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Review
. 2006 Jul;20(7):479-85.
doi: 10.1155/2006/497059.

Clinical recommendations for the use of recombinant human erythropoietin in patients with hepatitis C virus being treated with ribavirin

Morris Sherman  1 , Lawrence Cohen, Mary Anne Cooper, Magdy Elkashab, Victor Feinman, David Fletcher, Nigel Girgrah, Jenny Heathcote, Mark Levstik, William B McNaull, David Wong, Florence Wong, Colina Yim
Affiliations
Review

Clinical recommendations for the use of recombinant human erythropoietin in patients with hepatitis C virus being treated with ribavirin

Morris Sherman et al. Can J Gastroenterol. 2006 Jul.

Abstract
in English, French

Today, combination antiviral therapy with pegylated interferon-alpha and ribavirin (RBV) allows many patients infected with hepatitis C virus (HCV) to achieve a sustained virological response, which is equivalent to cure. Data also support the clinical benefit of combination antiviral therapy in patients coinfected with HCV and HIV, and in patients who have received a liver transplant. Antiviral therapy with pegylated interferon-alpha and RBV is, however, associated with a high incidence and significant magnitude of anemia. This anemia may have several mechanisms, including bone marrow suppression and hemolysis. In addition, patients coinfected with HIV may have both pre-existing and RBV-associated anemia. Management of anemia in patients with HCV through RBV dose reduction or treatment discontinuation may compromise the effectiveness of treatment, because studies have demonstrated that treatment adherence or maintenance of antiviral therapy dose is an important predictor of sustained virological response. Anemia associated with combination antiviral therapy in patients with HCV is frequently associated with an inadequate or blunted endogenous erythropoietin response. Accumulating evidence now supports the use of recombinant human erythropoietin (rHuEpo) to manage anemia in these patients, with the objective of maintaining the RBV dose, but clinical standards are lacking. The present article reviews the data relevant to the use of rHuEpo in this patient population and proposes a set of clinical practice standards to assist clinicians in selecting patients for rHuEpo and in implementing rHuEpo therapy effectively.

De nos jours, la polythérapie antivirale à l’interféron pégylé alpha et à la ribavirine (RBV) permet à de nombreux patients infectés par le virus de l’hépatite C (VHC) de profiter d’une réaction virologique soutenue, équivalant à la guérison. Les données appuient également le bienfait clinique de la polythérapie antivirale chez les patients co-infectés par le VHC et le VIH et chez les patients greffés du foie.

La thérapie antivirale à l’interféron pégylé alpha et à la RBV s’associe toutefois à une forte incidence d’anémie de grande envergure. Cette anémie peut se manifester par divers mécanismes, y compris la suppression médullaire et l’hémolyse. De plus, les patients co-infectés par le VIH peuvent souffrir à la fois d’anémie préexistante et d’anémie causée par la RBV. La prise en charge de l’anémie chez les patients atteints du VHC par une réduction de la dose de RBV ou l’abandon du traitement peut compromettre l’efficacité du traitement. En effet, les études ont démontré que l’adhésion au traitement ou le maintien de la dose antivirale constituent des prédicteurs importants d’une réaction virologique soutenue.

L’anémie associée à la polythérapie antivirale chez les patients atteints du VHC s’associe souvent à l’insuffisance ou à l’émoussement de la réaction de l’érythropoiétine endogène. Les données probantes s’accumulent pour soutenir le recours à l’érythropoiétine humaine recombinante (rHuEpo) afin de prendre en charge l’anémie chez ces patients en vue de maintenir la dose de RBV, mais il n’existe pas de normes cliniques à cet effet. Le présent article analyse les données reliées à l’utilisation de rHuEpo au sein de cette population de patients et inclut une série de normes de pratique clinique pour aider les cliniciens à sélectionner les patients qui prendront de la rHuEpo et à implanter une thérapie efficace à la rHuEpo.

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Figures

Figure 1)
Figure 1)
Progression of fibrosis in patients with hepatitis C virus infection pre-orthotopic liver transplantation (pre-OLT) and post-OLT according to duration of infection. Adapted from reference
Figure 2)
Figure 2)
Impact of four hepatitis C antiviral treatment regimens on hemoglobin levels during 24 to 48 weeks of therapy. EOT End of therapy; PEG IFN-α2b Pegylated interferon-alpha2b; RBV Ribavirin. Adapted from reference
Figure 3)
Figure 3)
Mean hemoglobin (Hb) levels (A) and mean ribavirin dose (B) with recombinant human erythropoietin (rHuEpo) and standard of care in patients with hepatitis C virus being treated with combination therapy with ribavirin plus interferon-alpha. Adapted from reference
Figure 4)
Figure 4)
Approach to the use of epoetin alpha in the management of anemia associated with combination antiviral therapy in patients infected with hepatitis C virus. Hb Hemoglobin
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References

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