August 12, 2010

Caregiver Relationship Predicts Post-Transplant Anxiety

Depression, anxiety reduced after liver transplant, but improvement is attenuated by emotional distance

Publish date: Aug 12, 2010

THURSDAY, Aug. 12 (HealthDay News) -- Many patients with end-stage liver disease (ESLD) have less depression and anxiety after receiving a liver transplant, but this improvement is attenuated in individuals with emotionally distant caregiving relationships, according to research presented at the International Congress of Behavioral Medicine, held from Aug. 4 to 7 in Washington, D.C.

Anne Eshelman, Ph.D., of the Henry Ford Hospital in Detroit, and colleagues surveyed 74 patients with ESLD before liver transplant and six months' post-op, and asked their primary caregivers what degree of closeness they felt in their relationship.

The researchers found that caregivers reporting maximum closeness were in the majority (44 versus 30). Depression and anxiety decreased after transplant, but more so in the patients whose caregivers reported emotionally close relationships. Gender was a confounding variable, and further analysis suggested emotional closeness was more important for improvement in men than in women.

"For patients with ESLD, depression and anxiety decline sharply after liver transplant, but declines are attenuated for individuals with emotionally distant caregiving relationships. These findings suggest caregiving relationships as a target for psychotherapeutic intervention among patients with ESLD," the authors write.

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By Caitlin McHugh and Courtney McQueen
Published: Aug 11, 2010 6:21 pm

Researchers presented several studies at the 2010 International AIDS Conference in Vienna, Austria that evaluated heart function and heart disease in HIV-positive adults. Two studies found that even young, healthy people with HIV may show signs of heart problems; two additional studies showed that kidney disease and heart disease in people with HIV may be linked.

People with HIV can be particularly prone to heart disease and heart problems, with some studies estimating that heart disease causes a fifth of all deaths in people with HIV.

As a result, researchers are conducting studies to identify risk factors and how heart disease develops in HIV-positive adults.

Adults With HIV May Have High Rates Of Coronary Artery Narrowing

This pilot study examined 52 HIV-positive adults with a low risk for heart disease to determine the rate of coronary artery stenosis – narrowing of the arteries that bring blood to the heart muscle. Results showed that even in this low-risk group half of study participants had coronary artery narrowing.

Narrowing of the arteries restricts blood flow to the heart, which increases the risk for a heart attack. Since people with HIV are already at higher risk of heart problems, the researchers wanted to determine the rate of coronary artery narrowing in otherwise healthy people with HIV.

All the study participants were classified as low risk for heart disease based on their age, cholesterol levels, weight, and other factors. None had previously shown any signs or symptoms of heart problems.

In addition, the majority of participants (73 percent) had a low viral load (amount of virus in the blood) of 50 copies per milliliter or less.

Testing revealed that half of the participants in the study had coronary artery narrowing. Of these, half were mild cases and the rest were moderate or severe. A total of five study participants (10 percent) were diagnosed with severe artery stenosis.

The researchers could find no differences between participants in immune system functioning, or other medical tests, to explain who developed artery narrowing and who did not.

They concluded that all HIV-positive adults should be screened for heart disease regardless of risk factors or symptoms.

Fatty Liver Disease Is Associated With Heart Disease In People With HIV

This study was aimed at discovering whether fatty liver disease indicates heart disease in people with HIV.

Fatty liver disease is reversible and results from abnormal fat accumulation in liver cells. It can be caused by excessive drinking or obesity, but can also be caused by lipodystrophy, an abnormal change in the body’s fat distribution that is a common side effect of some antiretroviral medications.

Most of the 204 HIV-positive adults, with an average age of 44 years, did not have other HIV-related diseases.

Despite the age and relative health of the participants in the study, researchers found that over a third (36 percent) had heart disease. They also found that fatty liver disease was associated with heart disease.

Older age, high blood pressure, and possibly Ziagen (abacavir) use were also linked to heart disease.

The researchers concluded that fatty liver disease may indicate heart disease in people with HIV. They recommend that HIV-positive adults with fatty liver disease be tested for heart disease and consider discontinuing the use of Ziagen to prevent further heart problems.

Abnormal Heart Blood Flow Linked To Poor Kidney Function And Low CD4 Count

Another study examined patients in the HIV Clinic Database who had undergone a stress test, which determines the amount of blood flowing to the heart, between 2004 and 2009. Results showed that abnormal heart blood flow is linked to poor kidney function and low CD4 counts.

When heart blood flow is abnormal not enough oxygen reaches the heart, which increases a person’s risk of heart disease and heart attack. Abnormal heart blood flow often manifests as chest pain.

For the study, researchers compared 20 HIV-positive patients who had stress tests revealing abnormal blood flow to 20 HIV-positive patients of the same age and sex with normal tests.

The comparison showed that there were no significant differences in age, sex, body mass, heart disease risk factors, or antiretroviral therapy between the two groups.

However, the results did show that patients with poor kidney function and low CD4 counts (350 cells per microliter or less) were more likely to have abnormal blood flow as measured in the stress tests.

As a result of their findings, the researchers advise people with HIV who have kidney disease and a low CD4 count to work to reduce their risk of heart disease.

This includes avoiding cigarettes and alcohol, reducing blood pressure and cholesterol, exercising, and losing excess body fat.

Kidney Disease Linked To Recurrent Hospitalization In HIV-Positive Patients With Heart Failure

A study at St. Luke’s-Roosevelt Hospital Center in New York examined factors contributing to frequent hospitalization in HIV-positive patients with heart failure.

A total of 77 patients were followed over the course of one year. Researchers recorded factors such as viral load, CD4 count, heart and kidney function, blood pressure, and number of hospitalizations.

The results revealed that chronic kidney disease was the only factor that was significantly associated with frequent hospitalization.

Researchers determined that 61 percent of the patients had chronic kidney disease and that kidney disease nearly doubled the number of yearly hospital visits necessary.

They concluded that kidney disease is the primary factor responsible for recurrent hospitalizations in HIV-positive adults with heart failure.

For more information, please see the AIDS 2010 conference website.

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PRINCETON, N.J., Aug. 12 /PRNewswire/ -- EDDA Technology announced today that the number of clinical cases evaluated for pre- and post- operative assessment using IQQA®-Liver in hospitals has exceeded 1000 examinations, since the first commercial system installation in Q2 2009. EDDA's IQQA®-Liver, now marketed worldwide, is a comprehensive workflow solution supporting modern multidisciplinary liver imaging evaluation and management.
Primary liver cancer represents one of the most common malignancies in the world and accounts for almost 1.25 million deaths annually. In the US, liver disease is among the ten major causes of death. The management of hepatic tumors presents a challenging problem. Advanced preoperative imaging assessment is paramount in determining appropriate treatment, and requires the participation of a multidisciplinary team of surgeons, oncologists, hepatologists, and interventional radiologists specializing in liver malignancy.

IQQA®-Liver is designed to cope with such a challenge. It provides an innovative toolset for real-time interactive assessment and volumetric quantification of liver, liver lobes, hepatics lesions and vessels. With the intuitive and easy-to-use tools, physicians may in real-time perform virtual simulation of resection, lobular/segmental/vascular manipulation and quantification to achieve desired planning result typically within minutes.

EDDA's proprietary IT technology allows enterprise-wide deployment of IQQA®-Liver via web so as to quick share data and results anywhere anytime among the multidisciplinary liver team.

IQQA®-Liver has clearance by the FDA, China SFDA, Taiwan DOH, and carries the CE mark. It is currently in use at numerous prestigious liver transplantation/surgery/interventional centers worldwide, including University of Colorado Hospitals Denver, Shanghai Zhongshan Hospital, Shanghai Ruijin Hospital, Tianjin First Center Hospital, Beijing You'an Hospital, Nanjing Gulou Hospital and etc.

In one study, University of Colorado Hospital Denver used IQQA®-Liver to retrospectively evaluate the entire living liver donor (LLD) candidate studies rejected in a 2 year period, and found that about 48% that were previously rejected due to anatomic abnormalities by conventional CT visualization could have favorable anatomy for LLD. According to Dr. Igal Kam, Chief of Transplantation, and Dr. Paul Russ, Professor of Radiology, "IQQA®-Liver allows for better understanding of surgical anatomy and surgical planning in the preoperative evaluation. This will have positive outcome on available livers and LLD selection." Results will be presented at the XXIII International Congress of the Transplantation Society in Vancouver. EDDA will exhibit IQQA®-Liver at this congress (booth #38).

About EDDA Technology

EDDA Technology, Inc. is an innovative clinical computer solution provider in healthcare imaging and analysis. EDDA offers a series of next generation computer assistance solutions to the entire patient care management cycle, including enabling early detection and diagnosis of diseases, as well as enhancing efficiency and precision in treatment planning, management and follow-up. EDDA's goal is to deliver, with broad accessibility, advanced information analysis technologies that improve clinical workflow and accuracy. A privately held Delaware corporation, EDDA is headquartered in Princeton, New Jersey, and has a subsidiary in Shanghai, China. IQQA® is a registered trademark of EDDA Technology. http://www.eddatech.com/

SOURCE EDDA Technology, Inc.

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HFCS - the poison that promotes obesity and liver damage

Posted: 2010/08/12
From: Mathaba

(NaturalNews) Two new studies have added more reason for concern that high-fructose corn syrup causes significantly more harm to the body than its mere sugar content would suggest.

High-fructose corn syrup contains 55 percent fructose and 45 percent glucose. In contrast, table sugar (also known as sucrose) contains a 50-50 split.

In the first study, published in the journal Pharmacology, Biochemistry and Behavior, researchers from Princeton University found that rats consuming high fructose corn syrup gained more weight and developed more cardiovascular risk factors than rats consuming equivalent amounts of sucrose.

"Some people have claimed that high-fructose corn syrup is no different than other sweeteners when it comes to weight gain and obesity, but our results make it clear that this just isn't true, " researcher Bart Hoebel said.

Hoebel and colleagues fed two groups of rats an identical diet, supplemented with one of two sweetened beverages. One beverage consisted of a sucrose solution in concentrations similar to those found in many sweetened beverages. The other consisted of a high-fructose corn syrup solution at roughly half the concentration of a typical soda. The researchers found that the rats consuming the corn syrup solution gained significantly more weight than the rats consuming the sucrose solution.

In a followup experiment, the researchers compared metabolic changes in rats fed only rat chow with rats fed chow plus a high-fructose corn syrup solution. All the rats consumed the same amount of calories.

After six months, the rats in the corn syrup group had gained 48 percent more weight. They also underwent an increase in fat deposition (especially in the abdomen) and a drop in circulating triglycerides. These changes are consistent with metabolic syndrome, a cluster of symptoms that predispose humans to cardiovascular disease and diabetes.

Every rat consuming high-fructose corn syrup became obese. In contrast, rats fed a high-fat diet did not become obese in all cases.

Another study, conducted by Duke University researchers, once again implicates high-fructose corn syrup in a heightened risk of liver damage.

Previous research has suggested that large amounts of fructose liver in the same way as excessive alcohol consumption. Another study linked high-fructose corn syrup specifically with a form of liver scarring known as non-alcoholic fatty liver disease (NAFLD).

The new study, published in the Journal of Hepatology, found that high-fructose corn syrup worsened the effects of NAFLD.

"We found that increased consumption of high fructose corn syrup was associated with scarring in the liver ... among patients with NAFLD," researcher Manal Abdelmalek said.

The researchers analyzed the diets and livers of 427 adults with NAFLD, and found that only 19 percent of them never consumed fructose-containing beverages. In contrast, 52 percent of participants had between one and six servings of a fructose-containing beverage per week, while another 29 percent had at least one serving per day. The higher patients' fructose intake, the worse the scarring of their livers.

"We have identified an environmental risk factor that may contribute to the metabolic syndrome of insulin resistance and the complications of the metabolic syndrome, including liver injury," Abdelmalek said.

Abdelmalek noted that NAFLD is a severe problem that cannot be treated and may lead in some cases to liver cancer, liver failure and a need for liver transplant.

Researchers are still unsure why high-fructose corn syrup appears to damage the body more than its extra 5 percent fructose content would suggest. Some have hypothesized that the negative effects come from the massive quantities in which it is consumed -- high-fructose corn syrup is found in nearly all processed foods.

Other researchers have observed that beverages made with high-fructose corn syrup contain high levels of reactive carbonyls, which can damage cells. Still others have noted that the fructose in high-fructose corn syrup is chemically unbonded and thus spreads through the body more freely than the fructose in table sugar.

Sources for this story include:
http://www.aolnews.com/health/artic...
http://www.nytimes.com/2009/03/21/d...
http://www.sciencedaily.com/release...
http://www.foodconsumer.org/newsite....

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Public release date: 12-Aug-2010

Contact: Katie Marquedant
kmarquedant@partners.org
617-726-0337
Massachusetts General Hospital

A protein known to be involved in a rare hereditary cancer syndrome may have a role in the regulation of liver stem cells and the development of liver cancer. In the August 15 issue of Genes & Development, a Massachusetts General Hospital (MGH) research team describes finding that the protein called merlin, encoded by the NF2 (neurofibromatosis type 2) gene, controls the activity of adult stem cells that give rise to the two major types of liver cells.

"We found that mutation of the NF2 tumor suppressor gene in the mouse liver led to a dramatic overproliferation of liver stem cells – the cells that contribute to the liver's remarkable ability to regenerate," says Andrea McClatchey, PhD, of the MGH Center for Cancer Research, who led the study. "These mice go on to develop the two forms of liver cancer that are most common in humans, suggesting that liver stem cells may be the cells of origin of these tumors."

The liver has a rare ability to regenerate and replace damaged or missing tissue. If one lobe is removed for transplantation, the rest of the donor's organ will return to its previous size and the transplanted lobe will grow to match the needs of the recipient. This regeneration usually involves proliferation of the most characteristic liver cells, called hepatocytes, and of bile duct cells; but if that growth is blocked or those cells are damaged, a population of less-differentiated progenitor cells will start to expand. These liver stem cells have been identified in rodents, and potential equivalents found but not confirmed in humans.

Previous research also indicated that liver stem cells may be the source of some tumors in animals, and suggested that the tumor suppressor gene NF2 may help prevent tumor development. Originally discovered through its involvement in the rare genetic disorder neurofibromatosis type 2, the NF2 gene codes for merlin, a protein known to suppress the activity of a number of cellular receptors. One of these is the epidermal growth factor receptor (EGFR), and oversignaling by that protein is known to lead to several types of cancer. The current study was designed to investigate the role of NF2 and merlin in the fetal and adult mouse liver, including possible involvement with tumor development.

The researchers found that infant mice lacking functioning NF2 in their livers developed dramatic overgrowth of liver stem cells, to the point of crowding out hepatocytes. Mice that did not die from a lack of functioning liver cells soon developed the two major types of liver cancer, and the fact that stem cell overgrowth preceded tumor development strongly suggested that the undifferentiated progenitors were the source of the tumors. Blocking the expression of NF2 in the livers of adult mice had minimal effect on the animals unless a portion of the liver was surgically removed, setting off the regeneration process and leading to the same stem cell overproliferation and tumor development.

McClatchey explains that the study's findings provide new information about liver stem cells and how their proliferation is controlled; identifies a new animal model for liver cancer, the lack of which has seriously impeded understanding the disease; and suggests that liver tumors may originate from liver stem cells and that excess EGFR signaling leads to liver tumor development. "These results are consistent with our previous studies showing that merlin helps to regulate EGFR activity at the cell membrance," she says. "We also showed that merlin's role in cell-to-cell communication is essential for cells to stop growing when they fill the appropriate space. Since liver progenitors need to be poised to regenerate in case of injury, they may be particularly sensitive to the loss of merlin's regulatory function." McClatchey is an associate professor of Pathology at Harvard Medical School.

###

Co-lead authors of the Genes and Development report are Samira Benhamouche, PhD, and Marcello Curto, MD, PhD, MGH Center for Cancer Research. Additional co-authors are Ichiko Saotome, Andrew Gladden, PhD, and Ching-Hui Liu, MGH Center for Cancer Research; and Marco Giovannini, MD, PhD, House Ear Institute, Los Angeles. The study was supported by grants from the Tucker-Gosnell Foundation, the U.S. Department of Defense and National Institutes of Health, and the Children's Tumor Foundation.

Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $600 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, systems biology, transplantation biology and photomedicine.

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Poor kidney function common among HIV-infected injection drug users

Public release date: 12-Aug-2010

Contact: Shari Leventhal
sleventhal@asn-online.org
202-416-0658
American Society of Nephrology

Careful monitoring of kidney health may be warranted in this population

Poor kidney function is common among injection drug users, particularly those with HIV, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN). The results suggest that clinicians should monitor the kidney function of HIV-infected injection drug users and consider them candidates for medical treatments to protect their kidneys when appropriate.

HIV-infected individuals are more likely to have kidney disease compared with the general population. This may be due to a direct effect of HIV infection as well as indirect effects related to known risk factors for kidney disease that are commonly present among HIV-infected populations—for example, the presence of other illnesses, toxic effects of antiretroviral medications, low socioeconomic status, and African American race. Research also indicates that injection drug users exhibit increased risk of becoming infected with HIV. While little information is available about the burden of kidney disease in injection drug users, this population's drug use, higher prevalence of viral hepatitis, and poor access to medical care may increase the risk of kidney disease.

To investigate the issue, Shruti H Mehta, PhD (Johns Hopkins Bloomberg School of Public Health) and her colleagues analyzed the presence of proteinuria, or excess excretion of protein in the urine, in HIV-positive and HIV-negative injection drug users. Individuals with proteinuria often develop kidney disease; therefore, screening for proteinuria may help physicians prevent or slow damage to the kidneys.

Researchers analyzed information from 902 injection drug users who were predominantly African American, 273 of whom were infected with HIV. 24.8% had proteinuria and prevalence was 2.9 times higher among HIV-infected (45%) compared with uninfected individuals (16%). HIV infection, unemployment, increased age, diabetes, hepatitis C infection, and high blood pressure were linked to a higher prevalence of proteinuria.

Because proteinuria can lead to kidney failure and increases one's risk of developing cardiovascular disease, clinicians should aggressively screen HIV-infected injection drug users for proteinuria and consider them candidates for medical treatments that protect the heart and kidneys.

###

Study co-authors include Elizabeth Yanik (University of North Carolina-Chapel Hill School of Public Health); Gregory Lucas, MD, PhD (Johns Hopkins School of Medicine); David Vlahov, PhD (New York Academy of Medicine); and Gregory Kirk, MD, PhD (Johns Hopkins Bloomberg School of Public Health and Johns Hopkins School of Medicine).

Disclosures: The authors reported no financial disclosures.

The article, entitled "HIV and Proteinuria in an Injection Drug User Population," will appear online at http://cjasn.asnjournals.org/ on August 12, 2010, doi 10.2215/CJN.01030210.

The content of this article does not reflect the views or opinions of The American Society of Nephrology (ASN). Responsibility for the information and views expressed therein lies entirely with the author(s). ASN does not offer medical advice. All content in ASN publications is for informational purposes only, and is not intended to cover all possible uses, directions, precautions, drug interactions, or adverse effects. This content should not be used during a medical emergency or for the diagnosis or treatment of any medical condition. Please consult your doctor or other qualified health care provider if you have any questions about a medical condition, or before taking any drug, changing your diet or commencing or discontinuing any course of treatment. Do not ignore or delay obtaining professional medical advice because of information accessed through ASN. Call 911 or your doctor for all medical emergencies.

Founded in 1966, the American Society of Nephrology (ASN) is the world's largest professional society devoted to the study of kidney disease. Comprised of 11,000 physicians and scientists, ASN continues to promote expert patient care, to advance medical research, and to educate the renal community. ASN also informs policymakers about issues of importance to kidney doctors and their patients. ASN funds research, and through its world-renowned meetings and first-class publications, disseminates information and educational tools that empower physicians.

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New Potential Asthma Treatment Discovered By Researchers


Posted by trump44 on Aug 12th, 2010

Researchers believe they may have discovered evidence that a current protein used to treat cancer and other diseases may also be an effective asthma treatment. Interferon is a protein currently used to treat cancer, MS and hepatitis C. Researchers believe the protein will work by blocking the creation of the cells that cause allergic reactions, which is the basic cause of chronic asthma. These cells are created after the body has come in contact with certain animal hair and pollens.

Researchers believe this could be an exciting breakthrough as interferon is already approved and available for use so the usual delays in bringing a medication to market will not be an issue in this case. Another reason researchers are excited about their discovery is that the only asthma treatment available are medications that provide temporary relief and it is possible that interferon could be more of a long term asthma treatment.

Asthma sufferers currently number around 20 million in the United States, many of which are children.

Researchers believe the evidence they have discovered should warrant a clinical trial to see if interferon could become a new asthma treatment therapy.

Julie Peters
Worlds Breaking News

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Introduction
Hepatitis-associated aplastic anemia is a common syndrome in patients with bone marrow failure. However, hepatitis-associated aplastic anemia is an immune-mediated disease that does not appear to be caused by any of the known hepatitis viruses including hepatitis C virus.

In addition, to the best of our knowledge there are no reported cases of patients with chronic hepatitis C virus infection developing aplastic anemia associated with pegylated interferon alpha 2a treatment.Case presentation. We report the case of a 46-year-old Greek man who developed severe aplastic anemia during treatment with pegylated interferon alpha 2a for chronic hepatitis C virus infection. He presented with generalized purpura and bruising, as well as pallor of the skin and mucous membranes.

His blood tests showed pancytopenia. He underwent allogeneic bone marrow transplantation after completing two courses of immunosuppressive therapy with antithymocyte globulin and cyclosporin A.

Conclusions:
The combination of a specific environmental precipitant represented by the hepatitis C virus infection, an altered metabolic detoxification pathway due to treatment with pegylated interferon alpha 2a and a facilitating genetic background such as polymorphism in metabolic detoxification pathways and specific human leukocyte antigen genes possibly conspired synergistically in the development of aplastic anemia in this patient.

Our case clearly shows that the causative role of pegylated interferon alpha 2a in the development of aplastic anemia must not be ignored.

Author: Savvas Ioannou Gregorios Hatzis Ioanna Vlahadami Michael Voulgarelis

Credits/Source: Journal of Medical Case Reports 2010, 4:268

Published on: 2010-08-12
 
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Which Roads Lead to NASH?

Posted on July 17, 2010 by Kristine Novak, PhD, Science Editor

The progressive liver disease nonalcoholic steatohepatitis (NASH) is mediated by an innate immune response in the liver that causes tissue damage and fibrosis. The innate immune system protects against invading pathogens, but it’s not clear how it becomes activated in livers of patients with NASH. In the July issue of Gastroenterology, Kouichi Miura et al. describe an immune signaling pathway that controls the development of NASH in livers of mice.

Miura et al. induced steatohepatitis in mice by feeding them a choline-deficient amino-acid–defined diet (CDAA). In patients with NASH, Kupffer cells (liver macrophages) produce inflammatory and fibrogenic factors that activate hepatic stellate cells (HSCs) to produce inflammatory cytokines such as interleukin (IL)-1b. What activates these Kupffer cells? Kupffer cells and other cells of the innate immune system express Toll-like receptors (TLRs), which recognize microbial structures and activate production of inflammatory cytokines. So, Miura et al. induced NASH in mice that that did not express a TLR that had been previously associated with liver injury­–TLR9­­­­, which recognizes bacterial DNA.

The development of NASH through TLR9 and TLR4 on Kupffer cells.

Livers of TLR9-null mice developed less steatosis, fibrosis, and inflammation than wild-type mice fed the CDAA diet, and Kupffer cells of the TLR9-null mice did not produce IL-1b. They found that Kupffer cell production of IL-1b promoted NASH by increasing lipid accumulation in hepatocytes and death of these liver cells; it also activated the fibrogenic response of HSCs. Mice that lacked the receptor for IL-1b (IL-1R) or had disruptions in other components of the IL-1R signaling pathway did not develop NASH. The IL-1 signaling pathway therefore mediates disease pathogenesis in these mice.

Previous studies have shown that lipopolysaccharide (LPS), a gut bacteria-derived endotoxin that activates another TLR, TLR4, also induces Kupffer cell activity and can cause NASH. Further studies are needed to learn whether TLR4 and TLR9 have synergistic effects in NASH progression. In patients, Kupffer cells, as well as other liver cells, might encounter bacteria-derived components such as LPS and DNA, simultaneously or sequentially, to activated TLR4 and TLR9 on Kupffer cells and initiate the pathogenic process.

Other liver cell types besides Kupffer cells are also probably involved in the pathogenesis of NASH, and it is not clear what ligands actually activate TLRs in patients with NASH. Bacterial DNA was detected in blood taken from mice on the CDAA diet, so DNA derived from gut bacteria might activate TLR9. TLR9 can also recognize DNA released from necrotic hepatocytes to activate liver inflammation and injury­—another potential pathway to NASH.

Miura K, Kodama Y, Inokuchi S, et al. Toll-like receptor 9 promotes steatohepatitis by induction of interleukin-1β in mice. Gastroenterology 2010;139: 323–334.

Read the article online at Gastroenterology. This article has accompanying CME.

Read the accompanying editorial: Gao B. Innate immunity and steatohepatitis: A critical role of another toll (TLR-9). Gastroenterology 2010;139: 27–30.

Source
Clin Gastroenterol Hepatol. 2010 Aug 5. [Epub ahead of print]

Beste LA, Ioannou GN, Larson M, Chapko M, Dominitz JA.

Health Services Research and Development Center of Excellence, VA Puget Sound Healthcare System, Seattle WA; Northwest Hepatitis C Resource Center, VA Puget Sound Healthcare System, Seattle WA; Division of General Internal Medicine, VA Puget Sound Healthcare System.

Abstract

BACKGROUND & AIMS: A significant proportion of patients with hepatitis C virus (HCV) infection discontinue antiviral treatment prematurely. Risk factors for discontinuation before 48 weeks among patients with genotype 1 HCV vary over the course of therapy. We investigated the rates and risk factors for treatment discontinuation within 12 weeks, 12-24 weeks, and 24-48 weeks after therapy began. METHODS: We retrospectively evaluated data from all Veterans Affairs (VA) patients with genotype 1 HCV who initiated pegylated interferon and ribavirin therapy from 2002 to 2007 (n=11,019). We accounted for appropriate discontinuation because of lack of viral response. RESULTS: Overall, 53% of patients completed at least 38.4 weeks of therapy (80% of the projected 48 weeks), 16.5% discontinued early because of viral nonresponse, and 30.9% discontinued despite viral response or in the absence of virologic data. Cirrhosis, diabetes, pre-treatment substance use disorder, lower baseline concentration of hemoglobin, and lack of hematopoietic growth factor use independently predicted discontinuation within the first 12 weeks (P<.05 for all). Among patients with documented early virologic responses, higher baseline levels of creatinine, depression, and lack of growth factor use predicted discontinuation from 12 to 24 weeks. No factors independently predicted discontinuation from 24 to 48 weeks among patients that responded to treatment at 24 weeks. CONCLUSION: Early discontinuation of antiviral therapy is common. Use of growth factors was the strongest independent predictor of treatment retention before 24 weeks and should be evaluated prospectively. Early interventions are also warranted for other risk factors for early discontinuation, such as pre-existing substance use, depression, comorbid cirrhosis, or diabetes. Copyright © 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.

PMID: 20692371 [PubMed - as supplied by publisher]

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August 11, 2010

The pharmaceutical company Crucell, in collaboration with Harvard University, "plans to test its experimental AIDS vaccine in the U.S. and in Africa, advancing the quest for a protective shot against" HIV, Bloomberg reports. The trial will test the vaccine in uninfected adults "to assess its safety and ability to prompt an immune response ... the company said in a statement." Bloomberg continues, "The vaccine combines shots ... in a so-called prime-boost approach that's designed to both kill infected cells and prevent HIV from entering those that are uninfected" (Bennett, 8/11).

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Aug. 11, 2010, 2:00 a.m. EDT
 
Crucell and Harvard (BIDMC) Join Forces with IAVI to Advance AdVac(R)-based AIDS Vaccine

LEIDEN, NETHERLANDS, Aug 11, 2010 (MARKETWIRE via COMTEX) -- Dutch biopharmaceutical company Crucell N.V. (NYSE Euronext, NASDAQ: CRXL) (SWISS: CRX) today announces its intention to participate in an international Phase I clinical trial in the United States and Africa of a combination of two AdVac(R)-based AIDS vaccine candidates, Ad26.ENVA.01 and Ad35-ENV, in healthy adults who are not infected with HIV. The clinical trial, which will be led by the International AIDS Vaccine Initiative (IAVI), represents a collaboration between IAVI, Crucell, the Ragon Institute, and Beth Israel Deaconess Medical Center (BIDMC), a major teaching hospital of Harvard Medical School.

The Ad26.ENVA.01 vaccine candidate used in this study is manufactured by Crucell, while the Ad35-ENV vaccine is developed by IAVI. Both vaccines candidates are based on Crucell's proprietary AdVac(R) technology. The planned Phase 1 trial of the vaccine combination, which follows a Phase I trial of the Ad35-ENV vaccine by IAVI and a Phase I trial of Ad26.ENVA.01 by the Harvard-Crucell consortium, supported by the National Institute of Allergy and Infectious Diseases (NIAID), represents a key step towards proof of concept studies to evaluate the efficacy of the vaccine combination in humans.

The Phase I trial is designed to test two AIDS vaccine candidates in a prime-boost combination in HIV-uninfected healthy adult volunteers. The objectives are to evaluate the safety of the candidate vaccines Ad26.ENVA.01 and Ad35-ENV and their ability to provoke an immune response when administered in a prime-boost regimen.

"We are very happy that IAVI has decided to support the NIAID- sponsored Crucell-Harvard AIDS vaccine program, making it possible to advance this vaccine candidate further towards proof of concept Phase IIb efficacy trials in humans," said Jaap Goudsmit, Chief Scientific Officer at Crucell. "A different prime-boost AIDS vaccine approach has been shown in the RV144 trial (Thai Trial) to protect against HIV in humans, for the first time in the history of AIDS vaccine development. Our program to develop this combination vaccine represents one of the most advanced AIDS vaccine programs in the world and is based on the best science available today. We have the obligation as vaccine producers to do everything in our power to bring an effective AIDS vaccine to all people in need."

About Crucell

Crucell N.V. /quotes/comstock/15*!crxl/quotes/nls/crxl (CRXL 20.22, -0.06, -0.30%) (SWISS: CRX) is a global biopharmaceutical company focused on research development, production and marketing of vaccines, proteins and antibodies that prevent and/or treat infectious diseases. In 2009 alone, Crucell distributed more than 115 million vaccine doses in more than 100 countries around the world, with the fast majority of doses (97%) going to developing countries. Crucell is one of the major suppliers of vaccines to UNICEF and the developing world. Crucell was the first manufacturer to launch a fully-liquid pentavalent vaccine. Called Quinvaxem(R), this innovative combination vaccine protects against five important childhood diseases. Over 130 million doses have been sold since its launch in 2006 in more than 50 GAVI countries. With this innovation, Crucell has become a major partner in protecting children in developing countries. Other products in Crucell's core portfolio include a vaccine against hepatitis B and a virosome-adjuvanted vaccine against influenza. Crucell also markets travel vaccines, such as an oral anti-typhoid vaccine, an oral cholera vaccine and the only aluminum-free hepatitis A vaccine on the market. The Company has a broad development pipeline, with several product candidates based on its unique PER.C6(R) production technology. The Company licenses its PER.C6(R) technology and other technologies to the biopharmaceutical industry. Important partners and licensees include Johnson & Johnson, DSM Biologics, sanofi-aventis, Novartis, Wyeth, GSK, CSL and Merck & Co. Crucell is headquartered in Leiden, the Netherlands, with offices in China, Indonesia, Italy, Korea, Malaysia, Spain, Sweden, Switzerland, UK, the USA and Vietnam. The Company employs over 1200 people. For more information, please visit http://www.crucell.com/.

About Crucell's AdVac(R) technology

AdVac(R) technology is a vaccine technology developed by Crucell. It is considered to play an important role in the fight against emerging and re-emerging infectious diseases, and in biodefense. The technology supports the practice of inserting genetic material from the disease-causing virus or parasite into a 'vehicle' called a vector, which then delivers the immunogenic material directly to the immune system. Most vectors are based on an adenovirus, such as the virus that causes the common cold. The AdVac(R) technology is specifically designed to manage the problem of pre-existing immunity in humans against the most commonly used recombinant vaccine vector, adenovirus serotype 5 (Ad5), without compromising large-scale production capabilities or the immunogenic properties of Ad5. AdVac(R) technology is based on adenoviruses that occur less frequently in the human population, such as Ad26 and Ad35. In contrast to, for instance, Ad35 antibodies, antibodies to Ad5 are widespread among people of all ages and are known to lower the immune response to Ad5- based vaccines, thereby impairing the efficacy of these vaccines. All vaccine candidates based on AdVac(R) are produced using Crucell's PER.C6(R) production technology.

About the Crucell-Harvard (BIDMC) AIDS/HIV Vaccine (Phase I)

In April 2008, Crucell announced the start of a Phase I clinical study of the novel recombinant HIV vaccine. The vaccine is based on Crucell's AdVac(R) and PER.C6(R) technologies, using adenovirus serotype 26 (rAd26) as vector, and is jointly developed by Crucell and the BIDMC, funded by a grant from the US National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health. The rAd26 vector is designed to avoid pre- existing neutralizing antibodies to the more commonly used adenovirus serotype 5 (Ad5). Phase I clinical studies are being conducted at the Brigham and Women's Hospital in Boston, USA and are focused on assessing the safety and immunogenicity of the vaccine in several trials including single and multi-dose regimens. In October 2009, preliminary results of the Phase I study were presented at La Conference AIDS Vaccine 2009 in Paris, France. The presentation was given by Dr Dan H. Barouch, MD, PhD, Associate Professor of Medicine, Division of Vaccine Research, Department of Medicine, BIDMC, Boston, USA. The preliminary results of this study show that a 3-dose regimen of this HIV candidate vaccine is safe and immunogenic.

About the International AIDS Vaccine Initiative (IAVI)

IAVI's core mission is to support in every way the development of preventive AIDS vaccines that are not only safe and effective, but also accessible to all people. To that end, IAVI invests the bulk of its resources in the research and clinical assessment of candidate vaccines against strains of HIV that are prevalent in the developing world, where some 95% of new HIV infections occur. For more information, visit http://www.iavi.org/.

About Beth Israel Deaconess Medical Center (BIDMC)

BIDMC is a patient care, teaching and research affiliate of Harvard Medical School, and consistently ranks in the top four in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana- Farber/Harvard Cancer Care Center. For more information, visit http://www.bidmc.org/.

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Source
A. Mangia; O. Dalgard; N. Minerva; H. Verbaan; D. Bacca; H. Ring-Larsen; M. Copetti; V. Carretta; V. Piazzolla; R. Cozzolongo; L. Mottola; A. Andriulli

Posted: 08/11/2010; Alimentary Pharmacology & Therapeutics. 2010;31(12):1346-1353.
© 2010 Blackwell Publishing

Abstract and Introduction

Abstract

Background The optimal dose of ribavirin to be used in combination with Peg-IFN in patients with HCV genotypes 2 and 3 undergoing short treatment has not been established.

Aim To explore the relationship between starting ribavirin doses, expressed as mg/kg body weight and both rapid viral response at treatment week 4 (RVR) and sustained virological response (SVR) in patients treated for 12–14 weeks with peg-interferon α-2b and ribavirin.

Methods A post hoc analysis of data collected from two multicenter clinical trials was performed. Multiple regression analyses were employed to identify independent baseline and on-treatment predictors of RVR and SVR. For each dose of ribavirin, the empirical estimated probability of response was computed and the continuous exposure index was dichotomized by using a recursive partitioning and amalgamation method.

Results A nonlinear relationship was ascertained between ribavirin dose and RVR, but not SVR. A dose of 15.2 mg/kg was selected as the best splitting value for discriminating RVR vs. non-RVR. Regression analysis identified low baseline viraemia, genotype 2 and high ribavirin dose as independent prognostic factors for RVR. The likelihood of an SVR was not correlated with baseline ribavirin dose, but was independently predicted by adherence to the full dose throughout treatment and normal platelet counts.

Conclusions Starting high ribavirin doses appears capable of increasing the rate of RVR in patients with HCV genotypes 2 and 3 undergoing short treatment. Maintenance of the full planned dose throughout treatment is essential for achieving optimal SVR rates.

Introduction

The benefit of short (12 or 14 weeks) therapy with Peg-Interferon (Peg-IFN) in combination with ribavirin for patients with chronic HCV genotype 2 or genotype 3 infection has been documented in recent clinical investigations.[1–6] Patients who will benefit the most by short therapy are lean, noncirrhotic individuals capable of clearing the virus at treatment week 4.[7] This experimental evidence has been incorporated in some, but not all, treatment guidelines issued by scientific societies[8–10] and hence, uncertainties still remain about implementing short therapy in everyday clinical practice. Indeed, a clear-cut benefit of short therapy in comparison with the standard 24-week treatment did not emerge in some other clinical trials.[11, 12]

A controversial issue in genotypes 2 and 3 therapy that might explain part of previous inconsistencies across trials is the optimal dose of ribavirin to be used in combination with Peg-IFN: whenever ribavirin was given at higher dosage (800–1400 mg daily, according to body weight) than the one currently recommended (800 mg daily), the benefit of short therapy appeared evident;[1–4] on the contrary, when the administered dosage was the fixed 800 mg daily dosage,[11, 12] the benefit waned off.

The predominant mechanism(s) of ribavirin action against HCV is (are) yet to be established. Although ribavirin monotherapy imposes a transient HCV decline early on therapy, the drug has no apparent long-term effect on serum HCV RNA levels;[13, 14] however, in combination with interferon, it dramatically improves the success of therapy. In naïve patients undergoing treatment with conventional interferon and ribavirin, higher ribavirin concentrations were associated with a higher likelihood of response.[15] Plasma ribavirin concentrations have been shown to correlate with the starting dose of the drug,[15] and therefore selecting appropriate starting dose and maintaining it throughout treatment impact positively on therapeutic outcome. In genotype 1 patients, the probability of achieving a sustained virological response (SVR) increased as a function of the ribavirin dose (mg/kg of body weight), with a 40–50% increase for a 12–16 mg/kg dose.[16] Data are less clear for genotypes 2 and 3 infection, as a single study failed to prove a correlation between probability of SVR after 24 weeks of treatment and the ribavirin dose.[16] Although debate is ongoing as to which ribavirin dosage should be administered in combination with Peg-IFN, it is clear that ribavirin activity is dose/exposure-dependent[15, 16] and selecting and maintaining the optimal dose of the drug might be crucial for a successful therapy. This concept might apply particularly when considering short treatment duration. The objective of this analysis was to explore the relationship between starting ribavirin and both rapid viral response at treatment week 4 (RVR) and SVR in patients with genotypes 2 and 3 undergoing short (12 or 14 weeks) therapy with ribavirin and Peg-IFN α-2b.

Patients and Methods
 
Study Subjects

Data used in this analysis were collected from two multicentre clinical trials, run in Italy and Scandinavia, in naïve patients with genotypes 2 and 3. The complete inclusion and exclusion criteria, study design and primary results are available elsewhere.[5, 7] The primary efficacy objective of these trials was to compare SVR following Peg-IFN α-2b (Peg-Intron; Schering-Plough, Kenilworth, NJ, USA) plus ribavirin administered for short (12 or 14 weeks respectively) or standard (24 weeks) duration. All patients received Peg-IFN α-2b 1.5 μg/kg subcutaneously weekly together with ribavirin administered orally. In the study by Mangia et al.,[7] 718 patients were treated with Peg-IFN α-2b plus ribavirin 1000 or 1200 mg/day on the basis of body weight higher or lower than 75 kg; 496 patients with week 4 viral clearance (labelled as rapid virological responders, RVR) were allocated to 12-week treatment duration, whereas those without RVR were given therapy for 24 weeks. Italian patients with missing serum creatinine values at baseline were not included in the present analysis. In the 428 patients enrolled in the trial by Dalgard et al.,[5] ribavirin dose varied according to body weight as follows: 800 mg for body weight <65 kg, 1000 mg for body weight ranging from 65 to 85 kg, 1200 for body weight ranging from 85 to 105 kg and 1400 for body weight >105 kg. For the sake of homogeneity with the design of the Italian study, of the original 428 Scandinavian patients, only 148 individuals with RVR who were treated for 14 weeks and 130 non-RVR patients whose treatment lasted 24 weeks were considered eligible for the present investigation; the remaining 150 patients with RVR who were treated for the standard 24 weeks were excluded. Among Scandinavian patients considered eligible, only 10 had body weight >105 kg and required 1400 mg; therefore, the combined database allowed us to evaluate a large series of patients, including a comparable number of genotypes 2 and 3, who received similar dosages of ribavirin.

Per protocol, the ribavirin dose had to be reduced by 200 mg daily in patients who experienced a decrease in haemoglobin level of more than 2 g/dL during treatment, and by 400 mg daily if haemoglobin levels decreased to less than 10 g/dL. Ribavirin was discontinued if haemoglobin levels decreased to less than 8.5 g/dL. The use of erythropoietin was not allowed. Anaemia was defined as haemoglobin concentration <10 g/dL documented on at least one occasion during the studies. For patients who were intolerant to Peg-IFN α-2b, dose reductions in decrements of 12% of the assigned dose were allowed.

Analytical Methods

Definitions: The HCV RNA level was measured using the COBAS AMPLICOR HCV Test [(Roche Molecular Systems, Branchburg, NJ, USA), version 2.0; limit of detection 50 IU/mL]. Rapid virological response (RVR) was defined as undetectable serum HCV RNA at treatment week 4. End-of-treatment response (ETR) was defined as undetectable HCV RNA at weeks 12, 14 or 24 according to the different therapeutic regimens and SVR was defined as undetectable HCV RNA at the end of a 24-week follow-up period.

Statistical Analysis

As the primary objective of the present study was to explore the impact of ribavirin dose on both RVR and SVR, only patients who could tolerate anti-viral drugs for the planned length of therapy were retained in the analysis. Patients who had reduction in ribavirin and/or Peg-IFN at some point during treatment but completed the planned treatment duration were retained. Consequently, of the total 905 eligible patients enrolled in the two previous trials, only 673 patients (405 from the Italian cohort and 268 from the Scandinavian cohort) were retained. Of the 232 excluded patients, 120 had no serum creatinine available for glomerular filtration (GFR) rate calculation and 112 (10 among patients treated for 12–14 weeks and 102 among those treated for 24 weeks) had a premature treatment discontinuation for major side effects or were lost to follow-up.

Baseline patient characteristics were reported as frequencies and groups were compared with Pearson chi-square. Multiple logistic regression analyses were employed to identify independent baseline and on-treatment predictors of RVR and SVR, with age, gender, body mass index, genotype, baseline viraemia, platelet count, aspartate aminotransferase-to-platelet ratio index (APRI) score[17, 18] and starting ribavirin dose as dependent variables. An exploratory analysis was made to assess the nature of the relationship between dose of ribavirin adjusted for GFR and response probability: for each dose, the empirical estimated probability of response was computed. Moreover, the continuous exposure index was dichotomized using the best splitting value by using a Recursive Partitioning and Amalgamation (RECPAM) method.[19] All analyses were performed using SAS release 9.1 (SAS Institute, Cary, NC, USA). Two-tailed P-values <0.05 were considered significant.

Results
 
Characteristics of Patients

Baseline features of patients derived from the two studies are outlined in Table 1. There were differences in demographics, serum biochemistry and virological features of patients from the two cohorts: in the Scandinavian cohort, patients were as a mean 10 years younger, had a prevalent genotype 3 infection and lower frequency of advanced liver damage, as indicated by the lower proportion of individuals with low platelet counts and APRI score >2. Conversely, a higher proportion of Italian patients received a high (≥15 mg/kg) dose of ribavirin, a finding that might be related to differences in the schedule of ribavirin administration between the two studies: a more stringent weight-related dosing in the Scandinavian trial, and a looser relation to body weight in the Italian study.

Sustained virological response rates and predictability of SVR by RVR in accordance with the different duration of treatment are reported in Table 2.

Impact of Ribavirin Dosing on Rapid Virological Response

No patient had to reduce the ribavirin dose by treatment week 4, so that the relationship between starting ribavirin dose and the probability of RVR could be detailed. As shown in Figure 1, the dose of ribavirin, expressed in mg/kg of body weight, may be a determining factor of RVR in genotype 2 and 3 patients: the probability of RVR increased with increasing ribavirin dose. However, the relationship was a nonlinear one and the probability increased from approximately 54% to 80% for a ribavirin dose increase from 13 to 15.2 mg/kg. The dose of 15.2 mg/kg was determined as the best splitting value for discriminating RVR vs. non-RVR: among the 147 patients receiving a dose of ribavirin higher than 15 mg/kg, an 80% probability of achieving an RVR was observed, while for the 528 patients who received a lower dose, the RVR rate was 67%. At the univariate analysis of predictors of RVR, body mass index, genotype, viral load and ribavirin dose were significantly associated with RVR (Table 3). Multiple logistic regression analysis identified low baseline viraemia (<400 000 IU/mL) (OR = 2.5; 95% CI 1.6–3.8), genotype 2 (OR = 1.7; 95% CI 1.2–2.5) and high ribavirin dose (15 mg/kg) (OR = 1.6; 95% CI 1.1–2.6) as independent prognostic factors.


Figure 1. Probability of rapid virological response (RVR) in patients with hepatitis C virus genotypes 2 and 3 as a function of the ribavirin dose per kilogram of body weight after 12–14 weeks treatment. Observed values are presented as circles. The dashed lines are the 95% point-wise confidence intervals.

Predictors of RVR at the univariate analysis are shown separately for HCV genotypes 2 and 3 in Table 4. At multivariate analysis, young age and low viraemia were independent predictors of RVR in genotype 2 patients, OR = 2.06, 95% CI 1.16–3.64 and OR = 2.01 (1.18–3.40) respectively. For genotype 3 patients, independent predictors of RVR were low viraemia (OR = 2.84, 95% CI 1.60–5.01), high ribavirin dose (OR = 2.13, 95% CI 1.07–4.26) and young age (OR = 2.91, 95% CI 1.77–4.80).

Impact of Ribavirin Dosing on Sustained Virological Response

As per protocol, anti-viral therapy lasted 12–14 weeks in 473 patients with RVR and 364 of them (77.0%) attained an SVR. The likelihood of an SVR was not correlated with baseline ribavirin dose, expressed in mg/kg of body weight, but rather with the inability to adhere to the prescribed dose of the drug. Low viral load (P = 0.033), normal platelet count (P = 0.0001) and maintenance of full dose of ribavirin throughout treatment were associated with SVR (P = 0.0001). Decreasing ribavirin dose relative to target during treatment was a predictor of relapse: of patients who achieved an SVR, only 7% had to reduce the dose of ribavirin after the initial 4 weeks of therapy with a consequent 25% of total amount of ribavirin reduction, whereas 19% of those who failed to clear the virus did so. At multivariate analysis, independent predictors of SVR in patients with RVR were no ribavirin dose reduction (OR = 3.1; 95% CI 1.6–5.9) and normal platelet counts (OR = 2.75; 95% CI 1.6–4.7).

Two hundred patients without RVR were treated per protocol for the standard 24 weeks of therapy and 134 of them achieved an SVR (67%). At univariate analysis, female gender (P = 0.09) and high baseline ribavirin dose (P = 0.05) emerged as the only two predictors of SVR. In particular, of 30 patients without RVR who received ribavirin at dose of ≥15 mg/kg of body weight, 23 (78.7%) individuals attained an SVR, as opposed to 110 of 170 patients in the lower ribavirin dose (64.7%). Dose reduction of ribavirin only occurred in 2% of those without RVR and was not associated with response. At the multivariate analysis, no factor was independently associated with SVR.

Ribavirin-related Side Effects

Sixty four of 673 patients with RVR required modification of the ribavirin dose because of a drop in haemoglobin levels below 10 g/dL. Anaemia was more frequently detected among patients treated with ribavirin dose of ≥15 mg/kg than in those who were treated with lower doses (9.5 vs. 4.4%), but the difference was not significant (P = 0.11). Other ribavirin related side effects as cutaneous rash, cough and dry skin were not differently distributed among patients in the low and high ribavirin dosage: 3% vs. 2.4% (P = 0.35).

Discussion
 
Current analysis evaluated the impact of ribavirin dosing on the therapeutic outcome in patients with genotypes 2 and 3 infection who received Peg-IFN α-2b in combination with ribavirin for a short treatment duration. Original data were derived from two clinical trials where patients were allocated to short or standard treatment duration depending on whether or not they attained an RVR.[5, 7] We could ascertain a relationship between the dose of ribavirin, expressed as mg/kg of body weight, and the likelihood of achieving an RVR. The relationship held true particularly for patients infected with HCV genotype 3. Furthermore, in RVR patients, the SVR rate was higher among those who were compliant with the initially assigned ribavirin dose throughout treatment.

Weight-based dosing of ribavirin has been extensively utilized in patients with genotype 1, in whom a relationship between ribavirin dose and SVR has been established when the drug was administered in association with either Peg-IFN α-2a or α-2b.[20–25] Based on these data, the ribavirin dose of 15 mg/kg was selected as the best balance between efficacy and a manageable safety profile. Data are less clear for genotypes 2 and 3. When administered in combination with Peg-IFN α-2a for 48 weeks, ribavirin doses of 800 or 1000–1200 mg daily produced equivalent outcomes.[22] Similarly, a comparative trial of fixed-dose (800 mg daily) or weight-based doses of ribavirin (800–1400 mg daily) in combination with Peg-IFN α-2b showed equal SVR rates: 67.7% vs. 65.0%.[23] This study also documented that responses were consistent across all body weight categories in the weight-based group, but lower SVR were attained with increasing weight.[22] However, a randomized study of Peg-IFN α-2a plus ribavirin for 24 weeks at doses of either 400 or 800 mg claimed no decrease in SVR rates in the lower dose group among patients with genotype 3 infection, but SVR rates declined from the 67.5% rate in the 800 mg group to 63.9% in the 400 mg group.[24]

It needs to be reminded that all previous trials administered therapy for at least 24 weeks. In principle, it might be conceivable that for the overall population of genotype 2 and 3 patients, a fixed 800 mg/day dose of ribavirin could be enough to achieve optimal response rates after 24 weeks of therapy. However, as shorter treatment courses may be viable in select genotype 2 and 3 patients, such as those with RVR, it could be speculated that much more promising results could be obtained by weight adjustment of ribavirin dose when considering abbreviated treatment. Indirect evidence supports this claim. In the NORDynamIC trial, patients who achieved SVR had significantly lower body weight than those who did not; as a fixed dose of 800 mg of ribavirin was administered to all patients, it is plausible that SVR patients had been exposed to higher dose of ribavirin than those who did not achieve SVR.[13] A post hoc analysis of the trial showed that the chance of achieving an SVR was associated with higher median serum ribavirin concentrations at week 4.[25]

In a study from Taiwan, an RVR rate of 86% was registered following therapy with Peg-IFN alpha-2a and weight-based ribavirin (1000–1200 mg daily); considering that the mean body weight of patients included in the study was 68 kg, a mean dose of 15–20 mg/kg was administered and could be one factor that might have impacted on the pronounced RVR rate.[4] In opposition, the ACCELERATE trial administered a fixed dose of 800 mg to patients whose mean body weight was 81.5 kg; consequently, they received a low ribavirin dose (9.8 mg daily, as a mean) and attained an RVR at a rate as low as 65.5%.[12] We acknowledge that although suggestive, all mentioned lines of evidence should be interpreted with caution because they were derived from secondary analyses with potential confounding variables.

The present analysis has added new evidence to the ongoing debate on the optimal ribavirin dosage. We found a relationship between body weight and RVR, an observation suggesting that the dose of ribavirin per kilogram may contribute substantially to response to therapy in patients undergoing short therapy. It is important to note that the type of the relationship was nonlinear, but S-shaped, with a low and a high threshold value for dosing of ribavirin. From our analysis, it turned out that a threshold value of ≥15.2 mg/kg was expected to result in a better outcome of therapy when considering short treatment. In previous studies,[16] the concept that ribavirin clearance is linearly dependent on renal function was not incorporated into the analysis, at variance in our patients as suggested by Bruchfeld,[25] the renal effect could be excluded after the adjustment for GFR. As a matter of fact, 80% of patients given ribavirin dose ≥15.2 mg/kg achieve an RVR as compared to 54% of those who were given 13 mg/kg.

Reddy et al. reported that as long as patients achieved RVR, ribavirin dose reduction had minimal impact on SVR after standard treatment duration.[26] Our findings on RVR patients who were treated with only 12–14 weeks of therapy demonstrate lower SVR rates when the initial dosage of ribavirin had to be reduced. Indeed, 46 of 473 patients with RVR required dose modification because of a drop in haemoglobin levels below 10 g/dL, and 54% of them attained an SVR as opposed to a 79% rate in those who could tolerate the starting dose of ribavirin throughout treatment. Although data modelling suggests that RVR increases with ribavirin doses that equate to ≥15 mg/kg, there is also a simultaneous increase in the rate of anaemia. To contrast anaemia development, the use of off-label erythropoietin has been implemented,[27–29] but the drug was not allowed in our patients for cost-saving considerations.

In summary, the results of our study suggest that in patients with HCV genotypes 2 and 3 infection completing short therapy with Peg-IFN α-2b in combination with weight-based doses of ribavirin, a high starting dose of ribavirin appeared one of the factors influencing the rate of RVR. We would recommend administering ribavirin at a dose of ≥15 mg/kg when considering short treatment duration. Larger prospective studies would be required to confirm the role of higher ribavirin doses on SVR, as both the need of maintaining the full planned dose of ribavirin throughout treatment to achieve an optimal SVR rate and the improvement of SVR in patients still viremic at treatment week 4 after an intensified ribavirin dosing suggest that higher ribavirin dosage affects SVR. Finally, the evidence that genotype 3 may derive more benefit from high dosages of ribavirin warrants further confirmation of the present post hoc analysis.

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MSD Posted on:12 Aug 10

12 August 2010, Hoddesdon – The National Institute for Health and Clinical Excellence (NICE) today issued a final appraisal determination (FAD) on the use of peginterferon alfa and ribavirin for the treatment of chronic hepatitis C, which includes MSD’s ViraferonPeg and Rebetol treatment regimen. The updated guidance recommends? combination therapy with peginterferon alfa and ribavirin as a treatment option for patients who are co-infected with HIV or patients with hepatitis C who require re-treatment (as they either did not respond to previous combination treatment, or peginterferon alfa monotherapy, or responded initially to treatment but subsequently relapsed).1

People co-infected with HIV and the hepatitis C virus (HCV) are at greater risk of developing liver disease than those infected with hepatitis C alone. The prevalence of HCV infection in HIV-positive individuals is higher than in the general population but varies among clinics according to risk factors for HIV acquisition. Around a third of people with HIV are estimated to have chronic HCV infection.

An estimated 200,000 to 500,000 people are infected with hepatitis C in England and Wales, with the majority unaware they have the condition. Hepatitis C is an infectious disease of the liver caused by HCV. The virus is acquired primarily through percutaneous exposure to contaminated blood. In approximately 80% of cases the virus will not be cleared and will develop into the chronic form of the disease.2

The final appraisal determination builds on existing guidance issued by NICE in 2004 and 2006 for the treatment of moderate-severe chronic hepatitis C and mild chronic hepatitis C respectively , and reinforces the importance of treating hepatitis C and HIV co-infection.

The previous NICE guidance (TA106 and TA75) recommend combination therapy with ribavirin and either peginterferon alfa-2a or peginterferon alfa-2b for adults with chronic hepatitis C. The previous guidance also recommends that monotherapy with peginterferon alfa-2a or peginterferon alfa-2b should be used only by people who are unable to tolerate ribavirin or for whom ribavirin is contraindicated.1

Treatment with peginterferon alfa and ribavirin aims to clear the virus from the blood.1 Successful treatment is usually indicated by a sustained virological response, which is considered to indicate permanent resolution of infection.1

Dr Harpal Lamba, MSD Medical Affairs, commented “We welcome NICE’s FAD for the use of peginterferon alfa and ribavirin for the treatment of chronic hepatitis C. This guidance will support healthcare professionals to consistently manage patients with hepatitis C when re-treatment is needed or where patients are co-infected with HIV.”

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About MSD

MSD is a trading name of Schering-Plough Limited and Merck Sharp & Dohme Limited in the UK. For more information on Merck Sharp & Dohme Limited and Schering-Plough Limited, please visit http://www.msd-uk.co.uk/.

Notes to editors:

About ViraferonPeg (peginterferon alfa-2b) and Rebetol (ribavirin)

ViraferonPeg is indicated for the treatment of adult patients with chronic hepatitis C who are positive for hepatitis C virus NRA (HCV-RNA), including patients with compensated cirrhosis and/or co-infected with clinically stable HIV.

The best way to use ViraferonPeg in this indication is in combination with Rebetol. This combination is indicated in naïve patients including patients with clinically stable HIV co-infection and in patients who have failed previous treatment with interferon alpha (pegylated or nonpegylated) and ribavirin combination therapy or interferon alpha monotherapy.

Combination therapy with peginterferon alfa (2a or 2b) and ribavirin is recommended as a treatment option for adults with chronic hepatitis C: who have been treated previously with peginterferon alfa (2a or 2b) and ribavirin in combination, or with peginterferon alfa monotherapy, and whose condition either did not respond to treatment or responded initially to treatment but subsequently relapsed or who are co-infected with HIV.1

The registered trademark holder for ViraferonPeg® and Rebetol® is Schering-Plough Limited in Switzerland. For more information refer to the Summary of Product Characteristics.

About hepatitis C1

Hepatitis C is an infectious disease of the liver caused by HCV. The virus is acquired primarily through percutaneous exposure to contaminated blood. People infected with HCV are often asymptomatic, but about 20% develop acute hepatitis. In approximately 80% of people who are infected, the virus is not cleared and they go on to develop chronic hepatitis C. Chronic hepatitis C is categorised as mild, moderate or severe depending on the extent of liver damage. The rate of progression from mild to severe disease is slow but variable, taking about 20 to 50 years from the time of infection. About 30% of infected people develop cirrhosis within 20 to 30 years, and some of these develop hepatocellular carcinoma. Some people with end-stage liver disease or hepatocellular carcinoma may require liver transplantation.

About the NICE guidance on peginterferon alfa and ribavirin1

Peginterferon alfa and ribavirin for the treatment of chronic hepatitis C (part review of technology appraisal guidance 75 and 106) – Final appraisal determination

This guidance should be read in conjunction with the following NICE guidance:

• NICE technology appraisal guidance 75 (TA75) ‘interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of chronic hepatitis C’ (which covers moderate to severe hepatitis C)
• NICE technology appraisal guidance 106 (TA106) ‘peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C’.

Guidance [section 1]:

Combination therapy with peginterferon alfa (2a or 2b) and ribavirin is recommended as a treatment option for adults with chronic hepatitis C;

• who have been treated previously with peginterferon alfa (2a or 2b) and ribavirin in combination, or with peginterferon alfa monotherapy, and whose condition either did not respond to treatment or responded initially to treatment but subsequently relapsed; or
• who are co-infected with HIV.

Shortened courses of combination therapy with peginterferon alfa (2a or 2b) and ribavirin are recommended for the treatment of adults with chronic hepatitis C who:

• have a rapid virological response to treatment at week 4 that is identified by a highly sensitive test; and
• are considered suitable for a shortened course of treatment.

When deciding on the duration of combination therapy, clinicians should take into account the licensed indication of the chosen drug (peginterferon alfa-2a or peginterferon alfa-2b), the genotype of the hepatitis C virus, the viral load at the start of treatment and the response to treatment (as indicated by the viral load).

Overview of previous guidance [section 2.5]:

Previous NICE guidance (TA106 and TA75) recommends combination therapy with ribavirin and either peginterferon alfa-2a or peginterferon alfa-2b for adults with chronic hepatitis C. The previous guidance also recommends that monotherapy with peginterferon alfa-2a or peginterferon alfa-2b should be used only by people who are unable to tolerate ribavirin or for whom ribavirin is contraindicated. The recommended duration of treatment is 24 or 48 weeks depending on a combination of factors, including the HCV genotype, the viral load at the start of treatment and whether a person has a rapid virological response to treatment. For people with mild HCV infection, the person and their clinician should decide whether to treat immediately or adopt an approach of ‘watchful waiting’ (see TA106). The use of peginterferon alfa and ribavirin combination therapy is also considered suitable for people who are co-infected with HCV and HIV, unless it is contraindicated.

http://guidance.nice.org.uk/TA106/Guidance
http://www.nice.org.uk/nicemedia/pdf/TA075guidance.pdf
http://guidance.nice.org.uk/TA/WaveR/20

For more information:
http://www.msd-uk.co.uk/

Editor's Details
Anna Radnavale
http://www.msd-uk.co.uk/

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PRINCETON, N.J., Aug. 12 /PRNewswire-FirstCall/ -- Pharmasset, Inc. (Nasdaq: VRUS) has received fast track designation from the U.S. Food and Drug Administration (FDA) for PSI-7977 for the treatment of chronic hepatitis C virus (HCV) infection. PSI-7977 is an oral uridine nucleotide analog polymerase inhibitor of HCV. Pharmasset recently completed dosing in a 28 day Phase 2a trial to evaluate PSI-7977 in combination with Pegasys (pegylated interferon) plus Copegus (ribavirin) in treatment-naive patients chronically infected with HCV genotype 1. Pharmasset expects to initiate a 12-week Phase 2b study of PSI-7977 in the fourth quarter of 2010.

Under the FDA Modernization Act of 1997, fast track designation may facilitate the development and expedite the review of a drug candidate that is intended for the treatment of a serious and life-threatening condition and demonstrates the potential to address an unmet medical need for such a condition. PSI-7977 was granted the fast track designation primarily due to the need for HCV treatments with novel mechanisms of action, oral administration, different resistance profiles and improved safety and efficacy over the existing standard of care for both treatment-naive and treatment-experienced patients.

"The FDA's fast track designation for PSI-7977 acknowledges the urgent need for new HCV drugs," stated Dr. Michael Rogers, Pharmasset's Chief Development Officer. "Currently, there are no HCV nucleoside/tide inhibitors approved for the treatment of chronic HCV infection. We continue to work closely with the FDA on the development and regulatory review of PSI-7977, which has demonstrated compelling antiviral activity, a high barrier to resistance and has been generally well-tolerated in clinical trials to date."

About Pharmasset

Pharmasset is a clinical-stage pharmaceutical company committed to discovering, developing, and commercializing novel drugs to treat viral infections. Pharmasset's primary focus is on the development of oral therapeutics for the treatment of hepatitis C virus (HCV) and, secondarily, on the development of Racivir(TM) for the treatment of human immunodeficiency virus (HIV). Our research and development efforts focus on nucleoside/tide analogs, a class of compounds which act as alternative substrates for the viral polymerase, thus inhibiting viral replication. We currently have four clinical-stage product candidates. RG7128, a cytosine nucleoside analog for chronic HCV infection, is in two Phase 2b clinical studies in combination with Pegasys(R) plus Copegus(R) and is also in the INFORM studies, the first series of studies designed to assess the potential of combinations of small molecules without Pegasys(R) and Copegus(R) to treat chronic HCV. These clinical studies are being conducted through a strategic collaboration with Roche. Our other clinical stage HCV candidates include PSI-7977, an unpartnered uracil nucleotide analog that has recently completed 28 days of dosing in a Phase 2a study, and PSI-938, an unpartnered guanosine nucleotide analog in a Phase 1 study. We also have in our pipeline an additional purine nucleotide analog, PSI-661, in advanced preclinical development. Racivir, for the treatment of HIV, has completed a Phase 2 clinical study.

Pegasys® and Copegus® are registered trademarks of Roche.

Contact
Richard E. T. Smith, Ph.D.
VP, Investor Relations and Corporate Communications
richard.smith@pharmasset.com
Office: +1 (609) 613-4181

Pharmasset, Inc.
303-A College Road East
Princeton, NJ 08540 U.S.A.
Phone: (609) 613-4100
Fax: (609) 613-4150
http://www.pharmasset.com/
Nasdaq: VRUS

Forward-Looking Statements

Pharmasset "Safe Harbor" Statement under the Private Securities Litigation Reform Act of 1995: Statements in this press release that are not historical facts are "forward-looking statements," including, without limitation, statements that involve risks, uncertainties, and other important factors, including, without limitation, the risk of cessation or delay of any of the ongoing or planned clinical trials and/or our development of our product candidates, the risk that the results of previously conducted studies involving our product candidates will not be repeated or observed in ongoing or future studies involving our product candidates, the risk that our collaboration with Roche will not continue or will not be successful, and the risk that any one or more of our product candidates will not be successfully developed and commercialized. For a discussion of risks, uncertainties, and other important factors, any of which could cause our actual results to differ from those contained in the forward-looking statements, see the section entitled "Risk Factors" in our Annual Report on Form 10-K for the fiscal year ended September 30, 2009 and our Quarterly Reports on Form 10-Q for the periods ended December 31, 2009, March 31, 2010 and June 30, 2010 filed with the Securities and Exchange Commission and discussions of potential risks, uncertainties, and other important factors in our subsequent filings with the Securities and Exchange Commission.

SOURCE Pharmasset, Inc.

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