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Treatment of HBV–HCV coinfection
Rocío Torres Ibarra1,
Corresponding author
drarociotorres@prodigy.net.mx

Address for correspondence:
1 Servicio de Infectología, IMSS Centro Médico la Raza, México, D.F. México
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="p0005" class="elsevierStylePara elsevierViewall">Hepatitis B and C viruses are the most frequent causes of chronic disease worldwide&#46; Chronic liver disease can progress to cirrhosis and develop into hepatocarcinoma &#40;HCC&#41;&#46; Coinfection with both viruses may occur because they share the same transmission routes&#46; Coinfection with hepatitis C virus &#40;HCV&#41; and hepatitis B virus &#40;HBV&#41; is a more serious disease with a higher risk of progression to HCC than HCV infection alone&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">According to estimates of the World Health Organization &#40;WHO&#41;&#44; approximately 350 million people are infected with HBV and 170 million are infected with HCV&#46; The number of HBV&#8211;HCV-coinfected patients is unknown&#44; but it is estimated that it is in between 9&#37;-30&#37;&#44; depending on the geographical region&#46; In Western Europe&#44; the frequency of HBV&#8211;HCV coinfection is 0&#46;68&#37; in a selected healthy population&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">In an Italian study&#44; it was found that the possibility of coinfection is increased with age&#44; being most frequent in patients older than 50 years&#46; At present&#44; there are large trials&#44; therefore the prevalence may be over-or underestimated&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">In all patients presenting with a first episode of acute hepatitis&#44; serological studies must be carried out for various hepatotropic viruses&#44; including HBV and HCV&#46; HBV superinfection may exist in patients with HCV and HCV superinfection may exist in patients with HBV&#46; The possibility of coinfection should be considered for patients with chronic HBV or HCV infection who have been exposed to risk factors such as intravenous drug use&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Interaction of hepatitis viruses</span><p id="p0025" class="elsevierStylePara elsevierViewall">Several studies have proved that HBV and HCV interact and affect host immune response&#46; HCV infection may suppress HBV replication&#44; as proved by studies which found low levels of HBV DNA polymerase and reductions in the expression of hepatitis B surface antigen &#40;HB<span class="elsevierStyleInf">s</span>Ag&#41; and hepatitis B core antigen &#40;HB<span class="elsevierStyleInf">c</span>Ag&#41; in the livers of coinfected patients&#46; On the other hand&#44; patients with chronic HBV infection superinfected by HCV may eliminate HB<span class="elsevierStyleInf">e</span>Ag and HB<span class="elsevierStyleInf">s</span>Ag by seroconversion of anti-HB<span class="elsevierStyleInf">e</span> and anti-HB antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Sheen et al&#46; carried out a longitudinal study of a large population of HBV-infected patients and found that the annual incidence of seroconversion of HB<span class="elsevierStyleInf">s</span>Ag was higher &#40;2&#46;08&#37;&#41; in HCV coinfected patients than in HBV mono-infected patients &#40;0&#46;43&#37;&#41;&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">Several mechanisms have been proposed for the inhibition of HBV replication by HCV&#46; Shih et al&#46; suggested that the core protein of HCV suppresses HBV&#46; Another study found that the core protein of HCV suppresses the activity of HBV&#44; affecting transcription&#46; This inhibitory effect seems to be most evident in genotype 1 HCV <span class="elsevierStyleItalic">in vitro</span> and <span class="elsevierStyleItalic">in vivo&#46;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Other authors have reported that HBV may inhibit replication of HCV&#46; The replication of HBV DNA is negatively correlated to HCV RNA levels in coinfected patients&#46; An Italian study showed that HCV RNA was eliminated from 71&#37; of coinfected patients and from 14&#37; of HCV monoinfected patients&#46; HBV replication is associated with high levels of ALT&#44; but HCV replication is not&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="p0035" class="elsevierStylePara elsevierViewall">The foregoing proves either virus may play a dominant roll&#44; as both have the ability to induce seroconversion and eliminate the other&#46; The chronology of infection plays a role in the determination of the dominant virus&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical characteristics</span><p id="p0040" class="elsevierStylePara elsevierViewall">Various immunological profiles for HCV and HBV infections have been described&#58; acute dual viral hepatitis&#44; chronic hepatitis C with hidden coinfection with HBV&#44; and superinfection by either virus&#46; One of these manifestations will prevail&#44; depending on the location&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">1&#46; Acute dual HBV&#8211;HCV hepatitis</span><p id="p0045" class="elsevierStylePara elsevierViewall">In acute infections&#44; HBV and HCV interact in a manner similar to that observed in chronic infections&#46; In 1982&#44; Liaw et al described coinfection caused by accidental puncture of health-care personnel for the first time&#46; These patients presented with acute HCV infection&#44; but diagnosis of HBV infection was delayed by 6 weeks because of the masking effect of HCV&#46; Acute dual HBV&#8211;HCV hepatitis can also occur because of blood transfusion&#46; Mimms et al&#46; studied patients with acute infections with both viruses and compared them to patients who were monoinfected by HBV&#46; They observed decreased levels of alanin aminotransferases &#40;ALT&#41;&#44; delayed appearance of HBsAg&#44; and a shorter period of HBsAg anti-genemia in coinfected patients than in monoinfected patients&#44; suggesting that HCV suppresses HBV activity&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">2&#46; Hidden hepatitis B</span><p id="p0050" class="elsevierStylePara elsevierViewall">Hidden hepatitis B entity refers to a condition in which patients have low levels of HBV DNA and in whom serological markers of HBV are absent&#46; Liver cirrhosis occurs in 33&#37; of HBV&#8211;HCV coinfected patients and in only 19&#37; of HCV carriers with undetectable HBV DNA&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">3&#46; HCV superinfection</span><p id="p0055" class="elsevierStylePara elsevierViewall">HCV superinfection has been described in Asiatic areas in which there is a high prevalence of HBV&#46; This superinfection results in suppression of HBV replication and elimination of HBsAg carriers&#46; After this stage&#44; HCV infection prevails and patients develop chronic hepatitis&#44; a much more severe disease with a much greater risk of fulminant hepatitis and for which the mortality rate is as high as 10&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">4&#46; HBV superinfection</span><p id="p0060" class="elsevierStylePara elsevierViewall">HBV superinfection is less common in patients with chronic hepatitis caused by HCV&#46; Only two cases have been reported in which there was suppression of HCV and replication of HBV&#46; HBV superinfection is associated with an increased risk of fulminant hepatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">5&#46; Fulminant hepatitis</span><p id="p0065" class="elsevierStylePara elsevierViewall">Chu et al&#46; carried out a study of patients in Taiwan who were hospitalized with acute hepatitis caused by HCV infection&#46; Eleven patients had fulminant hepatitis&#44; 23&#37; of whom had chronic infection by subjacent HBV compared with 2&#46;9&#37; patients without fulminating hepatitis&#46; These findings were confirmed by studies carried out in France and Taiwan&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">6&#46; Chronic hepatitis</span><p id="p0070" class="elsevierStylePara elsevierViewall">Treatment should be considered for patients in whom both HBV DNA and HCV RNA are present&#44; because of the possibility of progression to cirrhosis and decompensated liver disease&#46; It is also possible that inactive HBsAg carriers can exhibit symptoms of active HCV monoinfection&#46; Conversely&#44; an active HBV infection may be present together with inactive HCV infection &#40;HBV DNA-positive&#44; HBeAg-positive&#44; HCV RNA-negative&#44; anti-HCV-positive&#41;&#46; Active HBV infection and inactive HCV infection is less common than active HCV infection and inactive HBV infection&#44; which indicates that HCV is suppressed by HBV&#46; Treatment regimens differ according to individual profiles&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">7&#46; Cirrhosis</span><p id="p0075" class="elsevierStylePara elsevierViewall">HBV&#8211;HCV coinfected patients have a higher frequency of cirrhosis than subjects with chronic HBV monoinfection &#40;44&#37; vs 21&#37;&#44; respectively&#41; and a higher incidence of decompensated liver disease &#40;24&#37; KS 6&#37;&#44; respectively&#41; than subjects with chronic HBV monoinfection&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">8&#46; Hepatocellular carcinoma</span><p id="p0080" class="elsevierStylePara elsevierViewall">HBV&#47;HCV coinfection increases the risk of hepato-carcinoma&#46; The frequency of hepatocarcinoma is 63&#37; in coinfected patients and 15&#37; in HCV monoinfected patients&#46; Benvegnu et al&#46; reported that the coinfection was an independent predictor of HCC&#46;&#40;1&#41; Of the 290 cirrhosis patients studied&#44; 45&#37; of coinfected patients developed HCC after 10 years&#44; and 16&#37; and 28&#37; of HBV and HCV patients&#44; respectively&#44; developed HCC after 10 years&#46; Another South African study reported that the risk of HCC in coinfected patients was 83 times higher than that in patients monoinfected with either HBV or HCV&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="p0085" class="elsevierStylePara elsevierViewall">Coinfected patients have several profiles of viral replication and immunity&#44; and the disease has various clinical courses&#46; Because of this&#44; identification of prospects for treatment and selection of optimum antiviral therapy is difficult&#46; Guidelines have been established for treatment of chronic HBV and HCV hepatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="p0090" class="elsevierStylePara elsevierViewall">For viral hepatitis B infection&#44; the Asian Pacific Association for the Study of the Liver &#40;APASL&#41;&#44; the European Association for the Study of the Liver &#40;EASL&#41; and the American Association for the Study of Liver Diseases &#40;AASLD&#41; recommend that treatment of patients with&#58;</p><p id="p0095" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="li0005"><li class="elsevierStyleListItem" id="list0005"><span class="elsevierStyleLabel">1&#46;</span><p id="p0100" class="elsevierStylePara elsevierViewall">mild to serious chronic hepatitis&#44;</p></li></ul><ul class="elsevierStyleList" id="li0010"><li class="elsevierStyleListItem" id="list0010"><span class="elsevierStyleLabel">2&#46;</span><p id="p0105" class="elsevierStylePara elsevierViewall">levels of aminotransferases twice normal levels or biopsy evidence of significant liver damage&#44;</p></li></ul><ul class="elsevierStyleList" id="li0015"><li class="elsevierStyleListItem" id="list0015"><span class="elsevierStyleLabel">3&#46;</span><p id="p0110" class="elsevierStylePara elsevierViewall">HBV DNA levels &#62; 105 copies&#47;mL&#44; and</p></li></ul><ul class="elsevierStyleList" id="li0020"><li class="elsevierStyleListItem" id="list0020"><span class="elsevierStyleLabel">4&#46;</span><p id="p0115" class="elsevierStylePara elsevierViewall">HBeAg positivity or HBeAg negativity&#46;</p></li></ul></p><p id="p0120" class="elsevierStylePara elsevierViewall">Interferon alfa-2b&#44; lamivudine&#44; adenovirus&#44; entecavir&#44; and peginterferon alfa-2a&#46; Treatment indications have also been established for patients with chronic HCV infection&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Contraindications</span><p id="p0125" class="elsevierStylePara elsevierViewall">The presence of decompensated liver disease or liver failure in chronic HBV or HCV infections constitutes an indication for liver transplantation&#46; Until now&#44; there was no standard management protocol for subjects coinfected with HBV and HCV&#46; In general&#44; the criteria for treatment of monoinfections may be applied for HBV&#8211;HCV coinfections with chronic hepatitis or compensated cirrhosis&#46; The antiviral regime should be chosen based on serological indexes and levels of viremia&#46;</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">1&#46; Interferon</span><p id="p0130" class="elsevierStylePara elsevierViewall">Interferon has immunomodulatory&#44; antiviral&#44; and anti-proliferative activities&#46; In chronic HCV infection&#44; combined antiviral therapy with peginterferon and ribavirin results in a sustained viral response &#40;SVR&#41; of up to 56&#37;&#46; In chronic HBV infection&#44; regular interferon is indicated for patients with elevated levels of ALT and HBV DNA&#44; as it results in a SVR of 35&#37; without inducing viral drug resistance&#46; Peginterferon alfa-2a was recently accepted in the USA for treatment of chronic HBV infection&#46;</p><p id="p0135" class="elsevierStylePara elsevierViewall">Interferon is the most studied drug for coinfected patients&#46; The first report on the use of interferon for coinfected patients was published by Burt et al&#46; in 1993 and showed that interferon resulted in a decrease in of HB<span class="elsevierStyleInf">e</span>Ag and a sustained HCV response&#46; In 1995&#44; Ghent et al&#46; compared the effects of treatment with interferon alfa &#40;3 million units three times per week for 6 months&#41; between 16 chronic coinfected hepatitis patients &#40;anti-HCV positive&#44; HCV RNA positive&#44; AgsHB positive&#44; and HBV DNA negative&#41; and patients with HCV alone&#46; Nineteen percent of patients who received interferon alfa had normal ALT levels and sustained virological responses &#40;control group &#61; 21&#37;&#41;&#44; and two patients seroconverted to AgsHB negative&#46; This study showed that the use of interferon is indicated when there is no evidence of HBV replication&#46; Weltman et al&#46; treated eight coinfected patients with 3 million units of interferon alfa three times per week for 6 months and obtained similar results&#46; In an Indian study&#44; seven coinfected patients &#40;AgsHB positive&#44; HBV DNA positive&#44; anti-HCV positive&#44; HCV RNA positive&#41; were treated with high doses of interferon alfa-2b &#40;6 million units three times per day for 6 months&#41;&#46; After 6 months of treatment&#44; none of the patients was positive for HBV DNA&#44; all were positive for AgeHB&#44; and HCV RNA was absent in 29&#37; &#40;sustained virological response &#61; 29&#37;&#41;&#46;</p><p id="p0140" class="elsevierStylePara elsevierViewall">Villa et al&#46; studied 30 patients with coinfection &#40;Ag-sHB positive&#44; anti-HCV positive&#44; HCV RNA positive&#41; who received 6 or 9 million units of interferon alfa three times per week for 6 months&#46; The high dose of interferon was most effective for clearance of HCV RNA &#40;31&#46;2&#37;&#41; and HBV DNA &#40;100&#37;&#41;&#46; The level of histological damage was less in patients given the high dose of interferon&#46;</p><p id="p0145" class="elsevierStylePara elsevierViewall">Most patients with inactive hepatitis B and HCV who are HBV DNA positive relapse after interferon treatment and do not exhibit a SVR&#46; There are no studies on the use of peginterferon for treatment of coinfection&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">2&#46; Interferon plus ribavirin</span><p id="p0150" class="elsevierStylePara elsevierViewall">Liu et al&#46; treated 24 patients &#40;AgsHB positive&#47;anti-HCV positive&#41; with interferon alfa-2a &#40;6 million units three times per week for 12 weeks followed by 3 million units three times per week for 12 weeks&#41; and ribavirin &#40;1200 mg daily for 24 weeks&#41;&#46; Seventeen patients were positive for HBV DNA and HCV RNA&#44; with an SVR of 43&#41; for HCV RNA clearance vs 60&#41; in control patients with HCV monoinfected&#44; 6 of the 17 patients with detectable baseline HBV DNA disappearing at the end of the treatment remaining negative 24 weeks after the treatment &#40;35&#37;&#41; and sustained biochemical response of 43&#37;</p><p id="p0155" class="elsevierStylePara elsevierViewall">Hung et al&#46; treated 36 patients with coinfection &#40;Ag-sHB positive&#44; anti-HCV positive&#44; HCV RNA positive&#41; with 3 or 5 million units of interferon alfa-2b three times per week and 800-1200 mg ribavirin daily for 24 weeks&#46; The SVR was 69&#37; and the sustained biochemical response was 56&#37;&#46; Two &#40;11&#37;&#41; of the 18 patients with detectable HBV DNA at the beginning of treatment were free of HBV DNA after treatment and 53&#37; patients who were HBV DNA negative at the initiation of treatment experienced reactivation of HBV DNA in week 48 of the follow-up phase&#46;</p><p id="p0160" class="elsevierStylePara elsevierViewall">Chiang et al&#46; administered combined therapy with high doses of interferon-2b &#40;6 million units three times per week for 24 weeks&#41; and ribavirin &#40;1000-1200 mg&#47;day for 24 weeks&#41; to 42 coinfected patients and a group with HCV monoinfection&#46; The SVR was 69&#37; and 67&#46;2&#37; in HCV coinfected and HCV monoinfected patients&#44; respectively&#46; HBV DNA was absent after treatment in five of 16 patients &#40;31&#37;&#41; who were HBV DNA positive at the initiation of treatment&#46; These results prove that combination treatment is effective for coinfected patients&#44; mainly those who have replication of active HCV&#46; However&#44; possible reactivation of HBV infection should be taken into account&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">3&#46; Interferon and lamivudine</span><p id="p0165" class="elsevierStylePara elsevierViewall">Marine et al&#46; treated eight patients &#40;AgeHB positive&#44; HBV DNA positive&#44; HCV RNA positive&#41; with five million units of interferon plus 100 mg of lamivudine daily for 12 months followed by 100 mg per day of lamivudine only for 6 months&#46; AgeHB and HBV DNA were eliminated in three patients &#40;37&#46;5&#37;&#41;&#46; ALT concentrations were normalized in four patients &#40;50&#37;&#41; who also had persistent HCV RNA clearance 12 months after treatment &#40;SVR &#61; 50&#37;&#41;&#46; The results of this study suggest that lamivudine may be effective for treatment of patients with chronic hepatitis C and active replication of HBV&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">4&#46; Adefovir and entecavir</span><p id="p0170" class="elsevierStylePara elsevierViewall">There are no published studies on the use of these drugs for patients with coinfection&#44; but they may be useful for treatment of coinfected patients in whom the dominant virus is HBV&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">5&#46; Liver transplantation</span><p id="p0175" class="elsevierStylePara elsevierViewall">The unit of participant organs systems &#40;UNOS&#41; reported that 14 patients in the USA received transplants because of coinfection with HBV and HCV in 2004 and that 434 transplants were performed on such patients since 1988&#46; However&#44; posttransplantation data were limited&#46;</p><p id="p0180" class="elsevierStylePara elsevierViewall">Serological and virological tests of HBV&#8211;HCV coinfected patients are necessary before considering treatment&#46; Identification of the dominant virus is useful for determining the treatment strategy&#44; because treatment can exacerbate liver disease by inducing loss of viral suppression of the dominant virus&#46; All coinfected patients are prospects for therapy provided that they meet the inclusion criteria for treatment of patients with HBV or HCV monoinfection&#46; When HCV infection is the dominant disease&#44; the treatment of choice is interferon plus ribavirin&#46; When HBV infection is the dominant disease&#44; the treatment of choice is interferon with or without lamivudine&#46; Further studies on treatment with adefovir&#44; entecavir&#44; and triple therapy with lamivudine&#44; ribavirin and interferon for coinfected patients are required before recommendations can be made&#46; Further studies are necessary on peginterferon in coinfected patients&#44; even though it is already a standard treatment for HCV or HBV monoinfection&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Recommendations of the consensus panel</span><p id="p0185" class="elsevierStylePara elsevierViewall">In patients with HCV-HBV coinfection&#44; which of the two viruses must be treated&#63;</p><p id="p0190" class="elsevierStylePara elsevierViewall">Although consensus was not reached&#44; most panelists &#40;55&#37;&#41; recommended individualizing each case according to the level or replication of the HBV&#44; while the remaining 44&#37; preferred to treat the HCV infection first&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Evidence quality&#58; 2</span><p id="p0195" class="elsevierStylePara elsevierViewall">What treatment is recommended&#63;</p><p id="p0200" class="elsevierStylePara elsevierViewall">Most members of the panel of consensus recommended combined treatment with pegylated interferon and ribavirin&#46; A minority &#40;22&#37;&#41; preferred triple therapy with pegylated interferon&#44; ribavirin&#44; and a nucleotide analog&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Evidence quality&#58; 2</span><p id="p0205" class="elsevierStylePara elsevierViewall">What follow-up visits are required for patients with HCV-HBV coinfection&#63;</p><p id="p0210" class="elsevierStylePara elsevierViewall">The frequency and number of follow-up consultations are similar to those required by a HCV monoinfected patient&#44; but departures from this schedule may be required because of individual circumstances&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Evidence quality&#58; 3</span><p id="p0215" class="elsevierStylePara elsevierViewall">What criteria should be applied to determine the SVR of these patients&#63;</p><p id="p0220" class="elsevierStylePara elsevierViewall">The panel of consensus considers that the criteria for viral responses in HCV and HBV monoinfected patients should apply&#46;</p></span><p id="p0225" class="elsevierStylePara elsevierViewall">Evidence quality&#58; 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Article information
ISSN: 16652681
Original language: English
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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