0

0.7

0.7

4.0

0.3

 

 


Treatment Antiviral Resistance

 

888. Lamivudine-resistant Mutation Among Treatment-naive Hepatitis B Patients Is Common and May Be Associated with Treatment Failure

S. K. Fung; T. Mazzulli; M. El-Kashab; M. Sherman; V. Popovic; E. Sablon

 

 

Background:

Pre-existing hepatitis B (HBV) antiviral resistance mutations (AVR) to lamivudine (LAM) among treatment-nave HBV patients have been reported to occur at low frequency, but the clinical significance with regard to antiviral therapy remains unclear.

 

Aims:

To document the prevalence of antiviral resistance (AVR) mutations among untreated HBV patients using a sensitive line probe assay and to determine whether AVR mutations are associated with reduced efficacy to antiviral therapy.

 

Patients and Methods:

Consecutive untreated adult patients with chronic hepatitis B attending the liver clinics of University Health Network and Mount Sinai Hospital (Toronto, Canada) from 11/06 03/08 were tested for AVR. Patients were deemed to be treatment-nave after a careful treatment history corroborated by a family member, where possible. HBV DNA was quantified by PCR (Roche TaqMan, LLQ 6 IU/ml). HBV genotype and AVR mutations were detected using INNO-LiPA HBV DRv2 and DRv3 (InnoGenetics, Gent, Belgium). Statistical analysis was performed using SPSS v13 (Chicago, IL).

 

Results:

209 treatment-nave adult patients were tested for AVR: 69% male, 15% cirrhotic, mean age 3817 years, 85% Asian, 51% HBeAg positive. Mean HBV DNA was 5.72.3 log10 IU/ml and HBV genotypes A, B, C and D were found in 8%, 32%, 47% and 10% patients, respectively. The prevalence of AVR mutations was: rtL180M, 10%; rtM204V/I, 12%; rtL80V/I, 9%; rtV173L, 3%; rtA181V/T, 0%, rtN236T, 0%. Patients with high viral load and male gender were more likely to harbor AVR mutants. Among 21 patients with LAM-resistance at baseline, 12 did not meet treatment criteria (immune tolerant or inactive carriers), while the remainder is scheduled to start or has already started therapy. 3 patients received lamivudine 100 mg daily (mean duration 11 months); 1 had primary nonresponse, while 2 had virologic breakthrough. However, in 3 patients treated with adefovir 10 mg daily or tenofovir 300 mg daily (mean duration 7 months), all had undetectable HBV DNA at last follow-up.

 

Conclusions:

Mutations associated with the rt180/204 nucleoside resistance pathway were common (10% patients), whereas those associated with the rt236 nucleotide pathway were not found in any patient in this study. Among patients with pre-existing LAM-resistance, lamivudine resulted in treatment failure requiring salvage therapy, whereas adefovir or tenofovir showed no reduced efficacy. Our data suggest AVR testing among treatment-nave patients is important, in order to tailor antiviral therapy and optimize treatment response. However, further studies are required to determine the role of AVR testing in routine clinical practice.