Toward Improved Outcomes in HCV Mono- and Coinfection
Toward Improved Outcomes in HCV Mono- and Coinfection
The addition of telaprevir and boceprevir to treatment regimens for HCV genotype 1 has greatly changed the outcome of chronic HCV treatment. However, these drugs have significant side effects and drug interactions, little is known so far about their effectiveness in real life, and their use in HCV/HIV-coinfected patients is off-label.
Ahmed and colleagues presented the experience at Chelsea and Westminster Hospital with using boceprevir and telaprevir in 5 coinfected patients with previous treatment failure and who had bridging fibrosis or cirrhosis on liver biopsy. All patients achieved early virologic response, and 4 patients achieved SVR at 24 weeks. The remaining patient had an undetectable viral load at the end of treatment but died during follow-up.
Adverse events, including anemia, were common, and 80% of patients received erythropoietin. No patient had a detectable HIV load during treatment. Evaluation of 7 coinfected patients who started a telaprevir-based regimen is ongoing.
The use of telaprevir at the Icahn School of Medicine at Mount Sinai and John Hopkins University in 33 coinfected and 117 monoinfected patients also showed good results and no statistically significant difference between groups in the SVR12 rate (61% vs 43%; P = .07), even though the coinfected group consisted of a more difficult-to-treat population (more African Americans and more prior nonresponders or patients who were intolerant of therapy). Discontinuation because of adverse events and severe anemia was common, but the proportions did not differ between the groups.
A recurrent theme during ICVH was the issue of drug/drug interactions with the use of the new direct-acting antivirals, especially in coinfected patients. Boceprevir and telaprevir are both CYP3A inhibitors, although telaprevir is a little more permissive than boceprevir when it comes to drug/drug interactions. For example, efavirenz can be used at an increased dose (1125 mg 3 times daily) with telaprevir, but cannot be used with boceprevir. Atazanavir boosted with ritonavir is also an acceptable option in patients taking telaprevir, but the US Food and Drug Administration does not recommend its use with boceprevir because of the potential for HIV escape. Because data on drug/drug interactions in clinical settings are not always available, clinicians should be cautious when they select a treatment regimen for coinfected patients.
Treating Chronic HCV Infection: Real-Life Experiences
The addition of telaprevir and boceprevir to treatment regimens for HCV genotype 1 has greatly changed the outcome of chronic HCV treatment. However, these drugs have significant side effects and drug interactions, little is known so far about their effectiveness in real life, and their use in HCV/HIV-coinfected patients is off-label.
Ahmed and colleagues presented the experience at Chelsea and Westminster Hospital with using boceprevir and telaprevir in 5 coinfected patients with previous treatment failure and who had bridging fibrosis or cirrhosis on liver biopsy. All patients achieved early virologic response, and 4 patients achieved SVR at 24 weeks. The remaining patient had an undetectable viral load at the end of treatment but died during follow-up.
Adverse events, including anemia, were common, and 80% of patients received erythropoietin. No patient had a detectable HIV load during treatment. Evaluation of 7 coinfected patients who started a telaprevir-based regimen is ongoing.
The use of telaprevir at the Icahn School of Medicine at Mount Sinai and John Hopkins University in 33 coinfected and 117 monoinfected patients also showed good results and no statistically significant difference between groups in the SVR12 rate (61% vs 43%; P = .07), even though the coinfected group consisted of a more difficult-to-treat population (more African Americans and more prior nonresponders or patients who were intolerant of therapy). Discontinuation because of adverse events and severe anemia was common, but the proportions did not differ between the groups.
Drug/Drug Interactions
A recurrent theme during ICVH was the issue of drug/drug interactions with the use of the new direct-acting antivirals, especially in coinfected patients. Boceprevir and telaprevir are both CYP3A inhibitors, although telaprevir is a little more permissive than boceprevir when it comes to drug/drug interactions. For example, efavirenz can be used at an increased dose (1125 mg 3 times daily) with telaprevir, but cannot be used with boceprevir. Atazanavir boosted with ritonavir is also an acceptable option in patients taking telaprevir, but the US Food and Drug Administration does not recommend its use with boceprevir because of the potential for HIV escape. Because data on drug/drug interactions in clinical settings are not always available, clinicians should be cautious when they select a treatment regimen for coinfected patients.
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