慢性乙肝核苷药物治疗中的DNA反弹与病毒变异

肝胆速递

Virological breakthrough and resistance in patients with chronic hepatitis B receiving nucleos(t)ide analogues in clinical practice
慢性乙肝核苷药物治疗中的DNA反弹与病毒变异

肝胆速递：DNA反弹并非都与变异有关；规律检测DNA水平很重要

Virological breakthrough and resistance in patients with chronic hepatitis B receiving nucleos(t)ide analogues in clinical practice†

    Chanunta Hongthanakorn,
    Watcharasak Chotiyaputta,
    Kelly Oberhelman,
    Robert J. Fontana,
    Jorge A. Marrero,
    Tracy Licari,
    Anna S. F. Lok‡,*

Hepatology
Article first published online: 25 MAY 2011

DOI: 10.1002/hep.24318

    Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI

    ‡

    fax: 734-936-7392

Email: Anna S. F. Lok ([email protected])

*Division of Gastroenterology, University of Michigan Health System, 3912 Taubman Center, SPC 5362, 1500 East Medical Center Drive, Ann Arbor, MI 48109

    †

    Potential conflict of interest: R.J.F. did consulting/research for Bristol-Myers Squibb and GlaxoSmithKline, and was on the Speaker's Bureau for Gilead Sciences and Genentech. A.S.F.L. did consulting for Gilead Sciences, Roche, Bristol-Myers Squibb, and GlaxoSmithKline; and received grant/research support from Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Schering-Plough, and Roche.

Virological breakthrough (VBT) is the first manifestation of antiviral drug resistance during nucleos(t)ide analogue (NUC) treatment of chronic hepatitis B (CHB), but not all VBTs are due to drug resistance. This study sought to determine the incidence of VBT and genotypic resistance (GR) in patients with CHB who were receiving NUCs in clinical practice. Records of patients with CHB who were receiving NUCs were reviewed. All patients with VBT were tested for drug resistance mutations. Of 148 patients included, 73% were men and mean age was 44.9 years. During a mean follow-up of 37.5 ± 20.1 months, 39 (26%) patients had at least 1 VBT. Of these 39 patients, 15 (38%) were not confirmed to have VBT on retesting, and 10 of these 15 had no evidence of GR. The cumulative probability of VBT, confirmed VBT, and GR at 5 years was 46.1%, 29.7%, and 33.9%, respectively. In multivariate analysis, failure to achieve undetectable hepatitis B virus (HBV) DNA was the only factor significantly associated with VBT. Among the 10 patients who had VBT but no confirmed VBT or GR and who were maintained on the same medications, serum HBV DNA decreased in all 10, and nine had undetectable HBV DNA at a mean of 6.8 months after the VBT. Four patients had persistently undetectable HBV DNA, six had transient increase in HBV DNA during follow-up, and none had GR. Conclusion: VBT was common in patients with CHB receiving NUCs in clinical practice, but nearly 40% of the VBTs were not related to antiviral drug resistance. Counseling of patients with CHB on medication adherence and confirmation of VBT and/or GR can avoid unnecessary changes in antiviral medications. (HEPATOLOGY 2011;)

Five nucleos(t)ide analogues (NUCs)—lamivudine, adefovir, entecavir, telbivudine, and tenofovir—have been approved for the treatment of chronic hepatitis B (CHB). NUCs are administered orally and have very few side effects; however, these medications suppress but do not eradicate hepatitis B virus (HBV). Therefore, most patients with CHB will require long-term treatment to derive clinical benefit. However, long-term NUC treatment is associated with increasing risk of drug resistance, particularly when NUCs with low genetic barrier to resistance are used as monotherapies.

Virological breakthrough (VBT) is the first clinical manifestation of antiviral drug resistance and may precede biochemical breakthrough (BBT).1-3 Phase 3 clinical trials of NUCs in NUC-naive patients revealed that 0%-87.5% of patients with VBT had confirmed genotypic resistance (GR).4-9 In the phase 3 trial of telbivudine versus lamivudine, 32 of 680 (4.7%) and 99 of 687 (14.4%) patients who received telbivudine and lamivudine, respectively, experienced VBT after 1 year of treatment, but only 28 (87.5%) and 75 (75.8%) patients with VBT were confirmed to have GR.9 In the phase 3 trial of entecavir versus lamivudine, 11 of 679 (1.6%) and 88 of 668 (13.2%) patients who received entecavir and lamivudine, respectively, experienced VBT after 1 year of treatment, but 0 (0%) of the entecavir-treated and 65 (73.9%) of lamivudine-treated patients with VBT were confirmed to have GR.7, 8 In the phase 3 trial of tenofovir, 10 of 426 (2.3%) patients who received tenofovir experienced VBT after 1 year of treatment, but none of these patients were confirmed to have GR.4 These data indicate that not all VBTs are related to antiviral drug resistance.

Possible explanations for the discrepancy between the rates of VBT and GR include poor adherence to medications, failure to detect drug-resistance mutations due to insensitive assays, and failure to recognize new mutations associated with antiviral drug resistance. VBT during the first year of treatment was attributed to medication nonadherence in patients who received entecavir or tenofovir in the phase 3 trials.4, 7 Medication adherence is likely to be lower in clinical practice than in phase 3 clinical trials, where highly motivated patients are recruited and closely monitored. Differentiating between VBT due to medication nonadherence and VBT due to drug resistance is important, because virological response can be restored by reinforcement of adherence in the former case whereas rescue therapy is needed in the latter situation.

The aims of this study were (1) to determine the incidence of VBT and GR in patients with CHB who were treated with NUCs in clinical practice, (2) to determine the factors associated with VBT in patients with CHB who were receiving NUCs, and (3) to determine the outcomes of patients with VBTs that were not confirmed to be associated with antiviral drug resistance mutations.

ALT, alanine aminotransferase; Anti-HBe, antibody to hepatitis B e antigen; BBT, biochemical breakthrough; CHB, chronic hepatitis B; CI, confidence interval; GR, genotypic resistance; HBeAg, hepatitis B e antigen; HBV, hepatitis B virus; HIV, human immunodeficiency virus; HR, hazard ratio; NUC, nucleos(t)ide analogue; ULN, upper limit of normal; VBT, virological breakthrough.

肝胆速递

慢性乙型肝炎患者接受核苷（酸）类似物在临床实践中患者的病毒学突破和阻力†

    Chanunta Hongthanakorn，
    Watcharasak Chotiyaputta，
    凯利奥伯黑尔曼，
    罗伯特·J·丰塔纳，
    豪尔赫·马雷罗，
    特雷西利卡里，
    安娜·S.和F.乐‡*

文章首次在网上公布：2011年5月25日

DOI：10.1002/hep.24318

    部消化内科，内科，密歇根卫生系统大学，安阿伯，MI

    ‡

    传真：734-936-7392

电子邮件：安娜·S.：F.乐（[email protected]）

*科，消化内科，密歇根卫生系统大学，3912陶布曼中心，SPC 5362，1500东医疗中心驱动器，安阿伯，MI 48109

    †

    潜在的利益冲突：R.J.F.做咨询/百百时美施贵宝公司和葛兰素史克公司的研究中，与是扬声器的局Gilead Sciences公司和基因技术公司。 A.S.F.L. Gilead Sciences公司，罗氏，百时美施贵宝（Bristol-Myers公司Squibb），葛兰素史克公司做了咨询，并授予/研究由百百时美施贵宝公司，Gilead Sciences公司，葛兰素史克公司，先灵葆雅和罗氏公司的支持。

病毒学突破（VBT）是第一个在核苷（酸）类似物（NUC）治疗慢性乙型肝炎（CHB）的抗病毒药物耐药性的表现，但，并非所有VBTs是由于耐药性。本研究的目的是确定的发病率，，VBT与基因型耐药（GR）在慢性乙型肝炎患者在临床实践中接受NUCs。慢性乙型肝炎患者接受NUCs记录进行了审查。所有患者VBT耐药突变进行了测试。包括148例患者中，73％为男性，平均年龄为44.9岁。在一个平均随访37.5±20.1个月，39例（26％）患者至少有1 VBT。这39例患者中，有15人（38％）没有证实有VBT上重新测试，没有证据的GR和10这15个。 VBT，确认的累积概率VBT，与，GR在5年分别为46.1％，29.7％，33.9％，。在多变量分析中，未能达到检测不到乙肝病毒（HBV）DNA是唯一的因素显着相关的VBT。其中有VBT但没有确认的VBT或GR和保持在同一药物的10例患者中，血清HBV DNA下降在所有10个，和9有6.8个月后，在平均的VBT不到HBV DNA。 4例患者持续检测不到HBV DNA，6例在随访过程中的短暂升高，HBV DNA，并没有GR。结论：在患者与CHB接受NUCs的临床实践中，VBT是常见的，但近40％不相关的VBTs的抗病毒药物耐药性。 VBT和/或GR坚持服药和确认CHB患者的咨询，可避免不必要的变化抗病毒药物。 （肝胆病2011 ;)

五核苷（酸）类似物（NUCs）拉米夫定，阿德福韦，恩替卡韦，替比夫定和替诺福韦已被批准用于治疗慢性乙型肝炎（CHB）。 NUCs是口服给药，很少有副作用，但这些药物抑制，但不根除乙肝病毒（HBV）。因此，大多数慢性乙肝患者需要长期治疗，获得临床获益。然而，长期的NUC治疗耐药的风险增加相关的，特别是当NUCs低遗传障碍阻力作为单一疗法使用。

病毒学突破（VBT）是第一个抗病毒药物的耐药性和临床表现，可生化突破之前（BBT）.1-3 3期临床试验显示，国统会初治患者的NUCs 0％-87.5％的患者VBT已确认基因型耐药（GR）.4-9 3期试验中，替比夫定与拉米夫定（lamivudine）32 680（4.7％）和99 687（14.4％）患者接受替比夫定和拉米夫定，分别​​治疗1年后，经验丰富的VBT与VBT，但只有28人（87.5％）和75（75.8％）例患者被证实有GR.9在3期试验中，恩替卡韦与拉米夫定（lamivudine）11 679（1.6％）和88 668例（13.2％），接受恩替卡韦和拉米夫定，分别​​治疗1年后，经验丰富的VBT，但0（0％），恩替卡韦治疗，并与VBT拉米夫定治疗的患者中有65（73.9％）被证实有GR.7，8替诺福韦3期试验中，10 426例（2.3％），1年的治疗后，替诺福韦经验丰富的VBT，但这些患者都没有证实有GR.4这些数据表明，并非所有的的VBTs相关的抗病毒药物性。

VBT和GR率之间的差异可能的解释包括对药物治疗的依从性差，无法检测到耐药性突变，由于不敏感的检测，并没有认识到新的基因突变与抗病毒耐药性。 VBT在治疗的第一年，是由于对药物的依从性患者接受恩替卡韦或替诺福韦在第3阶段trials.4，7服药依从性可能比在3期临床试验，积极进取的患者在临床实践中的招募，并密切监察。 VBT由于对药物的依从性和VBT由于耐药性的区别是很重要的，因为病毒学应答，可以恢复在前者的情况下，坚持加强，而在后一种情况下是必要的抢救治疗。

本研究的目的分别为：（1）确定VBT和GR VBT在慢性乙型肝炎患者接受NUCs确定的因素在临床实践中，（2）NUCs治疗慢性乙型肝炎患者的发病率， （3），以确定的与VBTs患者未确认到与抗病毒耐药突变的结果。

丙氨酸氨基转移酶（ALT），抗-HBe，抗体，乙肝e抗原，BBT，生化突破;慢性乙型肝炎，慢性乙型肝炎; CI，置信区间; GR，基因型耐药e抗原，乙肝e抗原，乙肝病毒，乙肝病毒;艾滋病毒，人类免疫缺陷病毒，人力资源，风险比; NUC，核苷（酸）类似物; ULN，正常的上限; VBT，病毒学突破。

肝胆速递

Discussion

This study examined the rates of VBT, confirmed VBT and GR in 148 CHB patients treated with NUCs in clinical practice. We found a high rate of VBT, 39 (26%) patients experienced at least 1 episode of VBT with a cumulative probability of 46% at 5 years. Twenty-four (16%) patients had confirmed VBT; of these, 19 (79%) had GR by direct sequencing. An additional five patients had GR but were not confirmed to have VBT on retesting or received rescue therapy without retesting. Thus, in total 24 (16%) patients had GR. The finding that 38% of patients who experienced VBT were not confirmed to have VBT on retesting and 38% did not have antiviral resistance mutations on direct sequencing suggests that medication nonadherence may be the cause of the VBT in these patients.

We acknowledge that direct sequencing is insensitive and will not detect viral variants that comprise <20% of the viral population. In this study, all patients were also tested by a line probe assay which is more sensitive and can detect viral variants that comprise >5% of the viral population. Two additional patients were found to have N236T mutation by the line probe assay. Thus, signature antiviral resistance mutations were not detected in 13 (33%) patients with VBT by both direct sequencing and line probe assay. None of these 13 patients was noted to have other substitutions in the reverse transcriptase region of the HBV polymerase gene. Only one had BBT. In phase 3 clinical trials of NUCs for CHB, 65.7% to 87.5% of patients receiving lamivudine or telbivudine and 0% of patients receiving entecavir or tenofovir, who experienced VBT during the first year had GR.4, 7-9

Although antiviral resistance mutations may be detected if we had used more sensitive methods such as single genome sequencing or pyrosequencing, follow-up data suggest that most of the patients who experienced VBT but did not have confirmed VBT or GR were not adherent to their antiviral medication(s). Because this was a retrospective study, data on medication adherence was not available; however, follow-up data suggest that non adherence was an important cause of these unconfirmed VBTs. All 10 patients who continued treatment with the same medication(s) had further decrease in serum HBV DNA levels and all but one had undetectable HBV DNA after the VBT. Six of these 10 patients experienced ≥1 episode of transient increase in serum HBV DNA level during follow-up despite counseling on the importance of medication adherence. None of the five retested for GR was found to have antiviral resistance mutations and all had subsequent decline in serum HBV DNA during continued treatment with the same medication(s). We acknowledge that our attribution that nonadherence was an important cause of VBT is speculative. In a separate prospective study of 105 patients in whom adherence was evaluated using a self-administered questionnaire, 26% admitted to missing their medication at least once in the past 30 days and patients who had <100% adherence on serial assessments had a trend toward a higher rate of VBT.14 Medication adherence has been shown to be important in maintaining response in patients receiving treatment for other conditions. Published studies showed that patients who were adherent to antihypertensive medications were more likely to have adequately controlled blood pressure.15-17 Several studies of antiretroviral medications in patients with HIV infection also revealed that failure to adhere to HIV treatment regimens and repeated drug holidays (defined as stopping treatment entirely for ≥48 hours) were associated with a higher rate of virological failure.18, 19 In one study of HIV treatment that included a protease inhibitor, 80% of patients with <80% adherence had virological failure, compared to 22% of those with ≥95% adherence.20

There are very little data on adherence to NUC treatment for hepatitis B. In a previous study of a pharmacy claims database that included 11,100 patients receiving NUCs for CHB, we found that mean adherence 1 year after enrollment, defined as percent of days in which the patient had medications during that year, was 87.8%.21 In that study, we were not able to correlate medication adherence with virological response or occurrence of VBT. In the current study, we found that nadir response and type of medication used were significantly associated with the occurrence of VBT. Thus, patients who had rapid response with undetectable serum HBV DNA within 1 year of treatment and those who had undetectable serum HBV DNA at some point during the course of treatment were less likely to experience VBT. These data are in accord with previous studies showing that undetectable serum HBV DNA after 24 weeks of treatment is associated with significantly lower rates of antiviral resistance.22, 23 As expected, among NUC-naive patients, those receiving entecavir monotherapy were less likely to experience VBT than those receiving lamivudine monotherapy. Among NUC-experienced patients, those receiving combination therapy (lamivudine + adefovir or emtricitabine + tenofovir) or tenofovir monotherapy were less likely to experience VBT than those receiving lamivudine, adefovir, or entecavir monotherapy. This is not surprising, because these patients had previous nonresponse or resistance to lamivudine or adefovir, and it is now known that switching from lamivudine to adefovir or entecavir monotherapy in patients with prior lamivudine resistance is associated with a high rate of subsequent resistance to adefovir or entecavir.24-26 In this study, all the patients who received entecavir or tenofovir alone or in combination with another NUC had undetectable HBV DNA within 6 months of rescue therapy, whereas three patients with lamivudine resistance still had detectable HBV DNA 6 months after rescue therapy with adefovir alone or in combination with lamivudine.

In conclusion, this study revealed that VBT was common in clinical practice. However, VBT was not always related to antiviral drug resistance. Patients with CHB receiving NUC therapy who experienced VBT should be counseled on medication adherence, and for patients who are immunocompetent and have compensated liver disease, confirmation of VBT and/or determination of GR is prudent before the initiation of rescue therapy to avoid unnecessary changes in antiviral medications. We acknowledge that this study is limited by the small number of patients, the heterogeneity in treatment regimens, and the lack of data on medication adherence. However, the results of this study highlight the importance of HBV DNA monitoring and counseling on medication adherence throughout the course of NUC treatment and the fine balance between prompt initiation of rescue therapy versus avoidance of unnecessary changes to the treatment regimen.

肝胆速递

讨论

本研究旨在探讨率VBT，VBT和GR在148例慢性乙型肝炎患者，治疗NUCs在临床实践中证实。我们发现率很高VBT，39例（26％），VBT的累积概率为46％，5年经历了至少1集。二十四例（16％）已证实的VBT这些，有19（79％）GR直接测序。另外5例患者GR，但没有证实有VBT重新测试或接受抢救治疗无复验。因此，在共24个（16％）患者GR。这一发现，38％的患者经历了VBT没有证实有的VBT对复验，38％的人没有抗病毒药物耐药突变的直接测序表明，药物治疗依从性的原因可能是在这些患者中的VBT。

我们承认，直接测序法是不敏感的，并不会检测病毒的变种，包括20％的病毒数量。在这项研究中，所有患者也进行了测试，这是更为敏感，而且可以检测到病毒变种含有> 5％的病毒人口由一条线探针检测。另外两个病人被发现有N236T突变的线探针检测。因此，签名抗病毒药物耐药突变均未检出13个（33％）患者VBT直接测序和线性探针检测。这13例患者的HBV聚合酶基因的逆转录酶区有其他的替代。只有一个BBT。在第3阶段的临床试验的NUCs为CHB，65.7％，87.5％的患者接受拉米夫定或替比夫定和0％的患者接受恩替卡韦和替诺福韦，谁经历VBT在第一年GR.4 7-9

虽然抗病毒药物的耐药性突变可以被检测到，如果我们使用了更敏感的方法，如单基因组测序和焦磷酸测序，后续的数据表明，大多数的患者经历VBT，但没有证实VBT或GR贴到他们的抗病毒药物（）。因为这是一项回顾性研究中，用药依从性的数据不可用，但是，后续的数据显示，依从性是一个重要的这些未经证实VBTs的原因。所有10例患者继续治疗，同样的药物（S），进一步降低血清中HBV DNA水平，但检测不到HBV DNA后VBT。六这10个患者出现短暂增加血清HBV DNA水平≥1集在随访过程中坚持服药的重要性，尽管咨询。 5重新测试，GR没有被发现有抗病毒耐药突变，在同样的药物（S）继续治疗后血清中HBV DNA下降。我们认识到，我们的归属，依从性是一个重要的原因VBT是投机性的。在另一项前瞻性研究的105例患者中谁坚持使用自填式问卷进行了评估，26％的人承认缺少他们的药物至少在过去的30天，患者<100％坚持串行评估的趋势已被证明是重要的，在保持其他条件的接受治疗的患者的反应率较高VBT.14用药依从。已发表的研究结果表明谁是附着在抗高血压药物的患者更可能有适当的控制血液在HIV感染患者的抗逆转录病毒药物pressure.15-17的一些研究还显示，如果不坚持艾滋病毒治疗方案，并重复用药假期（定义完全停止治疗≥48小时），更高的速率的病毒学failure.18，19在一项研究中的艾滋病毒治疗，其中包括一种蛋白酶抑制剂，80％的患者有80％坚持与病毒学失败，相比22 ％与≥95％adherence.20，的

有非常少的数据在坚持索赔数据库，其中包括11,100 NUCs为CHB患者接受NUC治疗B型肝炎的药店在先前的研究中，我们发现，平均坚持1年后入学％的天数定义为在这一年的病人有药物，为87.8％.21在这项研究中，我们不能够关联服药依从性病毒学应答或发生VBT。在目前的研究中，我们发现，VBT的发生与最低点的响应和类型的药物，用于显着。因此，患者有1年以内的治疗和在一些点在治疗过程中检测不到血清HBV DNA检测不到血清HBV DNA快速反应是不太可能体验到VBT。这些数据是符合以前的研究显示，24周的治疗后，血清HBV DNA检测不到与显着较低的利率正如预期的那样，在国统会初治患者的抗病毒resistance.22，23，那些接受恩替卡韦单药治疗是不太可能体验到VBT比那些接受拉米夫定单药治疗。在国统会经验的患者中，接受联合治疗（拉米夫定+阿德福韦或恩曲他滨+替诺福韦）或替诺福韦单药治疗是不太可能体验到的VBT比那些接受拉米夫定，阿德福韦或恩替卡韦单药治疗。这并不奇怪，因为这些患者以前无应答或耐拉米夫定或阿德福韦，它是目前已知的开关从拉米夫定，阿德福韦或恩替卡韦单药治疗之前，拉米夫定耐药患者与随后的电阻率很高阿德福韦或在这项研究中entecavir.24-26，所有的患者接受恩替卡韦或替诺福韦单独或与另一国统会抢救治疗后6个月内HBV DNA检测不到，而拉米夫定耐药的患者仍然有可检测到HBV DNA 6个月后救援阿德福韦单独或联合拉米夫定治疗。

总之，这项研究显示，VBT在临床实践中是常见的。然而，VBT不是总是有关抗病毒药电阻。 CHB接受NUC治疗经历VBT的患者应坚持服药辅导，为患者免疫和补偿肝病，VBT确认和/或确定GR开始前的抢救治疗，以避免不必要的变化是谨慎的抗病毒药物。我们承认，这项研究是由少数的患者，治疗方案的异质性，服药依从性的数据缺乏的限制。然而，这项研究结果突出整个国统会迅速开始抢救性治疗与避免不必要的治疗方案之间的待遇和良好的平衡的过程中HBV DNA监测和用药依从性辅导的重要性。

StephenW

这是一个很不错的文章，并应仔细阅读。
阅读完整的文章在这里：
http://onlinelibrary.wiley.com/doi/10.1002/hep.24318/full

咬牙硬挺

感谢分享，看来相关知识是不断更新的，以前的结论不一定一直正确，只是战友们可怜了，无所适从

xiangsiwuyong

看了也是白看，一句话都不懂，全部是英文版的