Peginterferon alfa-2b plus ribavirin for naïve patients with genotype 1 chronic hepatitis C: a randomized controlled trial

Peginterferon alfa-2b plus ribavirin for naıve patients with genotype 1chronic hepatitis C: a randomized controlled trial*

Savino Bruno1,†, Calogero Camma2,3,†, Vito Di Marco2, Mariagrazia Rumi4, Maria Vinci5,Mario Camozzi6, Chiara Rebucci7, Danilo Di Bona2, Massimo Colombo4, Antonio Craxı2,

Mario U. Mondelli7,*, Giovanbattista Pinzello5

1Clinica Medica, Ospedale San Paolo and Liver Unit, Ospedale Fatebenefratelli e Oftalmico, Milano, Italy2Cattedra e Unita Operativa di Gastroenterologia, University of Palermo, Italy

3IBIM, Consiglio Nazionale delle Ricerche, Palermo, Italy4Cattedra e Unita Operativa di Gastroenterologia, IRCCS Ospedale Maggiore, University of Milano, Italy

5Divisione di Gastroenterologia, Ospedale Niguarda, Milano, Italy6Servizio di Anatomia Patologica, Ospedale Niguarda, Milano, Italy

7Dipartimento di Malattie Infettive e Laboratori di Ricerca-Area Infettivologica, IRCCS Policlinico San Matteo and University of Pavia,

Via Taramelli 5, 27100 Pavia, Italy

0168-8278/$30.00 q 2004 European Association for the

doi:10.1016/j.jhep.2004.05.012

Received 12 January 2004; received in revised form 21* The authors declare that they did not receive funding

the drug in this study.

* Corresponding author. Tel.: C39-382-502636; fax: C

E-mail address: [email protected] (M.U. M

Abbreviations: HCV, hepatitis C virus; HCV-RNA, hepa

ratio.

† Savino Bruno and Calogero Camma contributed equ

See Editorial, pages 488–490

Background/Aims: We assessed the effectiveness and safety of an induction dose of peginterferon alfa-2b (PEG-IFN)

plus ribavirin for initial treatment of patients with genotype 1 chronic HCV infection in a randomized, controlled,

multicenter trial.

Methods: Three hundred and eleven naıve patients infected with genotype 1 and chronic hepatitis were randomlyassigned to 48-week treatment with PEG-IFN once weekly (80–100 mg depending on body weight for 8 weeks, followed

by 50 mg for the next 40 weeks), or standard interferon alfa-2b (IFN) 6 million units on alternate days, both in

combination with ribavirin (1000–1200 mg/day).

Results: PEG-IFN plus ribavirin significantly increased sustained virological response (SVR) compared with IFN

plus ribavirin (41.1 vs. 29.3% respectively, PZ0.030). Less patients discontinued PEG-IFN than IFN (19 vs. 31%,

PZ0.010). By logistic regression, SVR in the PEG-IFN group was independently associated with age !50 years, and

mild fibrosis at liver biopsy.

Conclusions: Combination therapy with an induction dose of PEG-IFN was a more effective and better toleratedtreatment for naıve patients with genotype 1 than combination therapy with high dose standard IFN. In patients aged

less than 50 years with mild fibrosis this schedule achieves a very high rate of SVR.

q 2004 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Keywords: Multicenter trial; Combination therapy; Fibrosis

Journal of Hepatology 41 (2004) 474–481

www.elsevier.com/locate/jhep

Study of the Liver. Published by Elsevier B.V. All rights reserved.

April 2004; accepted 28 May 2004; available online 8 July 2004

neither do they have a relationship with the pharmaceutical company involved in the manufacture of

39-382-526450.

ondelli).

titis C virus ribonucleic acid; RCT, randomized controlled trial; CI, confidence interval; OR, odds

ally to this study.

S. Bruno et al. / Journal of Hepatology 41 (2004) 474–481 475

1. Introduction

Two multinational randomized controlled trials (RCTs)

have shown that a body weight dose (1.5 mg/kg once

weekly) of peginterferon alfa-2b (12 kDa) plus a low dose

(800 mg/day) of ribavirin [1] or a fixed dose (180 mg/week)

of peginterferon alfa-2a (40 kDa) once weekly plus a

standard dose of ribavirin [2] are significantly more

effective than a 3 million units dose of interferon alfa and

ribavirin in previously untreated patients with chronic

hepatitis C. In these two large phase III RCTs, the sustained

virologic response (SVR) rate in genotype 1-infected

patients was 42 [1] and 46% [2], with a similarly high

discontinuation rate, ranging from 10 [1] to 14% [2], caused

by drug toxicity. In both patients receiving pegylated and

standard interferons the impact of adherence to therapy was

most significant in those with genotype 1 infection [3],

indicating that dosing of interferon was a prerequisite of

strategic importance in ‘difficult to treat’ patients, and

should be weighted against the risk of anticipated treatment

discontinuation because of drug toxicity.

The aims of this pragmatic [4] RCT were: (1) to compare

the efficacy and safety of an initial induction period of

a ‘crudely weight-based’ dose of peginterferon alfa-2b

(PEG-IFN) followed by a lower flat dose, and a high fixed

dose of standard interferon alfa 2b (IFN) both in com-

bination with ribavirin in treatment-naıve patients chroni-

cally infected with HCV genotype 1, and (2) to identify

predictors of response to treatment.

2. Methods

2.1. Patients

Between January 2000 and June 2000, all consecutive patientssatisfying predefined inclusion criteria (see below) were recruited fromeight Italian tertiary referral liver units. Inclusion criteria were as follows:(1) previously untreated HCV RNA positive patients aged between 18 to65 years with aminotransferase (ALT) values above 1.5 the upper normallimit; (2) liver biopsy performed within 6 months prior to enrolment and adiagnosis of chronic hepatitis with any degree of fibrosis; (3) hemoglobinR13 g/dl for males, R12 g/dl for females, WBC count >3.000/mm3,granulocyte count >1.500/mm3, platelet count >80.000/mm3, bilirubin,albumin and serum creatinine levels within normal limits. Patients wereexcluded if they had advanced cirrhosis, i.e. large esophageal varices (F2 ormore [5]), history of gastrointestinal bleeding, ascites or encephalopathy;hepatocellular carcinoma; anti-HIV or HBsAg positivity; alcohol abuse(R80 g/day); parenteral drug addiction if not abstaining for at least 2 years;and any other contraindications to interferon or ribavirin.

2.2. Study design

The study was designed before results from registration trials ofpegylated interferon were available and conducted according to theguidelines of the Declaration of Helsinki and the applicable provisions ofGood Clinical Practice. The study protocol was approved by each center’sinstitutional Ethics Committee, and written informed consent was obtainedfrom all patients. Consent forms were administered by physicians notinvolved in the treatment of patients enrolled in the trial. Randomization ofpatients to treatment was done by a central randomization center (IBIMConsiglio Nazionale delle Ricerche, Palermo) by a computer-generated

scheme. Patients were stratified according to center and randomized inblocks of four to the PEG-IFN or standard IFN arms. Patients who met theinclusion criteria were randomly assigned with equal probability to one ofthe two treatment groups.

The experimental arm received peginterferon alfa-2b (PEG-Intron,Schering Corp, Kenilworth, NJ, USA) subcutaneously at a dose of 100 mgfor weight 65 kg or more and 80 mg for weight below 65 kg, once weeklyfor the first 8 weeks, followed by a fixed dose of 50 mg once weekly for thenext 40 weeks plus ribavirin (Rebetol, Schering Corp) for 48 weeks. Thecontrol arm received standard interferon alfa-2b (Intron A, Schering Corp)6 million units subcutaneously every other day plus ribavirin for 48 weeks.For both arms, ribavirin was given orally in two divided doses per day at adose of 1000 mg/day for patients weighing 75 kg or less and 1200 mg/dayfor those weighing more than 75 kg.

Patients were withdrawn from treatment if they did not achieve avirologic response which was defined as undetectable serum HCV RNAby PCR 24 weeks after starting treatment. This endpoint was in accordwith the rule for terminating treatment as defined by the EuropeanAssociation for the Study of the Liver (EASL) Consensus Conference onHepatitis C [6].

Serum HCV-RNA was measured at each center by a qualitative PCRassay (Cobas Amplicor HCV Test version 2.0; limit of detection: 50 IU/ml)before treatment, during treatment at weeks 12, 24 and 48, and aftertreatment at weeks 12 and 24. Quantification of serum HCV-RNA levelsbefore treatment was performed at a central laboratory (Laboratoridi Ricerca-Area Infettivologica, IRCCS Policlinico San Matteo andUniversity of Pavia) by Versant HCV RNA 3.0 bDNA (Bayer Co.,Tarrytown, N.Y.) and expressed in IU/ml. Genotyping was performed byINNO-LiPA, HCV II, Bayer.

Slides of liver biopsy specimens were coded and read by a singlepathologist (M.C., Niguarda Hospital, Milan), who was unaware of clinicaldata, and classified according to the numerical scoring system of Ishak et al.[7]. Steatosis was graded as follows: 0 absent; 1 mild: 1–20% ofhepatocytes affected; 2 moderate: 21–40% of hepatocytes affected; 3severe: >40% of hepatocytes affected.

2.3. Assessment of efficacy

Responses to treatment were as defined by the EASL ConsensusConference on Hepatitis C [6]. The primary end point was sustainedvirological response (SVR), defined as the absence of detectable hepatitis Cvirus RNA by polymerase chain reaction 24 weeks after cessation oftherapy. All patients stopping the planned treatment or missing twoconsecutive weeks of treatment at any time either for subjective intoleranceor because of side effects were considered withdrawals from treatment.Analysis of results was performed including the latter by intention to treat.Reporting of this RCT was performed according to the criteriarecommended by the last CONSORT statement [8].

2.4. Assessment of safety

The World Health Organization (WHO) grading system of toxicity wasused for recording side effects. Adverse events were graded as mild,moderate, severe or potentially life-threatening according to the modifiedWHO guidelines [9]. The protocol guidelines allowed for dose modificationin patients who had relevant adverse events or important abnormalities inlaboratory values. If these resolved, drugs were increased again to theintended dose. For severe adverse effects and/or intolerable symptoms,therapy was stopped.

2.5. Statistical analysis

SVR was chosen as the primary outcome to calculate sample size. Onehundred and sixteen patients were needed in each group, assuming a 20%difference in the rate of SVR between the peginterferon (45%) and thestandard interferon (25%) groups, a 5% alpha error, and a 10% beta error.A 30% excess of inclusions was allowed in order to compensate forwithdrawals. Thus, a sample size of 151 subjects for each group wasestimated.

The Kaplan–Meier method was used to estimate the occurrence oftreatment discontinuation. Differences in the discontinuation rate were

S. Bruno et al. / Journal of Hepatology 41 (2004) 474–481476

assessed by the log-rank test. On the basis of experience gathered fromprevious studies [1,2,10] we selected, as candidate predictors of SVR, age,sex, weight, body mass index, platelet counts, ALT, g-glutamyl transferase(gGT) levels, liver histology, HCV RNA levels before treatment, weightbased (mg/kg) dose of ribavirin, and finally treatment with peginterferon.Variables significant (P!0.05) on univariate analysis were included in amultivariate logistic regression model. All analyses used a two sidedP!0.05 significance level and were conducted with the PROC LOGISTICsubroutine in SAS (SAS Institute, Inc., Cary, North Carolina, USA) [11].

2.6. Study organization, clinical centers and role

of the founding source

This study was independently designed and not supported bypharmaceutical companies. Schering-Plough Italy supplied peginterferonalfa-2b, while both ribavirin and standard interferon alfa-2b was providedby the National Health System.

This study adheres to the International Committee of Medical JournalEditors standards of accountability, access to data, and control ofpublication [12].

3. Results

3.1. Patients baseline features

Four hundred and thirty consecutive patients were

assessed for eligibility for the study, and 323 of these

were included. Twelve patients were excluded after

randomization because of unwillingness to give informed

consent (Fig. 1).

The patients enrolled in the two treatment groups shared

similar demographic and virologic characteristics (Table 1).

Nine (2.9%) of 311 patients were infected with subtype 1a

and 302 (97.1%) with subtype 1b. More than half of

Fig. 1. Flow chart of the selection process of the two groups of patients.

The distribution per center of patients included in the trial was as

follows: San Giuseppe Hospital (Milano) 11 patients, San Paolo

Hospital (Milano) 70 patients, University of Messina Medical Center

(Messina) 8 patients, Niguarda Hospital (Milano) 49 patients,

University of Palermo Medical Center (Palermo) 82 patients, IRCCS

San Matteo Hospital (Pavia) 31 patients, IRCCS Spallanzani (Rome) 10

patients, IRCCS Ospedale Maggiore (Milano) 50 patients.

the patients had histological evidence of steatosis. Twenty-

one percent of the patients had advanced fibrosis, i.e. R4 by

Ishak score.

3.2. Outcomes

PEG-IFN treated patients showed a significantly higher

rate of end-of-treatment virologic response as well as SVR

than patients treated with standard IFN (Table 2). The

proportion of patients with a post-treatment virologic

relapse was similar between PEG-IFN and standard IFN

treated patients (23.9 vs. 27.9%, PZ0.58). The highest rate

of SVR was achieved in patients under 50 years (51.5%),

whereas the lower rates of SVR were obtained in patients

with a fibrosis stage R3 by Ishak score (17.2%), in both

treatment groups.

Overall, serum HCV RNA was negative by the end of

treatment in 149 patients. Among these patients, only 4%

had abnormal ALT values. Among 111 patients (35.7%)

who achieved a SVR, 9 (8.1%) had abnormal ALT.

One hundred and forty-eight subjects were eligible for

the analysis of early virologic response to PEG-IFN as 15

patients discontinued therapy before week 12. By week 12,

95 of 148 patients (64.1%) were HCV-RNA negative and,

among these, 66 patients (69.4%) achieved SVR. By

converse, of the 53 non-responders at week 12, only one

(1.9%) achieved a SVR. Similar results were observed in the

standard IFN group (data not shown).

3.3. Variables associated with sustained virological

response (SVR)

By univariate analysis, young age, high baseline platelet

counts, normal g-GT levels, treatment with PEG-IFN,

absence of steatosis and mild fibrosis at liver biopsy were

associated with a higher chance of SVR (Table 2). There

were no significant differences in the probability of SVR

between different baseline weight or body mass index,

between different baseline ALT levels, between different

baseline grading and between different pre-treatment

HCV-RNA levels (Table 2). By multivariate analysis

(Table 3a), treatment with PEG-IFN, young age, normal

pre-treatment g-GT, mild fibrosis and absence of steatosis at

baseline liver biopsy were independent predictors of SVR in

all patients. Multivariate analysis performed on the 163

patients treated with PEG-IFN plus ribavirin (Table 3b)

showed that once again SVR was commoner in young

patients, and those with mild fibrosis at liver biopsy.

The correlation between SVR and fibrosis at baseline

liver biopsy is shown in Fig. 2. Only 1 of 14 patients (7.1%)

in the worst histological class (fibrosis score 6, by Ishak) had

a SVR. At the other extreme, a subject in the best

histological class (fibrosis score 1, by Ishak) had a

likelihood of a SVR of 61.3% (19 of 31 actual cases).

We did not find any significant correlation between

SVR and the weight based doses of both PEG-IFN (mg /kg)

Table 1

Baseline characteristics of participants by treatment groups

Variable PEG-IFN-a2b plus ribavirin (nZ163) IFN-a2b plus ribavirin (nZ148) P

Age (yrs) 49.91G11.11 49.51G11.10 0.75

Male sex (n (%)) 101 (62) 93 (62) 0.99

Weight (kg) 69.41G11.95 71.56G13.04 0.13

Body mass index (kg/m2) 24.60G3.25 24.97G3.51 0.33

Haemoglobin (g/dl) 14.90G1.23 14.83G1.46 0.66

White blood cell count (!103/mmc) 4.8G3.8 4.2G2.9 0.07

Platelet count (!103/mmc) 188G63.02 190G53.67 0.86

g-glutamyltransferase (UNL) 1.78G1.19 1.79G1.52 0.93

Mean aminotransferases levels (UNL)

Aspartate aminotransferase 2.02G1.02 1.85G1.07 0.17

Alanine aminotransferase 3.23G2.00 2.78G2.05 0.052

Serum HCV-RNA (n (%))

%8!105 IU/ml 90 (55.2) 89 (60.1) 0.39

O8!105 IU/ml 73 (44.8) 59 (39.8)

Mean HCV-RNA levels (IU/ml!106) 2.69G8.85 2.11G5.91 0.24

Histology at biopsy

Grading (n (%))

Mild (1–8) 137 (84) 125 (84.6) 0.92

Moderate/severe (9–18) 26 (16) 23 (15.4)

Mean grading 6.85G1.94 6.76G1.81 0.68

Staging (n (%))

1 31 (19) 24 (16.2) 0.65

2 76 (46.6) 70 (47.3)

3 19 (11.6) 25 (16.9)

4 13 (7.9) 10 (6.7)

5 10 (6.1) 5 (3.4)

6 14 (8.6) 14 (9.5)

Mean staging (HAI score) 2.62G1.19 2.61G1.23 0.44

Steatosis (n (%))

0 68 (41.7) 65 (43.9) 0.67

1 62 (38.1) 52 (35.1)

2 29 (17.7) 24 (16.2)

3 4 (2.4) 7 (4.7)

Abbreviations: PEG-IFN-a2b, peginterferon alfa-2b; IFN-a2b, interferon alfa-2b; yrs, years; ULN, upper limit of normal; HCV-RNA, hepatitis C virus

ribonucleic acid; IU, international units. Values with plus/minus signs are meansGSD.

S. Bruno et al. / Journal of Hepatology 41 (2004) 474–481 477

and ribavirin (mg/kg). The mean weighted dose of PEG-IFN

was 0.85 mg/kgG0.12 in SVR and 0.82 mg/kgG0.12 in non-

SVR (PZ0.16), and the mean weighted dose of ribavirin

was 15.82 mg/kgG2.02 in SVR and 15.47 mg/kgG1.84 in

non-SVR (PZ0.25) (Fig. 3).

3.4. Safety evaluation

Side effects leading to treatment discontinuation

occurred in 77 patients (24.8%), more often during the

first 24 weeks of treatment (Table 4). The cumulative rate of

discontinuation was significantly lower in the PEG-IFN

group in comparison with IFN group (Fig. 4). In both groups

the leading cause of discontinuation was the occurrence of

adverse events rather than hematological abnormalities

(Table 4). Severe (grade 3 or 4) adverse events occurred

more often in patients receiving standard IFN than in those

receiving PEG-IFN (22 vs. 11%, (PZ0.007).

In the PEG-IFN, neither the baseline characteristics of

the patients nor the weight-based PEG-IFN (mg/kg) nor

ribavirin (mg/kg) doses were able to identify patients who

withdrew from treatment.

Overall, 133 subjects (42.7%) required dose

reduction of one or both drugs of the treatment

regimens (44.6% in the peginterferon alfa-2b and

38.5% in the standard interferon groups, PZ0.15).

The most common event leading to dose reduction was

anemia (Table 4). In the PEG-IFN group, dermato-

logical (42%), neuro-psychiatric (29%), and gastro-

intestinal (19%) symptoms were the leading cause of

dose reduction. Injection site reaction in the PEG-IFN

group was observed in a minority of patients: 21 out of

163 (12.8%).

The full dose of PEG-IFN was tolerated by 113 of 163

patients (69.3%) while only 71 of 148 subjects (48%)

tolerated IFN (P!0.001). Among patients treated with

PEG-IFN, a dose reduction of ribavirin was needed in 65 of

163 patients (39.8%). This dose reduction did not decrease

the likelihood of viral clearance. The rate of SVR was

50.7% (33 of 65) in subjects who reduced the ribavirin

dose and 46.2% (31 of 67) in patients who received

Table 2

Efficacy of treatment according to regimens administered and baseline characteristics

Variable End-of-treatment response Sustained response

Biochemical n (%) Virological n (%) Biochemical n (%) Virological n (%)

Treatment regimens

Peginterferon plus ribavirin 90/163 (55.2) 88/163 (54) 68/163 (41.7) 67/163 (41.1)

Interferon plus ribavirin 70/148 (47.3) 61/148 (41.2) 47/148 (31.8) 44/148 (29.7)

P value 0.16 0.024 0.069 0.037

Dose of ribavirin (mg/kg)

!15 72/143 (50.3) 67/143 (46.8) 46/143 (32.1) 45/143 (31.5)

R15 88/168 (52.4) 82/168 (48.8) 69/168 (41.1) 66/168 (39.3)

P value 0.72 0.73 0.10 0.15

Age (yrs)

%50 82/132 (62.1) 71/132 (53.8) 65/132 (49.2) 68/132 (51.5)

O50 78/179 (43.5) 78/179 (43.6) 50/179 (27.9) 43/179 (24.0)

P value 0.001 0.075 0.001 0.001

Sex

Male 99/194 (51) 94/194 (48.4) 70/194 (36.1) 68/194 (35)

Female 61/117 (52.1) 55/117 (52.9) 45/117 (38.5) 43/117 (36.7)

P value 0.85 0.80 0.67 0.76

Weight (kg)

%70 90/166 (54.2) 85/166 (51.2) 66/166 (39.8) 63/166 (37.9)

O70 70/145 (48.3) 77/145 (53.1) 49/145 (33.8) 48/145 (33.1)

P value 0.29 0.74 0.27 0.37

Body mass index (kg/m2)

O25 66/137 (48.2) 64/137 (46.7) 43/137 (31.4) 42/137 (30.6)

%25 94/174 (54) 85/174 (48.8) 72/174 (41.3) 69/174 (39.6)

P value 0.31 0.71 0.07 0.10

Serum HCV RNA (IU/ml)

R8!105 92/179 (51.4) 86/179 (48) 67/179 (37.4) 69/179 (38.5)

!8!105 68/132 (51.5) 63/132 (47.7) 48/132 (36.3) 42/132

P value 0.98 0.95 0.84 0.21

Platelet count (!103/mmc)

%180 60/137 (43.8) 56/137 (40.9) 42/137 (30.6) 38/137 (27)

O180 100/174 (57.4) 93/174 (53.4) 73/174 (41.9) 73/174 (41.9)

P value 0.017 0.028 0.04 0.009

g glutamyl transferase (UNL)

%1 107/163 (65.6) 99/163 (60.7) 78/163 (47.8) 76/163 (46.6)

O1 53/148 (35.8) 50/148 (33.8) 37/148 (25) 35/148 (23.6)

P value 0.001 0.001 0.001 0.001

Alanine aminotransferase (UNL)

%3 115/215 (53.5) 105/215 (48.8) 83/215 (38.6) 80/215 (37.2)

O3 45/96 (46.8) 44/69 (45.8) 32/96 (33.3) 31/96 (32.2)

P value 0.28 0.6 0.37 0.40

Histology at biopsy

Staging

1 37/55 (67.3) 31/55 (56.4) 28/55 (50.9) 31/55 (56.4)

2 83/146 (56.8) 75/146 (51.7) 64/146 (43.8) 61/146 (41.8)

3 23/44 (52.3) 22/44 (50) 10/44 (22.7) 9/44 (20.45)

4 9/23 (39.1) 10/23 (43.5) 6/23 (26.1) 5/23 (21.7)

5 2/15 (13.3) 3/15 (20) 3/15 (20) 3/15 (20)

6 6/28 (21.4) 8/28 (28.6) 4/28 (14.3) 2/28 (7.1)

P value 0.001 0.044 0.001 0.001

Grading

Minimal–mild (1–8) 140/262 (53.4) 130/262 (49.6) 103/262 (39.6) 99/262 (37.8)

Moderate/severe (9–18) 20/49 (40.8) 19/49 (38.8) 12/49 (24.5) 12/49 (24.5)

P value 0.10 0.16 0.049 0.075

Steatosis

Present 73/178 (41) 69/178 (38.7) 47/178 (26.4) 44/178 (24.7)

Absent 87/133 (65.4) 80/133 (60.1) 68/133 (51.1) 67/133 (50.3)

P value 0.001 0.001 0.001 0.001

Abbreviations: yrs, years; ULN, upper limit of normal; HCV-RNA, hepatitis C virus ribonucleic acid; IU, international units.

S. Bruno et al. / Journal of Hepatology 41 (2004) 474–481478

Table 3a

Logistic regression models to predict sustained virological response in all patients (nZ311)

Variable Code b SE P Value Odds ratio (95% CI)

Treatment 0: interferon alfa-2b; 1: peginterferon alfa-2b 0.65 0.27 0.015 1.93 (1.13–3.28)

Age 0: %50 years; 1: O50 years K0.94 0.27 0.0007 0.38 (0.22–0.66)

Staging 0: 1–2 fibrosis score; 1:3 fibrosis score; 2:4

fibrosis score; 3: 5–6 fibrosis score

K0.51 0.18 0.005 0.59 (0.41–0.85)

Steatosis 0: absent; 1: present K0.67 0.27 0.014 0.50 (0.29–0.87)

g-glutamyltransferase 0: normal; 1: elevated K0.63 0.28 0.028 0.53 (0.30–0.93)

Adjusted for baseline platelet count.

Table 3b

Logistic regression models to predict sustained virological response in patients treated with peginterferon alfa-2b (nZ163)

Variable Code b SE P Value Odds ratio (95% CI)

Age 0: %50 years; 1: O50 years K0.94 0.37 0.012 0.38 (0.18–0.81)

Staging 0: 1–2 fibrosis score; 1:3 fibrosis score; 2:4 fibrosis score;

3:5–6 fibrosis score

K0.68 0.28 0.014 0.50 (0.28–0.87)

Adjusted for baseline platelet count, baseline activity score, steatosis and baseline g-glutamyltransferase levels.

S. Bruno et al. / Journal of Hepatology 41 (2004) 474–481 479

the full dose of ribavirin (PZ0.60). In contrast, the

likelihood of sustained virologic response was significantly

lower when the dose of PEG-IFN was reduced (3 of 19;

15.8%) than when the full dose was administered (61 of

113; 54%) (PZ0.002).

Mean decrease in hemoglobin from baseline to week 24

of treatment was 2.75G1.30 g/dl in the PEG-IFN and

2.87G1.52 g/dl in the standard IFN groups (PZ0.49). A

similar decrease in hemoglobin but of marginal statistical

significance was observed from baseline to the end of

treatment in the peginterferon alfa-2b (2.19G1.30 g/dl)

and in the standard interferon groups (2.68G1.45 g/dl)

(PZ0.064). Anemia was managed by reducing ribavirin to

600 mg/day in 69 of 311 patients (22.2%) or by its

discontinuation in 10 of 311 subjects (3.2%).

In all the 311 patients, the mean decrease from baseline

to the end of treatment was 2.6!103G1.6!103/mmc for

WBC and 17.6!103G50.4!103/mmc for platelets, with-

out any significant differences between the two treatments

groups.

Fig. 2. Sustained virologic response rate of the 163 patients treated with

peginterferon alfa-2b plus ribavirin as a function of fibrosis by Ishak

score, at baseline liver biopsy.

4. Discussion

This study shows that an induction dose of 100–80 mg

PEG-IFN once weekly for 8 weeks, followed by a fixed dose

of 50 mg once weekly for the next 40 weeks in combination

with a standard dose of ribavirin significantly improves

Fig. 3. Box plots of weighted doses of PEG-IFN (A), and Ribavirin (B)

according to sustained virological responses (SVR). Box plots include

the middle 50% of the data. The horizontal bars inside the box represent

medians. The upper and lower ends of the boxes (hinges) represent the

approximate upper and lower quartiles of the data distribution.

Extreme data are connected to the ends of the boxes by vertical bars.

The diamonds include the middle 68% of the data (meanG1 standard

deviation). [This figure appears in colour on the web.]

Table 4

Frequency of discontinuations and dose reductions according to

treatment groups

Peginterferon

a-2b plus

ribavirin

(nZ163)

Interferon

a-2b plus

ribavirin

(nZ148)

Discontinuation (total) (n (%)) 31 (19) 46 (31)

Time of discontinuation

At 1–24 weeks (n (%)) 22 (13.4) 37 (25)

At 25–48 weeks (n (%)) 9 (5.5) 9 (6)

Causes of discontinuation

Adverse events (n (%)) 20 (12.3) 38 (25.7)

Hematological abnormality (n (%)) 9 (5.5) 7 (4.7)

Anemia (n (%)) 5 (3.1) 5 (3.4)

Neutropenia (n (%)) 2 (1.2) (0.7)

Thrombocytopenia (n (%)) 2 (1.2) 1 (0.7)

Hyperthyroidism (n (%)) 2 (1.2) 1 (0.7)

Dose reduction (total) (n (%)) 76 (44.6) 57 (38.5)

Causes of dose reduction

Adverse events (n (%)) 21 (12.8) 16 (10.8)

Hematologicalabnormality (n (%)) 53 (32.5) 39 (26.3)

Anemia (n (%)) 41 (25.1) 28 (18.9)

Neutropenia (n (%)) 12 (7.4) 8 (5.4)

Thrombocytopenia (n (%)) 0 (0) 3 (2.0)

Hyperthyroidism (n (%)) 2 (1.2) 2 (1.3)

S. Bruno et al. / Journal of Hepatology 41 (2004) 474–481480

SVR compared with a high dose of standard IFN plus a

standard dose of ribavirin. The reported values for efficacy

and safety are in keeping with two recent RCTs in which

two different types of pegylated interferons were adminis-

tered in combination with two different doses of ribavirin

[1,2]. It should, however, be emphasized that the present

study included only difficult to treat patients with genotype

1 with greater hepatic fibrosis and a mean age of about 50

years, mostly with community acquired infection, all

suggesting long duration hepatitis C. SVR rates in the

control group receiving standard IFN 6 million units every

Fig. 4. Cumulative rate of discontinuation of therapy in patients treated

with peginterferon-a2b plus ribavirin (PEG-IFN) and in patients

treated with interferon-a-2b and ribavirin (IFN). The difference was

statistically significant (PZ0.01, by log rank test).

other day, distinctly higher then the standard dose of

interferon (3 million units thrice weekly), proved disap-

pointing in patients with genotype 1. The high dose alternate

day regimen used in our study lacked the 48 h interruption,

which is deemed to account for failure of suppression of

viral replication of difficult genotypes [13], was chosen to

maximize response rates. Our finding of 30% SVR in

patients treated with high doses of standard IFN replicates

previous reports in genotype 1 infected patients who

received 3 million units standard IFN [1,2]. However,

when a significant heterogeneity in baseline characteristics

of patients is found between different RCTs, as expressed by

a similar rate of SVR in control groups who had received

different schedules of treatment, caution must be exercised

when comparing results.

In our patients age and degree of fibrosis at biopsy, but

not body weight, strongly predicted SVR to combination

therapy with peginterferon alfa-2b. These findings are in

keeping with those of others emphasizing the importance of

age and liver fibrosis in interferon unresponsiveness [1,2],

and suggest that antiviral treatment should be offered to all

eligible patients with difficult genotypes as early as possible

in the course of their liver disease.

Our observed value for effectiveness of combination

treatment are in keeping with the results of two previously

reported trials using PEG-Interferon a2a [2,14], which

showed that a full standard dose of ribavirin, is needed

particularly for genotype 1-infected patients. However, we

did not confirm the observation of Manns and colleagues

[1], who reported in a post hoc analysis a dose-response

relationship between the body weight dose of ribavirin and

the rate of SVR in the low dose (800 mg/day) ribavirin

arm of that trial. This study identified a dose of 10.6 mg/kg

as the lower end of the optimum dose range. However, the

mean body weight dose of ribavirin administered in the low

dose ribavirin arm of the study was 9.7 mg/kg. This

suboptimal dose could explain the dose-response relation-

ship observed.

One disputed point in hepatitis C therapy is whether

PEG-IFN should be dosed on body weight or given as a

fixed dose [15]. Our study based on flat doses of PEG-IFN

a2b showed no significant correlation between SVR and

the amount of PEG-IFN alfa-2b. Interestingly, the SVR

rates achieved with higher dose (1.5 mg/kg) peginterferon

alfa-2b in a previous study (1) paralleled the rates achieved

by our patients receiving an average of 0.85 mg/kg

peginterferon alfa-2b. Possible explanations are that our

patients were all European subjects characterized by a

normal mean body weight and that during the induction

phase of 8 weeks our patients were treated with a

substantially higher dose than the flat 50 mg/week dose

used for the following 40 weeks. The latter hypothesis is

supported by data suggesting that early viral clearance in

patients infected with genotype 1 could be improved by

using high dose PEG-IFN alfa-2b during the initial weeks of

treatment [16].

S. Bruno et al. / Journal of Hepatology 41 (2004) 474–481 481

Whatever the dose administered, PEG-IFN and ribavirin

combination therapy was poorly tolerated by our patients, as

shown also by others with other pegylated interferon

regimens [1,2,14]. We found that adverse events were the

main cause for discontinuation occurring during the first

12–24 weeks of treatment, as previously reported [3], and

failed to identify differences in the baseline characteristics

between compliers and non-compliers nor did we find any

relationship between weight-based dosing of both treat-

ments and treatment adherence. However, even with

accurate compliance data, tolerability remains difficult to

evaluate because compliance is a non-randomized process

within the trial, interacting with prognostic factors and

treatment response [17,18].

In conclusion, our findings that age and liver fibrosis

predict response rates to PEG-IFN and ribavirin combi-

nation therapy suggest that in young patients infected with

genotype 1 and minimal hepatic fibrosis treatment should be

considered in order to maximize chances of viral

eradication.

Acknowledgements

The authors thank Erica Villa, MD, and Filippo Schepis,

MD, for the careful help in revising the manuscript and

Lillian Shahied, PhD, for her forbearance in editing the

manuscript.

Appendix A

In addition to the authors, the following investigators

participated in this study:

Sonia Rossi, Istituto Scienze Biomediche, San Paolo

Milano

Alessio Aghemo, Cattedra e Unita Operativa di Gastro-

enterologia, IRCCS Ospedale Maggiore, University of

Milano, Italy.

Agostino Cividini, Dipartimento di Malattie Infettive,

IRCCS Policlinico San Matteo, and University of Pavia.

Antonio Bellobuono, Medicina Interna e Gastroentero-

logia Ospedale San Giuseppe, Milano

Giorgio Antonucci, Unita Operativa malattie Infettive,

Azienda Ospedaliera Spallanzani, Roma

Giovanni Raimondo, Giovanni Squadrito, Cattedra di

Medicina Interna, University of Messina.

Marcello Gambacorta, Ernesto Minola, Anatomia Pato-

logica, Ospedale Niguarda, Milano, Italy.

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