A Prospective Study Of Addiing On Peginterferon Therapy In Nucleoside Analogues Treated HBeAg Positive Chronic Hepatitis B Patients

BackgroundHepatitis B virus(HBV)infection remains an important global public health problem with high global morbidity and mortality.Approximately 240 million people are chronic HBV surface antigen(HBsAg)carriers,one third of which will develop into serious liver diseases including cirrhosis,liver cancer and liver failure.It is estimated that about 93 million cases were chronically infected with HBV in China,and the prevalence of HBsAg is 7.18%in 2006.Currently,there has been no efficient therapy for HBV elimination.Therefore,the main goal of treatment for CHB patients is to prevent disease progression and consequently hepatocellular carcinoma development by viral replication inhibition,thus improving survival and quality of life.The current anti-viral therapy for CHB employs nucleotide analogues(NAs)and interferon(IFN).In total 6 NAs,lamivudine(LAM),adefovir dipivoxil(ADV),entecavir(ETV),telbivudine(LdT)and tenofovir(TDF and TAF)are available for oral therapy.NAs are viral polymerases and reverse transcriptase inhibitors that can efficiently suppress HBV replication,resulting in rapid HBV DNA reduction.NA therapy has better patient compliance since it is oral administration with few side effects and has a high rate(>90%)of on-treatment virological responses.However,since NA does not target covalently closed circular DNA(cccDNA)transcription,this therapy does not usually achieve HBV elimination and rarely results in HBsAg loss even after long term treatment.Furthermore,relapse is a quite common event(about 50%)during post NA therapy follow-up.In addition,the currently widely accepted withdrawal criteria fit for limited number of HBeAg-positive patients.Existing data shows that the proportion of HBeAg-positive patients who meet the withdrawal criteria is less than 30%.Therefore,the risk of drug resistance,long-term safety and indefinite duration of therapy remain major concerns for NA.IFN-a has both direct antiviral and immunomodulatory effects.IFN-a could prevent the formation of replication-competent pregenomic RNA-containing HBV capsids,or otherwise accelerate their degradation.It can also enhance host immune clearance of HBV and mediate epigenetic repression of HBV cccDNA transcriptional activity.The major advantages of IFN-based therapy are a finite duration,absence of drug resistance,a high seroconversion rate,and an opportunity to obtain durable posttreatment responses;however,more adverse events,modest antiviral effect,subcutaneous injections,and poor tolerability during treatment are the major limitations for this therapy.Although IFN could induce immune clearance of infected cells by CTL cells,only a small number of patients may achieve sufficient immune clearance.The response rate varies among individuals.Selecting patients based on factors such as disease activity,HBV genotype,disease stage,and status of HBV DNA,HBeAg,and HBsAg can help predict individual response rates.In China,PEG-IFN therapy may achieve better clinical outcomes in patients with high levels of ALT or fluctuations,HBV DNA<2×108 IU/mL or fluctuations,and HBsAg quantifications below 25,000 IU/mL at the time of the baseline.About 30%of the current treatment of interferon could achieve ideal outcomes,reaching the withdrawal criteria.The current efficacy of antiviral monotherapy is limited.Patients treated with IFN may possess a higher rate of HBeAg seroconversion than accepting NA,but still far from satisfaction according to the current large-scale multicenter study.After a year of treatment,HBeAg seroconversion rate does not exceed 30%.Potent NAs are difficult to meet withdrawal criteria and require long-term treatment,which,however,can lead to poor patient compliance.How to achieve anti-viral treatment through limited duration and achieve long-term response after cessation the drug has become controversial in CHB treatment.The combination of NA and PEG-IFN has the advantage of increasing efficacy.At present,liver disease experts at home and abroad are actively exploring different combinations of IFN and NA and sequential treatments for improving the efficacy to enable more patients with CHB to discontinue safely.The combination of NA and PEG-IFN has been used in treatment for naive and NA suppressed CHB patients.For treatment of naive patients,there is no robust evidence that a de novo combination of PEG-IFN and NA is superior to PEG-IFN or NA alone.The level of viral suppression during initial combination therapy compared with IFN monotherapy is more preferable,and there is no difference in sustained virological response after discontinuation of the drug;so de novo combination of NA and PEG-IFN is not recommended.Short-term pretreatment with a NA prior to PEG-IFN for naive HBeAg-positive patients is not recommended.The pretreatment with short-term NA did not significantly increase the long-term response rate of PEG-IFN.However,patients with chronic hepatitis B who have been treated with NA and achieved long-term effective viral suppression may consider switching to or adding on PEG-IFN,which may increase the chance of CHB cure by synergistic antiviral activity and immunomodulatory effects.Clinical studies have demonstrated that NAs are effective in the initiation of sequential IFN combination therapy,which could reduce viral load,increase immune cell function and sensitivity to IFN therapy;on the other hand,it can also prevent recurrence of nucleoside drugs after drug withdrawal.However,after long-term effective treatment of NA,i.e.three years,additional PEG-IFN treatment could not bring clinical benefits.And all studies have shown that long-term use of nucleoside drugs in patients switching or adding on PEG-IFN will increase treatment costs and adverse reactions.Currently insufficient is the evidence on the therapeutic advantages of the hepatitis B combination therapy,and there are many unresolved issues such as the choice of patients,the timing of treatment and the duration of combined treatment.Therefore,each patient should be fully evaluated for potential advantages and disadvantages before application.In order to increase the clearance of HBV,combination therapy requires the selection of appropriate treatment timing and optimal combination therapy time.Our study is a non-randomized,controlled prospective study.The purpose of the study is to observe the efficacy and safety in HBeAg-positive CHB patients who was additionally treated with PEGASYS,PEG-IFN?-2a,after obtaining virological response,defined as HBV DNA level<200IU/mL,by treatment with nucleoside(acid)analogs ETV,ADV,and LAM.Our research proposes that the research population of the study achieved the virological response of the NA without a serological response.The patients treated with NA account for about 70%of this cohort.Moreover,treatment plan is adopted with adding PEG-IFN,where the risk of relapse of the patients' discontinuation of the NA was avoided compared to switch to PEG-IFN,and reducing unnecessary combination therapy in approximately 30%of patients compared to the initial combination therapy.The recommended treatment period with IFN in HBeAg-positive CHB patients was 48 weeks.Prolonged treatment may increase efficacy,while the adverse events and financial costs were gradually increased.Therefore,the combined treatment period in this study was set to 48 weeks.At the same time,our experiment also proposed to predict the patient's efficacy based on the baseline of HBsAg characteristics and dynamic changes of HBsAg and provide evidence for the individualized antiviral program of CHB patients.Methods1.Study cohort:HBeAg positive CHB patients achieved undetectable HBV DNA in serum but without HBeAg loss after at least one year of NA therapy with ETV,ADV,or LAM were enrolled into this double-blinded,non-randomized controlled study.Patients in NA+PEG-IFN group received 180?g of PEG-IFN-?2a by subcutaneous injection once weekly for 48 weeks.Patients in the NA group continued their original NA administered once daily for 48 weeks.Treatment would be stopped in patients met with the standard of withdrawal after 48 weeks of treatment.Treatment would continue for those who did not met with the criteria.All patients were followed for at least 48 weeks.For patients with potential drug resistance,viral mutations were detected and the antiviral treatment was adjusted according to the drug resistance profiles.2.Observation measures:Liver function test,serum HBsAg,HBeAg,and HBV DNA load were performed at baseline,12w,24w,and 48w of treatment.The main outcome measures were rates of HBeAg loss and seroconversion in the end of treatment and 48 weeks post treatment.The secondary outcome measures were the level of HBsAg decline and loss in the end of treatment and 48 weeks post treatment;the relationship between the dynamic changes of HBsAg and the curative effects;the safety of adding PEG-IFN in NA treated patients;the drug resistance in patients treated with NA.The long-term follow-up is the occurrence of primary liver cancer and the relapse after NA withdrawal.A special case observation form was designed for follow-up.Data were analyzed by SPSS 17.0.Results1.Study Cohort:In total 89 patients were enrolled into NA+PEG-IFN group.7 patients stopped IFN treatment due to adverse events.One patient lost visit.162 patients were enrolled into NA group matched by age and sex.No significant differences were found on ages,gender,NA duration,titer of HBsAg and HBeAg,ALT level and HBVDNA load between the two groups.2.HBeAg seroconversion:The rate of HBeAg seroconversion in NA group was lower in NA group than in NA+PEG-IFN group(12W,0%vs.12.30%;24W,0%vs.23.4%;36W 6.2%vs.39.5%;48W 7.4%vs.40.74%,respectively.P<0.001).Patients with lower titer of HBsAg(median:605.3 vs.314IU/mL,P<0.001)and HBeAg(1.5 vs.9.5S/CO,P<0.001)at baseline,elevated ALT level(75.6%vs.23.2%,P<0.001)during treatment were easier to achieve HBeAg seroconversion(univariable analysis).While add-on PEG-IFN therapy,HBsAg<1000IU/mL,HBeAg<10S/CO were independent predictive factors for HBeAg seroconversion(OR(95%CI):11.4(4.9-26.8),P<0.001;2.8(4.9-26.8),P=0.01;6.1(2.4-15.4),P<0.001)?Interaction effects were observed between add-on PEG-IFN and elevation of ALT level during treatment.Multivariate analysis showed that HBsAg<1000 IU/mL,HBeAg<l OS/CO were independent predictive factors for HBeAg seroconversion(OR(95%CI):10.6(3.4-33.0),P<0.001;4.0(1.3-12.4),P<0.001)among patients received add-on PEG-IFN therapy.3.The mean HBsAg decline from baseline to week 48 was significantly greater in NA+PEG-IFN group than in NA group(1.04 vs.-0.08 log10 IU/mL,P<0.001).Nine patients of NA+PEG-IFN group obtained HBsAg loss at 48-week treatment(11.1%vs.0%,P<0.001)and three of them achieved HBsAg seroconversion(3.7%vs.0%,P=0.014).No significant difference on ages,gender,NA duration,ALT/AST level,elevation of ALT/AST during treatment,lower titer of HBeAg(<10S/CO)were found between patients with HBsAg loss and without,Lower titer of HBsAg and HBeAg were associated with HBsAg loss on 48W post treatment.Moreover,all patients obtained HBsAg loss occurred in patients with HBsAg<1000IU/mL at baseline?The positive and negative predicative value of baseline HBsAg<1000IU/mL for HBsAg loss on 48W post treatment were 30%and 100%,respectively.4.Treatment discontinuation and relapse:In total 45 patients(NA group:N=12;NA+PEG-IFN group:N=33)met the treatment discontinuation criteria and 42 of them(NA group:N=9;NA+PEG-IFN group:N=33)stopped treatment.A higher SVR48 was observed in NA+PEG-IFN group(29.6%vs.3.1%,P<0.001)while no significant difference on relapse between the two groups(NA vs.NA+PEG-IFN group:44.4%vs.27.2%,P=0.32).A higher titer of HBeAg(?5S/CO)and HBsAg(? 1000IU/mL)at baseline were risk factors of relapse.5.Therapy tolerance and safety events:7 cases in the NA+PEG-IFN group were dropped due to treatment intolerance.Only mild to moderate safety events were observed during treatment.No SAE occurred due to PEG-IFN therapy.Conclusions1.Add-on PEG-IFN therapy leads to a higher rate of HBeAg seroconversion on post-treatment 48W and more satisfactory treatment outcome among HBeAg positive CHB patients with response to prior NA treatment.2.Add-on PEG-IFN may enhance HBsAg loss among HBeAg positive CHB patients with response to prior NA treatment,which leads to "functional cure".3.HBsAg<1000IU/mL or HBeAg<10S/CO at baseline may help to identify certain patients possibly benefit from add-on PEG-IFN therapy and hence to obtain ideal endpoint and clinical cure.4.Add-on PEG-IFN was well-tolerated and no relevant safety concerns were observed.