Article: Hepatitis B Virus Reactivation During Successful Treatment of Hepatitis C Virus with Sofosbuvir and Simeprevi

This article is being re-posted from a previous newsletter.  I have been hearing from patients who have been inquiring about treatment with a DAA and who are also co-infected with chronic hepatitis B.  People co-infected with HCV and HBV should make their medical providers aware that their chronic hepatitis B should be monitored on a regular basis.  The article below recommends that people being treated with a DAA should be monitored every 2 weeks.  -Alan

Snapshots - Alan Franciscus

Article:  Hepatitis B Virus Reactivation During Successful Treatment of Hepatitis C Virus with Sofosbuvir and Simeprevir—J. M. Collins et. Al
  Source:  Clinical Infectious Diseases Advance Access

Results and Conclusions: This was a case report of two individuals with hepatitis C. 

The first case was a 55 yo man who was coinfected with hepatitis B and hepatitis C genotype 1a.  He had been previously treated with pegylated interferon plus ribavirin but did not achieve a cure.  He was started on sofosbuvir and simeprevir.  After week 4 he was HCV undetectable, but at week 7 he started to have severe liver symptoms (AST of 1792 IU/L, ALT of 1495 IU/L, total bilirubin of 12.2 mg/dl and INR of 1.96) and his hepatitis B viral load rose to 22 million.  His other tests (antinuclear antibody, ferritin, a-fetoprotein, etc.) were also abnormal.

The HCV treatment was discontinued, and hepatitis B treatment (tenofovir/emtricitabine) was started and the hepatitis B viral load subsequently decreased to less than 20 IU/mL.  The hepatitis B treatment was continued for ongoing hepatitis B suppression.

The second case was a 57 yo man with HCV genotype 1a.  He had been treated for HCV with pegylated interferon plus ribavirin but had not been cured. He was positive for the hepatitis B virus, but the hepatitis B viral load was below the level of detection (20 IU/mL).  He was started on HCV treatment—sofosbuvir and simeprevir and his HCV and hepatitis B viral loads were monitored every two weeks.  After two weeks, his HCV viral load was undetectable and his hepatitis B viral load increased to 353 IU/mL.  After four weeks of HCV treatment, HCV was still undetectable, but the hepatitis B viral load increased to 11,255 IU/mL.  The liver function tests were normal, and there were no other signs of liver disease.  The patient remained on sofosbuvir/simeprevir treatment.  Tenofovir was added to the HCV treatment regime to treat hepatitis B. 

The Bottom Line:  The reactivation of HBV in people who were coinfected with HBV and HCV was rare in the days of pegylated interferon based therapies.  This was most likely because PEG works against HBV whereas the new HCV direct acting antivirals do not have antiviral properties that will suppress hepatitis B while treating HCV.   

Editorial Comment:  A couple of important points:

• Everyone with hepatitis C should be tested for hepatitis B (and A), and if not previously infected should be vaccinated.
• People who are chronically infected with HBV and HCV who are being treated with the direct-acting antiviral medications (Harvoni or Viekira Pak) and monitored very closely—every two weeks as listed in the second study—for HBV flares and treated for chronic HBV as needed. 

Snapshots, by Alan Franciscus, Editor-in-Chief

Originally Published July 15, 2015

Article: Hepatitis C treatment in the elderly: New possibilities and controversies towards interferon-free regimens—Vespasiani-Gentilucci U, et al.
  Source: World Journal of Gastroenterology, 07/06/2015

Results and Conclusions:  In this article the authors discuss some important issues regarding the treatment of elderly patients with interferon-free therapies.  Elderly patients have additional health concerns that affect treatment decisions including:

• A generally faster disease progression to cirrhosis and liver cancer than those who are younger
• More extrahepatic conditions such as fatigue, cognitive issues
• A potential decrease in quality of life
• Possible drug-drug interactions with medications taken by the elderly (diabetes, heart, blood-pressure medications)

The authors recommend that the best case scenario is to treat every elderly patient because of the risk of accelerated disease progression.  If this is not realistic, we should be treating those who need treatment first who are in danger of disease progression.   The patients who are not in immediate need of treatment should be monitored on a regular basis.  As with current recommendations, those who have only a short-term survival are excluded from HCV antiviral treatment.  

The Bottom Line:  In general, the elderly population faces many health complications.  The elderly also face discrimination from healthcare professionals.  It is important that everyone with hepatitis C have an advocate—a family member or friend to help them through the intricacies of monitoring HCV and accessing HCV treatment.  

Editorial Comments:  We now have medications that have fewer side effects and have been found to be safe in people with mild to moderate kidney impairment.  It is important that the newly approved drugs and the investigational drugs be tested with the many medications that are commonly prescribed to the elderly.

Everyone deserves the right to be cured of hepatitis C including the elderly with hepatitis C.  More importantly, don’t we have an obligation to make sure that our elderly population with hepatitis C be treated and cured?  This way they can live their lives in relative health and know that they no longer have to deal with the potential physical and emotional consequences of living with hepatitis C.  

Article:  Hepatitis B Virus Reactivation During Successful Treatment of Hepatitis C Virus with Sofosbuvir and Simeprevir—J. M. Collins et. Al
  Source:  Clinical Infectious Diseases Advance Access

Results and Conclusions: This was a case report of two individuals with hepatitis C. 

The first case was a 55 yo man who was coinfected with hepatitis B and hepatitis C genotype 1a.  He had been previously treated with pegylated interferon plus ribavirin but did not achieve a cure.  He was started on sofosbuvir and simeprevir.  After week 4 he was HCV undetectable, but at week 7 he started to have severe liver symptoms (AST of 1792 IU/L, ALT of 1495 IU/L, total bilirubin of 12.2 mg/dl and INR of 1.96) and his hepatitis B viral load rose to 22 million.  His other tests (antinuclear antibody, ferritin, a-fetoprotein, etc.) were also abnormal.

The HCV treatment was discontinued, and hepatitis B treatment (tenofovir/emtricitabine) was started and the hepatitis B viral load subsequently decreased to less than 20 IU/mL.  The hepatitis B treatment was continued for ongoing hepatitis B suppression.

The second case was a 57 yo man with HCV genotype 1a.  He had been treated for HCV with pegylated interferon plus ribavirin but had not been cured. He was positive for the hepatitis B virus, but the hepatitis B viral load was below the level of detection (20 IU/mL).  He was started on HCV treatment—sofosbuvir and simeprevir and his HCV and hepatitis B viral loads were monitored every two weeks.  After two weeks, his HCV viral load was undetectable and his hepatitis B viral load increased to 353 IU/mL.  After four weeks of HCV treatment, HCV was still undetectable, but the hepatitis B viral load increased to 11,255 IU/mL.  The liver function tests were normal, and there were no other signs of liver disease.  The patient remained on sofosbuvir/simeprevir treatment.  Tenofovir was added to the HCV treatment regime to treat hepatitis B. 

The Bottom Line:  The reactivation of HBV in people who were coinfected with HBV and HCV was rare in the days of pegylated interferon based therapies.  This was most likely because PEG works against HBV whereas the new HCV direct acting antivirals do not have antiviral properties that will suppress hepatitis B while treating HCV.   

Editorial Comment:  A couple of important points:

• Everyone with hepatitis C should be tested for hepatitis B (and A), and if not previously infected should be vaccinated.
• People who are chronically infected with HBV and HCV who are being treated with the direct-acting antiviral medications (Harvoni or Viekira Pak) should be monitored very closely—every two weeks as listed in the second study—for HBV flares and treated for HBV as needed. 

http://hcvadvocate.org/news/newsLetter/2015/advocate0715_mid.html#4