Sunday, August 20, 2017

(grazoprevir-ruzasvir-uprifosbuvir) Shorter anti-HCV regimen effective in patients with or without cirrhosis

In Case You Missed It

Full Text
Shortening the duration of therapy for chronic HCV
Lancet Published online August 9, 2017
PDF provided by @HenryEChang via Twitter

Shorter anti-HCV regimen effective in patients with or without cirrhosis
Last Updated: 2017-08-18
By Will Boggs MD
NEW YORK (Reuters Health) - An eight-week regimen containing grazoprevir-ruzasvir-uprifosbuvir appears to be effective for treating hepatitis C virus (HCV) infection in patients with or without cirrhosis, according to findings from a pair of randomized phase 2 open-label trials.

Dr. Edward J. Gane from Auckland Clinical Studies, in Auckland, New Zealand, and colleagues - in part A of the C-CREST-1 and C-CREST-2 trials - randomly assigned 240 patients with HCV genotype 1, 2 or 3 and without cirrhosis to receive an eight-week course of a daily three-drug combination:

- grazoprevir 100 mg, plus

- either elbasvir 50 mg or ruzasvir 60 mg, plus

- either 300 mg or 450 mg of uprifosbuvir.

The studies were funded by Merck and Co.

Sustained virologic response rates 12 weeks after the end of therapy (SVR12) were 92% with both doses of the grazoprevir-ruzasvir-uprifosbuvir regimen and ranged from 85% to 88% (depending on uprifosbuvir dose) with grazoprevir-elbasvir-uprifosbuvir, according to one of the reports, both online August 9 in The Lancet Gastroenterology and Hepatology.

All four regimens were well-tolerated.

"These results support the selection of grazoprevir plus ruzasvir plus uprifosbuvir 450 mg as the regimen for further clinical investigation in broader populations," the researchers conclude.

Dr. Eric Lawitz from Texas Liver Institute at the University of Texas Health San Antonio and colleagues extended these findings in part B of C-CREST-1 and C-CREST-2. In this trial, 675 patients with HCV-1, -2, -3, -4 or -6, with or without cirrhosis, received eight, 12, or 16 weeks of grazoprevir-ruzasvir-uprifosbuvir 450 mg, with or without ribavirin.

SVR12 rates with eight weeks of therapy were 93% in individuals with genotype 1a, 98% with genotype 1b, 86% with genotype 2 (without cirrhosis; patients with HCV-2 and cirrhosis received a longer course), 95% with genotype 3 (treatment naive, without cirrhosis) and 100% with genotypes 4 and 6.

"We were surprised by the relatively lower efficacy of an 8-week duration of this regimen among those with genotype 2 infection," Dr. Lawitz told Reuters Health by email. "However, extending therapy to 12 weeks overcame this effect."

SVR12 rates were generally higher among participants with or without cirrhosis who received 12 or 16 weeks of therapy.

There were no documented virologic failures after week 12 of follow-up, although 10 participants who achieved SVR12 were lost to follow-up.

As in part A of the study, treatment with this fixed-dose combination with or without ribavirin was generally well tolerated.

"Results from the current studies support further investigation of grazoprevir, ruzasvir, and uprifosbuvir as a pan-genotypic regimen in individuals infected with HCV with and without cirrhosis, and suggest that this combination has the potential to provide a safe, single-duration regimen in most populations, including individuals with cirrhosis infected with genotype 3 who had previously received treatment with pegylated interferon and ribavirin," the researchers conclude.

"We await data from phase 3 to know how this regimen might impact the current treatment landscape," Dr. Lawitz said. "We hope that this regimen will be able to give providers more options with regard to pan-genotypic regimens for the treatment of HCV."

Dr. Eleanor M. Wilson from the University of Maryland School of Medicine, Baltimore, who coauthored an accompanying comment in the journal, told Reuters Health by email, "The safety and efficacy data seem promising, but it's still investigational, so not sure about its impact on the field of hepatitis C treatment yet."

"With the recent approvals of Vosevi and Mavyret, in addition to the previously available options, I think the overall take-away is that it's fantastic that there are more hepatitis C treatment options for patients and providers," she said. "It's tremendous that previously so-called 'difficult-to-treat patients' including those with previous treatment experience, comorbid conditions like HIV or renal disease, and those with advanced fibrosis and cirrhosis now have a variety of safe and highly effective options to treat their hepatitis C."

"My area of expertise is in novel treatment approaches, including strategies to reduce the treatment duration in order to increase access and decrease treatment cost, as well as options for patients who haven't successfully cleared HCV with first-line therapy (due to problems of adherence or viral resistance), and from that standpoint, it's an exciting time to be a hepatitis C provider," Dr. Wilson said.

Dr. Mark Sulkowski, who directs the viral hepatitis center at Johns Hopkins University in Baltimore, told Reuters Health by email, "We currently have multiple outstanding HCV regimens for the treatment of all genotypes of hepatitis C, which typically include combinations of direct-acting antiviral inhibitors of HCV protein targets NS3 (protease), NS5A and NS5B (polymerase). While we have seen the regulatory approval of multiple inhibitors of the NS3 and NS5A proteins, to date, only one (nucleotide) inhibitor of the NS5B polymerase active site has been approved, sofosbuvir."

"The C-CREST-1 and -2 studies provide a phase 2 evaluation of another (nucleotide) analogue inhibitor of NS5B, uprifosbuvir," said Dr. Sulkowski, who was not involved in the research. "Based on the results of these studies, uprifosbuvir appears to be poised to move to phase 3 studies, and if successful in phase 3 trials, this agent could become a valuable addition to the available drugs to treat hepatitis C."

Dr. Gane did not respond to a request for comment.
Merck funded the trials and employed most of the authors.

SOURCE: Lancet Gastroenterol Hepatol 2017.

Direct-acting antiviral agents against hepatitis C virus and lipid metabolism

World J Gastroenterol. Aug 21, 2017; 23(31): 5645-5649
Published online Aug 21, 2017. doi: 10.3748/wjg.v23.i31.5645

Direct-acting antiviral agents against hepatitis C virus and lipid metabolism
Tatsuo Kanda, Mitsuhiko Moriyama

Core tip: Eradication of hepatitis C virus (HCV) decreases the rate of complications, including liver-related and liver-unrelated death, and improves patient quality of life. Individuals infected with HCV have an increased risk of cardiovascular diseases and intracerebral hemorrhage, which are both associated with lipid metabolism. HCV infection causes abnormal host lipid metabolism. Treatment with interferon-based and interferon-free regimens has an impact on the eradication of HCV, as well as lipid abnormalities, during treatment and after treatment. Further observations are needed to determine the long-term effects on lipid metabolism caused by HCV and by eradication of the virus.

Hepatitis C virus (HCV) infection induces steatosis and is accompanied by multiple metabolic alterations including hyperuricemia, reversible hypocholesterolemia and insulin resistance. Total cholesterol, low-density lipoprotein-cholesterol and triglyceride levels are increased by peginterferon and ribavirin combination therapy when a sustained virologic response (SVR) is achieved in patients with HCV. Steatosis is significantly more common in patients with HCV genotype 3 but interferon-free regimens are not always effective for treating HCV genotype 3 infections. HCV infection increases fatty acid synthase levels, resulting in the accumulation of fatty acids in hepatocytes. Of note, low-density lipoprotein receptor, scavenger receptor class B type I and Niemann-Pick C1-like 1 proteins are candidate receptors that may be involved in HCV. They are also required for the uptake of cholesterol from the external environment of hepatocytes. Among HCV-infected patients with or without human immunodeficiency virus infection, changes in serum lipid profiles are observed during interferon-free treatment and after the achievement of an SVR. It is evident that HCV affects cholesterol metabolism during interferon-free regimens. Although higher SVR rates were achieved with interferon-free treatment of HCV, special attention must also be paid to unexpected adverse events based on host metabolic changes including hyperlipidemia.

Hepatitis C virus (HCV) encodes at least 10 viral proteins, which include structural (core, E1, E2 and p7) and non-structural (NS2, NS3, NS4A, NS4B, NS5A and NS5B) proteins[1]. HCV is a leading cause of cirrhosis and hepatocellular carcinoma in the United States and Japan. Eradication of HCV is important for preventing death due to these liver diseases.

Associations of HCV with host lipoproteins have been reported[2]. Hepatocytes take up low-density lipoproteins (LDLs) and very low-density lipoproteins through LDL receptors. Antibodies to the HCV envelope may disrupt the HCV lipid-containing envelope[3]. These antibodies could provide an efficient mode of viral entry into liver cells[2]. HCV core protein colocalizes with apolipoprotein AII at the surface of lipid droplets, suggesting a relationship between the expression of HCV core protein and cellular lipid metabolism[4]. HCV infection or core protein expression also increases the expression of sterol regulatory element binding protein 1c and its target, fatty acid synthase (FASN), which are both involved in lipid synthesis[5].

Although interferon-free regimens could result in higher sustained virologic response (SVR) rates, Endo et al[6] reported that serum cholesterol levels were significantly increased during combination treatment with the HCV NS5B inhibitor sofosbuvir and the HCV NS5A inhibitor ledipasvir, compared with those during interferon-included regimens[7]. Of interest, the authors also observed that regardless of the regimens, total cholesterol, LDL cholesterol and high-density lipoprotein (HDL) cholesterol levels increased post-treatment[6].

HCV increases FASN levels[5], resulting in the accumulation of fatty acids in hepatocytes (Figure 1). Fatty acids are needed for cell growth, cell adhesion, extracellular matrix formation, cell migration and cell invasion, which are essential for cancer development. Synthesis of cholesterol requires 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. Among HMG-CoA reductase inhibitors, fluvastatin is an anti-HCV reagent that is used in combination with interferons[8]. Steatosis and abnormal lipid metabolism caused by HCV infection may enhance lipid droplet formation in hepatocytes[9-11]. Lipid droplets, which store neutral lipids, are required for the formation of infectious HCV particles[11].

Figure 1 Hepatitis C virus and fatty acid synthesis. DAAs: Direct-acting antiviral agents; HCV: Hepatitis C virus; HMG-CoA, 3-hydroxy-3-methylglutaryl coenzyme A.

In most cells, the major source of new sterol is endogenous synthesis from acetyl-CoA[12]. HMG-CoA is formed from acetyl-CoA and acetoacetyl-CoA[12]. There are at least 4 mechanisms for acquiring cholesterol: (1) de novo synthesis within the cells and uptake of unesterified or esterified cholesterol from the external environment via; (2) the LDL receptor (LDLR); (3) scavenger receptor class B type I (SR-BI); or (4) Niemann-Pick C1-like 1 protein (NPC1L1)[13]. HDL particles containing apoA-I can be bound by SR-BI in hepatocytes and endocrine cells[13]. Interestingly, LDLR, SR-BI and NPC1L1 are candidate receptors that may be involved in HCV[14-16].

The total cholesterol pool in a human is 2.2 g/kg body weight. There is a continuous flow of cholesterol from the endoplasmic reticulum to the cell membrane and then from the plasma membrane to the liver and intestine[13]. In humans, the flux of cholesterol through the whole body is approximately 10 mg/d per kilogram body weight[17], although the half-life of plasma cholesterol is only a few days[13]. The serum lipids, total cholesterol, cholesteryl ester, LDL cholesterol and HDL cholesterol levels were significantly lower in HCV-related cirrhosis patients than in controls. HCV-related cirrhosis severely impairs liver lipid metabolism[18] (Figure 2). The serum total cholesterol level is an independent predictor of significant fibrosis[19]. When evaluating serum total cholesterol levels, liver function should also be checked (Figure 2).

Figure 2 Effects of hepatitis C virus infection on liver function and liver lipid metabolism. DAAs: Direct-acting antiviral agents; HCV: Hepatitis C virus.

Total cholesterol, LDL cholesterol and triglyceride levels are increased by peginterferon and ribavirin combination therapy when an SVR is achieved in patients with HCV genotype 1[20]. HCV eradication is closely related to lipid metabolism in patients treated with interferon-based regimens. Lange et al[21] examined the serum lipid profiles of 575 European HCV genotype 1-infected patients before, during and after treatment with peginterferon-α-2a (180 μg/wk) and ribavirin (1000-1200 mg/d) for 48 wk. The authors found substantial pretreatment hypocholesterolemia with a nonresponse to interferon-α-based therapy, and lower pretreatment cholesterol levels were an independent predictor of not attaining an SVR[21]. After treatment-induced HCV eradication, the median cholesterol levels increased above baseline. Kuo et al[22] reported that chronic HCV infection is associated with hypocholesterolemia and hypotriglyceridemia, and these conditions can be reversed by successful antiviral therapy.

Serfaty et al[23] reported that hypobetalipoproteinemia is prevalent and associated with steatosis, especially in patients infected with HCV genotype 3. It has been reported that HCV, particularly genotype 3, is associated with steatosis. Poynard et al[24] reported that an SVR, achieved with interferon-based regimens, is associated with a reduction in steatosis in HCV genotype 3 patients, as well as a correction of serum cholesterol levels at baseline. Steatosis is significantly more common in HCV genotype 3 patients than in those with other HCV genotypes, and in patients treated with peginterferon alpha-2a plus ribavirin, an SVR is associated with reduction of steatosis[25]. New treatments using HCV NS3/4A protease inhibitors have limited activity against HCV genotype 3[26]. HCV NS5B and HCV NS5A inhibitors have also performed poorly in HCV genotype 3 patients[26].

Endo et al[6] studied 276 patients with chronic HCV genotype 1b infection who were treated with interferon-free regimens. Of these 276 patients, 141 were treated with the HCV NS5A inhibitor daclatasvir plus the HCV NS3/4A inhibitor asunaprevir for 24 wk[27,28] and 135 were treated with sofosbuvir plus ledipasvir for 12 wk[6].

In the daclatasvir plus asunaprevir-SVR group, the total cholesterol levels were significantly increased throughout the observation period, and the total cholesterol levels were significantly increased at 4 wk after treatment and 12 wk after treatment, compared with those at the end of treatment (EOT)[6]. Serum LDL cholesterol levels increased after the EOT. HDL cholesterol was significantly increased throughout the treatment period, but there were no significant changes in serum triglyceride levels[6].

In the sofosbuvir plus ledipasvir-SVR group, the total cholesterol levels were markedly increased from the early stage of therapy and lasted until the EOT[6]. The total cholesterol levels were sharply decreased after the EOT (P < 0.001). Changes in the LDL cholesterol levels were quite similar to those found in the total cholesterol levels. After the EOT, the HDL cholesterol levels were decreased compared to those during therapy (P < 0.001), but there were no significant changes in triglyceride levels[6]. Hashimoto et al[29] also reported that the increase in cholesterol levels during treatment was much greater in the sofosbuvir plus ledipasvir-SVR group than in daclatasvir plus asunaprevir-SVR group. The authors also observed that a rapid increase in the serum LDL cholesterol concentration during the interferon-free treatment was associated with the type of regimen and decrease in the HCV core protein level. Morales et al[30] also reported that there was a significant increase in the LDL and total cholesterol levels after treatment, compared to the pre- and post-treatment laboratory data from 52 patients receiving sofosbuvir-based regimens, but there was no change in body mass index between pre-and post-treatment. Among HIV/HCV coinfected patients, an increase in LDL cholesterol was observed after an SVR was achieved with interferon-free treatment[31].

HCV infection induces steatosis and is accompanied by multiple metabolic alterations, such as hyperuricemia, reversible hypocholesterolemia, insulin resistance, arterial hypertension and visceral adipose tissue expansion[32-34]. Eradication of HCV with interferon-free regimens increases total cholesterol levels. Because of the worsening nutritional status as an adverse event of interferon-based regimens, it is difficult to examine the effects of HCV on serum lipid profiles[6]. It is evident that HCV affects cholesterol metabolism during interferon-free regimens because these regimens have no influence on the nutritional status of the host[6]. The increase in cholesterol levels during treatment was much greater in the sofosbuvir plus ledipasvir-SVR group than in the daclatasvir plus asunaprevir-SVR group[6,29]. Although higher SVR rates were achieved with interferon-free treatment of HCV, special attention must also be paid to unexpected adverse events based on host metabolic changes.

Full Text
Article online @  World J Gastroenterology  

Barriers to Treatment Access for Chronic Hepatitis C Virus Infection

July/August 2017
IAS–USA Topics in Antiviral Medicine
Current Issue
July/August 2017 (Volume 25, Issue 3)
This journal is intended to be a resource for physicians and other health care practitioners who are actively involved in the care of patients with HIV or other viral infections

Cases From the Field
Barriers to Treatment Access for Chronic Hepatitis C Virus Infection: A Case Series
Alexander J. Millman, MD; Boatemaa Ntiri-Reid, JD, MPH; Risha Irvin, MD, MPH; Maggie H. Kaufmann, MA, MPH; Andrew Aronsohn, MD; Jeffrey S. Duchin, MD; John D. Scott, MD, MSc; Claudia Vellozzi, MD, MPH

Restrictive policies on access to new, curative hepatitis C treatments represent a substantial barrier to treating patients infected with hepatitis C. This case series demonstrates challenges experienced by patients and practitioners in accessing these treatments and highlights several strategies for navigating the treatment preauthorization process.
Full Article - Download PDF

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Cases From the Field
Special Contribution

Saturday, August 19, 2017

Podcast - Listen to Mark Sulkowski MD discuss improving HCV patient care

Mark S. Sulkowski, MD - Emerging Issues and Challenges for Improving HCV Patient Care: Expert Perspectives on the Importance of Interdisciplinary Collaboration
Released Aug 16, 2017

Listen to Mark Sulkowski, MD, Ira M. Jacobson, MD, and Trang M. Vu, MD, discuss HCV screening, testing, linkage to care, noninvasive tests for fibrosis, drug and alcohol use, treatment regimens in patients with cirrhosis, adherence to therapy and cure.

Although this patient friendly podcast and slideshow is aimed at clinicians, taking part in the program is beneficial for anyone who may consider being tested for HCV or have been diagnosed and thinking about treatment.

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Mark S. Sulkowski, MD - Emerging Issues and Challenges for Improving HCV Patient Care: Expert Perspectives on the Importance of Interdisciplinary Collaboration

Biopsy Specimens from Allograft Liver Contain Histologic Features of Hepatitis C Virus Infection after Virus Eradication

AGA Reading Room

Below is the abstract of the article. The full journal article is available to read for free on MedPage Today - click here

Biopsy Specimens from Allograft Liver Contain Histologic Features of Hepatitis C Virus Infection after Virus Eradication

Background & Aims
Most patients, even those who have received a liver transplant, achieve a sustained virologic response (SVR) to therapy for hepatitis C virus (HCV) infection. Little is known about the histologic features of liver biopsy specimens collected after SVR, particularly in patients who have received a liver transplant. We aimed to better characterize the histologic features of allograft liver biopsy specimens from patients who achieved SVR to anti-HCV therapy after liver transplantation.

We performed a retrospective analysis of 170 allograft liver biopsy specimens from 36 patients who received a liver transplant for chronic HCV infection, had recurrent HCV infection after transplantation, and subsequently achieved SVR (collected from 1999 through 2015 at four medical centers). SVR was defined as an undetectable serum HCV RNA level 24 weeks after completion of HCV treatment. A total of 65 biopsy specimens were post-SVR (at least one post-SVR from each patient; some biopsy specimens were collected at later time points from a subset of patients). We performed polymerase chain reaction analysis for HCV RNA on a subset of the biopsy specimens (28 collected before SVR and 32 after SVR).

Of the 65 post-SVR biopsy specimens, 45 (69%) had histologic features of active HCV infection. Of the initial post-SVR biopsy specimens collected from each of the 36 patients, 32 (89%) showed these changes. For patients with more than one post-SVR biopsy specimen, six (46%) had no change in fibrosis between biopsies, and fibrosis worsened for three patients (23%) based on their most recent biopsy. The HCV RNA level was undetectable in 31 of the 32 biopsy specimens analyzed by polymerase chain reaction.

In a retrospective analysis of allograft liver biopsy specimens from patients who achieved SVR after a liver transplant for chronic HCV infection, histologic changes associated with active HCV were present in 69% and fibrosis continued to progress in 23%, despite the lack of detection of HCV RNA. Pathologists should be aware of patients' SVR status when analyzing liver biopsy specimens to avoid diagnoses of chronic HCV-associated hepatitis. Because of the persistent inflammatory activity and fibrosis after SVR, clinicians should continue to monitor patients carefully after SVR to anti-HCV therapy.

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Treating HCV in Incarcerated Populations Key to Disease Elimination

Treating HCV in Incarcerated Populations Key to Disease Elimination
by Pippa Wysong
Contributing Writer, MedPage Today
Hepatitis C virus (HCV) rates in America's prisons and jails are high, largely because this is where many people with high-risk behaviors such as injection drug use end up. But in order to help reach the World Health Organization goal of elimination of HCV, this population needs more screening and treatment -- not only to help people with the infection, but also to reduce the risk of transmission.
Continue reading MedPage Today article published in AGA Reading Room

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Friday, August 18, 2017

Organ crosstalk: Fatty liver can cause damage to other organs

Organ Crosstalk: Fatty Liver Can Cause Damage to Other Organs
The consensus among scientists until now has been that overweight people have an increased risk for diabetes, cancer, high blood pressure and heart attack. However, studies show that not only the extent, but above all the location and function of adipose tissue play a decisive role in the development of the disease. Several years ago, scientists of the German Center for Diabetes Research (DZD) in Tübingen discovered that a fatty liver can cause damage to other organs. Now, in two just-published studies they demonstrate the effects of fatty liver disease on the function of the hormone-producing islet cells in the pancreas and on renal function.

Nonalcoholic fatty liver disease is becoming more and more common. Approximately every third adult in the industrialized countries has a morbidly fatty liver. This not only increases the risk of chronic liver diseases (liver cirrhosis and liver cancer), but also in particular type 2 diabetes and cardiovascular diseases. The cause for this is the altered secretion behavior of the fatty liver. It increasingly produces glucose, unfavorable fats and proteins, such as the hepatokine fetuin-A, all of which it releases into the bloodstream. Thus, the secreted substances of the fatty liver enter other organs and trigger reactions there. So far, however, it is not known exactly which effects this "organ crosstalk" has, which organs are most affected, and which "damage" can be caused by the hepatokine fetuin-A.

What effect does the protein fetuin-A, which is produced by the fatty liver, have on the pancreas?
To elucidate the causal mechanisms and the resulting changes, DZD researchers of the Institute for Diabetes Research and Metabolic Diseases (IDM) of Helmholtz Zentrum München at the University of Tübingen studied the influence of fetuin-A on pancreatic adipose tissue. Approximately one-third of the pancreatic adipose tissue consists of adipose precursor cells (a kind of stem cells) in addition to the mature adipose cells. If the pancreatic adipose cells are treated with fetuin-A in cell cultures*, the mature adipose cells – but in particular the adipose precursor cells in interaction with the islet cells – increasingly produce inflammation markers and immune-cell-attracting factors.

In addition, the researchers histologically analyzed tissue samples from 90 patients and found that the proportion of the pancreatic fat varied greatly. The number of defense cells of the immune system (monocytes / macrophages) was significantly increased in areas where many adipose cells had accumulated.

In a cohort of 200 subjects with an increased risk of type 2 diabetes, the pancreatic fat content was measured by means of magnetic resonance imaging and compared with diabetes parameters. It was found that in persons who had already experienced a worsening of blood glucose regulation, an increased pancreatic fatty degeneration was associated with a reduced insulin secretion. The investigations were carried out by Professor Hans Ulrich Häring and the Endocrinology Research Group, together with scientists from the Department of Experimental Radiology at the University of Tübingen.

In summary, these analyses, published in the journals Diabetologia and Diabetes Metab Res Rev, suggest that a fatty liver, together with a fatty degeneration of the pancreas, triggers an increased local immune cell infiltration and inflammation that accelerate the course of the disease.

Fetuin-A leads to pathological changes of the kidney

However, adipose tissue is not harmful per se. It can even have protective effects. For example, adipose tissue located around blood vessels or the kidney has regenerative properties. "The factor that leads to pathological changes is fetuin-A, which is produced by the fatty liver," said Professor Dorothea Siegel-Axel, head of the working group “Adipose Tissue and Complications” in Tübingen. As a result, instead of protecting tissue as before, the adipose tissue now elicits inflammatory processes. This leads to a restriction of renal function. This is demonstrated by studies on arteries and the kidney, which have recently been published by the working group in the journal Scientific Reports (Nature Group).

"The statement that obesity in itself always has a disease-causing effect is too imprecise. Not until further parameters have been determined, such as fatty liver and hepatokine levels, as well as the elicited changes in other organs, can we obtain more exact indications as to whether a person has an increased disease risk or not,” said Professor Häring, board member of the DZD and director of the IDM, summarizing the current results.

Original publications:
Gerst F. et al. (2017): Metabolic crosstalk between fatty pancreas and fatty liver: effects on local inflammation and insulin secretion. Diabetologia, DOI: 10.1007/s00125-017-4385-1

Wagner R. et al (2017): The protective effect of human renal sinus fat on glomerular cells is reversed by the hepatokine fetuin-A. Scientific Reports, DOI: 10.1038/s41598-017-02210-4

Heni M. et al. (2010): Pancreatic fat is negatively associated with insulin secretion in individuals with impaired fasting glucose and/or impaired glucose tolerance: a nuclear magnetic resonance study. Diabetes Metab Res Rev;26(3):200-5. DOI: 10.1002/dmrr.1073

* The cells for the cultures were obtained from residual tissue in the course of surgery, which was no longer required for diagnostics and was explicitly released by the patients.


Novel treatments for HCC in the era of hepatitis C therapies

In Case You Missed It


Source - ImedexCME
Published on Apr 17, 2017
In this presentation from the 2017 Great Debates & Updates in GI Malignancies, Dr. Ghassan Abou-Alfa provides an update in novel treatments for hepatocellular carcinoma (HCC) in the era of hepatitis C therapies.       

Which Hepatitis C Treatment to Start in 2017 - Are All Treatments Created Equal?

Which Hepatitis C Treatment to Start in 2017

Article Link -
August 17, 2017

Are All Treatments Created Equal?
Considering the variety of treatments now available, what's the best DAA for each patient? Even with sofosbuvir/velpatasvir/voxilaprevir on the market, picking the right drug will depend on each patient's medical history, level of liver damage, coinfections and, to some extent, insurance coverage.

Continue reading.....

Hepatitis C - Newly Approved Mavyret Has High Response Rates

The Lancet
Download Full Text Article - PDF provided by Henry E. Chang‏ via Twitter:
Glecaprevir plus pibrentasvir for chronic hepatitis C virus genotype 1, 2, 4, 5, or 6 infection in adults with compensated cirrhosis (EXPEDITION-1): a single-arm, open-label, multicentre phase 3 trial
Xavier Forns, Samuel S Lee, Joaquin Valdes, Sabela Lens, Reem Ghalib, Humberto Aguilar, Franco Felizarta, Tarek Hassanein, Holger Hinrichsen, Diego Rincon, Rosa Morillas, Stefan Zeuzem, Yves Horsmans, David R Nelson, Yao Yu, Preethi Krishnan, Chih-Wei Lin, Jens J Kort, Federico J Mensa
Summary Background
The once-daily, ribavirin-free, pangenotypic, direct-acting antiviral regimen, glecaprevir coformulated with pibrentasvir, has shown high rates of sustained virological response in phase 2 and 3 studies. We aimed to assess the efficacy and safety of 12 weeks of coformulated glecaprevir and pibrentasvir in patients with hepatitis C virus (HCV) infection and compensated cirrhosis......
Continue reading....

The Lancet
Download Full Text Article - PDF provided by Henry E. Chang‏ via Twitter:
New anti-HCV drug combinations: who will benefit?
Publication stage: In Press Corrected Proof
In The Lancet Infectious Diseases1 Xavier Forns and colleagues present the results of a phase 3 trial assessing the efficacy and safety of 12 weeks of treatment with glecaprevir (300 mg) coformulated with pibrentasvir (120 mg) in patients with chronic hepatitis C virus (HCV) genotype 1, 2, 4, 5, or 6 infection and compensated cirrhosis. Of 146 enrolled patients, 145 (99%, 95% CI 98–100) achieved a sustained virological response. The study did not include patients with decompensated cirrhosis; the same is true for studies of sofosbuvir, velpatasvir, and voxilaprevir.2....
Continue reading......

Newly Approved Hepatitis C Drug Has High Response Rates
By Amy Orciari Herman
Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM
Nearly all patients with chronic hepatitis C virus (HCV) infection treated with glecaprevir-pibrentasvir achieved sustained virologic response after 12 weeks of therapy, according to results of an industry-funded, phase 3 trial in the Lancet Infectious Diseases. The once-daily combination drug (brand name, Mavyret) was approved by the FDA earlier this month to treat all HCV genotypes.

The trial enrolled 146 adults with HCV genotype 1a, 1b, 2, 4, 5, or 6 and compensated cirrhosis who either had not been previously treated, or had not responded to interferon-based treatment or to treatment with sofosbuvir plus ribavirin (with or without pegylated interferon). At 12 weeks after treatment ended, all but one patient had sustained virologic response. A patient with HCV genotype 1a and a history of treatment with pegylated interferon plus ribavirin relapsed at week 8.

Nearly 70% of patients had adverse events, most of which were mild (e.g., fatigue). No serious events were related to the study drug.

The Lancet
Lancet Infectious Diseases article (Free abstract)
Lancet Infectious Diseases comment (Subscription required)
Background: Physician's First Watch coverage of glecaprevir-pibrentasvir (Free)

Hepatitis C - Medivir licenses exclusive rights to MIV-802 for Greater China to Ascletis

Medivir licenses exclusive rights to MIV-802 for Greater China to Ascletis

Stockholm, Sweden and Hangzhou, China— Medivir AB (Nasdaq Stockholm: MVIR) and Ascletis today announce that Ascletis has licensed the exclusive rights to develop, manufacture and commercialize Medivir’s nucleotide polymerase inhibitor for hepatitis C, MIV-802 (Ascletis code: ASC21), in Greater China.

Under the terms of the agreement, Medivir received an upfront payment, and is entitled to receive milestones based on successful development through commercial launch and tiered royalties on net sales of MIV-802 containing products. Ascletis will fund clinical development, manufacturing and commercialization of MIV-802 in Greater China.

“We are pleased to have Ascletis as a partner with their track record in advancing development of pharmaceuticals in Greater China and their portfolio of antivirals with which to create a combination drug against hepatitis C” said Christine Lind, CEO of Medivir.

“Ascletis has filed an NDA in China for its first HCV NS3/4A medicine, danoprevir, at the end of 2016 and has an HCV NS5A inhibitor in the late stage clinical development. By acquiring MIV-802, a nucleotide NS5B inhibitor, Asceltis is committed to treating, eventually eliminating, hepatitis C in greater China with its multiple leading antiviral combinations including MIV-802,” said Dr. Jinzi J. Wu, CEO of Ascletis.

For further information, please contact:
Ola Burmark, CFO Medivir AB, mobile: +46 (0) 725 480 580
Jianjiong Wang, Associate Director, Corporate Affairs, mobile: +86 181 0650 1929. Email:

About MIV-802
MIV-802 is a potent, pangenotypic nucleotide inhibitor of the HCV NS5B polymerase. Hepatitis C treatments comprise combinations of pharmaceuticals with different antiviral mechanisms. Preclinical data indicate that MIV-802 can be used effectively in combination with other classes of antiviral agents for the treatment of HCV, including protease inhibitors, non-nucleoside NS5B inhibitors, and NS5A inhibitors.

About Medivir
Medivir is a research-based pharmaceutical company with a focus on oncology. We have a leading competence within protease inhibitor design and nucleotide/nucleoside science and we are dedicated to develop innovative pharmaceuticals that meet great unmet medical needs. Medivir is listed on the Nasdaq Stockholm Mid Cap List.

Thursday, August 17, 2017

Gilead's VOSEVI HCV Regimen for Re-Treatment Receives Health Canada Approval

Gilead Receives Health Canada Approval for the First Once-Daily, Single Tablet HCV Regimen for Re-Treatment
August 17, 2017
Deb Schmitz
Please note: VOSEVI is available to eligible patients in Canada but is not yet covered by BC PharmaCare (or any provincial plans). VOSEVI is included in Gilead’s Momentum Patient Support Program

View all information, here..

VOSEVI is the First Once-Daily, Single Tablet HCV Regimen for Re-Treatment, and Completes Gilead’s Portfolio of Sofosbuvir-Based HCV Direct-Acting Antiviral Treatments

MISSISSAUGA, ON, Aug. 17, 2017 /CNW/ – Gilead Sciences Canada, Inc. (Gilead Canada) today announced that Health Canada has granted a Notice of Compliance for VOSEVI™ (sofosbuvir 400 mg/velpatasvir 100 mg/voxilaprevir 100 mg) tablets, a pan-genotypic single-tablet regimen for the treatment of chronic hepatitis C virus (HCV) infection in adults with genotype 1, 2, 3, 4, 5 or 6 previously treated with an NS5A inhibitor-containing regimen, or with genotype 1, 2, 3 or 4 previously treated with sofosbuvir-containing regimen without an NS5A inhibitor. The approval is based on data from the Phase 3 POLARIS-1 and POLARIS-4 studies that evaluated 12 weeks of VOSEVI in direct-acting antiviral-experienced chronic HCV-infected patients without cirrhosis or with compensated cirrhosis.

“HCV treatment has been transformed by effective direct-acting antiviral regimens, allowing health care providers the opportunity to cure many patients. However, for those patients who have failed with prior therapy, there remains an unmet clinical need for an effective and well-tolerated option,” said Dr. Stephen Shafran, Professor of Medicine, Division of Infectious Diseases, University of Alberta. “VOSEVI Phase 3 clinical studies have resulted in high cure rates among patients who were not previously cured with several widely-prescribed DAA regimens, providing physicians with an important new therapeutic option that could offer hope for their hardest-to-cure patients.”

VOSEVI is the latest single-tablet regimen in Gilead’s portfolio of sofosbuvir-based DAA treatments that offer people living with HCV a short course of therapy to cure their HCV infection, with the convenience associated with once-daily single-tablet regimens. Since 2013, Gilead has brought to market four HCV treatments, including three single-tablet regimens. To date, more than an estimated 1.5 million patients worldwide have been prescribed sofosbuvir-based regimens.

“The evolution of Gilead’s portfolio of HCV single-tablet regimens has been driven by our commitment to address previously unmet needs and put the possibility of cure within reach for as many HCV patient populations as possible,” said Kennet Brysting, General Manager, Gilead Canada. “The approval of VOSEVI in Canada completes our HCV portfolio and this will enable the company to commit to collaborative partnerships that will help drive progress towards the goal of eliminating HCV in Canada by 2030.”

The approval of VOSEVI is supported by Phase 3 data from the POLARIS-1 study evaluating 12 weeks of treatment among adults with HCV genotype 1, 2, 3, 4, 5 or 6 infection with or without compensated cirrhosis who had failed prior treatment with an NS5A inhibitor-containing regimen, as well as Phase 3 data from the POLARIS-4 study evaluating 12 weeks of treatment among adults with HCV genotype 1, 2, 3 or 4 infection with or without compensated cirrhosis who had failed prior treatment with a DAA-containing regimen that did not include an NS5A inhibitor. In these populations across the two studies, 431 of the 445 patients treated with VOSEVI (97%) achieved the primary endpoint of SVR12, defined as maintaining undetectable viral load 12 weeks after completing therapy.

The most common adverse events (≥10 per cent of patients) among patients who received VOSEVI were headache, fatigue, diarrhea and nausea. The proportion of subjects who permanently discontinued treatment due to adverse events was 0.2 per cent for subjects who received VOSEVI for 12 weeks.

“As Canada moves forward with its World Health Organization commitment to eliminate hepatitis C by 2030, it is important for all patients to have the opportunity to access a cure, regardless if they are new to treatment, or they have failed a previous therapy,” said Dr. Morris Sherman, Chairperson, Canadian Liver Foundation and Hepatologist at Toronto General Hospital. “Treatment should be an option for everyone, including to those still seeking a cure. The CLF is pleased to see that additional effective therapies are available, and are becoming more accessible to all patients, regardless of where someone lives, or their ability to pay.”

Patient Support Program
To assist eligible HCV patients in Canada with access to VOSEVI, Gilead Canada has added VOSEVI to the Gilead Momentum Support Program™, which provides information to patients and healthcare providers to help facilitate patient access to medication. For more information regarding the Momentum Support Program in Canada, please call 1-855-447-7977.

Important Safety Information

VOSEVI is contraindicated with the following drugs products: dabigatran etexilate, phenobarbital, phenytoin, rifampin, rosuvastatin. VOSEVI is also contraindicated with the herbal product, St. John’s wort.

Warnings and Precautions
Serious Symptomatic Bradycardia When Coadministered with Amiodarone: Amiodarone is not recommended for use with VOSEVI due to the risk of symptomatic bradycardia, particularly in patients also taking beta blockers or with underlying cardiac comorbidities and/or with advanced liver disease. A fatal cardiac arrest was reported in a patient taking amiodarone who was coadministered a sofosbuvir containing regimen. In patients without alternative, viable treatment options, cardiac monitoring is recommended. Patients should seek immediate medical evaluation if they develop signs or symptoms of bradycardia.

Drug Interactions
Coadministration of VOSEVI is not recommended with carbamazepine, oxcarbazepine, rifabutin, rifapentine, atazanavir, lopinavir, efavirenz, and cyclosporine due to changes (decreased or increased) in concentrations of sofosbuvir, velpatasvir and/or voxilaprevir, and/or the other agent.

For additional important safety information for VOSEVI, including the complete warnings and precautions, adverse reactions and drug-drug interactions, please see the Canadian Product Monograph at

About Gilead Sciences
Gilead Sciences, Inc. (Gilead) is a biopharmaceutical company that discovers, develops and commercializes innovative therapeutics in areas of unmet medical need. The company’s mission is to advance the care of patients suffering from life-threatening diseases. Gilead has operations in more than 30 countries worldwide, with headquarters in Foster City, California. Gilead Sciences Canada, Inc. is the Canadian affiliate of Gilead Sciences, Inc. and was established in Mississauga, Ontario, in 2006.

Forward-Looking Statement
This press release includes forward-looking statements, within the meaning of the Private Securities Litigation Reform Act of 1995 that are subject to risks, uncertainties and other factors, including the risk that physicians may not see the benefits of prescribing VOSEVI for the treatment of adults with chronic HCV infection. These risks, uncertainties and other factors could cause actual results to differ materially from those referred to in the forward-looking statements. The reader is cautioned not to rely on these forward-looking statements. These and other risks are described in detail in Gilead’s Quarterly Report on Form 10-Q for the quarter ended March 31, 2017, as filed with the U.S. Securities and Exchange Commission. All forward-looking statements are based on information currently available to Gilead, and Gilead assumes no obligation to update any such forward-looking statements.

Canadian Product Monograph for VOSEVI, including the SERIOUS WARNINGS and PRECAUTIONS,
is available at

VOSEVI is a trademark of Gilead Sciences, Inc., or its related companies.

AbbVie's MAVIRET Approved by Health Canada

AbbVie's MAVIRET™ Approved by Health Canada for the Treatment of Chronic Hepatitis C in All Major Genotypes

MAVIRET is the first and only 8-week, pan-genotypic treatment for hepatitis C patients without cirrhosis and who are new to treatment*1
The approval is supported by a 97 percent (n=639/657) cure** rate across GT1-6 patients without cirrhosis and who are new to treatment2
MAVIRET is the only pan-genotypic treatment approved for use in patients across all stages of chronic kidney disease

MONTREAL, Aug. 17, 2017 /CNW/ - AbbVie (NYSE: ABBV), a global biopharmaceutical company, today announced that Health Canada has granted approval for MAVIRET™ (glecaprevir/pibrentasvir tablets), a once-daily, ribavirin-free treatment for adults with chronic hepatitis C virus (HCV) infection across all major genotypes (GT1-6). MAVIRET is the only 8-week, pan-genotypic treatment for patients without cirrhosis and who are new to treatment,* who make up a large portion of HCV patients in Canada.

"Despite recent advances in HCV treatment, physicians still face challenges treating patients with less common genotypes and those with other complicating health conditions," said Dr. Morris Sherman, MD, FRCPC, Chairperson, Canadian Liver Foundation. "In order to eliminate hepatitis C in Canada, we need to identify all those living with the virus and have effective treatment options for everyone. This new therapy provides another tool for physicians to expand treatment to a greater number of patients while at the same time shortening the duration which may lead to cost savings for the health care system."

MAVIRET is also approved for use in patients with specific treatment challenges, including those with compensated cirrhosis across all major genotypes, and those who previously had limited treatment options, such as patients with severe chronic kidney disease (CKD), those GT1 patients not previously cured with certain direct-acting antiviral (DAA) treatment, and those with GT3 chronic HCV infection.2 MAVIRET is the only pan-genotypic treatment approved for use in patients across all stages of CKD.2

"With the approval of MAVIRET, we are proud to bring the hope of a new cure to people living with hepatitis C in Canada, reflecting AbbVie's dedication to addressing critical unmet needs for patients," said Stéphane Lassignardie, General Manager, AbbVie Canada. "MAVIRET is designed to deliver a virologic cure for most HCV patients including those with specific treatment challenges. AbbVie will continue to work with local health authorities and stakeholders across Canada to get our treatment to as many patients as possible."

The efficacy and safety of MAVIRET was evaluated in nine Phase 2-3 clinical trials, in over 2,300 patients with genotype 1, 2, 3, 4, 5 or 6 HCV infection and with compensated liver disease (with or without cirrhosis).

Approximately 300,000 Canadians are infected with hepatitis C.3 In 2012 alone, more than 10,000 new cases of hepatitis C were reported, but 40 percent of patients are estimated to be living unaware of their disease.4 GT1 is the most common genotype in Canada and GT3 is the most difficult to treat.3,5 Over time chronic hepatitis C can lead to chronic liver diseases, with a risk of developing cirrhosis of up to 30 percent within 20 years6 of infection. Additionally, HCV is common among people with severe CKD, and some of these patients previously did not have a DAA-based treatment option.7

With 8 weeks of treatment, 97 percent (n= 639/657) of GT1-6 patients without cirrhosis and who were new to treatment achieved a virologic cure.1 These high cure rates were achieved in patients with varied patient and viral characteristics and including those with CKD.2 Additionally, 97.5 percent (n=274/281) of patients with compensated cirrhosis achieved a virologic cure with the recommended duration of treatment, including patients with CKD.2 In registrational studies for MAVIRET, less than 0.1 percent of patients permanently discontinued treatment due to adverse reactions.2 The most commonly reported adverse reactions (incidence greater than or equal to 10 percent) were headache and fatigue.2

"In an extensive clinical trial program, patients achieved high cure rates with MAVIRET regardless of genotype, fibrosis score, viral load, and even in patients with resistant virus strains and those with chronic kidney disease," said Dr. Magdy Elkhashab, Gastroenterologist/Hepatologist, Director of the Toronto Liver Centre. "In clinical practice, MAVIRET has the potential to simplify treatment decisions for physicians, offering, in one therapy, a cure for the majority of HCV patients and cutting out pre-testing before treatment initiation."

MAVIRET combines two new, potent direct-acting antivirals that target and inhibit proteins essential for the replication of the hepatitis C virus.2 The presence of most genotypes or baseline mutations that are commonly associated with resistance have been shown to have no relevant impact on efficacy.2

Canadians prescribed MAVIRET will have the opportunity to be enrolled in AbbVie Care, AbbVie's signature patient support program designed to provide a wide range of services including reimbursement assistance, education and ongoing disease management support. AbbVie Care will support people living with HCV throughout their treatment journey to achieve high cure rates in the real world.

Approval of MAVIRET followed Health Canada's Priority Review process, which is granted to new medicines intended for patients with a life-threatening disease where there is no existing treatment with the same profile or where the new product represents a significant improvement in the benefit/risk profile over existing products.8 AbbVie's investigational, pan-genotypic regimen was also recently approved by the European Commission and the U.S. Food and Drug Administration.

MAVIRET™ is approved in Canada for the treatment of chronic hepatitis C virus (HCV) infection in adults across all major genotypes (GT1-6).2 MAVIRET is a new, pan-genotypic, once-daily, ribavirin-free treatment that combines glecaprevir (100 mg), an NS3/4A protease inhibitor, and pibrentasvir (40 mg), an NS5A inhibitor, dosed once-daily as three oral tablets.2

MAVIRET is an 8-week, pan-genotypic virologic cure** for use in patients without cirrhosis and who are new to treatment,* such patients comprising the majority of people living with HCV.1 MAVIRET is also approved as a treatment for patients with specific treatment challenges, including those with compensated cirrhosis across all major genotypes, and those who previously had limited treatment options, such as patients with severe chronic kidney disease (CKD) and those with genotype 3 infection.2 It is the only pan-genotypic treatment approved for use in patients across all stages of CKD.2

Glecaprevir (GLE) was discovered during the ongoing collaboration between AbbVie and Enanta Pharmaceuticals (NASDAQ: ENTA) for HCV protease inhibitors and regimens that include protease inhibitors.

*Patients without cirrhosis and new to treatment with DAAs [either treatment-naive or not cured with previous IFN-based treatments ([peg]IFN +/- RBV or SOF/RBV +/- pegIFN)].
**Patients who achieve a sustained virologic response at 12 weeks post treatment (SVR12) are considered cured of hepatitis C.

About AbbVie
AbbVie is a global, research-driven biopharmaceutical company committed to developing innovative advanced therapies for some of the world's most complex and critical conditions. The company's mission is to use its expertise, dedicated people and unique approach to innovation to markedly improve treatments across four primary therapeutic areas: immunology, oncology, virology and neuroscience. In more than 75 countries, AbbVie employees are working every day to advance health solutions for people around the world. For more information about AbbVie, please visit us at and Follow @abbvieCanada and @abbvie on Twitter or view careers on our Facebook or LinkedIn page.

1 Decisions Resources Group. Hepatitis C virus: disease landscape & forecast 2016. January 2017.
2 MAVIRET (glecaprevir/pibrentasvir tablets) Product Monograph. Date of Preparation: August 16, 2017.
3 Messina, JP et al. "The global distribution of HCV genotypes." Hepatology, 2015; 61: 77–87. Supporting information hep27259-sup-0001-suppinfo.pdf. Accessed August, 2017.
4 Hepatitis C: Get the Facts. Government of Canada. Accessed August, 2017.
5 Wyles, D et al. SURVEYOR-II, Part 3: Efficacy and Safety of ABT-493/ABT-530 in Patients with Hepatitis C Virus Genotype 3 Infection with Prior Treatment Experience and/or Cirrhosis. Presented at the Annual Meeting of the American Association for the Study of Liver Diseases (AASLD) in Boston, US on November 11-15, 2016.
6 Hepatitis C Fact Sheet. World Health Organization. World Health Organization, July 2017. Web. Accessed August, 2017.
7 Fabrizi F, Poordad FF, Martin P. Hepatitis C infection in the patient with end stage renal disease. Hepatology. 2002;36(1):3-10.
8 Priority Review of Drug Submissions. Government of Canada. Accessed August, 2017.

SOURCE AbbVie Canada
For further information: Media: Muriel Haraoui, AbbVie Canada, (514) 717-3764,

Hepatitis C Medscape TV -  Hope and Uncertainty

Medscape TV - Hepatitis C Virus: Containing the Threat

August 17, 2017

July 17, 2017

June 21, 2017
EPISODE 1 - Strides and Obstacles

Six Episode Series
In the past few years, a new class of direct-acting antiviral agents has made the treatment of HCV easier and more effective than ever before, with cure rates nearing 100%, even among HIV-positive patients. But not all patients with HCV who are eligible for antiviral treatment are identified, and even fewer are being referred for care. Thus, HCV infection remains a significant risk for progression to cirrhosis, liver failure, and hepatocellular carcinoma. Liver specialists at two prestigious Chicago medical centers confront the key issues in the management of patients with chronic HCV infection.

Coming Soon
Episode 4 - New Regimens
Episode 5 - Dealing With Chronic Disease
Episode 6 - Strategies for Prevention
Free registration may be required