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A Randomized, Controlled Trial of Combination Therapy for Chronic Hepatitis B: Comparing Pegylated Interferon-α2b and Lamivudine with Lamivudine Alone

Henry Lik-Yuen Chan, MD; Nancy Wai-Yee Leung, MD; Alex Yui Hui, MB, BChir; Vincent Wai-Sun Wong, MBChB; Choong-Tsek Liew, MD; Angel Mei-Ling Chim, BSc; Francis Ka-Leung Chan, MD; Lawrence Cheung-Tsui Hung, MB, BChir; Yuk-Tong Lee, MD; John Siu-Lun Tam, PhD; Christopher Wai-Kei Lam, PhD; and Joseph Jao-Yiu Sung, MD, PhD
[+] Article and Author Information

From the Chinese University of Hong Kong and Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China.


Grant Support: Schering-Plough Corp. supplied pegylated interferon-α2b, and GlaxoSmithKline supplied lamivudine.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Joseph J.-Y. Sung, MD, PhD, Department of Medicine and Therapeutics, 9/F Prince of Wales Hospital, 30–32 Ngan Shing Street, Shatin, Hong Kong SAR, China; e-mail, joesung@cuhk.edu.hk.

Current Authors Addresses: Drs. H.L.-Y. Chan, F.K.-L. Chan, Lee, and Sung; Mr. Hui; Mr. Wong; Ms. Chim; and Mr. Hung: Departments of Medicine and Therapeutics, 9/F Prince of Wales Hospital, 30–32 Ngan Shing Street, Shatin, Hong Kong SAR, China.

Dr. Leung: Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, Hong Kong SAR, Hong Kong.

Dr. Liew: Department of Anatomical and Cellular Pathology, 1/F Prince of Wales Hospital, 30–32 Ngan Shing Street, Shatin, Hong Kong SAR, China.

Dr. Tam: Department of Microbiology, 1/F Prince of Wales Hospital, 30–32 Ngan Shing Street, Shatin, Hong Kong SAR, China.

Dr. Lam: Department of Chemical Pathology, 1/F Prince of Wales Hospital, 30–32 Ngan Shing Street, Shatin, Hong Kong SAR, China.

Author Contributions: Conception and design: H.L.-Y. Chan, J.J.-Y. Sung.

Analysis and interpretation of the data: H.L.-Y. Chan, J.J.-Y. Sung.

Drafting of the article: H.L.-Y. Chan.

Critical revision of the article for important intellectual content: H.L.-Y. Chan, J.J.-Y. Sung.

Final approval of the article: H.L.-Y. Chan, J.J.-Y. Sung.

Provision of study materials or patients: H.L.-Y. Chan, N.W.-Y. Leung, A.Y. Hui, V.W.-S. Wong, F.K.-L. Chan, L.C.-T. Hung, Y.-T. Lee.

Statistical expertise: H.L.-Y. Chan.

Obtaining of funding: C.-T. Liew, J.J.-Y. Sung.

Administrative, technical, or logistic support: A.M.-L. Chim, J.S.-L. Tam, C.W.-K. Lam, J.J.-Y. Sung.

Collection and assembly of data: A.M.-L. Chim.


Ann Intern Med. 2005;142(4):240-250. doi:10.7326/0003-4819-142-4-200502150-00006
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The antiviral effect of lamivudine, a nucleoside analogue, for treating chronic HBV infection is suboptimal. The drug is associated with a low HBeAg seroconversion rate, frequent post-treatment relapses, and development of drug resistance with extended treatment. Combination therapy with lamivudine and other nucleoside analogues (for example, adefovir dipivoxil and telbivudine) may not improve virologic response (2829), and combination therapy with lamivudine and interferon shows conflicting results (Table 4). In our study, we administered a combination of pegylated interferon-α2b and lamivudine in a staggered manner. Our rationale for staggered treatment was that initial treatment with pegylated interferon-α2b probably enhances the immune clearance of intrahepatic HBV, including the closed covalent circular DNA, and that adding lamivudine at a later phase theoretically suppresses HBV replication and prevents reinfection of the hepatocytes. This particular hypothesis requires confirmation with studies of viral kinetics.

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Figures

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Figure 1.
Study design.

Each arrow indicates a follow-up visit. B = baseline visit; R = randomization visit; S = screening visit.

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Figure 2.
Flow of patients included at various stages of the trial.

Severe relapse after cessation of treatment was defined as alanine aminotransferase (ALT ) level more than 10 times the upper limit of normal accompanied by hepatitis B virus (HBV ) DNA level greater than 500 000 copies/mL. These patients were given open-label lamivudine. HBeAg = hepatitis B e antigen.

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Figure 3.
Serial median log10 hepatitis B virus (HBV) DNA reduction (top) and serial median alanine aminotransferase (ALT) levels (bottom) among patients who received pegylated interferon and lamivudine combination treatment (solid line) versus patients who received lamivudine monotherapy (dotted line) from baseline to 24 weeks after treatment.

All randomly assigned patients were included in the analysis. The numbers of patients receiving open-label lamivudine treatment for hepatitis B relapse after cessation of studied drugs are presented. One patient in the combination treatment group and 2 patients in the lamivudine monotherapy group developed severe reactivation of hepatitis while receiving open-label lamivudine treatment and did not attend the follow-up visit at week 84 and week 76, respectively.

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Comments

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Pegylated Interferon-alfa2b and lamivudine in HBeAg-positive chronic hepatitis B
Posted on March 13, 2005
Martijn J. ter Borg
Erasmus Medical Center Rotterdam
Conflict of Interest: None Declared

TO THE EDITOR: With great interest we read the article by Chan and colleagues on the treatment with pegylated interferon of HBeAg-positive chronic hepatitis B (1). In this study, they found after 32 weeks of pegylated interferon-alfa2b combined with 52 weeks of lamivudine an end of follow-up response (HBeAg seroconversion and HBV DNA level less than 500.000 copies/ml) of 36%. This percentage is comparable with the HBeAg- seroconversion rates of two global studies investigating combination therapy of pegylated interferon and lamivudine for 1 year (2, 3).

In one of these studies, coordinated by our group (2), patients were treated for 52 weeks with pegylated interferon-alfa2b and lamivudine, and HBeAg-seroconversion was achieved in 25% at the end of treatment. In the study from Lau and colleagues (3), patients were treated with pegylated interferon-alfa-2a and lamivudine for 48 weeks and 24% of the patients had an HBeAg-seroconversion at the end of treatment. The 60% HBeAg- seroconversion at the end of treatment in the study by Chan et al. is very high compared to the previous studies, particularly taken into account the high prevalence of genotype C in this study, which is probably associated with a less favorable outcome (2).

Furthermore, for treatment-naïve patients, the study by Chan et al. shows a very high percentage of lamivudine resistance (40%) in the lamivudine monotherapy group as determined by the INNO-LiPA assay. In the combination therapy group this was 21%. In our study the lamivudine resistance rate was only 11% in the combination therapy group being determined by the same assay. It is tempting to speculate that some patients in the population studied by Chan et al. did have previous exposure to lamivudine therapy. We wonder whether the authors have an explanation for the high end of treatment response and for the high incidence of YMDD mutants.

Martijn J. ter Borg, MD Harry L.A. Janssen, MD

Dept. of Gastroenterology and Hepatology Erasmus Medical Center Rotterdam Dr. Molewaterplein 40 3015 GD Rotterdam The Netherlands

References:

1. Chan HL, Leung NW, Hui AY, et al. A randomized, controlled trial of combination therapy for chronic hepatitis B: comparing pegylated interferon-alpha2b and lamivudine with lamivudine alone. Ann Intern Med. 2005;142(4):240-50.

2. Janssen HL, van Zonneveld M, Senturk H, et al. Pegylated interferon alfa-2b alone or in combination with lamivudine for HBeAg- positive chronic hepatitis B: a randomised trial. Lancet. 2005;365(9454):123-9.

3. Lau G, Pivatvisuth T, Luo K, et al. Peginterferon alfa-2a (40KD) monotherapy and in combination with lamivudine more effective than lamivudine monotherapy in HBeAg-positive chronic hepatitis B: results from a large, multinational study. Hepatology. 2004;40(4, suppl. 1):171A.

Conflict of Interest:

None declared

Pegylated interferon alfa-2b and lamivudine in HBeAg positive chronic hepatitis B
Posted on April 14, 2005
Joseph JY Sung
Department of Medicine and Therapeutics, The Chinese University of Hong Kong
Conflict of Interest: None Declared

In Response

We appreciate the interest and comments of Dr. Dr. Janssen to our work. In our study, the proportion of patients who achieved HBeAg seroconversion at the end of combination pegylated interferon and lamivudine treatment (60%) was indeed substantially higher than that reported in 2 other multi-centered studies (25%-27%) [1,2,3]. We agree this result is surprising as peginterferon was given for 32 weeks in our study as compared to the longer (48-52 weeks) treatment duration in the other 2 studies. We started pegylated interferon alfa-2b 8 weeks prior to the commencement of lamivudine treatment as in contrast to the simultaneously administration of the drugs in other studies. We hypothesize that our staggered administration of immuno-modulator followed by lamivudine might allow maximal host immune stimulation by peginterferon as it avoids reduction of viral load by co-administration of anti-viral agent. This hypothesis however requires confirmation by future viral kinetics studies using different regimens of combination therapy. We suspect the inclusion of a significant proportion of patients who failed interferon and/or lamivudine treatment in the 2 multi-centered studies might affect their overall treatment response [2,3]. HBV genotype may not be important here as it was not found to influence the sustained virological response after we have followed up these patients for up to 3 years post-treatment [4].

We concur with Dr. Janssen that the rate of lamivudine resistance was high in our report. We have performed very extensive interview and medical record search to exclude previous usage of lamivudine on patient recruitment. As lamivudine was registered in Hong Kong in 1999, which coincided with the year we started our study, a hidden but significant previous exposure to lamivudine seemed extremely unlikely. The rate of lamivudine resistance among patients treated with lamivudine monotherapy in our study (40%) was comparable to that reported by Lau and colleagues (34%) [3]. The higher rate of lamivudine resistance as compared to previous early reports may be related to the higher sensitivity of the laboratory tool we use nowadays. We are not certain why our patients on combination treatment have a higher incidence of lamivudine resistant mutations (21%) as compared to the other 2 studies (11%). The relatively small number of patients in our study may impose some bias to the results. Whether patient ethnicity or viral genotype plays a role will require further investigations.

Reference

1. Chan HLY, Leung NWY, Hui, AY, et al. A randomized, controlled trial of combination therapy for chronic hepatitis B: Comparing pegylated interferon-alfa-2b and lamivudine with lamivudine alone. Ann Intern Med 2005;142:240-50.

2. Janssen HLA, van Zonneveld M, Senturk H, et al. Pegylated interferon alfa-2b along or in combination with lamivudine for HBeAg- positive chronic hepatitis B: a randomised trial. Lancet 2005;365:123-9.

3. Lau G, Pivatvisuth T, Luo K, et al. Peginterferon alfa-2a (40KD) monotherapy and in combination with lamivudine is more effective than lamivudine monotherapy in HBeAg-positive chronic hepatitis B : results from a large, multinational study. Hepatology 2004;40 supp 1:171A.

4. Chan HLY, Hui AY, Wong VWS, et al. Long-term follow-up of peginterferon and lamivudine combination treatment in HBeAg-positive chronic hepatitis B. Hepatology (in press).

Conflict of Interest:

None declared

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Summary for Patients

Combination Therapy for Chronic Hepatitis B

The summary below is from the full report titled “A Randomized, Controlled Trial of Combination Therapy for Chronic Hepatitis B: Comparing Pegylated Interferon-α2b and Lamivudine with Lamivudine Alone.” It is in the 15 February 2005 issue of Annals of Internal Medicine (volume 142, pages 240-250). The authors are H.L.-Y. Chan, N.W.-Y. Leung, A.Y. Hui, V.W.-S. Wong, C.-T. Liew, A.M.-L. Chim, F.K.-L. Chan, L.C.-T. Hung, Y.-T. Lee, J.S.-L. Tam, C.W.-K. Lam, and J.J.-Y. Sung.

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