Ifn after a mean 3 years UND on antivirals achieves 7 % hbsag loss.

[studyforhope]

HBsAg clearance after addition of 48 weeks of PEGIFN in HBeAg negative CHB patients on Nucleos(t)ide ther- apy with undetectable HBV DNA for at least one year: a multicenter randomized controlled phase III trial ANRS-HB06 PEGAN study: preliminary findings
Marc Bourlière1, Pascaline Rabiega2, Nathalie Ganne-Carrié4, Lawrence Serfaty5, Patrick Marcellin6, Noelle Pouget2, Dominique Guyader7, Christophe Hezode8, Magali Picon9, Xavier Causse10, Vincent Leroy11, Jean-Pierre Bronowicki12, Ghassan Riachi13, Isabelle Rosa14, Pierre Attali15, Jean-Michel Molina16, Yannick Bacq17, Albert Tran18, Jean Didier Grange19, Fabien Zoulim20, Hélène Fontaine21, Inga Bertucci22, Magali Bouvier-Alias23, Fab- rice Carrat2, Yves Benhamou3; 1hepato-gastroenterology, hopital saint joseph, Marseille, France; 2INSERM UMR-S1136, Medical school Saint Antoine, Paris, France; 3Hepato-Gastroenterology, Pitié Salpêtrière University Hospital, Paris, France; 4Hepato-Gas- troenterology, Jean Verdier Hospital, Bondy, France; 5Hepato-Gas- troenterology, Saint Antoine hospital, Paris, France; 6Hepatology, Beaujon Hospital, Clichy, France; 7Hepatology, Pontchaillou University Hospital, Rennes, France; 8Hepato-Gastroenterology, Henri Mondor University Hospital, Creteil, France; 9Hepato-Gas- troenterology, Aix General Hospital, Aix en provence, France; 10Hepato-Gastroenterology, La source Hospital, Orleans, France; 11Hepato-Gastroenterology, University Hospital, Grenoble, France; 12Hepato-Gastroenterology, Brabois University Hospital, Nancy, France; 13Hepato-Gastroenterology, Charles Nicolle Hos- pital, Rouen, France; 14Hepato-Gastroenterology, Intercommunal Hospital, Creteil, France; 15Hepato-Gastroenterology, Bicêtre Hos- pital, Le Kremlin Bicêtre, France; 16Infectious diseases, Saint Louis Hospital, Paris, France; 17Hepato-Gastroenterology, Trousseau Hospital, Tours, France; 18Hepato-Gastroenterology, Archet Hos- pital, Nice, France; 19Hepato-Gastroenterology, Tenon Hospital, Paris, France; 20Hepato-Gastroenterology, Hotel Dieu Hospital, Lyon, France; 21Hepato-Gastroenterology, Cochin Hospital, Paris, France; 22Viral hepatitis, INSERM-ANRS, Paris, France; 23Bacteri- ology and Immunology, INSERM U 635, Creteil, France
Background and Aims: Uncontrolled studies suggest that addi- tion of PEGIFN in CHB patients receiving NUCs with unde- tectable serum HBV DNA may increase HBsAg clearance. We conducted a multicenter randomized controlled study to evaluate this strategy. Patients and methods: The key inclusion criteria were: HBeAg negative CHB and documented nega- tive HBV DNA while on stable NUC regimens for at least 1 year. Patients with PEGIFN contra-indications were excluded. From Jan 2011 to July 2012, 183 patients (86% male, mean age 47.6 years range 28-74, HBV DNA undetectable for 192 weeks range 17-685) were randomized to receive a 48 weeks course of 180 μg/w PEGIFN-alfa-2a (Pegasys) in addition to the backbone NUC regimens (Group 1: n=90) or no additional therapy (Group 2: n=93). Patients were stratified according to the HBsAg titers (< or ≥ 2.25 log IU/ml). NUC regimens remained unchanged during the study period up to week 144. Treatments discontinuation was allowed if HBsAg clearance was sustained for 24 weeks. Patients were seen monthly during the first 48 weeks, then every 3 months. The primary end point was the proportion of patients with serum HBsAg clearance at week 96. Secondary endpoints included HBsAg clearance at Week 48. Preliminary Results: 85 patients initiated PEGIFN in group 1, 17 patients discontinued prematurely PEGIFN due to adverse events, and 4 patients had a dose reduction to 135μg/w. There was no discontinuation of the NUC regimens in all the patients of both groups. At week 48, 6 patients had an HBsAg clearance in group 1 and 1 in group 2 (p= 0.061). Demographic and baseline characteristics, CHB history and history of anti-HBV therapies were studied. HBsAg clearance at the end of PEGIFN treatment (W48) was associated with (1) baseline HBsAg titer (p= 0.018) and (2) history of HBeAg seroconversion prior to randomization (4/17 (23.5%) vs 2/61(3.3%))(p=0.0185). Conclusion: Addition of a 48 weeks course of PEGIFN alfa-2a to oral anti-HBV therapy in HBeAg negative CHB patients with undetectable serum HBV DNA for at least 1 year: (1) Results in a low rate of HBsAg clearance (6/90 (6.6%)) and (2) Suggests that low baseline HBs Ag titers and a history of HBeAg seroconversion either spontaneously or under HBV therapy may increase HBsAg clearance rate.

[studyforhope]

since your antihbcIgM was neg in july chances are you are in a chronic stage.
but i basically agree with the proposed plan of action of your doctor.

[StephenCastlecrag]

Many thanks for the detailed explanations. Much to absorb and think about.

[melcul]

I have one question about my status, if you can give me an advice please,
i just discovered the HBV in june with 350k hbsag and 170 mil hbvdna, alt was high like ,80-110-50-70-80(monthly) fibrsocan f0. now hbsag raised to 380k after 3 months. should i start treatment? i don't know in which phase am i. Doctor told me to wait until 6 months since discovered , that will be this decembe, and if ALT will not normalize to start with interferon/ and if not works with nucs. (sorry to post here but it would really help me your opinion)

[studyforhope]

ad3
a complete elimination of all cccdna and integrated hbv dna in a liver that was once fully infected seems quite impossible.

since a single virion is capable of reinfecting the whole liver,  an external  treatment free situation is only possible if liver internal mechanisms contain the spread of reinfection from remnants.

A very effective mechanism to prevent reinfection spreading are surface antibodies, the will complex and cover virions soon after they leave the seeding cell. But the complexing reaction takes time and needs to be quite complete on all sides of the virion, and the next available cell to infect is only microns away, thus even a high antibodyntiter will not be able to prevent reinfevtion in the close vicinity of anninfected cell, leading to a slow but consistent growth of an infected cell cluster.

A population of memory T cells class1 , if available towards proper epitopes of the local hbv, will have time to react to this growth, engage and produce high dose local ifn gamma and TNFalpha, that will noncytopathically lead to cccdna lysis and clearance of the cluster cells.
This how a cure is likely to work and also how about two billion people infected with hbv remnants stay clear of reactivated disease, provided the immune system is not severely weakened by chemotherapy or anti TNFalpha therapy.

[studyforhope]

ad2
i have also often seen the notion that a cell dividion will clear both daughter cells from cccdna. Presumably, when the nuclear envelope dissolves during mitosis, the cccdna is lost.
Either the strong effects of mitosis on chromatin structure dismantle the ccdnas minichromosomes protein content, or the newly forming nuclei are not able to receive the minichromosomes floating in the cytosol, since only newly aquired or produced cores have the translocation signal that allows them entry into the nucleus interior.
a study with chimeric mice in hamburg has shown that activating cell division in the chimeric liver leads to a substantial reduction in hbv cccdna content, supporting the above notions.
nevertheless i am not convinced that a random redistribution of the multiple hbv minichromosomes into the two resulting cells does not often lead to a propagation of the infection, in spite of cell division.

[studyforhope]

thank you for your important questions.
ad1
while a high percentage of hbv integrations involve only partial fragments, that might or might not include a complete surface antigen gene fragment, there will be some integrations of full genomes as well, even if only in a small percentage.
these will, depending on the spot at which they fuse into the host chromosome, be of variable transcriptional activity in the host hepatocyte.
chisaris transgenic mouse model relies completely on integrated hbv genomes, producing virions and other viral products.
The degree of integrated vs just cccdna dependent cell populations is no doubt related to the age of the infection.

the problem of hbv genome integration obviously poses a fundmental hurdle to efforts to permanently control hbv infection. As mentioned above, aqelimination by CTLs is still possible, but a slow and ineffective process.

[StephenCastlecrag]

I have some questions, hopefully you can answer.

1.Is it really possible to integrate the whole HBV genome into our own genome? I read from some of the literature that most of integrated HBV genome are truncated.
2.Do integrated HBV genes survive the host cell's division (mitosis)? It has often been stated in the literature that cccDNA may be lost during an infected cell's division. Presumably, this is the mechanism that leads to an overall reduction of cccDNA in the liver if the rate of loss is greater than the rate of replenishment of the cccDNA pool (the author of one paper argued that persistence of cccDNA pool may be due to some of the infected cells not dividing due to some unknown reason).
3. There seems to be more evidence (from highly sensitive assays and re-activation of HBV during immuno suppressive treatments) that in most cases, cure of HBV means a profound suppression of HBV by the immune system and not a complete elimination of all cccDNA.?

Many thanks in advance.

[studyforhope]

so here is the relevant portion of 1855 again. you need to read it very carefully. the loss of hbsag does not match the undetectability of the cccDNA at all, this either due to a low sensitivity of the cccDNA assay or we must assume that the surface antigen and the core and the intrahepatic HBV DNA were produced from genome integrated hbv DNA.
This is not as nice as it may sound, while you can destroy cccdna with high dose local cytokines, you cannot eliminate these integrated hbv genomes or partial genomes. the only eay to get rid of these hbv containing cells is direct cell killing by cd8 CTL t cells after recognition of effective class 1 epitopes, a very inefficient process, considering you have 10 trillion liver cells to screen and then selectively kill.


At the last follow up, these patients were on 0.5-1.0mg entecavir (n=23), 600mg telbivudine (n=9), 10mg adefovir (n=4), 300mg tenofovir (n=2), or combination therapy of lamivudine plus adefovir/tenofovir (n=2). Histology of the third biopsy showed complete resolution of interface hepatitis in 60% of patients with the remainder showing mild-to-moder- ate activity.

Persistent immunoreactivity for HBsAg was found in 80%, the mean number of hepatocytes positive for HBsAg being 10.4% (range 1-80%).
SO WHERE IS THE CCCDNA IN THESE HEPATOCYTES?

All but 1 (2.5%) was immunore- active for HBcAg. At baseline, the median serum HBV DNA, HBsAg, ihHBV-DNA and cccDNA levels were 6.84 logIU/ mL, 3.38 logIU/mL, 286 copies/cell, and 7.3 copies/cell, respectively. At the time of the last biopsies, 36 (90%) patients had undetectable serum HBV DNA (<20 IU/mL),

all but one patient still had detectable HBsAg (median: 2.74 logIU/mL),

all had detectable ihHBV-DNA (median: 0.4 copies/cell), but 18 (45%) patients had undetectable cccDNA. There was a trend of reduction of HBsAg, ihHBV-DNA and cccDNA levels from baseline to 1 year to last follow-up (all p<0.0001). The median log drop of HBsAg at last biopsy was 0.55 logIU/mL. The median percentage reductions of HBsAg, ihHBV-DNA and cccDNA at last biopsies were 71.46%, 99.85% and 99.89%, respectively. Conclusions: Long-term NA treatment significantly reduced cccDNA and ihDNA. 45% of patients had undetect- able cccDNA, although small amount of ihHBV-DNA were still detectable in all patients. Integrated HBV DNA may be a pos- sible source of detectable ihHBV-DNA and HBsAg. Continuous long-term NA therapy can reduce cccDNA to undetectable levels, suggesting a possible end-point of treatment.

However, INTEGRATED FULL SIZE HBV GENOMES WILL STILL BE ABLE TO PRODUCE NEW VIRIONS THAT CAN SPREAD AND SLOWLY REINFECT THE LIVER, MORE SO SINCE NO HBSAB IS AROUND TO NEUTRALIZE THESE VIRIONS TE BLOCK REINFECTION.

in some cases a cd8 t cell response might have developed that can reduce the hbv containing cells and slow the respreading. But remember that such a t cell is very effective in eliminating cccdna by cytokine bursts but very slow in eliminating integrated genomes by direct cell killing.

[stef2011]

no this just means, as posted many times, that the best results are achieved only after many years on nucs, from the small studies about 5-7years and this must be replicated on other studies...also let's keep in mind that this may pose a risk on new drugs market so i dont know if we will see many big add on studies on patients on nucs for 5-10years or more

[melcul]

or AASLD poster, sry, messed them up

[melcul]

Can you explain us the results that EASL posters shows at, there was one that actually said that after 5-10 years of nucs the hbsag along with cccdna was very low in like 98% patients, and in conclusion they said that probably they will cure it if continue , we were talking before about it, this are kinda contradictory results one after another .

[melcul]

such a low response ..

[Bnd11]

Anyway this is not a good news for us who are believe in sequential therapy...
(23% success rate for patients having hbsag titer lower than 180 iu/ml)

[studyforhope]

Strongly depending on hbsag titer at start of add on: lower than 180 IU 23% above that 3.3%.

More years before start of this sequential therapy might improve the results.

Note that the mean time on antivirals before add on was 192 weeks.