Recombinant interferon alfa-2b following prednisone withdrawal in the treatment of chronic type B hepatitis

JourmdofHepfor#gy,

ElSCYifX

1990; 11: s113-s117

5113

HEPAT 00734

Recombinant interferon alfa-2b following prednisone withdrawal in the treatment of chronic type I3 hepatitis

V. Perez, H. Tanno, F. Villamil and 0. Fay Buenos AiresandRosario

The aim of the study was to evaluate

Medical

School,

Hospiro Italiano,

the safety and effectiveness

hems

of interferon

Aires,

Argentina

alfa-2b, alone and following prednisone

withdrawal, in patients with chronic type B hepatitis. Thirty-five patients (27 men and eight women) were randomly allocated to two treatment groups. Group I {n = 17) recefcd 6 weeks of prednisone followed by interferon affa-2b (1NTRON A, Schering-Plough C-ration) 10 million units subcutaneously. three times a week for 16 weeks. Group I? (n = 18) was used as an untreated cuntlrol group for 24 weeks, after which they received 16 weeks of treatment with the same dose of interferon as Group I. Both groups were folbwed up for 24 weeks after treatment . In Group I, 10!17 patients (53.3% ) eliminated hepatitis B e antigen; WI7 (47.1%) developed antibodies to hepatitis B e antigen; 9117 (52.9%) hetrame hepatitis R

neg;itriue at

virus DNA negative and 1117 (5.9%) was hepatitis B S&W antigen the end of fu1Iow up. In Group II, during the control phase, 1118 (S.S%) became hepatitis l3 e antigen negative. When treated with interferon, 7115 (46.7%) eliminated the e antigen, and &I5 (40%) developed antibodies to hepatitis B e antigen and were hepatitis B virus DNA negative at the end of follow up. Serum aIanine aminotrartsferasereached normal ievels in all seroconverkd patients. Liver biopsies showed a marked reduction of inflammation and d&appearance of hepatitis B core antigen in liver cell nuclei in almost all cases. In conclusion, interferon alfa-Zb at a dose of 10 million units subcutaneously, three times a week for 16 weeks proved effective in achieving a sustained inbibitkn of viral replication in M-50% of these chronic hepatitis B patients. There was no statistical uifference in response and the group treated with interferon alone.

between

the group treated with prednisone

followed by interferon

niques, and IFN has now been used in numerous For decades, corticosteroids were used more or less empirically, and somewhat controversially, for the treatment of chronic type B hepatitis. In recent years, various rq~rts have shown that withdrawal of a short-term course of prednisone results in immunostimulation, associated with a temporary loss of the markers of hepatitis B virus (HBV) replication (l-3). The antiviral and immunomudulatory effects of interferon (IFN) have also been demonstrated, particularly since the introduction of recombinant production techCorrqvndmce:

01&82-3.50@

Pmressor

v. Perez, Suipacha 12 19-M,

trials for

the treatment of chronic type B hepatitis. Overall, the results have shown that about one-third of treated patients have a sustained loss of viral markers of active replication (Ixpatitls B e antigen (HBeAg), HBV DNA and MW I3NA @ymerax), normalized serum alauine auiino~sfc~ (ALT) values and show a reduction in inflammation

Thepossibility

on liver histobgy

(4-8).

that a combination of immunostimulation provided by corticosteroid withdrawal and immunestimulation and antiviral effects provided by IFN might be more effective than either agent alone has led to the initia-

(1011) Buenos AirfS. Argentina.

1990Elswicr ScienceFublishm B.V. (Biomxlical Division)

(s.c.) at a dose of 10 nullion units (MU) three times a week (t.i.w.) for a total of 16 weeks. Gravy II war obsewed with no treatment for 24 weeks followed by interferon alfa-2b 10MUs.c. 1.i.w. for 16 weeks. Both groups were followed up after treatment for 24 weeks. Pre-treatment patient characteristics were comparablein both groups (Table 1). Liver biopsy was performed within 6 months prior to entry. In addition to row tine stains, HBcAg in liver tissue was analysed by the immunopaoxidase technique. In 20 patients, a second tion of several multicentre trials, some of which have been completed and others are in progress (9-11). As a part of a multicentre study, we have carried out a randomized, controlled trial involving 35 patients with chronic hepatitis B. The results ofprednisone withdrawal followed by recombinant interferon alfa-Zb (INTRON A, SchtingPlough Corporation) were compared with those obtained

biopsy was carried out during the follow-up period. In Group 1, I5 patients had chronic active hepatitis (CAH) and three had cirrhosis.

In Group

II, 13 patients

had

CAH, four had chronic persistent hepatitis (CPH) and one had cirrhosis. The Knodell snore (12) was used to evaluate liver damage, before and after treatment, in setoconvened and non-seroconvened patients (Table 2).

with IFN alone.

Thirty-five patients with chronic type B hepatitis were included in the study. En@; criteria included: (i) age 18 :,ears and older, male or female; (ii) presence for more than 6 months of the vir.-’ markers HBsAg, HBeAg and HBV DNA, (iii) average ALT value at least 1.3.times the upper limit of normal; and (iv) compensated liver disease with a pmthrombin time prolonged by less than 3 s, normal serum albumin, normal bilirubin and no history of hepatic. eniephalopathy, bleeding oesophageal varices or ascites. Patients with antibodies to either hepatitis delta

Group I patients were seen every 2 weeks during the prednisone phase and at the end of weeks 1,2,4,8,12 and 16 during II+’ treatment. During the post-treatment folIoar up, patients were seen at the end of weeks 28,36 and 48. Group II patients were seen at the end of weeks 4, 8, 12,16, 20 and 24 during the control phase and at weeks 25,26,28,32 and 40 during the treatment phase. During post.treatment follow up. the patients were seen at the end of weeks 44,52 and 64. During each visit, a bload sample was taken In order to measure HBeAg, HBV DNA, ALT, agpartate aminott’ansfaase (AST) and bilirubin levels. A routine blood chemistry was also dune in each sample.

virus (HDV) or human immunodeficiency virus (HIV) were excluded, as were those with inadequate levels of haematoait (<30%), platelets (
HBsAg, antibodies to hepatitis B core antigen (antiHBc), anti-HBs, anti-HDV and anti-HIV were measured by ELISA (Abbott Laboratories, Chicago, IL, USA):

Group 1 received 60 mg of prednisone daily for 2 weeks, iollowed by 40 mg for 2 weeks and 20 mg for 2 weeks. They then received no medication for 2 weeks. Recombinant interferon alfa-2b was then given subcutaneously

HBeAg and anti-HBe were tested by RIA (SORIN, Salug@. Italy). HBV DNA was analyzed hy molecular hybridization techniques as previously reported by Lieberman et al. (13). A double repurified probe of 32Ml bp,

.

.

whfch did not cross-react with 0.1 fig of plasmid PBR 322 DNA, was used. Kybridiition was performed using the ‘2P-IabeUed HB” DNA probe under rtrbtgent conditions and the blot was exposed for 9 da:,% at -80 “C! with Kodak KAR.5 fibtt. Positive standards ?f HBV DNA, and r-ra of both known HBsAg positive patients and known HBV DNA T.Lgative patients were wed as controls.

and at theendaf week6(the endaf thepredtine phase) (Fig. I). In padents who seemconverted, there was a marked eievation of ALT immediately after discontinuation of prednisone, followpd by a progmsive decrease during the IFN phase. At the end of treatment, the reduction in ALTwas sigttiticant compared to baseline @ < 0.025). At the end of follow up, the IO seroconverted patients had normal ALTvalues.

Differences between ALT and HBV DNA valt~es at initial and follow-up evaluations were measured by ANOVA

In Group 1. 14117patients had a transient flare in ALT levels (LIDto Ill-times the uwer tint&of nomtal). In 1007,

(analysis

of variance).

ALTwen.

measured

the One was followed by elimination of HBeAg, white 4/I? showed a simile increase in ALT but wtdmut the

Basal values of HBV DNA

and

by Student’s t-test.

R*ruNs The mrticosteroid

phase in Group 1 was well tolerated,

and no serious complications ofcured. Some patients complained of instmmia. ttervous~~css, heart bum and increase in appetite. The symptoms was reduced progressively.

After mdom~tioo,

subsided when the dose

senmt ALT lexls

were higher in

Group I than in Gmup II (160 + 139 vs. 109 + 68 Ml). Basal ALT levels were higher in those patients rho later senxmwertcd than Umse who did not se-vert or controls (Group II) @ < 0.05). In Group I, during the prednisone pbue. patiettts who later mocoovened showed a marked fall in serum ALT @ < 0.05). In those that did not seroconvert, however, there WBSno difference between ALT values at week 0

..

.

subsequent disa~ca of HBeAg. In patients who did not serocot~vat, there were no zignbiieant changes in YIWI ALT vahtes compared to ‘axline either at the end of the prednisone phase or at t!! end of IFN treabnent. Overall,therewa~apeakinthemeansemmALTvalue at week 12, which was sipi6cantIy different to the values obtained at weeks 24,40 and 48 (p < 0.05). In Group II, there were no changes in AL.T levels during the 24-week control phasz. Viral markers At the end of f&w up in Gmttp I, lW17 patients (58.8%) had elitttitrated HBeAg, 8117 (47.1%) had develaped anti-HBe amiies, 9117 (52.9%) had become serum HBV DNA negative and one (5.9%) had eliminated HBsAy(Fig. 2). In Group If at week 24, one patient was HBeAg tiegative and had ttomtal ALT; for this reason, the patient was no, cmxidmd for treatment with IFN. At the end of folhnv up (week 6-Q. seven (46.7%) of the 15 treated patients itt Group 11 had eliminated HBeAg, 6115 (40.0%) had developed anti-HBe antibodies and 6115 (40.0%) were HRV DNA negative.

V. PEREZ et al,

S116

Liver biopsies were compared before and after treatment in 11 seroconverted patients and nine non-sefoconverted patients (Table 2). Using the Knodell score (121, liver inflammation was evaluated separately from fibrosis. Inflammation was found to be markedly reduced after serocmversion (p < Mll) while fibrosis remained unchanged. All of the 11 se-

tions of d&rent antiviral agents (16). Higher rates of response have also been obtained combining prednisone withdrawal with a course of IF?4 (9-I 1). In uur study, We have evaluated this combination and compared it with IJ?N alone. The results are summarized in Fig. 2. In Group 1, we achieved elimination of HBeAg in 58.8% of patients, vrith 47% seroconverting to anti-HBe and 52.9% eliminating HBV DNA. One case (5.9%) also

roconvertcd patients were positive for H8cAg in liver cell nuclei before treatment but only 1111 after seroccmver-

iost HBsAg. Comparing the percentage of responders in Groups I and II, there is a tendency in favour of the for-

SiOIL

mer, bu: the difference is not significant. The same results

In non-seroconverted

patients, there were “9 significant changes either in inflammation or fibrosis, Of the nine non-seroconverted patients with HBcAg in liver cell nuclei prior treatment.

to treatment,

819 remained

positive

after

Overall, therapy was well tolerated. The most frequent treatment-associated side effects were: fever, myalgia, herpes and aschenia in the first 2-3 weeks, and Iuossof appetite and weight, depression, chronic asthenia, hair loss, impotence, paraesthesia and leukopenia in the later stages of treatment. Only one patient from Group II discontinued treatment at week 10 because of intolerable adverse effects. In four patients (two from Group I and two from Group II), the dose of IFN was reduced to 5 MU tiw. because of severe side effects. At week 24, two patients from Group II were not considered for treatment because they did not fultil the inclusion criteria: one had prolonged infection and leulcopenia, and the other had become HBeAg negative and had normal ALT levels.

DiSCUSSiOIl

There is a wide variation in results from the numerous cfinical trials wifh IFN in chrmic hepatitis B (4-8,14). The differences are considered IO be due to variations in the dose, duration of treatment and, particularly, in patient selection. Overall, one-third of treated patients have achieved sustained loss of the markers of viral replication, with normalization of serum ALT levels and a reduction ir: liver inflammation, According to the present data, there are some predictive indicators of response. Those less likely to respond include young children, Asians, homosexuals, anti-HIV positive patients, those with low pre-treatment serum ALT and high pre-treatment HBV DNA Ievels (8,l S),

Some better results have been reported using combina-

were obtained

by Perrillo et al. in

a multicentre study

(17). They found, however,

that when pre-treatment ALTwas lower than 100 WI, the patient benefitted from a short course of prednisone prior to treatment with IFN. Our patient numbers were too small for us to confirm these findings. Since our seroconversion rates are high compared to those of other trials, we analysed the possible factors that may have influenced our results, Q) The dose of 10 MU t.i.w. is prob&Iy more effective tlvm lower doses. However, side effects are more in evidence with this dose than with a 5 MU dose, which Tsgeneraliy better tolerated. (ii) Our patients were all Caucasian and were m&y middle-aged. (iii) We had a low number of homosexuals (6/35). (iv) Chronic active hepatitis was present in 30135 M. (v) Our patients had h@b pre-treatment serum levels of ALT (160 f 139 IUII in Group I and 109 * 10% MI in Group II), Contrary to the observation that low pre-treatment levels of HBV DNA are predictive of seroconvtrsion, seroconverted patients in our series started with higher lev& of HBV DNA (p < 0.05). Analysis of the ALT curve (Fig. 1) showed a clear difference between seraconverted and non-set-nverted patients. In the latter, there were only minor changes during the prednisone and IFN phase, indicating a weak immunological reaction, which was probably the reason far

lack of seraconversion. Study of liver biopsies in 20 patienff kfore and after treatment showed a clear difkrence in relation to response (Table 2). in seroconvetied patients, chronic active hepatitis ameliorated to chronic persistent hepatitis but fibrosis remained unchanged; HBcAg was cleared from liver cell nuclei in all but one case. In non-setoconverted patients, the pre- and post-treatment liver biopsies showed no @Scant differences and all but one remained HBcAg positive. The results of our trial have shown the effectiveness of IF?4 in inducing a sustained loss of the

markers of viral replication, particularIywith appropriate selection of patients. However, they give no definitive

answer

with regard 10 the usefulness of prednisone

with-

A much bnger

follow

up of reroconverted

also needed in order to understand how IM the natural hirtoryofthe

drawal prior to IFN treatment. patients is

disease.

might change