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Chronic hepatitis C treatment in näive patients
Jorge Daruich
,
Corresponding author
jdhcv7@gmail.com

Correspondence and reprint request:
* Liver Unit, Hospital de Clínicas San Martín, University of Buenos Aires and Gastroenterología Diagnóstica y Terapéutica, Buenos Aires, Argentina
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Hepatitis C &#40;HCV&#41; is a major public health problem worldwide and it is considered that there are about 180 millions of infected people&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">Studies that analyze the natural history of hepatitis C show that&#44; of those individuals affected by a primo-infection&#44; 55 to 95&#37; evolve into chronicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Among the carriers of a chronic hepatic disease&#44; the HCV is one of the principal reasons of death &#40;liver failure and hepatocellular carcinoma&#41; and liver transplant and&#44; in agreement with some projections&#59; the incidence of this last one will increase furthermore in the next two decades&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">For more than 20 years&#44; the empirical treatment with interferon-alpha &#40;IFN&#945;&#41; in carriers of chronic hepatitis Non A Non B&#44; showed that the disease could be curable&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Later&#44; in 1997&#44; based on results obtained from randomized trials&#44; the first &#8220;Consensus on Management of Hepatitis C&#8221; of the National Institute of Health of The United States recommended IFN&#945;&#8217;s use in the treatment for chronic hepatitis C&#46; The percentage of sustained virological response &#40;SVR&#41; &#8212;HCV RNA non-detectable in serum by a high sensibility technique 24 weeks after treatment &#8212; reached by this therapy was from 12 to 16&#37;&#46; Later trials which associated&#44; empirically as well&#44; Ribavirin &#40;RBV&#41; with IFN&#945; showed encouraging results for the accomplishment of randomized trials and&#44; on the base of the above mentioned&#44; the Consensus on Management of Hepatitis C of the European Association for the Study of the Liver &#40;EASL&#41; also recommended this association for the therapy&#46; The reached SVR was around 40&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">Later&#44; the attachment of polyethylene glycol &#40;PEG&#41; to IFNa molecule &#40;pegylation&#41; modified its pharmacokinetic and pharmacodinamic properties&#44; allowed a weekly application and an increase on its efficacy&#46; The therapeutic randomized trials proved a higher SVR with the association PEG IFN&#945;-RBV when compared with PEG IFNa alone or IFN&#945;-RBV&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Since 2002 different medical societies of the world recommend the use of the association PEG IFN&#945;-RBV for the treatment of chronic hepatitis C&#46; Therefore&#44; this association is considered to be the standard of care at present and PEG IFN&#945; mo-notheraphy to be indicated only when RBV is con-traindicated&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Pegylated Interferons</span><p id="p0025" class="elsevierStylePara elsevierViewall">Pegylation is a procedure that allows the union of polyethylene glycol moieties &#40;PEG&#41; to pharmacolo-gic active proteins&#59; in this case&#44; IFN&#945;&#46; PEG is an amphiphilic polymer formed from the union of a changeable number of monomers of ethylene glycol&#46; Polymers can change in length&#44; chemical structure and molecular weight&#46; In addition&#44; polyethylene glycol is inert&#44; water-soluble&#44; and nontoxic and does not adversely affect the safety profile of the interfe-ron product&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="p0030" class="elsevierStylePara elsevierViewall">Pegylation of the IFN&#945; 2a and 2b provoke important modifications in these proteins&#58; slower absorption&#44; different distribution&#44; slower elimination&#44; and longer half life with major exposure to the drug and lesser antigenicity &#40;and thus reduced immunogenici-ty&#41;&#46; The two pegylated interferons available are dissimilar between them&#46; PEG IFN&#945; 2a is joined to a branched PEG molecule of 40 kDa and PEG IFN&#945; 2b to a linear chain of 12 kDa&#46; Also&#44; the sites and types of union of the aminoacids to PEG are different&#46; The branched PEG molecule of 40 kDa joins in stable unions of amide to lysine &#40;of the IFN&#945; 2a&#41; and the IFN&#945; 2b PEG of 12 kDa does it with by residues of histidyne creating an urethane bridge&#44; sensitive to hydrolysis&#46; These unions determine that PEG IFNa molecule 2a circulate without changing until its elimination interacting with its receptor in a totality permitting its pharmacological activity&#44; whereas PEG IFN&#945; 2b hydrolyzes easily and its pharmacological action is originally done by IFN&#945; 2b when letting go its pegylated molecule&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">PEG IFN&#945; 2a 180 <span class="elsevierStyleItalic">&#956;</span>g per week when subcuta-neously applied is absorbed slowly in a supported way and reaches its mean maximum serum concentration &#40;C<span class="elsevierStyleInf">max</span>&#41; &#40;14&#46;2 <span class="elsevierStyleItalic">&#956;</span>g&#47;L&#41; after one only dose at 80100 hours and its terminal elimination half-life after a single dose is approximately 80 hours&#46; After 5 to 8 weeks the C<span class="elsevierStyleInf">max</span> is 25 <span class="elsevierStyleItalic">&#956;</span>g&#47;L in 45 hours of supported stable serum levels for approximately 168 hours and will still be undetectable 4 to 6 weeks after 48 weeks therapy&#46; PEG IFN&#945; 2a displays restricted biodistri-bution with highest concentrations occurring in the liver&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="p0040" class="elsevierStylePara elsevierViewall">A subcutaneous dose of 1&#46;5 <span class="elsevierStyleItalic">&#956;</span>g&#47;kg per week of PEG IFN&#945; 2b is absorbed more rapidly than PEG IFN&#945; 2a and reaches its C<span class="elsevierStyleInf">max</span> between 20 and 32 hours after one application&#46; Passed the fourth week&#44; the C<span class="elsevierStyleInf">max</span> is similar and its terminal elimination half-life after a single dose is around 40 hours maintaining circulation levels of diminishing concentration between the doses&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="p0045" class="elsevierStylePara elsevierViewall">The serum concentration of HCV RNA is inversely proportional to PEG&#8217;s IFN&#945; levels&#46; Reason why a major tendency is observed especially during the first weeks of treatment on the fluctuation of the HCV RNA in individuals that received PEG IFN&#945; 2b&#46; This increase in the serum level of the HCV RNA at the end of the period between PEG IFN&#945; 2b doses can be diminished if the dose is increased or if there are two weekly doses applied&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Therapy for Chronic Hepatitis NaVe Patients</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Treatment objectives</span><p id="p0050" class="elsevierStylePara elsevierViewall">The objective of treatment for chronic hepatitis C is to prevent in the long term the complications and death that this disease may cause&#46; In a short term the most important aim is the SVR&#44; considered a vi-rological response&#44; normalization of the serum levels of ALT and histological improvement &#40;decrease of 2 points in the necro-inflammatory score without worsening of the fibrosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> On the other hand&#44; SVR has shown an improvement in patients&#8217; quality of life when comparing previous and post treatment with specific tests as SF36&#46; At a sanitary level&#44; HCV eradication reduced transmission risks&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">First treatment for chronic hepatitis C</span><p id="p0055" class="elsevierStylePara elsevierViewall">It is widely confirmed that the treatment for chronic hepatitis C patients must be done with the association PEG IFNa-RBV due to the major efficacy when compared with the monotherapy done with PEG&#945; IFN and with the association IFN&#945;-RBV&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The SVR in chronic hepatitis C patients who were treated with PEG IFNa-RBV in registration trials was 54 to 61&#37; &#40;<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> An important advance was made by a study done by Hadziyannis <span class="elsevierStyleItalic">et al&#46;</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> who compared the efficacy of different doses and time of therapy according to the genotype&#44; establishing that RBV&#8217;s dose in patients with genotypes 2 and 3 is of 800 mg per day associated with PEG IFN&#945; 2a during a period of 24 weeks&#44; whereas in patients with genotype 1 the RBV&#8217;s most effective dose is of 1-1&#46;2 g per day associated with PEG IFN&#945; 2a during a period of 48 weeks&#46;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia><p id="p0060" class="elsevierStylePara elsevierViewall">In these trials was possible to establish the importance of undetectable HCV RNA or a reduction in the viremia level &#8805; 2 log<span class="elsevierStyleInf">10</span> in the twelfth week of treatment&#46; Those patients who were presenting a decrease of HCV RNA level &#60; 2 log<span class="elsevierStyleInf">10</span> had a predictive negative value for reaching the SVR of order 98&#37;&#46; This observation was determinant to indicate the early suspension of the therapy in the week 12 in the latter group of patients&#44; especially genotype 1&#46; Nevertheless&#44; it is necessary to consider that the methodological rigor of clinical trials is not always carried out in welfare practice&#46; For example&#44; it is necessary that the level of initial viremia is determined in absolute values and not as sometimes happen&#44; that an informed result is bigger than a cut value determined by the manufacturer of the method or the biochemist that performs the study&#46; It is also important to perform the study with internationally approved commercial methods&#44; and that the later controls be done with the same method&#44; since the results of the different available commercial techniques or those developed &#8220;in house&#8221; are not equivalent&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Predictive factors in sustained treatment viral results</span><p id="p0065" class="elsevierStylePara elsevierViewall">In registration trials of PEG IFNa-RBV&#8217;S&#44; both predictive factors of SVR to the treatment are the viral genotype and the viremia level of pretreatment basal&#46; SVR is most elevated in genotype 2 and 3 patients who have a virema level of 600&#46;000 IU&#47;mL&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> It is also included in-between these factors&#44; the PEG IFNa 2b dose &#40;1&#46;5 <span class="elsevierStyleItalic">&#956;</span>g&#47;kg per week&#41; and the Ribavirin dose &#40;&#62; 10&#46;6 mg&#47;kg&#41;&#44; female sex&#44; under age of 40&#44; weight &#60; 75 kg&#44; non Afro-American race&#44; absence of insulin resistance&#44; ALT higher than 3 times the normal value and absence of bridging fibrosis or cirrhosis in the liver biopsy&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Therapy for Chronic Hepatitis Patients With Genotypes 2 and 3 Who Had Received No Previous Treatment</span><p id="p0070" class="elsevierStylePara elsevierViewall">As mentioned above&#44; the work done by Hadziyan-nis <span class="elsevierStyleItalic">et al&#46;</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> established that the time of treatment in genotype 2 and 3 patients had to be of 24 weeks&#44; with the association PEG IFN&#945;-RBV&#44; and this last one in a dose of 800 mg per day&#46; Because of the fact that about 90&#37; of the treated present a more than 2 log<span class="elsevierStyleInf">10</span> decrease of the HCV RNA in the week 12&#44; with normal or high aminotransferases&#44; it is not suggested to investigate the RVT&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Standard or individualized treatment</span><p id="p0075" class="elsevierStylePara elsevierViewall">Subsequently different studies tried to determine if it was feasible to shorten the therapeutic standard period from 24 weeks to 12-16 &#40;short treat-ment&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> All these trials have different designs&#44; reason why it is very important to be careful when they are interpreted&#46; In 2&#44; the analysis of the rapid virological response &#40;RVR&#41;&#44; this is non-detectable HCV RNA in the fourth week&#44; constitutes a part of the original design and was a determinant of the interpretation of the results&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> In agreement with the results of these two trials&#44; patients who achieve RVR can receive the short treatment since the SVR is equivalent to the obtained with the standard treatment of 24 weeks&#46; Nevertheless&#44; in the study done by Shiffman et al &#40;the protocol with major number of included patients&#41; which was not designed to evaluate RVR&#44; results prove a major percentage of SVR in those that are treated for 24 weeks&#46; The predictive factors &#40;with a statistically significant value&#41; of SVR in this protocol were&#58; genotype 2&#44; baseline HCV RNA &#8804; 400&#46;000 IU&#47;mL&#44; age &#8804; 45 years&#44; weight &#8804; 80 kg&#44; ALT 3 times higher than the normal value&#44; absence of bridging fibrosis or cirrhosis and standard treatment of 24 weeks&#46; The analysis of genotypes 2 and 3 patients proved that the predictive factors of SVR had low viremia level&#44; minor weight and absence of bridging fibrosis or cirrhosis in both groups&#46; The standard treatment was only predictive of SVR in those patients with genotype 2 and not in those with genotype 3&#46;</p><p id="p0080" class="elsevierStylePara elsevierViewall">Based on the analysis of the five studies mentioned before we may conclude that in patients with genotype 2 and 3 the standard treatment of 24 weeks is the recommended one&#46; Nevertheless&#44; a short therapy might be considered for those individuals by pretreatment HCV RNA &#8804; 400&#46;000 IU&#47;ml&#44; with RVR and intolerance to the treatment&#46; On the other hand&#44; in those patients who do not have RVR&#44; especially with genotype 3 and bridging fibrosis or cirrhosis might be considered to be a therapy of 48 weeks&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Therapy for Chronic Hepatitis Patients With Genotype 1 Who Had Received No Previous Treatment</span><p id="p0085" class="elsevierStylePara elsevierViewall">Chronic hepatitis C patients with genotype 1 are considered to be &#8220;difficult to cure&#8221;&#44; and in this group of patients the SVR is significantly minor that in those with genotypes non 1&#44; since it was demonstrated by the registration trials&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> It was demonstrated in these studies that there a better SVR in association with PEG IFN&#945;-RBV that with the monotherapy with PEG IFN&#945;-RBV or that with the combination IFN&#945;-RBV&#46;</p><p id="p0090" class="elsevierStylePara elsevierViewall">In the study of Manns et al was observed that those patients with genotype 1 that were receiving highest PEG IFN&#945; 2b dose &#40;1&#46;5 <span class="elsevierStyleItalic">&#956;</span>g&#47; kg per week&#41; and RBV dose &#40;&#62; 10&#46;6 mg&#47;kg per day&#41; for 48 weeks&#44; were reaching a major SVR &#40;48&#37;&#41;&#46; A later randomized study evaluated RBV&#8217;s dose according to weight and SVR&#44; showed that SVR was higher when administering RBV&#8217;s dose of 800 mg in those with a weight &#60;65 Kg&#44; 1000 mg per day for those with 65 to 85 kg&#44; 1200 mg per day for a weight between 85 and 105 kg and 1400 mg per day when weight was between 105125 kg&#46;</p><p id="p0095" class="elsevierStylePara elsevierViewall">The study of Hadziyannis&#44; <span class="elsevierStyleItalic">et al&#46;&#44;</span> showed one similar find since those patients with genotype 1 that they were receiving PEG IFN&#945; 2a &#40;180 <span class="elsevierStyleItalic">&#956;</span>g per week&#41; and RBV&#8217;s dose 1000-1200 mg&#47;kg per day for 48 weeks&#44; were reaching a major SVR &#40;52 &#37;&#41;&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Strategies of improvement for SVR</span><p id="p0100" class="elsevierStylePara elsevierViewall">Some studies related to chronic hepatitis C patients with genotype 1 suggest that a treatment with higher doses of PEG IFNa and or RBV for longer periods of 48 weeks&#44; might obtain a greater percentage of SVR&#46; On the other hand&#44; they proposed to diminish the time of therapy in some cases&#46;</p><p id="p0105" class="elsevierStylePara elsevierViewall">Probably the most representative study for the design shows that a longer therapy &#40;72 weeks&#41; could be a good strategy in those patients who do not present RVR &#40;HCV RNA non detectable in fourth week&#41; defined like &#8220;slow responders&#8221;&#44; since in this group the SVR was significantly superior when treatment was spreading to 72 weeks &#40;42 &#37;&#41; comparing it with those without RVR and that received the therapeutic association for 48 weeks &#40;35&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Long therapy &#40;72 weeks&#41; can be indicated for slow responders&#46;</p><p id="p0110" class="elsevierStylePara elsevierViewall">Other investigated alternative to improve SVR was the use of PEG IFN&#945; higher doses&#44; which did not prove to be superior to the standard dose&#46; In counterpart&#44; the use of RBV&#8217;s higher doses&#44; though it was associated to a greater significant of SVR&#44; was also associated with the significant increase of the anemia that needed-in a few studied cases-the use of Eritropoyetin and even in someone of them blood transfusions&#46; The disadvantage of this strategy is the managing of this adverse event and the inherent risks for the patients&#46;</p><p id="p0115" class="elsevierStylePara elsevierViewall">Another option that was investigated was a short treatment of 24 weeks&#46; In a recently published meta-analysis of 7 randomized controlled trials comparing the standard PEG IFN - RBV treatment &#40;48 weeks&#41; to less than 48 weeks in around 800 patients with HCV-1 with RVR&#44; showed a significantly less SVR in those with a short duration of therapy &#40;p &#61; 0&#46;004&#41;&#46; There was no significant difference in SVR rates between 24 and 48 weeks of treatment only in the subgroup of 212 patients with baseline low level of viremia &#40;HCV RNA &#8804; 400&#44;000 IU&#47;mL&#41; and RVR &#40;p &#61; NS&#41; suggesting that 24 weeks of therapy could be the appropriate treatment duration in this subgroup of HCV-1 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> Therefore&#44; in patients with these characteristics is possible to consider a short therapy&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Peg Ifn - Rbv-Amantadinetreatment</span><p id="p0120" class="elsevierStylePara elsevierViewall">The results obtained from the association of PEG IFNa - RBV - Amantadine in chronic hepatitis C patients are controversial&#46; Some studies do not show an increase of the SVR when comparing triple therapy with the standard treatment PEG IFNa - RBV and others&#59; on the contrary they show a better significant improved SVR in patients with genotype 1&#44; 2 and 3&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a><span class="elsevierStyleSup">&#44;</span><span class="elsevierStyleSup">53</span></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Therapy for Patients With Chronic Hepatitis C Genotype 4 Who Had Received No Previous Treatment</span><p id="p0125" class="elsevierStylePara elsevierViewall">Patients with chronic hepatitis C genotype 4 are relatively slightly frequent in our way&#44; even in registration trials where appear poorly represented&#46; Different studies which evaluate the therapy with the association PEG IFN&#945; - RBV as well as a meta-analysis show that the scheme of 48 weeks have a greater SVR in those with genotype 1&#44; but smaller in those with genotype 2 and 3&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> RVR have a similar impact on SVR that the observed in other genotypes&#44; allowing to shorten the therapeutic period to 24 weeks in this patients&#8217; subgroup&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Peg Ifn&#945; 2A <span class="elsevierStyleItalic">Versus</span> Peg Ifn&#945; 2B</span><p id="p0130" class="elsevierStylePara elsevierViewall">The information offered by trials which compare PEG IFN&#945; 2a with PEG IFN&#945; 2b&#44; both associated or not to RBV&#44; in patients with chronic hepatitis C is controversial&#46; Recently&#44; four studies published&#44; 3 of them were prospective<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> and one retrospective&#44; conclude in a different way&#46; The first&#44; prospective&#44; shows that both pegylated IFN are comparable in efficiency and adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Other two&#44; also prospective&#44; show that the safety profile of both is similar and that SVR is significantly greater &#40;statistically significant&#41; when patients are carriers of genotype 1 or non 1&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> receive treatment with PEG IFN&#945; 2a&#46; The fourth study &#40;the PRACTICE study&#41; includes 3414 patients treated in the routine clinical daily practice of 23 centers of Germany&#46; In this one&#44; when matched the included ones&#44; its observe that SVR is significantly greater in carriers of genotype 1 when they were treated by PEG IFN&#945; 2a&#44; whereas in those with genotypes 2 or 3 SVR was similar&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p><p id="p0135" class="elsevierStylePara elsevierViewall">A more global contribution on this controversy among the comparison of the efficacy of both pegyla-ted interferons &#40;partners to RBV&#41; offers Awad&#44; et al&#46;&#44; a meta-analysis of the Cochrane Hepato-Biliary Group&#46; These authors&#44; after a systematic search of publications which compare PEG IFN&#945; 2a <span class="elsevierStyleItalic">vs&#46;</span> PEG IFN&#945; 2b &#40;with or without RBV&#41; in different databases of the medical bibliography-until July 2009-select&#44; because they fulfill the strict methodological criteria 12 clinical randomized trials<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> and 8 in which it is evaluated SVR&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> The meta-analysis using intention-to-treat analysis for SVR included 4&#44;335 patients&#46; In this sub-analysis SVR together with PEG IFN&#945; 2a &#40;47&#37;&#41; is superior to the observed with PEG IFN&#945; 2b &#40;41&#37;&#41; &#40;p &#61; 0&#46;004&#41; for patients with genotype 1 and 4 as well for those with genotypes 2 and 3&#46; Reason why the authors of this meta-analysis conclude that the available evidence of today suggests that SVR with PEG IFN&#945; 2a is superior that the observed with PEG IFN&#945; 2b&#46; On the other hand&#44; the meta-analysis of adverse events leading to treatment discontinuation included 11 trials and showed not significant differences between the two PEG IFN&#945;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Chronic Hepatitis C Patients With Mild Histological Liver Injury</span><p id="p0140" class="elsevierStylePara elsevierViewall">Guidelines of treatment for chronic hepatitis C suggest to treat those patients with hepatic injury moderated to severe&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Patients with bridging fibrosis or cirrhosis&#44; independently of the genotype that they present&#44; have one significant minor percentage of SVR&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p><p id="p0145" class="elsevierStylePara elsevierViewall">A recently published meta-analysis which includes 10 clinical randomized trials&#44; evaluates SVR to treatment with the association IFN&#945; - RBV as well as PEG FN&#945; - RBV in patients with chronic hepatitis C and histological hepatic mild injury&#46; This study results showed that carriers of a histological mild lesion have a similar SVR as those with moderate or severe injury&#46; Therefore&#44; the therapy in this phase of the disease&#44; if effective&#44; would allow the accomplishment of the general objectives of the treatment for chronic hepatitis C and to improve the quality of life and to reduce simultaneously the transmission of HCV&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></span></span>"
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          "titulo" => "Therapy for Chronic Hepatitis NaVe Patients"
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              "titulo" => "First treatment for chronic hepatitis C"
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              "titulo" => "Predictive factors in sustained treatment viral results"
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          "titulo" => "Therapy for Chronic Hepatitis Patients With Genotypes 2 and 3 Who Had Received No Previous Treatment"
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              "identificador" => "sec0040"
              "titulo" => "Standard or individualized treatment"
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          "titulo" => "Therapy for Chronic Hepatitis Patients With Genotype 1 Who Had Received No Previous Treatment"
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          "titulo" => "Peg Ifn - Rbv-Amantadinetreatment"
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          "titulo" => "Therapy for Patients With Chronic Hepatitis C Genotype 4 Who Had Received No Previous Treatment"
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          "titulo" => "Peg Ifn&#945; 2A Versus Peg Ifn&#945; 2B"
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          "titulo" => "Chronic Hepatitis C Patients With Mild Histological Liver Injury"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abs0005" class="elsevierStyleSection elsevierViewall"><p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Hepatitis C &#40;HCV&#41; is a major public health problem worldwide and it is considered that there are about 180 millions of infected people&#46; The natural history of hepatitis C shows that&#44; of those individuals affected by a primo-infection&#44; 55 to 95&#37; evolve into chronicity&#46; The objective of treatment for chronic hepatitis C is to prevent in the long term the complications and death that this disease may cause&#46; In a short term the most important aim is the sustained virological response &#40;SVR&#41;&#44; considered a virological response&#44; normalization of the serum ALT level&#44; histological improvement&#44; improvement in patients&#8217; quality of life and the risk of transmission reduction&#46;</p><p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">The association Peginterferon alpha - Ribavirin &#40;PEG IFN&#945;-RBV&#41;&#44; at the moment&#44; is the standard of care of patients with chronic hepatitis C and compensated cirrhosis&#46; Two PEG IFN&#945; are licensed&#44; PEG IFN&#945; 2a and PEG IFN&#945; 2b&#46; Pegylation is a procedure that allows the union of polyethylene glycol moieties &#40;PEG&#41; to pharmacologic active proteins&#59; in this case&#44; IFN&#945;&#46; Pegylation of the IFN&#945; 2a and 2b provoke important modifications in these proteins&#58; slower absorption&#44; different distribution&#44; slower elimination&#44; and longer half life with major exposure to the drug and lesser antigenicity&#46; The two pegylated interferons available are dissimilar between them&#46; The SVR in chronic hepatitis C patients who were treated with PEG IFN&#945;-RBV in registration trials was 54 to 61&#37;&#46; Patients with genotypes 1 and 4 must be treated 48 weeks and those with genotypes 2 and 3&#44; 24 weeks&#46; In some situations patients could be treated lesser or longer time&#46; Results obtained from the association of PEG IFN&#945; - RBV - Amantadine in chronic hepatitis C patients are controversial&#46;</p><p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Meta-analysis comparing both PEG IFNs alpha shows a better SVR with PEG IFN&#945; 2a&#46; Therapies in patients with mild chronic hepatitis C have a similar SVR that those with more advanced liver disease and could be treated in this phase of the disease&#46;</p></span>"
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Association&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Global SVR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Genotype 1 SVR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Genotypes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="center" valign="middle">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">2 and 3 SVR &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">PEG IFN&#945; 2b 1&#46;5 ug&#47;kg&#47;week-RBV &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="center" valign="middle">PEG IFN&#945; 2a 180 ug&#47;week-RBV &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">56&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">46&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">PEG IFN&#945; 2a 180 ug&#47;week-RBV &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">61&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle">84 &#40;24 weeks therapy&#41;&nbsp;\t\t\t\t\t\t\n
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ISSN: 16652681
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos