EFFECT OF DDB MONOTHERAPY AND IN COMBINATION WITH AMANTADINE HYDROCHLORIDE AND RIBAVIRIN IN PATIENTS WITH CHRONIC HEPATITIS C VIRUS INFECTION

EFFECT OF DDB MONOTHERAPY AND IN COMBINATION WITH AMANTADINE HYDROCHLORIDE AND RIBAVIRIN IN PATIENTS

WITH CHRONIC HEPATITIS C VIRUS INFECTION

Hosny Mohamed Salama; Ayman Rashad Amer, Osama Mohamed Hammad, Wael Fathy El-Sayed

Tropical Medicine Department, Cairo Faculty of Medicine, Cairo University, Tropical Medicine Department, Beni-Suef Faculty

Of Medicine, Cairo University

ABSTRACT This study included 80 patients with chronic HCV infection presented to the

outpatient clinic of Tropical Medicine Department, Cairo University in the

period from March 2002 to March 2003. The 80 patients were randomly di-

vided into 4 groups (20 patients in each group). Group I received DDB

(Dimethyl Dimethoxy Biphenyl Dicarboxylate) orally (10 pillules t.d.s daily),

group II received DDB (as group I) puls 100 mg of amantadine capsules,

twice daily orally, group III received as group II plus ribavirin capsules

(each contains 200 mg), two capsules twice daily and group IV received sily-

marine 140 mg twice daily orally and served as a control group. All groups

received treatment for 3 months. DDB alone was effective in lowering serum

AST and normalization of serum ALT in the patients with no effect on

viraemia and no severe side effects. Addition of amantadine to DDB (group

II) led to clearance of viraemia in two patients (10%) and decrease of it in

the rest of patients with minimal side effects. Also addition of ribavirin to

DDB and amantidine (group III) led to clearance of viraemia in three

patients (15%) and significant decrease in the rest with mild side effects.

Liver biopsies of 5 patients in group I showed disappearance of portal

inflammation in two patients and piecemeal necrosis in three patients but

with no marked changes in the stage of fibrosis. DDB, amantidine and ri-

bavirin are cheap drugs, effective in controlling elevated AST and ALT in

chronic HCV patients with minimal side effects.

INTRODUCTION Hepatitis C virus (HCV) is a major cause of post transfusion hepatitis and

chronic liver disease (Choo, et al., 1990), and the prevalence of HCV infec-

tion in Egypt is the highest reported world-wide (Houghton, 1996 & Frank,

et al., 2000). About 85% of those infected with HCV will develop chronic

hepatitis of varying severity (Marcellin et al., 1999). Nearly 20% of patients

develop cirrhosis in 10-20 years and the incidence of hepato-cellular carci-

noma (HCC) is 1-4% per year in patients with cirrhosis (Sherlock & Doolry,

Sci. Med. J. ESCME, Vol. 16, No. 1, Jan. 2004

2002). Many lines of treatment of HCV infection have been tried including,

recombinant interferon-alpha (Rasi, et al., 1996), interferon-ribavirin com-

bination (Mc Hutchinson, et al., 1998), interferon-ribavirin-amantadine

(Brillanti, et al., 1999) and polythylenglycol (PEG)-conjugated interferon-

alpha (Zeuzem, et al., 2000). But interferon therapy is expensive and has

many side effects and other lines should be investigated. DDB (Dimethyl

Dimethoxy Biphenyl Dicarboxylate) is a synthetic analogue of schisandrin C

which is a traditional Chinese medicine since 1977 and was tried in treat-

ment of chronic HCV in China and Egypt with encouraging results

(Montasser, 2000 & 2001). THE AIM OF THE WORK The aim of this work is to assess the effect of DDB alone, with amantidine

HCL and both plus ribavirin in chronic hepatitis C patients and evaluate

their effects on liver enzymes and level of viraemia measured by polymerase

chain reaction (PCR).

PATIENTS AND METHODS This study included 80 patients with chronic HCV liver disease selected

from patients presenting to the outpatient clinic of Tropical Medicine De-

partment, Cairo University in the period from March 2002 to March 2003.

Inclusion criteria:

☯ Chronic HCV infection patients proved by positive HCV antibody and

positive serum HCV-RNA by PCR.

☯ Persistant elevation of ALT and AST levels for at least 6 months.

Exclusion criteria:

☯ Patients with liver cell failure or cirrhosis.

☯ Patients with mixed infection of HCV and HBV (detected by ELISA for

HBs Ag, HBs Ab and HBc-Ig ‘total’).

☯ Patients with renal failure.

☯ Patients with heart failure.

☯ Patients with epilepsy.

☯ Patients received specific therapy for HCV.

☯ Patients developed severe adverse effects to one of the drugs used.

The 80 patients were randomly divided into 4 groups (20 patients in each

group). Group I: received DDB orally (10 pillules three times daily) for 3

months. Group II: received DDB (as group I) and 100 mg amantidine cap-

sules (twice daily) orally for 3 months. Group III: received DDB and aman-

tidine (as group II) and ribavirin capsules (each contains 200 mg), two

capsules twice daily for 3 months. Group IV: received supportive treatment

(silymarine 140 mg) twice daily and served as a control group.

All patients were subjected to complete history, clinical examination ab-

dominal ultrasound, liver function tests (serum bilirubin, ALT, AST,

albumin and globulin and prothrombin time and concentration, kidney

function tests (blood urea and serum creatinine) and HCV –Ab. HCV-RNA

was detected in serum of patients using COBAS AMP/LCOR HCV MONI-

TOR (Roche diagnostics), quanitative for patients in groups II and III and

qualitative for patients in groups I and IV. Liver biopsy was performed for 5

patients in group I. All these tests and procedures were done at start of the

treatment and 3 months later.

Statistical analysis: Computer software package SPSS 10 was used for statistical analysis.

RESULTS • The study included 80 patients, 46 (57.5%) females and 34 (42.5%) males

with age ranged from 20 years to 52 years and a mean age value of 39.7 +

8.38. The clinical examination of patients revealed, jaundice in 4 (5%) pa-

tients, hepatomegaly in 29 (36.3%) patients, lichen planus in 8 (10%)

patients (Table 1).

• Concerning liver enzymes, there was a significant decrease in the mean

AST levels after treatment in groups I, II and III and when compared to

the control group (group IV), the decrease was found statistically signifi-

cant. There was a highly significant decrease in the mean ALT levels after

therapy in groups I, II and III when compared to the control group (Table

2). After 3 months of therapy all patients in groups I, II and III turned to

normal level of ALT except one patient in group II who had high ALT

level. No significant changes of total bilirubin levels were detected between

all groups.

• After 3 months of treatment no patient in group I and IV has become

negative for HCV-RNA by qualitative PCR, while there was significant

decrease of mean viral levels in group III, after treatment, detected by

quantitative PCR. In group II the mean viral level was decreased after

treatment by quantitative PCR but without significant difference (Table

3).

• As regard levels of viraemia in group II and III, the viraemia could not be

detected in 2 (10%) and 3 (15%) patients respectively (quantitative PCR

can not detect viraemia less than 600 IU/ml). There was no significant dif-

ference in virological response between males and females in groups II and

III. The side effects detected in patients were illustrated in table (4).

• Liver biopsies were taken from 5 patients in group I before and 3 months

after treatment. According to portal inflammation, 2 patients showed dis-

appearance of it (one had moderate and the other minimal portal

inflammation) and remained minimal in 2 patients and no response in one

patient with sever portal inflammation. Piecemeal necrosis disappeared in

3 patient who had mild piecemeal necrosis and there was no change in two

patients, one had minimal piecemeal necrosis and the other has no piece-

meal necrosis before treatment. As regard fatty degeneration, it

disappeared in two patients, increased in one patient and remained as be-

fore therapy in 2 patients. Fibrosis remained without changes in 4 patients

and increased in one patient. These date are illustrated in table (5).

Table (1): Clinical picture of 80 patients with chronic HCV hepatitis.

Clinical features No. (%)

Jaundice 4 (5%)

Hepatomegaly 29 (36.3%)

Lichen plannus 8 (10%)

Splenomegaly 0 (0%)

Ascites 0 (0%)

Table (2): Biochemical and Virological Response

Group 1 Group II Group III Group IV

Before After Before After Before After Before After

Min. 0.3 0.3 0.2 0.3 0.3 0.3 0.2 0.3

Max. 3.5 3.0 3.2 2.8 1.6 1.4 2.0 2.03

T-b

iliru

bin

N (0

.1-1

)

Mean + SD

0.75 + 0.68

0.74 + 0.56

0.9 + 0.67

0.78 + 0.53

0.67 + 0.36

0.66 + 0.28

0.74 + 0.46

0.69 + 0.38

Min. 54 22 50 22 45 15 50 20

Max. 95 62 85 71 77 71 90 109

AST

N

(0-3

2)

Mean + SD

60.15 + 11.8

48.75* + 9.2

62.7 + 9.8

43* + 15.4

63.45 + 97

47* + 18.4

61.15 + 13.1

52.6 + 22.2

Min. 50 31 45 8 54 8 60 31

Max. 96 32 91 67 85 30 96 93

AL

T

N (0

-32)

Mean + SD

65.3 + 13

26.5** + 9.7

63.7 + 10.8

23.15** + 13.9

68.65 + 12.2

23.76** + 10.3

70.7 + 17

54.2 + 23

Min. 38000 <600 29000 <600

Max. +ve +ve 68700000 1954000 1700000 815000 +ve +ve

PCR

Mean + SD

691097 +

1501461

273235 + 444300

488015 +

506250

154126* + 2150

* : means that P-value is <0.05. **: means that P-value is <0

Table (3): Virological Response in patients of groups II & III

Viremia before therapy Viremia after therapy

Weak Moderate High No Weak Moderate High

No. % No. % No. % No. % No. % No. % No. %

Group II 0 0 17 85 3 15 2 10 1 5 15 75 2 10

Group III 1 5 16 80 3 15 3 15 2 10 14 70 1 5

Table (4): Side effects detected in groups I, II & III

Side effects (S.E) Group I Group II Group III

Objective S.E N % M:F N % M:F N % M:F Mode changes 2 10 0/2 5 25 2/3 2 10 0/2 Dry mouth 2 10 0/2 4 20 1/3 3 5 1/2 Insomnia 2 10 0/2 3 15 1/2 2 10 1/1 Irritability 1 5 0/1 2 10 0/2 - 0 - Anorexia 2 10 1/1 3 15 1/2 1 5 0/1 Nausea 3 15 0/3 1 5 0/1 1 5 0/1 Easy fatiugability - 0 - - 0 - 1 5 1/0 Subjective S.E N % M:F N % M:F N % M:F Anaemia - 0 - - 0 - 1 5 1/0

Table (5): Histopathological changes

detected in five patients of group I

Pt no1 Pt no2 Pt no3 Pt no4 Pt no5

Be-fore

Af-ter

Be-fore

Af-ter Before Af-

ter Be-fore

Af-ter

Be-fore After

Portal inflam-mation

Mild Mild Mild No Moder-

ate No Mild Mild Se-vere

Se-vere

Piece-meal necrosis

Mild No Mild No Mild No No No Mild Mild

Fatty degen-eration

1+ 0 1+ 0 1+ 2+ 2+ 2+ 1+ 1+

Fibrosis No No No No Early Early Early Earl

y No Early

DISCUSSION HCV infection is a wide spread problem, following mainly blood transfusion,

surgical procedures, operations and dental procedures (Donaldson et al.,

1994). In Egypt, HCV infection is mainly caused by genotype 4. A trial of

interferon alfa (which is expensive with many side effects) plus ribavirin in

patients infected with this genotype resulted a virological sustained response

rate of 20.8% (El-Zayadi et al., 1999).

In our study DDB alone (10 pilules tds for 3 months) in group I was effective

in lowering mean serum AST, ALT with highly statistical significance and

also when compared to the control group with normalization of ALT in

100% of patients. This agrees with the results of Montasser, (2000) when

patients received 15 pilules bid for 3-6 months, then the dose was reduced to

10 pilules bid for 12 months according to the response. These results are also

in agreement with Liu (1987) and Gao et al., (1998). No significant change

was detected in mean bilirubin level after therapy, in contrast to studies

done by Montasser, (2000 & 2001), there were significant decrease in mean

serum bilirubin values. DDB alone had no effect on HCV RNA as no patient

turned to have PCR negative after three months of therapy. In Montasser,

(2000 & 2001) studies 10.66% and 15% of DDB treated cases turned to have

negative results after 12 months respectively. As regards side effects re-

ported in group I either subjective or objective as nausea, anorexia, dry

mouth, mood changes & irritability were mild and in agreement with Mon-

tasser, (2000).

In group II addition of amantadine HCL 200 mg/day to DDB for 3 months

was also effective in lowering mean serum AST, ALT with highly statistical

significance when compared to the control group with normalization of ALT

values in all patients except one patient and this agrees more or less with

Liu, (1987), Gao et al., (1998), and Montasser, (2001). Also there was no sig-

nificant change in mean bilirubin level in contrast to a series done by Mon-

tasser, (2001), there was significant decrease in mean serum bilirubin values.

Regarding levels of viremia of patients in group II, viremia decreases after

therapy, but this decrease was not of statistical significance, viremia of 10%

of cases could not be detected by quantitiative PCR. In Montasser, (2001)

study, 40% of cases turned negative PCR for HCV-RNA. Regarding side

effect reported in group II were mood change, dry mouth, insomnia, ano-

rexia, irritability & nausa. These side effects are in agreement with

Montasser, (2001).

In group III, addition of ribavirin 800mg/day to DDB & amantadine led also

to significant decrease in serum AST, ALT and normalization of ALT values

in all patients with no significant changes in mean bilirubin and hemoglobin

values and these agree with group I & II. Also, viremia showed significant

decrease in 15% of cases and viremia can not be detected by quantitative

PCR. In contrast, group II patients, showed a decrease in viremia but was

not statistically significant and viremia can not detected in 10% of cases.

Regarding side effects detected in this group were mild as in group I & II

except in one patient (5%) developed anaemia and easy fatiguability which

was reversible after cessation of treatment.

Concerning histopathology, liver biopsy was done to 5 patients in group I

before and after DDB treatment. It was the first study to be done for the as-

sessment of histopathological changes. It showed significant decrease in

portal inflammation in 2 patients and piecemeal necrosis in 3 patients but no

significant change in the stage of fibrosis after three months of therapy.

From this study we conclude that: DDB is effective in lowering serum AST

and normalization of serum ALT in chronic HCV patients, with no effect on

viraemia and no severe side effects. Addition of amantadine to DDB led to

clearance of viraemia in 10% of patients and decrease of it in the rest of pa-

tients with minimal side effects. Also addition of ribavirin to DDB and

amantadine led to clearance of viraemia in 15% of patients and significant

decrease in the rest with mild side effects. It was the first study for the as-

sessment of histopathological changes after DDB treatment. It showed

marked decrease in portal inflammation and piecemeal necrosis but with no

marked changes in the stage of fibrosis.

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دراسة تأثير حبيبات الدى دى بى وحدها أو مع عقار هيدروآلورايد األمنتادين

المزمن)سي(والريبافيرين على مرضى االلتهاب الكبرى الفيروسي *ووائل فتحى السيد* حسني محمد سالمه وأيمن رشاد عامر وأسامه محمد حماد

طب بني سويف جامعة القاهرة*قسمي األمراض المتوطنة بكلية طب القاهرة و

الملخص العربى

من المرضى المترددين على العيادةالمزمن ) سي( مريضًا بااللتهاب الكبدي ٨٠شملت هذه الدراسة

\ تم ،٢٠٠٣ إلى مارس ٢٠٠٢بقسم األمراض المتوطنة بجامعة القاهرة في الفترة من مارس الخارجية

تم): ١(المجموعة . مريضًا٢٠على آل مجموعة تحتوي مجموعات، ٤تقسيم المرضى عشوائيًا إلى

تم إعطائهم): ٢(، والمجموعة )يًا حبيبات ثالث مرات يوم١٠(إعطاء المرضى فيها عقار الدى دى بى

تم): ٣( والمجموعة ،)يوميًامج آبسولة مرتين ١٠٠(باإلضافة إلى عقار األمنتادين ) ١(ثل المجموعة م

١٢آبسولتين آل ) مج آبسولة٢٠٠ (باإلضافة إلى عقار الريبافيرين) ٢(إعطائهم مثل المجموعة

تم.ضابطة ساعة واستخدمت آمجموعة ١٢مجم آل ١٤٠أعطيت السيلمارين ) ٤(ساعة، والمجموعة

.إعطاء العالج للمرضى لمدة ثالثة شهور

دم ورجوع مستوى ASTآان مؤثرًا في تخفيض مستوى ) ١مجموعة (عقار الدى دى بى لوحده في ال

ALTفي الدم إلى طبيعته وبدون أي تأثير على الفيروسات بالدم وبدون أي مضاعفات شديدة .

اختفاء الفيروس في اثنين منأدى إلى) ٢مجموعة (إضافة عقار األمنتادين إلى عقار الدى دى بى

في باقي) حصائيًا في هذه الدراسةبالرغم من عدم أهميتها إ(وتقليل الفيروس بالدم %) ١٠(المرضى

.المرضى مع آثار جانبية طفيفة

أدى إلى اختفاء الفيروس في) ٣عة مجمو(نتادين إضافة عقار الريبافيرين إلى عقاري الدى دى بى واألم

. مع انخفاض ذو داللة إحصائية في الفيروسات بالدم مع آثار جانبية طفيفة%) ١٥(ثالثة من المرضى

تفى االلتهاب البابي في إثنين من ولقد اخ،)١(تم أخذ عينات آبدية من خمسة مرضى في المجموعة

%). ١٥(جي في ثالثة من المرضى وأيضا التنكرز التدري%) ١٠(المرضى

ي ؤثرة ف اقير رخيصة وم افيرين ، عق ادين والريب ى واألمنت دى دى ب ة أن ال ذه الدراس ن ه تخلص م نس

ى أن ) سي ( في مرضى االلتهاب الكبدي الفيروسي AST, ALTتحسين مستوى زمنين باإلضافة إل الم

.آثارهم الجانبية طفيفة