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Hbeag-Negative Hbeag-Positive ANTIVIRAL TREATMENT VIRAL HEPATITIS author by eLibrary Prof. MojcaBern Matičič, 2017 MD, PhD Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana ESCMIDFaculty of Medicine, University of Ljubljana © Slovenia Ljubljana: April 15, 2019 Global number of deaths due to infectious dieases, period 2000-2015 • Text here authorBy the year 2030: • Text here by 20 million • Text here new deaths eLibrary ESCMID © WHO Global hepatitis report, 2017. Available at: http://apps.who.int/iris/bitstream/10665/255017/1/WHO-HIV-2017.06-eng.pdf. Global number of deaths due to viral hepatitis in 2015 96% ofauthordeaths due to byHBV and HCV eLibrary ESCMID © WHO. Global hepatitis report, 2017. http://apps.who.int/iris/bitstream/10665/255017/1/WHO-HIV-2017.06-eng.pdf. Global number of deaths due to viral hepatitis in 2015 – hepatitis B and C are the major problems in Europe author by eLibrary ESCMID © WHO Global hepatitis report, 2017. Available at: http://apps.who.int/iris/bitstream/10665/255017/1/WHO-HIV-2017.06-eng.pdf. A lifecycle of the three viruses HBV HCV HIV Lifelong persistance Does NOT enter authorLifelong persistance in hepatocyte nucleus the hepatocyte nucleus integrated in cellular genome (cccDNK) by of memory cells eLibrary ESCMID © Soriano V, et al. J Antimicrob Chemother 2008;62:1–4. A lifecycle of the three viruses and their treatment HBV HCV HIV TREATMENT: TREATMENT: authorTREATMENT: No reservoir of infection Lifelong supression Clearance by Lifelong supression CURE eLibrary ESCMID © Soriano V, et al. J Antimicrob Chemother 2008;62:1–4. A lifecycle of the three viruses and treatment HBV HCV HIV TREATMENT: TREATMENT: authorTREATMENT: No reservoir of infection Lifelong supression Clearance by Lifelong supression CURE eLibrary ESCMID © Soriano V, et al. J Antimicrob Chemother 2008;62:1–4. The global burden of HBV and HCV infections HBV HCV author Chronically by infected 257 million 71 million eLibrary Infection 9% 20% diagnosed ESCMID Infection© 8% 7% treated WHO. Global hepatitis report, 2017. http://apps.who.int/iris/bitstream/10665/255017/1/WHO-HIV-2017.06-eng.pdf. author by eLibrary ESCMID © HEPATITIS C Hepatitis C is a sistemic disease that may lead to life-threatening conditions Extrahepatic manifestations Liver author40-73% by Immune Metabolic HCV induces crioglobulins – HCV induces insulin eLibraryClinical features : resistance – risk for Chronic hepatitis type 2 diabetes • Fatigue mellitus: • Arthralgias/arthritis • T2DM associated with • Purpura metabolic syndrome • Decompensated cirrhosis • Sicca syndrome HCV may contribute to other metabolic complications: • Peripheral neuropathy ESCMID - Coronary artery disease – Acute • Membranoproliferative coronary stroke glomerulonephritis Hepatocellular© - Cerebral vascular diseae - Stroke • B-cell Non-Hodgkin lymphoma carcinoma - Chronic kidney disease – End Stage Renal Disease Ramos-Casals M et al. J Hepatol 2017; 66:1282-99. Timeline of HCV Therapy author by eLibrary Sofosbuvir+Velpatasvir+Voxilaprevir ESCMID © P/R=pegylated nterferon+ribavirin RBV=ribavirin Sustained virological response (SVR) rates of HCV treatment (GT1, treatment naive) author by eLibrary ESCMID © Adapted from Strader DB, et al. Hepatology 2004;39:1147-71. INCIVEK [PI]. Cambridge, MA: Vertex Pharmaceuticals; 2013. VICTRELIS [PI]. Whitehouse Station, NJ: Merck & Co; 2014. Jacobson I, et al. EASL 2013. Amsterdam. The Netherlands. Poster #1425. Manns M, et al. EASL 2013. Amsterdam. The Netherlands. Oral #1413. Lawitz E, et al. APASL 2013. Singapore. Oral #LB-02; Afdhal N, et al. N Engl J Med 2014; 370: 1889-98; Kowdley K, et al. N Engl J Med 2014; 370: 1879-88. Sustained virological response (SVR) rates of HCV treatment (GT1, treatment naive) author by eLibrary ESCMID © Adapted from Strader DB, et al. Hepatology 2004;39:1147-71. INCIVEK [PI]. Cambridge, MA: Vertex Pharmaceuticals; 2013. VICTRELIS [PI]. Whitehouse Station, NJ: Merck & Co; 2014. Jacobson I, et al. EASL 2013. Amsterdam. The Netherlands. Poster #1425. Manns M, et al. EASL 2013. Amsterdam. The Netherlands. Oral #1413. Lawitz E, et al. APASL 2013. Singapore. Oral #LB-02; Afdhal N, et al. N Engl J Med 2014; 370: 1889-98; Kowdley K, et al. N Engl J Med 2014; 370: 1879-88. Direct-acting antivirals (DAAs) NS5A ihibitors Ombitasvir (OBV) Ledipasvir (LDV) Daclatasvirauthor (DCV) by Elbasvir (EBR) Pibrentasvir (PIB) Velpatasvir (VEL) eLibrary MK-8408 ruzasvir (RZR)* Polymerase inhibitors NS5B Protease inhibitors Sofosbuvir (SOF) NS3/4A ESCMID Dasabuvir (DSV) Voxilaprevir (VOX) Grazoprevir (GZR) Glecaprevir (GLE) © MK-3682 uprifosbuvir (UPR)* Asunaprevir (ASV) Paritaprevir (PTV) Boceprevir (BOC) Narlaprevir (NAR) Simeprevir (SMV) * Investigational drugs. Adapted from Manns MP, et al. Nat Rev Drug Discov. 2007;6:991-1000. DAA combinations of 2nd generation Pangenotypic author by SOFOSBUVIR/ eLibrary SOFOSBUVIR/ VELPATASVIR GLECAPREVIR/ VELPATASVIR/ PIBRENTASVIR VOXILAPREVIR ESCMID © MAV—VHC—MED—164—nov17—R—A—DLU déc18 v1 Resistance-associated substitutions (RASs)) author by eLibrary ESCMID © EASL. Recommendations on Treatment of Hepatitis C 2018..J Hepatol 2018 (in press);https://doi.org/10.1016/j.jhep.2018.03.026 Efficacy of SOF/VEL/VOX for 12 Weeks in DAA-Experienced Patients SVR12 in DAA-Experienced Patients With and Without RASs By HCV GT author by eLibrary ESCMID © No impact of RAS Sarrazin et al. EASL 2017; Poster THU-248. Which combination to choose? Drug-drug interactions Frequency of Underlyingauthor dosing diseasesby Special Treatment conditions duration eLibrary (Tx) Adverse Cirrhosis events ESCMID © Life style DDI, drug–drug interaction. author by EASL Recommendations on Treatment of Hepatitis C 2018 eLibrary Chair: Jean-Michel Pawlotsky EASL govrning board Representative : Francesco Negro Panel: AlessioESCMID Aghemo , Marina Berenguer, Olav Dalgard, Geoffrey Dusheiko, Fiona © Marra, Massimo Puoti, Heiner Wedemeyer Presented on April 14, 2018 at EASL, in press in J Hepatology DAAs approved in Europe in 2018 and recommended by EASL guidelines 2018 author by eLibrary ESCMID © EASL. Recommendations on Treatment of Hepatitis C 2018..J Hepatol 2018 (in press);https://doi.org/10.1016/j.jhep.2018.03.026 INDICATIONS for Treatment of HCV infection • All HCV infected patients UNIVERSAL ACCESS TO THERAPYauthor by • DAA based regimen without IFN and without ribavirine • For all patients: eLibrary • Those without and with cirrhosis (Child Pugh A) • Those naive and pretreated ESCMID • Same© regimen for those with HIV infection EASL. Recommendations on Treatment of Hepatitis C 2018..J Hepatol 2018 (in press);https://doi.org/10.1016/j.jhep.2018.03.026 EASL treatment recommendations 2018: no cirrhosis or compensated cirrhosis Pangenotypic regimens Genotype-specific regimens Genotype SOF/VEL/ SOF/VEL GLE/PIB SOF/LDV GZR/EBR 3D VOX author Genotype 1a Yes Yes No* byYes a Yesb No Genotype 1b Yes Yes No* Yes Yes Yes Genotype 2 Yes Yes No* No No No Genotype 3 Yesc eLibraryYes Yesd No No No Genotype 4 Yes Yes No* Yesa Yese No Genotype 5 Yes Yes No* Yesa No No Genotype 6 Yes Yes No* Yesa No No *Triple combination therapy efficacious but not useful due to the efficacy of double combination regimens. aTreatment-naïve patients withoutESCMIDcirrhosis or with compensated (Child-Pugh A) cirrhosis. bTreatment-naïve and treatment-experienced patients without cirrhosis or with compensated (Child-Pugh A) cirrhosis with an HCV RNA level ≤800,000 IU/mL (5.9©Log IU/mL). 10 cTreatment-naïve and treatment-experienced patients without cirrhosis. dTreatment-naïve and treatment-experienced patients with compensated (Child-Pugh A) cirrhosis. e Treatment-naïve patients without cirrhosis or with compensated (Child-Pugh A) cirrhosis with an HCV RNA level ≤800,000 IU/mL (5.9 Log10 IU/mL) EASL. Recommendations on Treatment of Hepatitis C 2018..J Hepatol 2018 (in press);https://doi.org/10.1016/j.jhep.2018.03.026 EASL treatment recommendations 2018: decompensated cirrhosis • No protease inhibitors +++ author • Sofosbuvir/Ledipasvir + RBV for 12 weeksby • Sofosbuvir/Velpatasvir + RBV for 12 weeks eLibrary • Treatment for 24 weeks without ribavirin (contra-indications or poor tolerance to ribavirin) ESCMID © EASL. Recommendations on Treatment of Hepatitis C 2018..J Hepatol 2018 (in press);https://doi.org/10.1016/j.jhep.2018.03.026 EASL treatment recommendations 2018: other special groups • Renal impairment • HBV coinfection author • Immune-complex mediated manifestationsby of chronic hepatitis C • Non-hepatic solid organ transplant recipients • PWIDs eLibrary • Haemoglobinopathies and bleeding disorders • Adolescents and children ESCMID © EASL. Recommendations on Treatment of Hepatitis C 2018..J Hepatol 2018 (in press);https://doi.org/10.1016/j.jhep.2018.03.026 DAAs and Drug-Drug Interactions author by eLibrary ESCMID © EASL. Recommendations on Treatment of Hepatitis C 2018..J Hepatol 2018 (in press);https://doi.org/10.1016/j.jhep.2018.03.026 Benefits of Curing HCV infection Cure author Decreased Improved clinical by HCV transmission outcomes Hepatic Extrahepatic Reduction in: eLibrary Improvement in: Cirrhosis All-cause mortality Decompensation Quality of life HCC Lymphoproliferative disorders Transplantation Diabetes, insulin resistance, ESCMID renal/cardiovascular outcomes © Neurocognition Smith-Palmer J, et al. BMC Infect Dis. 2015;15:19. Negro F, et al. Gastroenterology. 2015;149:1345-1360. George SL, et al. Hepatology. 2009;49:729-738. TAKE HOME MESSAGE • Potent and simplified therapies for HCV infection author by – Short duration, > 95% efficacy – No
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