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Comparison of the Efficacy of Lamivudine and Telbivudine in the Treatment of Chronic Hepatitis B: a Systematic Review

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Comparison of the Efficacy of Lamivudine and Telbivudine in the Treatment of Chronic Hepatitis B: a Systematic Review Zhao et al. Virology Journal 2010, 7:211 http://www.virologyj.com/content/7/1/211 REVIEW Open Access Comparison of the efficacy of lamivudine and telbivudine in the treatment of chronic hepatitis B: a systematic review Shushan Zhao1*, Lanhua Tang1, Xuegong Fan1*, Lizhang Chen1,2, Rongrong Zhou1, Xiahong Dai1 Abstract Background: Chronic viral hepatitis B remains a global public health concern. Currently, several drugs, such as lamivudine and telbivudine, are recommended for treatment of patients with chronic hepatitis B. However, there are no conclusive results on the comparison of the efficacy of lamivudine (LAM) and telbivudine (LdT) in the treatment of chronic hepatitis B. Results: To evaluate the comparison of the efficacy of LAM and LdT in the treatment of chronic hepatitis B by a systematic review and meta-analysis of clinical trials, we searched PUBMED (from 1990 to April 2010), Web of Science (from 1990 to April 2010), EMBASE (from 1990 to April 2010), CNKI (National Knowledge Infrastructure) (from 1990 to April 2010), VIP database (from 1990 to April 2010), WANFANG database (from 1990 to April 2010), the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Review. At the end of one-year treatment, LdT was better than LAM at the biochemical response, virological response, HBeAg loss, therapeutic response, while less than at the viral breakthrough and viral resistance, but there was no significant difference in the HBeAg seroconversion and HBsAg response. LdT was better than LAM at the HBeAg seroconversion with prolonged treatment to two years. Conclusions: In summary, LdT was superior in inhibiting HBV replication and preventing drug resistance as compared to LAM for CHB patients. But LdT may cause more nonspecific adverse events and can lead to more CK elevation than LAM. It is thus recommended that the LdT could be used as an option for patients but adverse events, for example CK elevation, must be monitored. Background anti-viral drugs including lamivudine, adefovir, entecavir, Chronic hepatitis B virus (HBV) infection is a serious tenofovir, and telbivudine[4]. global public health problem associated with cirrhosis, LdT was approved by the US Food and Drug Admin- liver failure and hepatocellular carcinoma (HCC) [1]. Of istration (FDA) on October 25, 2006. It is an L-nucleo- the two billion people who have been infected, more side that is structurally related to lamivudine and highly than 350 million have chronic hepatitis[2]. It is esti- selective for hepatitis B virus DNA and inhibits viral mated that between 235,000 and 328,000 people die DNA synthesis with no effect on human DNA or other annually due to liver cirrhosis and hepatocellular carci- viruses[5]. In the woodchuck model of HBV infection, noma, respectively[3]. Currently, several drugs are viral replication was inhibited within the first few days recommended for treatment of patients with chronic of treatment and was maintained throughout the treat- hepatitis B. These drugs can be divided into two main ment period. Then viral rebound with pretreatment groups based on their mechanism of action, namely levels between week 4 and week 8[5]. A placebo-con- immunomodulatory drugs like alpha interferons and trolled dose-escalation trial investigated daily dosing levels of LdT between 25 and 800 mg/day for 4 weeks. * Correspondence: [email protected]; [email protected] This study showed that LdT induced striking dose- 1Department of Infectious Diseases, Xiangya Hospital, Central South related suppression of serum HBV DNA levels and a University, Changsha, China nearly maximal viral load reduction was obtained at Full list of author information is available at the end of the article © 2010 Zhao et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Zhao et al. Virology Journal 2010, 7:211 Page 2 of 11 http://www.virologyj.com/content/7/1/211 dosages of 400-800 mg/day[6]. One-year data from the decompensated liver disease, HIV, hepatocellular carci- GLOBE study has recently been presented[7]. Among noma, prior liver transplantation and concomitant renal patients with HBeAg-positive chronic hepatitis B, the failure was excluded. rates of HBeAg seroconversion, virological response and HBeAg response were nonsignificantly higher in patients Types of interventions treated with LdT than in patient treated with LAM[7-9]. The comparisons will include lamivudine versus However other trials did not support this result[10,11]. telbivudine. And recently, some randomized controlled clinical trials compared the efficacy of LAM and LdT in the treatment Types of outcome measures of chronic hepatitis B and had different results. Thus, Proportion of patients with biochemical response, viro- we conducted this systematic review of these trials to logical response, HBeAg seroconversion, HBeAg loss, assess the evidence obtained on the efficacy of LdT therapeutic response, HBsAg response, creatine kinase treatment in chronic HBV infection. (CK) elevation at the end of one-year treatment or two- year treatment. Methods Search strategy Data extraction We searched the following databases until April 2010: Data was extracted independently by both authors (S. S. PUBMED (from 1990 to April 2010), Web of Science Zhao and L. H. Tang) using a pre-designed data extrac- (from 1990 to April 2010), EMBASE (from 1990 to tion form and the information subsequently was entered April 2010), CNKI (National Knowledge Infrastructure) into Review Manager (RevMan 5.0). Information was (from 1990 to April 2010), VIP database (from 1990 to extracted on data source; eligibility; methods; partici- April 2010), WANFANG database (from 1990 to April pants (age range, exclusion criteria, sample size, gender); 2010), the Cochrane Central Register of Controlled interventions; and results. We resolved any discrepancies Trials and the Cochrane Database of Systematic Review. between the extracted data by discussion, and, if Of these databases, CNKI, WANFANG and VIP data- required, referral to the third author (R. R. Zhou). bases provide literatures in Chinese. The search process Where data were not clear or not presented by the was designed to find initially all trials involving terms: author in the publication, we attempted to contact the “Hepatitis B”, “lamivudine”, “telbivudine”,"randomized trial author for further details. controlled trial” (and multiple synonyms for each term). Reference lists from retrieved documents were also Quality assessment searched. Computer searches were supplemented with a Quality of the trials was assessed using the QUOROM manual search. Search results were downloaded to a guidelines as well as using the Jadad scale[12]. reference database and further screened. Two authors (S. S. Zhao and L. H. Tang) independently screened all Data analysis citations and abstracts identified by the search strategy Data analysis was carried out with the use of Review to identify potentially eligible studies. Manager Software 5.0(Cochrane Collaboration, Oxford, United Kingdom). For each eligible study, dichotomous Types of studies data were presented as relative risk (RR), which is the All relevant randomised clinical trials will be included, probability that a member of an exposed group will irrespective of language, or blinding. Quasi-randomised develop a disease relative to the probability that a mem- studies, which use quasi-random method of allocating ber of an unexposed group will develop that same dis- participants to different interventions, and observational ease, and continuous outcomes were presented as studies will be excluded except for their report on weighted mean difference (WMD), which is calculated harms. as the difference between the mean value in the treat- ment and control groups, both with 95% confidence Types of participants intervals (CI). Meta-analysis was performed using fixed- Male or female patients, of any age or ethnic origin, effect or random-effect methods, depending on the who have chronic hepatitis B, defined as chronic hepati- absence or presence of significant heterogeneity. Statisti- tis B virus infection with evidence of hepatitis (alanine cal heterogeneity between trials was evaluated by the aminotransferase (ALT) elevation of at least one and a chi-square and I-square (I2) tests, with significance set half times the upper limit of normal range) and of viral at P < 0.10. In the absence of statistically significant het- replication (detectable hepatitis B virus DNA by DNA erogeneity, the fixed-effect method was used to combine hybridisation method or polymerase chain reaction the results. When heterogeneity was confirmed (P < (PCR)), will be included. Patients with cirrhosis, 0.10), the random-effect method was used. Additionally, Zhao et al. Virology Journal 2010, 7:211 Page 3 of 11 http://www.virologyj.com/content/7/1/211 sensitivity analysis should be carried out if low quality of a random-effects approach. The results of the seven trials were included. The overall effect was tested using trials showed normalization rates for ALT in the LdT z scores calculated by Fisher’sz’ transformation, with group as 81.2%, compared to 75.8% in the LAM group significance set at P < 0.05. after one-year treatment. And the biochemical response rates in LdT group was higher than LAM group[RR = Results 1.13, 95%CI(1.04-1.22), P = 0.003](Figure 1). When a We searched relevant literatures, and finally a total of study[7] was removed, the heterogeneity was assessed 171 studies identified by the searches(PUBMED:8; Web and not found to be a concern[Chi2 = 0.88, df = 5 (P = of Science:12; EMBASE:37; CNKI:42; VIP database:18; 0.97); I2 = 0%]. The difference in response rate between WANFANG database:33; the Cochrane Central Register two group were still significantly by use a fixed effects of Controlled Trials and the Cochrane Database of Sys- model[87.5% vs.
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