Expert Point of View - Outcomes and Treatments of Dual Chronic Hepatitis B and C - Chun-Jen Liu, MD, PhD

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4 WORLD GASTROENTEROLOGY NEWS JANUARY 2015 Editorial | Expert Point of View | Gastro 2015: AGW/WGO | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events Outcomes and Treatments of Dual Chronic Hepatitis B and C Chun-Jen Liu, MD, PhD Professor, Graduate Institute of Clinical Medicine, Hepatitis Research Center and Department of Internal Medicine National Taiwan University College of Medicine and Hospital Taipei, Taiwan ABSTRACT Dual infection with hepatitis C virus (HCV) and hepatitis B virus (HBV) infection is not rare in either virus endemic areas. In patients dually infected with both viruses, the disease outcomes are usually more severe than those with HBV or HCV monoin-fection. For dually infected patients with active hepatitis C, combined pegylated interferon alfa plus riba-virin therapy was effective. During post-treatment follow-up, the HCV response was sustained in 97% of patients. Moreover, the long-term outcomes including the development of HCC and liver-related mortality were improved. However, the optimal treatment strategies for dually infected patients with active hepatitis B or established cirrhosis remain unknown. Finally, the role of new direct-acting antiviral (DAA)-based therapy for the treatment of patients with dual HCV/ HBV infection also remains to be explored in future clinical trials. Introduction Usually, patients have chronic hepati-tis C virus (HCV) or hepatitis B virus (HBV) monoinfection. However, in areas or countries where hepatitis B virus (HBV) infection is endemic or among subjects at risk of parenteral viral transmission, it is not uncom-mon to encounter patients infected with both hepatitis B and C viruses1-3. Previous studies already clarified the following issues regarding dual HCV/HBV infection. First of all, in patients co-infected with hepatitis C and B, the disease manifestations are usually more severe than those with mono infection4-7. Furthermore, it is important to select the priority virus to be treated in patients with dual chronic hepatitis C/B by chronologi-cally monitoring the viral activity of either one. In dually infected patients with active hepatitis C, pegylated in-terferon (Peg-IFN) alfa plus ribavirin (RBV) was effective to achieve HCV RNA sustained virologic response (SVR)8; and the durability of HCV SVR was maintained in 97% dur-ing post-treatment 5-year follow-up study 9. Moreover, using Peg-IFN-based therapy, HBsAg seroclearance was documented in 5.4% of dually infected patients per year. Finally, apart from the short-term control of viral infection, a population-based study has demonstrated that the use of Peg-IFN plus RBV combination therapy significantly reduced the risk of hepatocellular carcinoma (HCC) development, liver-related mortality, and all-cause mortality 10. Clinical outcomes of dual chronic hepatitis C and B are usually worse Several hospital or community-based studies demonstrated that in patients co-infected with chronic hepatitis C and B, the disease outcomes are usually worse than those with either chronic HCV or HBV infection 1-7. Patients with HCV/HBV co-infection may exhibit various fluctuating viro-logical profiles; basically HCV and HBV can alternate their dominance during long-term follow-up. In Italy, a longitudinal follow-up study revealed the patterns and dynamics of virologi-cal dominance in these cases 11. Of 103 untreated HBV/HCV coinfected patients, active infection with HBV and HCV was revealed in 24 (23%) cases, inactive infection of both viruses was seen in 15 (15%) cases, ac-tive HBV and inactive HCV infection was seen in 15 (15%) cases, and active HCV and inactive HBV infection was found in 49 (48%) cases. During one year follow-up, fluctuation of HBV and/or HCV viremia levels was docu-mented in 32 subjects (31%). Based on these findings, careful evaluation of serum HBV DNA and HCV RNA levels is essential before the diagnosis of the viral dominance which will influence the therapeutic strategies in the co-infected patients. Determine the dominant virus(es) to be treated Active hepatitis C is found in at least 50% of dually infected patients 11. Moreover, HCV can be successfully eradicated in at least 50% of patients with chronic HCV mono-infection using combination therapy of Peg-


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