Jinyun Wei ,Yongyu Mei ,Jinping Li ,Jing Yun ,Xiohu Yng ,Zhen Xu ,Guoli Lin ,Jun Zhng ,Zhixin Zho ,*,Xiohong Zhng ,*

a Department of Infectious Diseases,The Third Affiliated Hospital of Sun Yat-sen University,Guangzhou,China

b Department of Infectious Diseases,Guangzhou Municipal Eighth People’s Hospital,Guangzhou,China

c Department of Infectious Diseases,The Third People’s Hospital of Shenzhen,Shenzhen,China

Keywords:

Hepatitis C virus (HCV)

Direct-acting antiviral agent (DAA)

Efficacy

Safety

ABSTRACT

Background and aims:To investigate the safety and efficacy of direct-acting antiviral(DAA)regimens in a cohort of Chinese patients with chronic hepatitis C virus (HCV) infection.

Methods:A total of 222 adult Chinese patients were enrolled and treated via DAA regimens in accordance with HCV management guidelines.Treatment responses were evaluated 4 weeks after treatment,at the end of treatment (EOT) and 12 weeks post-treatment.Virological responses,biochemical responses,model for end-stage liver disease (MELD) and Child-Pugh (CP) scores were recorded.

Results:A total of 218 patients(98.2%)achieved sustained virological response 12 weeks post-treatment and 4 patients relapsed.The combined number of rapid virological responses for all six regimens was 170/222 (76.6%),and 221/222 (99.6%) had achieved virological responses by the end of treatment.In decompensated cirrhosis patients the baseline mean CP score was 6.8 ± 1.3 and the mean MELD score was 10.1±3.3.Compared with the mean CP score at baseline,the mean score is significantly lower at the end of treatment (5.7 ± 1.3) and 12 weeks post-treatment (5.6 ± 1.0).Estimated glomerular filtration rates did not differ significantly from baseline during the treatment or 12 weeks post-treatment.The incidence of adverse events in patients with chronic hepatitis C and compensated cirrhosis was 42/172(24.4%),and in patients with decompensated cirrhosis it was 8/22(36.4%).The most frequently reported adverse events were elevated indirect bilirubin,fatigue and rash.There were no cases of serious adverse events,death or treatment discontinuation because of adverse events.

Conclusion:DAA regimens were highly effective and well tolerated irrespective of HCV genotype,cirrhosis,liver or kidney transplantation,hepatocellular carcinoma,HCV/hepatitis B virus co-infection,or renal failure.

1.Introduction

Hepatitis C virus (HCV) infection can cause liver inflammation and fibrosis,and may precede the development of cirrhosis and hepatocellular carcinoma(HCC).It has become a substantial public health problem,with approximately 185 million people infected worldwide.According to the World Health Organization more than 71 million people have chronic hepatitis C(CHC)worldwide,and an estimated 350,000 patients with CHC die each year,most because of liver cirrhosis and HCC.1-3In China an estimated 10 million people are infected with HCV,and the seroprevalence of anti-HCV antibodies in the general population is 0.43%.4,5Genotype(GT)1b is reportedly the most prevalent GT in China,but GT 3b is predominant in Southwest China.6-8

Previous HCV treatment with pegylated interferon alpha and ribavirin(RBV)is evidently less effective and more time-consuming than direct-acting antiviral agents (DAAs).To achieve a sustained virological response (SVR) was the goal of treatment.A SVR was defined as undetectable HCV viral load 12 or 24 weeks at the end of treatment.Since the approval of the first interferon-free DAA regimen in 2014,treatment has entered an era of all-oral DAAs.9Multiple clinical trials have demonstrated SVRs ranging from 86%to 100% in CHC patients with and without compensated cirrhosis(CC).10-15DAA-based regimens have become the standard treatment for chronic HCV infection worldwide.16In April 2017 the first all-oral DAA regimen was approved for the treatment of chronic HCV infection in Chinese adults.17To date,few real-world studies investigating its safety and efficacy in Chinese patients have been reported,however,particularly in patients with HCV-related decompensated cirrhosis (DC).The current real-world study was conducted to assess the safety and efficacy of DAA regimens in adult Chinese patients.

2.Patients and methods

2.1.Ethical approval

This study complied with the Declaration of Helsinki and was approved by the ethics committee of the Third Affiliated Hospital of Sun Yat-sen University.The ethical approval number was[2018]02-305-02.All participants provided written informed consent prior to enrolment in the study.

2.2.Patients

A total of 222 patients with CHC were recruited between September 2017 and February 2020,at (i) the Third Affiliated Hospital of Sun Yat-sen University,(ii)Guangzhou Municipal Eighth People’s Hospital,and(iii)the Third People’s Hospital of Shenzhen.The inclusion criteria were age ＞18 years,provision of informed consent,and a diagnosis of chronic HCV infection.16Pregnant or lactating women were excluded,as were patients with an intolerance to the DAA regimens.

2.3.Study design

The current real-world study was an observational,open-label,multicenter cohort study.A total of 222 patients underwent 8-24 weeks of treatment with one of the following DAA regimens in accordance with the guidelines for the management of chronic HCV infection:16(i) ombitasvir/paritaprevir/ritonavir (OPR) (275 mg once daily)+dasabuvir(DAS)(250 mg twice daily)for 8-12 weeks;(ii) daclatasvir (DCV) (60 mg once daily) + sofosbuvir (SOF)(400 mg once daily) ± RBV (10-15 mg/kg/day) for 12-24 weeks;(iii) SOF (400 mg once daily)/velpatasvir (VEL) (100 mg once daily)±RBV(10-15 mg/kg/day)for 12-24 weeks;(iv)SOF(400 mg once daily)+RBV(10-15 mg/kg/day)for 12-24 weeks;(v)elbasvir(ELB)(50 mg once daily)/grazoprevir(GRA)(100 mg once daily)for 12 weeks;(vi)DCV(60 mg once daily)+asunaprevir(ASV)(100 mg twice daily) for 24 weeks;(vii) glecaprevir (GLE) (300 mg once daily)/pibrentasvir(PIB)(120 mg once daily)±RBV(10-15 mg/kg/day).Patients were divided into CHC,CC and DC groups.

2.4.Study monitoring

Physical examinations,serum HCV RNA measurements,biochemical tests including alanine aminotransferase (ALT),aspartate aminotransferase (AST),albumin (ALB),total bilirubin(TBIL),serum creatinine(Scr)and calculated estimated glomerular filtration rate (eGFR),Child-Pugh (CP) score,model for end-stage liver disease (MELD) score and ultrasound examinations were performed at baseline,after 4 weeks of treatment,at the end of treatment(EOT)and at 12 weeks post-treatment.Hepatitis B virus(HBV) DNA and liver function were assessed at baseline,after 4 weeks of treatment,after 8 weeks of treatment,at EOT and at 12 weeks post-treatment.HCV RNA was assessed using the COBAS TaqMan HCV test version 2.0 (Roche Molecular Systems,Inc.,Branchburg,NJ,USA),with a lower limit of quantitation of 25 IU/mL.HCV genotyping was performed using the Siemens VERSANT HCV Genotype INNO-LiPA 2.0 assay (Siemens Healthcare Diagnostics,Inc.,West Sacramento,CA,USA).Assays for HBV DNA(COBAS Taqman with a lower limit of detection of 6 IU/mL;Roche,Nutley,NJ,USA),hepatitis B e antigen (HBeAg),hepatitis B e antibody (HBeAb),hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (HBsAb) (all MEIA;Abbott Laboratories,Abbott Park,IL,USA) were performed at a central laboratory.Adverse events (AEs) were recorded throughout the study.

2.5.Statistical analysis

The SPSS statistics software package(IBM SPSS Statistics Version 22,Chicago,IL,USA) was used for statistical analysis.Values were expressed as the mean ± standard deviation (SD).Differences in qualitative values were analyzed using the Chi-square test.Statistical analyses were performed using One-way analysis of variance(ANOVA) for multiple comparisons.Student’s t-test was used to assess differences between the two groups.All P-values were twotailed,and P ＜0.05 was deemed to indicate statistical significance.

3.Results

3.1.Baseline characteristics

Baseline characteristics are shown in Table 1.All 222 patients treated with DAAs completed the treatment and were included in the 12-weeks follow-up.Most patients were diagnosed with HCV infection alone,but 18 were diagnosed with HCV/HBV co-infection.GT 1 was predominant (139/222;62.6%),and there was one GT 1b patient with a L31V/Y93H mutation.Additionally,31 patients had CC,26 had DC,2 had received liver transplantation,2 had received kidney transplantation,3 had HCC,3 had renal failure and 9 had other conditions (1 depression,3 diabetes,4 hypertension and 1 myasthenia gravis).Anti-HCV therapy had been administered before the initiation of treatment in 19/222 patients (8.6%),including interferon or peginterferon + RBV (N = 14),ASV+DCV+RBV (N= 1),OPR+DAS(N=1),SOF+ RBV(N=2)and SOF + DCV followed by SOF + ledipasvir (N = 1).

3.2.Treatment regimens

Treatment regimens administered to patients with CHC,CC and DC are shown in Fig.1.Of the 222 patients,67(30.2%)were treated with OPR+DAS,51(22.9%)with DCV+SOF±RBV,39(17.5%)with SOF/VEL±RBV,25(11.3%)with SOF+RBV,21(9.5%)with ELB/GRA,14(6.3%)with DCV+ASV and 5(2.3%)with GLE/PIB±RBV(Fig.1).

3.3.Treatment effectiveness

Virological responses ordered by subgroup are shown in Fig.2.The combined number of rapid virological responses for all six regimens was 170/222 (76.6%),and 221/222 (99.6%) had achieved virological responses by the end of treatment.The sustained virological response at 12 weeks post-treatment (SVR12) was 218/222(98.2%).The SVR12 rate in the GT 3b subgroup was 86.7%.Of the 15 GT 3b patients,12 (4 CHC,3 CC and 5 DC) received DAAs with RBV,of whom 11/12(91.7%)achieved SVR12.In the 3 GT 3b patientswho received DAAs without RBV the SVR12 was 66.7% (2/3).Virological responses in patients treated via different regimens are shown in Table 2.The SVR12 rate of different treatment regimens was from 92%to 100%.The results of routine blood and biochemical tests in CHC patients are shown in Table 3,those of CC patients are shown in Table 4,and those of DC patients are shown in Table 5.ALT and AST levels in CHC and CC patients at end of treatment and 12 weeks post-treatment were significantly lower than those at baseline(P ＜0.05).In DC patients,compared with the AST level and CP score at baseline,the AST level and CP score were significantly lower at the end of treatment and 12 weeks post-treatment while HGB,WBC,PLT,ALT,TBIL,ALB,and MELD score at end of treatment and 12 weeks post-treatment are not statistically different from those at baseline (P ＞0.05).In DC patients,73.1% (19/26) patients exhibited improved CP score and 57.7% (15/26) patients exhibited improved MELD score at 12 weeks post-treatment.eGFR of three groups did not differ significantly from baseline during the treatment or 12 weeks post-treatment.

Table1 Baseline demographic and clinical characteristics of patients.

Fig.1.Treatment regimens for patients with CHC,CC and DC.

3.4.Safety and tolerability

In total 222 patients(165 CHC,31 CC,26 DC)completed the full treatment,including 28 who were in relatively small subgroups(previous transplant recipients,HCV/HBV co-infection,HCC and renal failure).AEs in the CHC,CC and DC patients are shown in Table 6.One patient in the DC group experienced virological relapse.The incidence of AEs in patients with CHC and CC was 42/172 (24.4%),and in patients with DC it was 8/22 (36.4%).The most frequently reported AEs were elevated indirect bilirubin,fatigue and rash.There were no cases of serious AEs,death or treatment discontinuation because of AEs.

The incidence of AEs in small subgroups was 3/28 (10.7%).All patients in small subgroups achieved SVR12 rate and no patients discontinued the treatment because of AEs.Most AEs reported were considered mild,and no severe AEs were reported.Hepatitis B reactivation occurred in one CHC patient at 12 weeks posttreatment.That patient recovered and achieved SVR12 after management with tenofovir.Three patients with HCV-related HCC underwent radiofrequency ablation or ethanol injection therapy before anti-HCV treatment,and tumor recurrence was observed in two patients (one after SVR24 and another after SVR72).

4.Discussion

Fig.2.Rates of virological response to DAA regimens.

Table2 Virological response of different treatment regimens.

The efficacy of treatment for chronic HCV infection has improved dramatically since 2011 because of the availability of DAAs.Most DAA-based regimens have been studied extensively in registered clinical trials,as well as in real-world cohorts.DAAs were not available in China prior to 2017,and accordingly only nine realworld studies in Chinese patients have been published,one investigating DCV + ASV,two investigating OPR + DAS,and six investigating SOF-based regimens.In many studies CHC patients have been treated with SOF-based generic DAAs that lack specificity and standardized follow-up monitoring protocols.18-26Therefore,a limitation of the currently available published real-world data is that they do not fully and accurately reflect the reality of treatment with DAAs in patients with chronic HCV infection in China.

The efficacy rates of DAA regimens in CHC patients reported in registered clinical trials and real-world studies range from 95% to100%.11,15,27,28Similarly,in the current study the efficacy of different DAA regimens was ＞95%.In contrast to pegylated interferon alpha and RBV regimens,relatively few factors influence virological responses to DAA-based treatment strategies.Liver cirrhosis is one factor that influences virological responses,and in many studies SVR rates in patients with cirrhosis and DC have been lower than the corresponding rates in patients without cirrhosis.29-31Another evidently influential factor is GT 3,specifically GT 3b.D’Ambrosio et al.27reported that GT 3 was associated with the lowest chance of achieving SVR,whereas other GTs had no significant effects on treatment outcome.In a registered phase III clinical trial conducted in China investigating SOF/VEL SVR12 was only 50% in GT 3b patients with CC.29

Table3 Biochemical tests of CHC patients.

Table4 Biochemical tests of CC patients.

Table5 Biochemical tests and CP and MELD scores of DC patients.

The current observational,open-label,multicenter,cohort study confirmed the safety and efficacy of DAA regimens in adult Chinese patients with chronic HCV infection in a real-world setting,including patients with serious and complex conditions such as CC,DC,HCV/HBV co-infection,HCC and renal failure,as well as liver and kidney transplant recipients.The overall SVR12 rate was 98.2%(218/222),but in liver cirrhosis patients it was 94.7%(93.6%for CC,96.2%for DC)and in GT 3 patients it was 92.3%(100%for GT 3a and 86.7%for GT 3b).The SVR12 rate was 96.2%in DC patients,which is similar to previously reported rates in patients on 12-weeks SOF/VEL + RBV regimens (92-94%).30It is also higher than reported rates in HCV patients with DC on 12-weeks SOF/VEL regimens(83-92%) and 24-weeks SOF/VEL regimens (86%) in registered clinical trials.30Notably,a 24-weeks DCV+SOF+RBV regimen was prescribed to a GT 3b DC patient who declined RBV because of concerns pertaining to potential thrombocytopenia,and that patient experienced virological relapse at 12 weeks post-treatment.The patient was then retreated with SOF/VEL + RBV for 24 weeks and achieved SVR12.In the present study all GT 1,3 and 6 DC patients received SOF-based therapy with RBV,and only one GT 2a patient received DCV+SOF without RBV.Thus,the addition of RBV to SOF-based therapy for DC patients(including rescue treatments)may be an option for achieving SVR.In the current study the SVR12rate in GT 3b patients who underwent DAA regimens that included RBV was 91.7% (11/12),and the SVR12 rate in GT 3b patients who underwent DAA regimens that did not include RBV was 66.7%(2/3).In another recent study the addition of RBV to SOF-based therapy increased the SVR rate,especially in CC and DC patients with HCV GT 3.31In our study,vrological relapse occurred in four patients,precluding viral eradication.Two were GT 3b patients (one of whom had DC) who received SOF + DCV therapy without RBV for 24 weeks and the other two were CC patients (one GT 1b and the other GT 6a) who received SOF + RBV for 24 weeks.This suggests that SOF + RBV treatment,even for 24 weeks,is not an optimal treatment in CC patients.The addition of RBV to SOF-based therapy may be associated with good treatment outcomes in DC patients and/or GT 3b patients.

Table6 Adverse events (AEs) during the treatment period.

In the current study,the eGFR did not differ significantly from baseline during treatment or at 12 weeks post-treatment,regardless of dialysis,kidney transplantation or cirrhosis(CC or DC)status,which suggests that DAA treatment has no appreciable effects on renal function.Additionally,compared with the mean CP score at baseline,the mean score is significantly lower at the end of treatment (5.7 ± 1.3) and 12 weeks post-treatment (5.6 ± 1.0).Of patients who achieved SVR12,at 12 weeks post-treatment 73.1%exhibited improved CP score and 57.7% exhibited improved MELD score.Both rates are higher than those reported by Curry et al.30(47% for CP score and 51% for MELD score).Those results demonstrate that DAA treatment improves CP score in some DC patients.Notably,however,it remains unclear why CP score did not improve in approximately 23%of the DC patients who achieved SVR12.The lack of improvement may have been associated with the presence of residual HCV RNA in liver tissues.32This lack of clarity reinforces the importance of long-term follow-up in DC patients.Additionally,with the decrease in HCV RNA in DC patients,AST level decreased significantly,and TBIL and ALB were not discernibly improved.This suggests that despite liver inflammation being relieved after HCV clearance,liver synthesis function and bilirubin metabolism may not be immediately restored.Further studies investigating longterm prognoses in DC patients after SVR12 are warranted.

In accordance with the recommendations of the European Association for the Study of the Liver,16none of DC patients in the current study received NS3/4A protease inhibitors,and they did receive NS5A inhibitors combined with NS5B polymerase inhibitors.In our study,the rates of AEs were 24.4% in CHC patients and 36.4% in CC and DC patients,and most adverse events were mild.The safety profiles associated with the DAA regimens in the present study were relatively similar to those reported in other real-world studies.18-28No patients with or without cirrhosis reported any severe AEs that led to treatment discontinuation,and no treatment-related deaths occurred.At baseline 8 patients with HCV/HBV co-infection received nucleoside analogs anti-HBV treatment,and 10 did not receive anti-HBV treatment.The combined safety and tolerability of the treatments were deemed to be acceptable.Only one CHC patient who did not receive anti-HBV treatment at baseline experienced reactivation of hepatitis B,at 12 weeks post-treatment.Reactivation may have been induced by reduced inhibition of HBV after HCV clearance,which suggests that HBV may be a long-term risk factor for reactivation of hepatitis after HCV eradication.This suggests that anti-HBV treatment should be initiated in patients with HBsAg at baseline and in patients who are HBV DNA-positive at baseline,and that liver function should be monitored during DAA treatment and assessed at 12 weeks posttreatment,as has been suggested in previous reports.16,33-35HCC was identified in three patients during baseline imaging,and all three subsequently underwent radiofrequency ablation.All three achieved SVR12,but two experienced early tumor recurrence.Reig et al.36reported early tumor recurrence in patients with HCVrelated HCC undergoing interferon-free therapy.This led the European Medicines Agency to issue a warning pertaining to DAAs and a potentially increased risk of tumor recurrence in patients with chronic HCV infection.37The sample size in the present study was too small to yield any reliable insight into this issue,but additional long-term follow-up studies are needed to determine whether DAA treatment increases the risk of early tumor recurrence in patients with HCV-related HCC.

The current study had several limitations.The number of participants with cirrhosis and the sizes of some of the subgroups of interest were small;therefore,any conclusions based on analyses of these patients should be drawn with caution.The observational non-randomized study design constitutes another limitation.However,the study did include centers from South China where＞100 chronic HCV patients were treated per year,thus constituting a good real-world representation of clinical practice in the region.

5.Conclusion

In conclusion,the current real-world cohort study suggests that in Chinese patients treatment with different DAAs is highly effective and well tolerated regardless of HCV genotype,cirrhosis,HCC,or HCV/HBV co-infection,and in liver and kidney transplant recipients.The addition of RBV to SOF/VEL therapy may be an option for achieving high SVR rates in patients with DC and/or GT 3b and providing a rescue treatment.The present study indicates the value of anti-HCV treatment in Chinese adults and how this therapy may be useful for treating patients with HCV infection in a real-world setting.

Authors’contributions

J.Wei and Y.Mei contributed equally to this work.Z.Zhao and X.Zhang:conceived and designed the study.Y.Mei,J.Li,J.Yuan,X.Yang,Z.Xu,G.Lin,J.Zhang,Z.Zhao and X.Zhang:collected the data.J.Wei and J.Zhang:interpreted and analyzed the data.J.Wei and X.Zhang:wrote the manuscript.All authors were involved in the final approval of manuscript.

Declaration of competing interest

The authors declare that they have no conflict of interest.

Acknowledgements

This work was supported by the Science and Technology Planning Project of Guangdong Province Grant(2014B020212025).The authors would like to thank all of the patients and their providers who participated in this study,as well as all of Yuankai Wu for his contributions to the development of the manuscript.