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News Review

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HEPATITIS JOURNAL REVIEW:
A Bi-Monthly Publication of the Hepatitis Support Project

September 12 , 2006
Volume 3, Issue 15


Liz Highleyman

To download pdf version click here


In This Issue:

Hepatitis C

• Medical Marijuana Improves HCV Treatment Response

• Longer Treatment for Patients Lacking Rapid Response

• Poorer Treatment Response in African-Americans Confirmed

• Hepatitis B and C Account for Most Cases of Cirrhosis and HCC

• Cancer Incidence in People with HBV or HCV

• Distribution of HCV Genotypes and Viral Load


Medical Marijuana Improves HCV Treatment Response
Medical cannabis can help patients with hepatitis C virus (HCV) stay on therapy and achieve better treatment response, according to a study in the October 2006 European Journal of Gastroenterology and Hepatology. D. Sylvestre and colleagues studied 71 hepatitis C patients at OASIS, a clinic for substance users in Oakland, CA, who had been on methadone maintenance for at least three months. About one-third (31%) used marijuana while on anti-HCV treatment with conventional interferon plus ribavirin. In an intent-to-treat analysis, 64% of cannabis users achieved an end-of-treatment response, compared with 47% of non-users; the corresponding figures for sustained virological response (SVR) were 54% and 18%. The frequency of side effects was similar among cannabis users and non-users, but more non-users discontinued therapy early (33% vs 5%). Marijuana users were more likely than non-users to be adherent (86% vs 59%) and to remain on therapy for at least 80% of the projected treatment duration (95% vs 67%). There was no direct dose-response relationship between the amount of cannabis consumed and the likelihood of SVR, and patients who used the largest amounts of cannabis did not show as much benefit from hepatitis C therapy.

The researchers concluded that “modest cannabis use may offer symptomatic and virological benefit to some patients undergoing HCV treatment by helping them maintain adherence to the challenging medication regimen.” However, there are concerns about the safety of marijuana use by individuals with chronic hepatitis C. Cannabis may suppress immune function, and a recent study showed that untreated HCV positive individuals who smoked cannabis daily were more likely to experience rapid fibrosis progression. In an accompanying editorial, B. Fischer and colleagues suggested that medical cannabis may be especially beneficial for patients on methadone maintenance, since methadone can cause some of the same side effects as interferon (e.g., fatigue, bone aches, depression). They added that, while further research is underway, they “advocate that in the interim existing barriers to cannabis use are removed for drug users undergoing HCV treatment.”

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Longer Treatment for Patients Lacking Rapid Response
A longer course of hepatitis C therapy may produce superior outcomes in patients who do not achieve rapid virological response by Week 4, according to a study in the August 2006 issue of Gastroenterology. J. Sanchez-Tapias and colleagues gave 510 treatment-naive patients 180 mcg/week pegylated interferon-alfa2a (Pegasys) plus 800 mg/day ribavirin. After 4 weeks, 326 patients who still had detectable HCV viral load were randomly assigned to continue treatment for a total of 48 or 72 weeks. Among these patients, end-of-treatment response rates were similar whether they were treated for 48 or 72 weeks, but the SVR rate was significantly higher among those receiving longer treatment (45% vs 32%). Among genotype 1 patients who still had detectable HCV RNA at Week 4, 44% of those treated for 72 weeks achieved SVR, compared with 28% of those treated for 48 weeks. Unsurprisingly, treatment discontinuation was more common among those who received prolonged treatment. The researchers concluded that “[e]xtension of treatment with peginterferon-alfa2a plus ribavirin from 48 to 72 weeks significantly increases the rate of SVR in patients with detectable viremia at Week 4 of treatment.”

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Poorer Treatment Response in African-Americans Confirmed
A recent study reported in the August 2006 issue of Gastroenterology provided further evidence that African-Americans are less likely to respond to interferon-based therapy for hepatitis C. H. Conjeevaram and colleagues studied 196 African-Americans and 205 Caucasians with genotype 1 HCV. Baseline characteristics were generally similar in the two groups, though the African-Americans had a higher average body weight, lower mean ALT level, and were more likely to have diabetes and hypertension. Patients were treated with 180 mcg/week Pegasys plus 1000-1200 mg/day ribavirin for up to 48 weeks. Racial differences in virological response were apparent as early as Week 4. African-Americans were significantly less likely to achieve SVR (28%) compared with Caucasians (52%). Breakthrough viremia during treatment was more common among African-Americans than Caucasians (13% vs 6%), though both groups had statistically similar post-treatment relapse rates (32% vs 25%, respectively). Similar proportions of patients in both groups experienced serious adverse events, dose modification, and treatment discontinuation. “African-Americans with chronic hepatitis C genotype 1 have lower rates of virologic response to peginterferon and ribavirin than Caucasians,” the researchers concluded, noting that “[t]hese differences are not explained by disease characteristics, baseline viral levels, or amount of medication taken.”

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Hepatitis B and C Account for Most Cases of Cirrhosis and HCC
Chronic hepatitis B virus (HBV) and/or HCV infection are responsible for a majority of cases of liver cirrhosis and hepatocellular carcinoma (HCC) worldwide, according to an analysis published in the October 2006 Journal of Hepatology. J. Perz and colleagues with the CDC obtained data from representative published reports on the prevalence of HBV and HCV among patients diagnosed with cirrhosis or HCC. They found that globally, 57% of cirrhosis cases were attributable to either HBV (30%) or HCV (27%), as were 78% of HCC cases (HBV 53%; HCV 25%). In most regions, HBV and/or HCV were implicated in half of all cases of cirrhosis and HCC. Using 2002 mortality estimates, they estimated that the two viruses together accounted for 446,000 cirrhosis deaths and 483,000 liver cancer deaths. “HBV and HCV infections account for the majority of cirrhosis and primary liver cancer throughout most of the world,” the researchers concluded, “highlighting the need for programs to prevent new infections and provide medical management and treatment for those already infected.”

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Cancer Incidence in People with HBV or HCV
Certain cancers other than HCC are also more common among people with HBV and/or HCV, according to a study in the August Journal of Hepatology. J. Amin and colleagues assessed data from a large community-based cohort that included 39,109 participants with HBV; 75,834 with HCV; and 2604 with both viruses; this information was cross-linked with the Australian cancer registry. Patients with HBV had an increased risk of Burkitt’s lymphoma, while those with HCV had a higher rate of  immunoproliferative malignancies (e.g., lymphomas and leukemias). As expected, the risk of HCC among people with one or both viruses was 20-30 times greater than that of the uninfected population. The researchers confirmed that the risk of HCC is greatly increased in people with HBV or HCV, and added that “[t]he modest though significant risk of immunoproliferative malignancies associated with HCV infection is consistent with recent findings.”

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Distribution of HCV Genotypes and Viral Load
A study reported in the August 2006 issue of Gastroenterology provided further data about the distribution of HCV genotypes and viral load levels in the United States. O. Nainan and colleagues from the CDC studied 275 HCV positive participants in the Third National Health and Nutrition Examination Survey (NHANES), conducted between 1988 and 1994. Genotype frequency, in descending order, was: 1a (142 patients), 1b (73 patients), 2b (27 patients), 3a (17 patients), 2a (8 patients), 6 (5 patients), and 4 (3 patients). Genotype 1 was most common in all age groups (about 75%), and was particularly dominant among non-Hispanic blacks (91%, compared with 70% among whites and 71% among Mexican-Americans). The mean HCV viral load was 2.1 million IU/mL; 53% of patients overall and 50% of those with genotype 1 had HCV RNA levels above 2 million IU/mL. The researchers concluded that “[p]ersons with chronic hepatitis C in the United States who may require treatment in the foreseeable future are predominantly infected with genotype 1, including a disproportionate number of non-Hispanic blacks.” Since genotype 1 HCV responds less well to treatment, they added, “[t]hese features emphasize the need for improved therapies that reduce or eliminate complications from genotype 1 infections.”


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