Clinical Infectious Diseases Advance Access published June 16, 2015
1 Hepatitis B Reactivation During Successful Treatment of Hepatitis C with Sofosbuvir and Simeprevir Jeffrey M. Collins1, Kara Loren Raphael2, Charles Terry2, Emily J. Cartwright3, Anjana
cr ipt
Pillai4, Frank A. Anania5, Monica M. Farley6 1
Fellow, Division of Infectious Diseases, Department of Medicine, Emory University School of
Medicine, Atlanta, GA USA 2
Resident, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
3
Assistant Professor of Medicine, Division of Infectious Diseases, Department of Medicine,
USA 4
Assistant Professor, Division of Digestive Diseases and Emory Transplant Center, Department
of Medicine, Emory University School of Medicine, Atlanta, GA USA 5
an
Professor of Medicine and Digestive Diseases, Director, Division of Digestive Diseases, Emory
University School of Medicine, Staff Physician, Atlanta VA Medical Center, Atlanta, GA USA 6
Professor of Medicine and Infectious Diseases, Director, Division of Infectious Diseases, Emory
M
University School of Medicine, Staff Physician, Atlanta VA Medical Center, Atlanta, GA USA
Corresponding Author: Jeffrey M. Collins, Emory University School of Medicine, Division of Infectious Diseases, Woodruff Memorial Building, Ste. 2101,1639 Pierce Drive, Atlanta, GA
Ac
ce
pt ed
30322. E-mail: [email protected]
© The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected].
Downloaded from http://cid.oxfordjournals.org/ at New York University on June 18, 2015
us
Emory University School of Medicine, Staff Physician, Atlanta VA Medical Center, Atlanta, GA
2 Abstract Treatment of HCV with potent, interferon-free, direct acting antiviral regimens with no activity against HBV may increase the risk for HBV reactivation in co-infected patients. We present two
cr ipt
cases of HBV reactivation during treatment with an all oral regimen of simeprevir and sofosbuvir and discuss strategies to prevent HBV flare.
Introduction
Sofosbuvir, an NS5B polymerase inhibitor combined with simeprevir, a second
us
hepatitis C virus (HCV) in chronic genotype 1 infection [1]. The increased risk of hepatic cirrhosis and hepatocellular carcinoma in individuals co-infected with hepatitis B virus (HBV) [2]
an
make these patients a priority for treatment with these newer, more effective anti-HCV therapies. However, little is known about the use of direct acting anti-viral medications in HBV/HCV co-infection as these patients were excluded from recently published clinical trials
M
[1,3]. HCV is known to cause suppression of HBV replication in co-infected patients [4], and increased HBV viral replication following successful treatment of HCV with pegylated interferonα (pegIFN-α) and ribavirin has been reported [5,6]. Since these all oral anti-HCV therapies have no activity against HBV, the risk for and magnitude of HBV viremia following HCV treatment
pt ed
may be increased. We present two cases of HBV viremia during successful treatment of HCV with sofosbuvir and simeprevir. Case 1
A 55-year-old male with a history of chronic HBV and genotype 1a HCV co-infection presented for treatment of HCV. Two previous treatment courses with pegIFN-α and ribavirin failed to produce a sustained virologic response. MRI of the abdomen demonstrated evidence
ce
of cirrhosis and portal hypertension. Clinically, the patient had compensated cirrhosis with Childs Pugh class A liver disease. A pre-treatment HCV viral load (VL) was 1.3 million IU/mL. HBV VL was 2,300 IU/mL (all previous HBV VL were less than 2,000 IU/mL), ALT 62 IU/mL,
Ac
AST 59 IU/mL, total bilirubin 0.7 mg/dL, platelets 135,000 per cm2, and INR 1.05; HBeAb was positive and HBeAg negative. Sofosbuvir and simeprevir were initiated and resulted in a rapid decline in HCV VL. At
week 2 the HCV VL was 26 IU/mL and by week 4 the HCV VL was undetectable. After 7 weeks of treatment the patient began to experience malaise, nausea and epigastric abdominal pain. Physical examination at week 8 revealed significant jaundice with tender hepatomegaly. Liver
Downloaded from http://cid.oxfordjournals.org/ at New York University on June 18, 2015
generation protease inhibitor, has been shown to produce a rapid and sustained clearance of
3 function tests were now significantly abnormal with an AST of 1792 IU/L, ALT of 1495 IU/L, total bilirubin of 12.2 mg/dL and INR of 1.96. Urine toxicology and blood acetaminophen level were negative. Serologies for HIV and hepatitis E were negative. His ANA titer was
1 Hepatitis B Reactivation During Successful Treatment of Hepatitis C with Sofosbuvir and Simeprevir Jeffrey M. Collins1, Kara Loren Raphael2, Charles Terry2, Emily J. Cartwright3, Anjana
cr ipt
Pillai4, Frank A. Anania5, Monica M. Farley6 1
Fellow, Division of Infectious Diseases, Department of Medicine, Emory University School of
Medicine, Atlanta, GA USA 2
Resident, Department of Medicine, Emory University School of Medicine, Atlanta, GA USA
3
Assistant Professor of Medicine, Division of Infectious Diseases, Department of Medicine,
USA 4
Assistant Professor, Division of Digestive Diseases and Emory Transplant Center, Department
of Medicine, Emory University School of Medicine, Atlanta, GA USA 5
an
Professor of Medicine and Digestive Diseases, Director, Division of Digestive Diseases, Emory
University School of Medicine, Staff Physician, Atlanta VA Medical Center, Atlanta, GA USA 6
Professor of Medicine and Infectious Diseases, Director, Division of Infectious Diseases, Emory
M
University School of Medicine, Staff Physician, Atlanta VA Medical Center, Atlanta, GA USA
Corresponding Author: Jeffrey M. Collins, Emory University School of Medicine, Division of Infectious Diseases, Woodruff Memorial Building, Ste. 2101,1639 Pierce Drive, Atlanta, GA
Ac
ce
pt ed
30322. E-mail: [email protected]
© The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected].
Downloaded from http://cid.oxfordjournals.org/ at New York University on June 18, 2015
us
Emory University School of Medicine, Staff Physician, Atlanta VA Medical Center, Atlanta, GA
2 Abstract Treatment of HCV with potent, interferon-free, direct acting antiviral regimens with no activity against HBV may increase the risk for HBV reactivation in co-infected patients. We present two
cr ipt
cases of HBV reactivation during treatment with an all oral regimen of simeprevir and sofosbuvir and discuss strategies to prevent HBV flare.
Introduction
Sofosbuvir, an NS5B polymerase inhibitor combined with simeprevir, a second
us
hepatitis C virus (HCV) in chronic genotype 1 infection [1]. The increased risk of hepatic cirrhosis and hepatocellular carcinoma in individuals co-infected with hepatitis B virus (HBV) [2]
an
make these patients a priority for treatment with these newer, more effective anti-HCV therapies. However, little is known about the use of direct acting anti-viral medications in HBV/HCV co-infection as these patients were excluded from recently published clinical trials
M
[1,3]. HCV is known to cause suppression of HBV replication in co-infected patients [4], and increased HBV viral replication following successful treatment of HCV with pegylated interferonα (pegIFN-α) and ribavirin has been reported [5,6]. Since these all oral anti-HCV therapies have no activity against HBV, the risk for and magnitude of HBV viremia following HCV treatment
pt ed
may be increased. We present two cases of HBV viremia during successful treatment of HCV with sofosbuvir and simeprevir. Case 1
A 55-year-old male with a history of chronic HBV and genotype 1a HCV co-infection presented for treatment of HCV. Two previous treatment courses with pegIFN-α and ribavirin failed to produce a sustained virologic response. MRI of the abdomen demonstrated evidence
ce
of cirrhosis and portal hypertension. Clinically, the patient had compensated cirrhosis with Childs Pugh class A liver disease. A pre-treatment HCV viral load (VL) was 1.3 million IU/mL. HBV VL was 2,300 IU/mL (all previous HBV VL were less than 2,000 IU/mL), ALT 62 IU/mL,
Ac
AST 59 IU/mL, total bilirubin 0.7 mg/dL, platelets 135,000 per cm2, and INR 1.05; HBeAb was positive and HBeAg negative. Sofosbuvir and simeprevir were initiated and resulted in a rapid decline in HCV VL. At
week 2 the HCV VL was 26 IU/mL and by week 4 the HCV VL was undetectable. After 7 weeks of treatment the patient began to experience malaise, nausea and epigastric abdominal pain. Physical examination at week 8 revealed significant jaundice with tender hepatomegaly. Liver
Downloaded from http://cid.oxfordjournals.org/ at New York University on June 18, 2015
generation protease inhibitor, has been shown to produce a rapid and sustained clearance of
3 function tests were now significantly abnormal with an AST of 1792 IU/L, ALT of 1495 IU/L, total bilirubin of 12.2 mg/dL and INR of 1.96. Urine toxicology and blood acetaminophen level were negative. Serologies for HIV and hepatitis E were negative. His ANA titer was
