Abstract

Thirty-nine hemophiliac patients, negative for human immunodeficiency virus, with chronic hepatitis C who failed to respond to interferon (IFN) at 3 million units (MU) given subcutaneously thrice weekly for at least 3 months were retreated with 5 MU IFN for 6 months followed by 3 MU IFN in combination with daily oral doses of 1 or 1.2 g ribavirin. Thirty-four patients (87%) completed the study. In 4 patients treatment was discontinued because of treatment-related symptoms; 1 patient dropped out. Dosage reduction was required in 10 patients (26%) because of ribavirin-related anemia or IFN-related side effects. By intention-to-treat analysis, 14 (37%) had a sustained virologic response with preference for those infected by genotypes other than type 1 (43% versus 12%) and with high transaminases levels (168 U/L versus 116 U/L). Thus, IFN and ribavirin combination therapy led to a sustained suppression of hepatitis in one third of hemophiliac patients resistant to conventional monotherapy.

Introduction

Chronic infection with hepatitis C virus (HCV) is the leading cause of liver-related morbidity and mortality in patients with hemophilia who have received multiple transfusions.1,2 It is not clear whether the cumulative lifetime risk of cirrhosis or hepatocellular carcinoma in these patients can be attenuated by treatment with interferon α (IFN-α). Hemophilic patients are frequently resistant to IFN therapy due to the long duration of HCV infection, high levels of viremia, and high prevalence of HCV genotype 1, which is an IFN-resistant virus strain.3-6 Controlled studies in nonhemophilic patients with chronic hepatitis C have demonstrated that higher rates (30%-40%) of sustained response are obtained with the administration of IFN in combination with the guanosine analogue ribavirin than with IFN monotherapy.7,8 Ribavirin is known to inhibit viral RNA polymerases in vitro,9 to increase the rate of virus mutations,10,11 to influence Th1/Th2 balance by causing a shift toward Th1 responses,12 and to suppress HCV-specific interleukin-10 (IL-10) production.13 The fact that nonhemophilic patients resistant to IFN monotherapy could achieve more sustained responses with combined administration of IFN and ribavirin14 provided the rationale for retreating all hemophilic patients refractory to IFN monotherapy with combination therapy.

Study design

This multicenter open trial consisted of a treatment period of 12 months and a 6-month posttreatment follow-up period. The study was designed by the Hepatitis Study Group of the Association of Italian Hemophilia Centers, which includes all the hemophilia centers participating in the previous IFN treatment trial of naive patients.3 The study was carried out according to the international standard criteria for good clinical practice. Written informed consent was obtained from each patient.

Between January and December 1998, we treated antihuman immunodeficiency virus (HIV)–negative adults (older than 18 years) with inherited bleeding disorders and chronic hepatitis C, not responding to or having a hepatitis relapse after treatment with 3 million units (MU) IFN given thrice weekly for a minimum of 3 months. Patients were included in the study after a 6-month washout period if they had abnormal serum aminotransferase (alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) levels and detectable serum HCV-RNA by reverse transcription-polymerase chain reaction (RT-PCR) as previously described.3 Nineteen patients (49%) were previously treated in the context of the multicenter controlled trial of IFN-α2b at the dose of 3 MU thrice weekly3 and the remaining 20 were patients with similar features who had received 3 MU of IFN-α2a or IFN-α2b outside the trial (Table 1).

Table 1.

Characteristics of the 39 patients at study entry

Patient characteristics
Mean age, y (range) 40  (22-65) 
Sex (M/F) 37/2  
Hemophilia A (%) 30  (77) 
Hemophilia B (%) 7  (18)  
Other inherited bleeding disorders (%) 2  (5)  
Disease duration, y (range) 24  (14-40)  
Mean ALT, IU/mL (range) 135  (46-441)  
Median HCV-RNA, MEq/mL (range) 4.3  (< 0.2-43.0)  
HCV genotype (%)  
 1a 21  (54)  
 1b 8  (20)  
 2b 2  (5) 
 3a 7  (18)  
 4 1  (3)  
Outcome of previous IFN monotherapy (%)  
 Nonresponse 24  (62)  
 Transient response 15  (38) 
Patient characteristics
Mean age, y (range) 40  (22-65) 
Sex (M/F) 37/2  
Hemophilia A (%) 30  (77) 
Hemophilia B (%) 7  (18)  
Other inherited bleeding disorders (%) 2  (5)  
Disease duration, y (range) 24  (14-40)  
Mean ALT, IU/mL (range) 135  (46-441)  
Median HCV-RNA, MEq/mL (range) 4.3  (< 0.2-43.0)  
HCV genotype (%)  
 1a 21  (54)  
 1b 8  (20)  
 2b 2  (5) 
 3a 7  (18)  
 4 1  (3)  
Outcome of previous IFN monotherapy (%)  
 Nonresponse 24  (62)  
 Transient response 15  (38) 

Each patient received 5 MU recombinant IFN-α2b (Intron A, Schering-Plough, Milan, Italy) by subcutaneous injections thrice weekly for 6 months followed by 3 MU thrice weekly for 6 additional months. An oral dose of 1000 to 1200 mg ribavirin (1200 mg if body weight was above 75 kg; Rebetol, Schering-Plough) was given daily for 12 months. Combination therapy was interrupted if a biochemical and virologic response was not achieved after the first 6 months or a permanent breakthrough occurred.

Pretreatment serum levels of HCV-RNA were quantitatively measured by a branched-DNA signal amplification assay (bDNA, Quantiplex, HCV-RNA 2.0 assay; Chiron, Emeryville, CA; sensitivity threshold of this assay is 0.2 mEq/mL15). HCV was typed by an hybridization assay (Inno-Lipa II, Innogenetics, Zwijndrecht, Belgium). Serum HCV-RNA was assessed by nested RT-PCR, using specific primers from the 5′ noncoding region with a limit sensitivity of 50 copies/mL.16 

Continuous variables were expressed as mean or median values and ranges. Categorical variables were expressed as frequency and percent values and compared by the Fisher exact test. The Wilcoxon rank sum test was used to analyze the distribution of quantitative variables of the relevant clinicopathologic parameters. The median values were compared by the median test for 2 samples. All comparisons were 2-tailed. Response to treatment was evaluated in accordance with the intention-to-treat analysis. Univariate analysis was performed with each variable to assess any association with response to treatment.

Results and discussion

All but one patient who refused to continue therapy at month 2 completed the study. Twenty-seven patients (69%) became HCV-RNA negative during the first 6 months of therapy and were continued on combination therapy until month 12. One responder, however, discontinued treatment at month 6 because of the occurrence of side effects. Five (19%) patients experienced a hepatitis breakthrough 6 to 11 months after starting therapy. At the end of treatment, 18 (46%) patients had normal ALT values and no HCV-RNA. Hepatitis relapse occurred in 4 end-of-treatment responders during the posttreatment follow-up period. Overall, 14 patients (36%) had a sustained response.

In nonhemophilic patients with chronic hepatitis C, retreatment of transient responders to IFN monotherapy with IFN plus ribavirin was associated with a high rate (49%) of sustained virologic response.17 Relatively high rates (30%) of sustained virologic responses to retreatment with combination therapy of nonhemophilic patients who failed to respond to IFN monotherapy, including those infected by genotype 1, have been recently reported.13,18 In this study, we were surprised to see that retreatment with combination therapy led to a sustained virologic response not only in the 7 (47%) hemophilic patients who transiently responded to IFN monotherapy, but also in the 7 (29%) hemophilic patients who were primary nonresponders to IFN monotherapy. One possible explanation for these favorable results might be the use of relatively high doses of IFN, that is, 5 MU in the initial 6 months of therapy, which is known to overcome resistance of HCV infection to the first course of treatment with standard doses of 3 MU IFN.19 In both our study and that performed in the United States in nonhemophilic nonresponders,13 HCV genotype 1 was a strong predictor of nonresponse to retreatment with combination therapy. These findings parallel previous data showing that genotype 1 is an independent predictor of resistance to combination therapy in both naive and relapsed patients. The serum ALT level became normal at month 1 (86%) in 12 sustained responders compared to 1 (25%) patient with a posttreatment relapse. At variance with previous studies20,21 we found that high pretreatment serum ALT levels predicted a therapeutic response (Table2).

Table 2.

Pretreatment characteristics of the patients who had a sustained response and those without sustained response to combination therapy

Patient characteristicsSustained
responses
(n = 14)
Not sustained
responses
(n = 25)
P
Mean age, y (range) 39  (27-65) 40  (22-63) NS  
Mean ALT, IU/mL (range) 168  (56-441) 116  (46-234) .028  
Median HCV-RNA, MEq/mL (range) 2.5  (< 0.2-43.0) 4.9  (< 0.2-33.0) NS  
HCV   .047 
 HCV 1* (%) 8  (57) 22  (88)  
 HCV 2 or 3 (%) 6  (43) 3  (12)  
Outcome of previous IFN monotherapy (%)    
 Nonresponse 7  (50) 17  (68) NS  
 Transient response 7  (50) 8  (32) NS 
Patient characteristicsSustained
responses
(n = 14)
Not sustained
responses
(n = 25)
P
Mean age, y (range) 39  (27-65) 40  (22-63) NS  
Mean ALT, IU/mL (range) 168  (56-441) 116  (46-234) .028  
Median HCV-RNA, MEq/mL (range) 2.5  (< 0.2-43.0) 4.9  (< 0.2-33.0) NS  
HCV   .047 
 HCV 1* (%) 8  (57) 22  (88)  
 HCV 2 or 3 (%) 6  (43) 3  (12)  
Outcome of previous IFN monotherapy (%)    
 Nonresponse 7  (50) 17  (68) NS  
 Transient response 7  (50) 8  (32) NS 

NS indicates not significant.

*

Includes 1 patient with genotype 4.

Treatment was generally well tolerated by most patients, but it had to be discontinued in 4 (10%) because of the occurrence of side effects such as fatigue, anorexia, and nausea. Reduction of IFN dosage was required in 4 patients (10%) because of onset of fatigue, thrombocytopenia, and hypothyroidism. Ribavirin reduction was required in 6 patients (16%) because of the occurrence of hemolytic anemia 1 to 3 months after treatment onset. In all patients, hemoglobin levels transiently decreased during treatment (median variation from baseline, 2.9 g/dL; range, 0.2-5.2 g/dL). The 10% dropout rate caused by unwanted effects compares favorably with the figures of treatment toxicity reported by the megatrials in nonhemophilic patients.7,8,17 

In conclusion, our finding that one third of nonresponders eventually achieved a sustained response with retreatment by combination therapy may have an important clinical impact, because chronic hepatitis C is a major cause of morbidity and mortality from liver disease in HIV-free hemophilic patients.1,22 The relevance of our findings lies also in the fact that hemophilic patients not responding to IFN monotherapy represent more than two thirds of all treated patients3,5,23 and that health-related quality of life, markedly impaired in patients with chronic hepatitis C, is expected to improve in those who respond to IFN treatment.24,25 

We thank Dr Antonio Russo, Department of Epidemiology, Local Health Authority of Milan, for his help in statistical analysis.

The following colleagues participated in this study by the Hepatitis Study Group of the Association of Italian Hemophilia Centers: M. Morfini, Department of Hematology and Hemophilia Center, Careggi Hospital, Florence; G. Tagariello, Hemophilia Center, Castelfranco Veneto Hospital, Treviso; M. G. Mazzucconi, Department of Hematology, La Sapienza University, Rome; F. Baudo, Department of Hematology and Hemophilia Center, Niguarda Hospital, Milan; G. Muleo, Department of Hematology and Hemophilia Center, Pugliese Hospital,Catanzaro; A. Rocino, Department of Hematology and Hemophilia Center, S. Giovanni Bosco Hospital, Naples; G. Rossetti, Hemophilia Center, S. Chiara Hospital, Trento; and L. Tasso (deceased), Division of Infectious Diseases, G. Gaslini Hospital, Genoa.

The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked “advertisement” in accordance with 18 U.S.C. section 1734.

References

References
1
Darby
SC
Ewart
DW
Giangrande
PLF
et al
Mortality from liver cancer and liver disease in haemophilic men and boys given blood products contaminated with hepatitis C.
Lancet.
350
1997
1425
1431
2
Makris
M
Preston
FE
Rosendaal
FR
Underwood
JCE
Rice
KM
Triger
DR
The natural history of chronic hepatitis C in hemophiliacs.
Blood.
94
1996
746
752
3
Rumi
MG
Santagostino
E
Morfini
M
et al
A multicenter controlled, randomized, open trial of interferon α2b treatment of anti-human immunodeficiency virus-negative hemophilic patients with chronic hepatitis C.
Blood.
89
1997
3529
3533
4
Telfer
P
Devereux
H
Colvin
B
Hayden
S
Dusheiko
G
Lee
C
Alpha interferon for hepatitis C virus infection in haemophilic patients.
Haemophilia.
1
1995
54
58
5
Hanley
JP
Jarvis
LM
Andrews
J
et al
Interferon treatment for chronic hepatitis C infections in hemophiliacs. Influence of virus load genotype and liver pathology on response.
Blood.
87
1996
1704
1709
6
Pawlotsky
JM
Roudot-Thoraval
F
Bastie
A
et al
Factors affecting treatment responses to interferon α in chronic hepatitis C.
J Infect Dis.
174
1996
1
7
7
McHutchison
JG
Gordon
SC
Schiff
ER
et al
Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis C.
N Engl J Med.
339
1998
1485
1492
8
Poynard
T
Marcellin
P
Lee
SS
et al
Randomised trial of interferon alfa-2b plus ribavirin for 48 weeks or for 24 weeks versus interferon alfa-2b plus placebo for 48 weeks for treatment of chronic infection with hepatitis C virus.
Lancet.
352
1998
1426
1432
9
Lohmann
V
Korner
F
Herian
U
Bartenschlager
R
Biochemical properties of hepatitis C NS5B RNA-dependent RNA polymerase and identification of amino acid sequence motifs essential for enzymatic activity.
J Virol.
71
1997
8416
8428
10
Crotty
S
Maag
D
Arnold
JJ
et al
The broad-spectrum antiviral ribonucleoside ribavirin is an RNA virus mutagen.
Nat Med.
6
2000
1375
1379
11
Crotty
S
Cameron
CE
Andino
R
RNA virus error catastrophe: direct molecular test by using ribavirin.
Proc Natl Acad Sci U S A.
98
2001
6895
6900
12
Hultgren
C
Milich
DR
Weiland
O
Sallberg
M
The antiviral compound ribavirin modulates the T helper (Th) 1/Th2 subset balance in hepatitis B and C virus-specific immune responses.
J Gen Virol.
79
1998
2381
2391
13
Cramp
ME
Rossol
S
Chokshi
S
Carucci
P
Williams
R
Naoumov
NV
Hepatitis C virus-specific T-cell reactivity during interferon and ribavirin treatment in chronic hepatitis C.
Gastroenterology.
118
2000
346
355
14
Di Bisceglie
AM
Thompson
J
Smith-Wilkaitis
Brunt
EM
Bacon
BR
Combination of interferon and ribavirin in chronic hepatitis C: re-treatment of nonresponders to interferon.
Hepatology.
33
2001
704
707
15
Detmer
J
Lagier
R
Flynn
J
et al
Accurate quantification of HCV-RNA from all HCV genotypes using branched-DNA (bDNA) technology.
J Clin Microbiol.
34
1996
901
907
16
Rumi
MG
Del Ninno
E
Parravicini
ML
et al
Long-term titrated recombinant interferon-α 2a in chronic hepatitis C: a randomized controlled trial.
J Viral Hepat.
2
1995
73
76
17
Davis
GL
Esteban-Mur
R
Rustgi
V
et al
Interferon alfa-2b alone or in combination with ribavirin for the treatment of relapse of chronic hepatitis C.
N Engl J Med.
339
1998
1493
1499
18
Cheng
SJ
Bonis
PAL
Lau
J
Pham
NQ
Wong
JB
Interferon and ribavirin for patients with chronic hepatitis C who did not respond to previous interferon therapy: a meta-analysis of controlled and uncontrolled trials.
Hepatology.
33
2001
231
240
19
Saracco
G
Ciancio
A
Olivero
A
et al
A randomized 4-arm multicenter study of interferon α-2b plus ribavirin in the treatment of patients with chronic hepatitis C not responding to interferon alone.
Hepatology.
34
2001
133
138
20
Davis
GL
Lau
JYN
Factors predictive of a beneficial response to therapy of hepatitis C.
Hepatology.
26(suppl 1)
1997
122
127
21
Rumi
MG
Del Ninno
E
Parravicini
ML
et al
A prospective randomized trial comparing lymphoblastoid to recombinant interferon alfa 2a as therapy for chronic hepatitis C.
Hepatology.
24
1996
1366
1370
22
Troisi
CL
Hollinger
FB
Hoots
WK
et al
A multicenter study of viral hepatitis in a United States hemophilic population.
Blood.
81
1993
412
418
23
Pinilla
J
Quintana
M
Magallon
M
High-dose and long-term treatment of α interferon in hemophilic patients with chronic C virus hepatitis.
Blood.
91
1998
727
728
24
Foster
GR
Goldin
RD
Thomas
HC
Chronic hepatitis C virus infection causes a significant reduction in quality of life in the absence of cirrhosis.
Hepatology.
27
1998
209
212
25
Bonkovsky
HL
Woolley
JM
Reduction of health-related quality of life in chronic hepatitis C and improvement with interferon therapy.
Hepatology.
29
1999
264
270

Author notes

Massimo Colombo, Division of Hepatology, IRCCS Maggiore Hospital, Via Pace 9, 20122 Milan, Italy; e-mailmassimo.colombo@unimi.it.