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778 Original article

Hematological and biochemical changes due to anti‑hepatitis C virus therapy Ashraf G. Dalaa, Mohamed H. Badra, Mohamed A. Helwab, Baher E. Maadawi Radia

aDepartment of Internal Medicine, Faculty Objective b of Medicine, Menoufia University, Menoufia The aim of the study was to assess the hematological and biochemical changes in patients Hepatology Center, Menoufia, Egypt who have received anti‑hepatitis C virus (HCV) therapy before treatment and follow‑up after Correspondence to Baher E. Maadawi Radi, 3 months of treatment as regards the advantages and disadvantages through a follow up of MBBCh, Shabas Elshouhada, Dessouq, the studied patients. Kafr Al Sheikh 32717, Egypt Tel: +20 100 975 9737; Background e‑mail: [email protected] There is a dramatic improvement in HCV therapy following the introduction of oral medicines that directly inhibit the replication cycle of HCV, so the follow up of patients who are receiving Received 26 December 2018 Revised 09 February 2019 therapy before and 6 months after treatment is mandatory to choose the best drug for each Accepted 12 February 2019 patient with the least side effects. Published 30 September 2020 Patients and methods Menoufia Medical Journal 2020, 33:778–782 This study was done on 200 patients admitted to the Kafr El‑Sheikh Hepatology Center diagnosed as HCV‑infected patients. Those patients were classified according to the Child classification as Child A score 6. Of them, 100 patients received sofosbuvir + ledipasvir and another 100 patients received sofosbuvir + daclatasvir, respectively. All patients were subjected to the following investigations before and 6 months after treatment: complete blood count, biochemical investigations including serum albumin, alanine transaminase, aspartate transaminase, random blood sugar, blood urea, serum creatinine, total and direct bilirubin, and alkaline phosphatase, thyroid‑stimulating hormone level, alpha‑fetoprotein, and antinuclear antibody. Results All the previous laboratory investigations were done to all 200 patients, recorded and compared before treatment and 6 months after treatment. Conclusion Ledipasvir and sofosbuvir for 8 weeks or 12 weeks is a highly effective treatment option for the treatment of hepatitis C‑infected patients and give best results more than sofosbuvir and daclatasvir.

Keywords: biochemical investigations, Child score, oral anti‑hepatitis C virus therapy

Menoufia Med J 33:778–782 © 2020 Faculty of Medicine, Menoufia University 1110‑2098

Introduction understanding of the pathophysiology of the disease, and because of developments in diagnostic procedures Chronic hepatitis is not a single disease but is a clinical and improvements in therapy and prevention [3]. The and pathological syndrome of multiple etiologies primary goal of HCV therapy is to cure the infection and is characterized by varying degrees of liver cell or to achieve a sustained virological response (SVR) necrosis, inflammation, and fibrosis continuing defined as undetectable HCV RNA 12 weeks after without improvement for at least 6 months [1]. treatment completion. An SVR corresponds to a Hepatitis C virus (HCV) infection is one of the cure of the HCV infection, with a very low chance main causes of chronic liver disease worldwide. The of late relapse. An SVR is generally associated with long‑term natural history of HCV infection is highly normalization of liver enzymes and improvement or variable. The hepatic injury can range from minimal disappearance of liver necroinflammation and fibrosis histological changes to extensive fibrosis and cirrhosis in patients without cirrhosis [3]. Patients with advanced with or without hepatocellular carcinoma [2]. There fibrosis or cirrhosis remain at risk of life‑threatening are ∼71 million chronically infected individuals worldwide, many of whom are unaware of their This is an open access journal, and articles are distributed under the terms infection, with important variations according to the of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 geographical area [2]. Clinical care for patients with License, which allows others to remix, tweak, and build upon the work HCV‑related liver disease has advanced considerably non‑commercially, as long as appropriate credit is given and the new during the last two decades, thanks to an enhanced creations are licensed under the identical terms. 1110-2098 © 2020 Faculty of Medicine, Menoufia University DOI: 10.4103/mmj.mmj_398_18 [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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complications. However, hepatic fibrosis may regress followed up for 3 months and then another blood and the risk of complications such as hepatic failure sample was taken from each patient to do the same and portal hypertension is reduced after sustained previous investigations and to compare between them. virologic response [4]. Recent data suggest that the risk of hepatocellular carcinoma and liver‑related Statistical analysis mortality is significantly reduced, but not eliminated, in patients with cirrhosis who clear HCV compared All data were collected, tabulated, and statistically with untreated patients and nonsustained virological analyzed. The descriptive measures were mean value responders, especially in the presence of cofactors and SD for quantitative data, besides frequency and the of liver morbidity, such as the metabolic syndrome, percentage for qualitative data were calculated by using harmful alcohol consumption, and/or concurrent Epi‑Info, version 6, Division of Health Informatics hepatitis B virus infection [5]. & Surveillance (DHIS), Center for Surveillance, Epidemiology & Laboratory Services (CSELS) The aim of this study was to assess hematological and Newyork, USA and SPSS, IBM SPSS Statistics for biochemical changes in patients who have received Windows, version 8 (IBM Corp., Armonk, N.Y., USA). anti‑HCV therapy before and 3 months after treatment. The analytic measures were t test for comparison of two independent quantitative variables that are normally distributed and χ2 test for comparison between two independent qualitative variables that are normally Patients and methods distributed. This study was done at Kafr El‑Sheikh Hepatology Centre from January 2016 to January 2017 with a follow‑up period of an average 6 months. The study was approved by the Ethics committee of Menoufia Results Faculty of Medicine. All patients gave written Our study was conducted on 200 patients infected informed consent before inclusion into the study. with HCV to evaluate the possible hematological The study included 200 patients classified as Child A and biochemical changes due to anti‑HCV therapy. score 6, 100 patients receiving sofosbuvir + ledipasvir The mean age was 40.60 years in patients receiving and 100 patients receiving sofosbuvir and daclatasvir, sofosbuvir + ledipasvir and men represent 70% and respectively. The mean age was 40.60 years in patients women represent 30%. But in patients receiving receiving sofosbuvir + ledipasvir and men represent 70% ‘sofosbuvir + daclatasvir ,’ the mean age was and women represent 30%. But in patients receiving 42.64 years and men represent 74% and women ‘sofosbuvir + daclatasvir,’ the mean age was 42.64 years represent 26%, with no significant differences and men represent 74% and women represent 26%, between the two groups of patients regarding age and with no significant differences between the two groups sex (Table 1). Laboratory results of patients receiving of patients regarding age and sex. sofosbuvir + ledipasvir before treatment and 3 months after treatment were tabulated and compared and All patients were subjected to the following investigations there were statistically significant difference between 6 months before and after treatment: complete patients receiving sofosbuvir + ledipasvir before blood count, biochemical investigations [serum and after treatment as regards serum creatinine, albumin, alanine transaminase (SGPT), aspartate SGPT, SGOT, serum albumin, hemoglobin transaminase (SGOT), random blood sugar, blood concentration, and platelet concentration (Table 2). urea, serum creatinine, total and direct bilirubin and Laboratory results of patients receiving sofosbvir alkaline phosphatase, thyroid‑stimulating hormone and daclatasvir before treatment and 3 months after level, alpha‑fetoprotein, and antinuclear antibody]. treatment were tabulated and there were statistically significant difference between patients receiving Blood sample technique Table 1 Comparison between two groups of patients Blood samples were taken from a peripheral vein receiving sofosbuvir + ledipasvir and the patients group after sterilization of the skin with betadine to do the receiving sofosbuvir + daclatasvir as regards age and sex laboratory investigations 6 months before and after Sof + ledipasvir Sof + DAC Test P treatment of HCV infection. (n=100) (n=100) Age (mean±SD) 40.60±10.6 42.64±7.77 t=2.411 0.122 Sex [n (%)] Follow‑up Male 70 (70) 74 (74) χ2=0.397 0.529 Female 30 (30) 26 (26) Patient were discharged after first blood sample was taken to receive his anti‑HCV medications and were DAC, daclatasvir; SOF, sofosbuvir. [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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‘sofosbuvir + daclatasvir’ before and after treatment significant differences between patients receiving as regards serum creatinine, SGPT, SGOT, ‘sofosbuvir + daclatasvir’ before and 3 months serum albumin, total bilirubin, and hemoglobin after treatment as regards FIB 4 score and MELD concentration (Table 3). Laboratory results of both score (Table 6). There were statically significant patient groups are recorded, tabulated, and compared. differences between two groups of patients receiving There were statistically significant difference between sofosbuvir + ledipasvir and sofosbuvir + daclatasvir two groups of patients receiving sofosbuvir + ledipasvir after 3 months of treatment as regards FIB 4 score and sofosbuvir + daclatasvir after treatment as and MELD score (Table 7). regards alpha‑fetoprotein, serum creatinine, SGPT, SGOT, serum albumin, total bilirubin, hemoglobin concentration, and platelet concentration (Table 4). There were statically significant difference between Discussion patients receiving sofosbuvir + ledipasvir before and A dramatic improvement in HCV therapy followed 3 months after treatment as regards FIB 4 score the introduction of oral medicines that directly inhibit and MELD score (Table 5). There were statically the replication cycle of HCV. These medicines, called

Table 2 Comparison between patients receiving (sofosbuvir + ledipasvir) before and after treatment as regards liver function tests, kidney functions, complete blood count, and biochemical markers Sofosbuvir + ledipasvir Before After t test P Biochemical markers FBS (mg/dl) 93.96±14.06 95.98±16.13 0.891 0.346 ALP (IU/l) 81.60±20.41 83.60±21.10 0.464 0.496 AFP (ng/dl) 2.95±1.02 3.08±1.13 0.733 0.393 TSH (mIU/l) 2.43±0.76 2.45±0.68 0.038 0.845 Kidney function test Serum creatinine (mg/dl) 1.22±0.46 1.06±0.33 7.894 0.005* Liver function test SGPT (U/l) 50.63±31.01 35.14±19.52 17.870 0.001* SGOT (U/l) 52.01±29.50 37.98±20.82 15.090 0.001* Serum albumin (g/dl) 3.93±0.71 4.18±0.47 8.535 0.004* Total bilirubin (mg/dl) 1.07±0.57 1.04±0.43 0.253 0.615 CBC Hb (g/dl) 10.72±1.08 12.37±1.58 23.513 0.001* PLT (109/l) 171.93±53.49 193.57±58.63 7.436 0.007* WBCs (109/l) 6.01±1.91 5.76±2.28 0.738 0.391 AFP, alpha‑fetoprotein; ALP, alkaline phosphatase; FBS, fasting blood glucose; Hb, hemoglobin; PLT, platelets; SGOT, aspartate transaminase; SGPT, alanine transaminase; TSH, thyroid‑stimulating hormone; WBCS, white blood cells. *Statistically significant difference.

Table 3 Comparison between patients receiving sofosbuvir + daclatasvir before and after treatment as regards liver function tests, kidney function tests, complete blood count, and biochemical markers Sof + DAC Before After t test P Biochemical markers FBS (mg/dl) 96.42±11.41 93.54±13.70 2.610 0.108 ALP (IU/l) 77.32±15.41 79.54±15.23 1.050 0.307 AFP (ng/dl) 2.68±0.94 2.69±0.93 0.002 0.961 TSH (mIU/l) 2.40±0.79 2.47±0.80 0.380 0.538 Kidney function test Serum creatinine (mg/dl) 1.07±0.33 0.95±0.39 5.107 0.025* Liver function test SGPT (U/l) 59.02±36.75 46.34±21.96 8.771 0.003* SGOT (U/l) 62.75±34.54 46.52±26.69 13.825 0.001* Serum albumin (g/dl) 3.50±0.73 3.82±0.61 11.644 0.001* Total bilirubin (mg/dl) 1.48±0.59 1.28±0.41 7.697 0.006* CBC Hb (g/dl) 10.76±1.23 11.73±1.31 31.589 0.001* PLT (109/l) 153.06±43.72 159.26±39.90 1.097 0.296 WBCs (109/l) 6.68±9.57 5.81±1.77 0.803 0.371 AFP, alpha‑fetoprotein; ALP, alkaline phosphatase; FBS, fasting blood glucose; Hb, hemoglobin; PLT, platelets; SGOT, aspartate transaminase; SGPT, alanine transaminase; SOF+DAC, sofosbuvir and daclatasvir; TSH, thyroid‑stimulating hormone; WBCS, white blood cells. *Statistically significant difference. [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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Table 4 Comparison between two groups of patients receiving sofosbuvir + ledipasvir and sofosbuvir + daclatasvir after treatment as regards liver function tests, kidney function tests, complete blood count, and biochemical markers After Sofosbuvir + ledipasvir Sof + DAC t test P Biochemical markers FBS (mg/dl) 95.98±16.13 93.54±13.70 1.329 0.250 ALP (IU/l) 83.60±21.10 79.54±15.23 2.435 0.120 AFP (ng/dl) 3.08±1.13 2.69±0.93 7.316 0.007* TSH (mIU/l) 2.45±0.68 2.47±0.80 0.010 0.920 Kidney function test Serum creatinine (mg/dl) 1.06±0.33 0.95±0.39 4.165 0.043* Liver function test SGPT (U/l) 35.14±19.52 46.34±21.96 14.541 0.001* SGOT (U/l) 37.98±20.82 46.52±26.69 6.360 0.012* Serum albumin (g/dl) 4.18±0.47 3.82±0.61 21.147 0.001* Total bilirubin (mg/dl) 1.04±0.43 1.28±0.41 17.198 0.001* CBC Hb (g/dl) 12.37±1.58 11.73±1.21 10.284 0.002* PLT (109/l) 193.57±58.63 159.26±39.90 23.409 0.001* WBCs (109/l) 5.76±2.28 5.81±1.77 0.033 0.856 AFP, alpha‑fetoprotein; ALP, alkaline phosphatase; FBS, fasting blood glucose; Hb, hemoglobin; PLT, platelets; SGOT, aspartate transaminase; SGPT, alanine transaminase; Sof + DAC, sofosbuvir and daclatasvir; TSH, thyroid‑stimulating hormone; WBCS, white blood cells. *Statistically significant difference.

Table 5 Comparison between patients receiving sofosbuvir + ledipasvir before and 3 months after treatment as regards The pan‑genotypic combination of daclatasvir and FIB 4 score and MELD score sofosbuvir, with or without ribavirin, has achieved high Sofosbuvir + ledipasvir Before After t test P SVR rates. Daclatasvir is an inhibitor of the HCV FIB 4 1.98±1.43 1.55±1.02 5.856 0.016* NS5A replication complex; sofosbuvir is a nucleotide MELD 5.13±0.66 4.60±0.52 41.187 0.001* inhibitor of the HCV NS5B polymerase. Both had *Significant value with P less than 0.05. FIB 4, method of staging of favorable safety profiles and are dosed once daily, liver fibrosis; MELD, model for end‑stage liver disease. with few clinically significant drug–drug interactions, including a lack of interactions with cyclosporine or Table 6 Comparison between patients receiving sofosbuvir + daclatasvir before and 3 months after treatment as regards tacrolimus [7]. The regimen was effective across all five FIB 4 score and MELD score HCV genotypes enrolled, consistent with the expected Sof + DAC Before After t test P pan‑genotypic activity of daclatasvir and sofosbuvir. FIB 4 2.56±1.53 2.02±1.45 6.437 0.012* Other oral regimens have thus far been evaluated MELD 7.07±0.80 7.28±0.76 3.563 0.061 primarily against HCV genotypes 1 and 4 in transplant *Significant value with P less than 0.05. FIB 4, method of staging of recipients or in those with advanced cirrhosis [8]. liver fibrosis; MELD, model for end‑stage liver disease; Sof + DAC, The fixed‑dose combination of ledipasvir, an NS5A sofosbuvir + daclatasvir. inhibitor, and sofosbuvir (ledipasvir + sofosbuvir) Table 7 Comparison between two groups of patients for 12 weeks had proven to be highly effective and receiving sofosbuvir + ledipasvir and sofosbuvir + well tolerated in patients with HCV genotype 1 in daclatasvir after 3 months of treatment as regards FIB 4 phase III studies, with rates of SVR at 12 weeks score and MELD score posttreatment of 94–99% [9]. A published trial in After Sofosbuvir + ledipasvir Sof + DAC t test P FIB 4 1.55±1.02 2.02±1.45 6.946 0.009* patients with HCV genotype 4 who received 12 weeks MELD 4.60±0.52 7.28±0.76 86.545 0.001* of ledipasvir + sofosbuvir. Overall, SVR 12 rates of *Significant value with P less than 0.05. FIB 4, method of staging of 93–95% were observed, with slightly lower rates liver fibrosis; MELD, model for end‑stage liver disease; Sof + DAC, for interferon‑experienced patients (91%) [10]. The sofosbuvir + daclatasvir. efficacy and safety of ledipasvir/sofosbuvir alone and with ribavirin were evaluated for 8 and 12 weeks in direct‑acting antivirals (DAAs), target three important Egyptian patients with and without cirrhosis, who regions within the HCV genome: NS3/4 A protease, were infected with HCV genotype 4, including those NS5A, and NS5B RNA‑dependent polymerase. These who had failed previous treatment with sofosbuvir medicines had led to higher SVRs than interferon‑based regimens. Of the 255 patients in the study, 61% were regimens, shorter in treatment duration, orally men, 67% were treatment naïve, 21% had cirrhosis, and administered, and had fewer side‑effects. Individual 80% had IL28B non‑CC genotype [11]. DAAs vary in therapeutic efficacy, genotypic efficacy, adverse events, and drug–drug interactions, and must be Abergel et al. [10] published a trial on patients used in combination with at least one other DAA [6]. with HCV genotype 4 who received 12 weeks of [Downloaded free from http://www.mmj.eg.net on Thursday, January 14, 2021, IP: 156.204.184.20]

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ledipasvir–sofosbuvir. Overall, SVR 12 rates of Conclusion 93–95% were observed, with slightly lower rates for interferon‑experienced patients (91%). Ledipasvir + sofosbuvir for 12 weeks was a highly effective treatment option for treatment‑naïve HCV Shiha et al. [11] evaluated the efficacy and safety of patients and give better results than sofosbuvir and ledipasvir/sofosbuvir alone and with ribavirin for 8 and daclatasvir, respectively. 12 weeks in Egyptian patients with and without cirrhosis, who were infected with HCV genotype 4, including Financial support and sponsorship those who had failed previous treatment with sofosbuvir regimens. Of the 255 patients in the study, 61% were Nil. men, 67% were treatment naïve, 21% had cirrhosis, and 80% had IL28B non‑CC genotype. In this study, Conflicts of interest there were statistically significant differences between There are no conflicts of interest. patients receiving (sofosbuvir + ledipasvir) before and after treatment as regards serum creatinine, SGPT, SGOT, serum albumin, hemoglobin concentration, platelet concentration, FIB 4, and MELD score. References Also, there were statistically significant differences 1 Desmet VJ, Gerber M, Hoofnagle JH, Manns M, Scheuer PJ. Classification between patients receiving ‘sofosbuvir + daclatasvir’ of chronic hepatitis: diagnosis, grading and staging. Hepatology 1994; 19:1513–1520. before and after treatment as regards serum creatinine, 2 Blach S, Zeuzem S, Manns M, Altraif I, Duberg AS, Muljono DH, SGPT, SGOT, serum albumin, total bilirubin, Abaalkhail F. Global prevalence and genotype distribution of hepatitis C hemoglobin concentration, and FIB 4. But, there virus infection in 2015: a modeling study. 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