Optimization of direct anti-viral agent treatment schedule: Focus on HCV genotype 3

Abstract

Background and aim

Direct antiviral agents (DAAs) have led to high sustained virological responses (SVR) in hepatitis C virus (HCV) patients. However, genotype 3 patients respond to treatment in a suboptimal way. This study aims to identify which of the several treatment schedules recommended for genotype 3 would constitute the best option.

Methods

Twenty-four Italian centers were involved in this real-life study of HCV genotype 3 patients treated with DAAs. To expand the number of cases, we conducted a systematic review of the literature on the outcome of genotype 3 patients treated with DAAs.

Results

A total of 233 patients with HCV genotype 3 were enrolled. Cirrhotic patients accounted for 83.7%. Overall, the SVR12 rate was achieved by 205 patients (88.0%); the SVR rates were 78.8% after sofosbuvir/ribavirin, 92.5% after sofosbuvir/daclatasvir ± ribavirin, and 100% after sofosbuvir/ledipasvir (seven patients). No difference in rate of SVR was observed in cirrhotic and non-cirrhotic patients (92.2 vs 94.4) using a combination regimen of NS5A and NS5B inhibitors.

The systematic review of the literature provided data of 3311 patients: The mean weighted SVR12 rate was 84.4% (CI: 80.4–87.8); the rates varied from 79.0% (CI: 70.9–85.3) with sofosbuvir/ribavirin, to 83.7% (CI: 66.2–93.1) with sofosbuvir/ledispavir, and to 88.2% (CI: 83.3–91.7) with sofosbuvir/daclatasvir.

Conclusions

Our results reinforce the concept that patients with HCV genotype 3 should no longer be considered difficult-to-treat individuals. The optimal therapeutic regimen for these patients appears to be the combination sofosbuvir/daclatasvir, administered for 12 weeks without the use of RBV in non-cirrhotic patients. In cirrhotics the meta-analytic approach suggests extending therapy to 24 weeks.

Keywords

HCV genotype 3 cirrhosis direct antiviral agent meta-analysis

Key summary

In the era of direct antiviral agents (DAAs), the schedule of treatment for hepatitis C virus (HCV) genotype 3 is not optimized, with low rates of sustained virological response (SVR), especially in cirrhotic patients.

In our cohort (233 genotype 3 patients) the use of a schedule containing a combination of NS5A and NS5B demonstrated high efficacy (>90%) without difference in cirrhotic and non-cirrhotic patients.

The meta-analytic approach in 3311 patients confirms the higher efficacy of the combination of sofosbuvir and daclatasvir.

The extension of treatment to 24 weeks independently of the use of ribavirin seems to be the best option in difficult-to treat-patients (cirrhotic and treatment-experienced patients).

Introduction

Hepatitis C virus (HCV) genotype 3 is the second most common subtype, most prevalent in the South Asian region. It accounts for about 50 million infected individuals worldwide.^1,2

At the time when pegylated-interferon (IFN) in combination with ribavirin (RBV) was the only available treatment for chronic HCV infection, genotype 3 was considered an “easy to treat” genotype, and several studies showed this regimen to be effective in 68% to 90% of patients.^3,4

The shift from IFN-based therapy to all-oral IFN-free therapies has been a watershed for the management of chronically HCV-infected patients. The first licensed direct antiviral agent (DAA) was sofosbuvir, a pangenotypic NS5B inhibitor: When given in combination with RBV, the regimen proved sub-optimal for HCV genotype 3, as sustained virological response (SVR) rates were unexpectedly lower than those registered in non-3 genotypes. This notion applies especially to cirrhotic patients with HCV genotype 3 infection.⁵ In fact, in registration trials SVR was achieved in 47% of treatment-naïve cirrhotic patients, and in 21% of treatment-experienced patients with cirrhosis, when treatment lasted for only 12 weeks.^6,7 Extending sofosbuvir/RBV treatment to 24 weeks resulted in 92% SVR rates for treatment-naïve patients, but for treatment-experienced patients SVR rates remained at an unacceptable 62%.⁸ In the DAAs era, HCV-3 genotype has emerged as the new “difficult to treat” genotype.

A partial explanation for the previous different rates may be related to the fact that most of the available DAAs have been designed to fit with the catalytic/functional sites of HCV genotype 1 protease, polymerase and NS5A proteins. Consequently, many of the currently approved DAAs are HCV-genotype restricted with robust in vitro efficacy toward genotype 1, and less so toward genotype 3.⁹ Moreover, the impact of baseline and on-treatment appearance of resistant antiviral variants in genotype 3 treatment failure has not yet been systematically investigated.¹⁰ When pangenotypic NS5A inhibitors like daclatasvir or velpatasvir were employed in combination with sofosbuvir, the therapeutic outcome remarkably improved.^11,12 Indeed, in registration trials the sofosbuvir/daclatasvir combination for non-cirrhotic genotype 3 patients achieved SVR rates above 95%, both in naïve and experienced patients.¹¹ However, this same therapeutic regimen proved less effective in cirrhotic patients, with SVR rates dropping to 57% and 63% in naïve and treatment-experienced cohorts, respectively.¹¹ For the latter subgroup of patients, SVR rates attained a value of 86% when this regimen was complemented by the inclusion of RBV and prolonged to 16 weeks.¹³ Several real-world studies using sofosbuvir and daclatasvir, with or without RBV, reported SVR rates >80% in cirrhotic patients with genotype 3, including those with decompensation.^14,15 Therefore, the current therapeutic strategies for genotype 3 patients seem to be optimal only for those without cirrhosis, while for cirrhotic patients the optimization of the schedule with current DAAs requires further investigation.

The present report focuses on HCV genotype 3 cirrhotic patients treated with second-generation DAAs and aims to identify the best treatment option in relation to the type of combination of administered drugs, duration of treatment and the need to include RBV in the treatment schedule. In addition, with the intent to ensure the robustness of our project, we enlarged the number of genotype 3-infected patients treated with the new DAAs by scrutinizing the available studies in the recent literature, and pooled the data obtained from our cohort of patients with those retrieved by our search in a meta-analysis.

Material and methods

Study design and patients population

From May 2015 to September 2016, a consortium of 23 community and academic Italian centers (the ITAL-C consortium) conducted an observational real-life study collecting consecutive patients infected by all HCV genotypes treated with any of the new DAA regimens.¹⁶ From this large database, we extracted data on all patients infected by the HCV genotype-3. Patients with any of the following features were excluded: infection with HCV genotypes other than 3, active hepatocellular carcinoma (HCC) on imaging, human immunodeficiency virus (HIV) and/or hepatitis B virus (HBV) co-infection, liver-transplant recipients, active alcohol consumption; patients with an estimated glomerular filtration rate <30 ml/min. All patients had no history of prior alcohol abuse. Eligible patients were>18 years old with chronic HCV infection, either naïve or treatment experienced. Treatment-experienced patients may have received prior therapy with peg-IFN and RBV in combination or not with first-generation DAAs. In Italy antiviral therapy with DAAs is reimbursed by the national health system only in patients who fulfill specific criteria: patients with advanced fibrosis (F3 sec. Metavir); patient with cirrhosis; patients with previous HCC with a complete response to curative therapies; patients with significant fibrosis (≥F2) and recipients of solid organ transplantation (other than liver) or bone marrow transplantation; patients with any degree of fibrosis with severe extrahepatic manifestations (cryoglobulinemic syndrome with organ damage, B-cell lymphoproliferative syndromes). Therefore all the patients in the cohort fit one of these criteria.

The treatment regimen was chosen individually by the prescribing clinician in accordance with national and international guidelines,^17–19 although in seven cases a non-recommended therapy was prescribed (namely ledipasvir and sofosbuvir) because of its use as individual compassionate therapy. Treatment duration (12/24 weeks) was dictated by the severity of liver disease, with longer treatment reserved for cirrhotic patients. All patients who received at least one dose of the new DAAs were included in the study. The study protocol was approved July 27, 2016 by the Ethics Committee of the Casa Sollievo della Sofferenza Hospital, in San Giovanni Rotondo, Italy. Each patient included in the study provided a written informed consent. All the study’s procedures were conducted according with the provisions of the Declaration of Helsinki and Good Clinical Practice Guidelines. For each enrolled participant, baseline characteristics were acquired: gender, body mass index (BMI), age, prior treatment, cirrhotic status, decompensating events (ascites, esophageal bleeding, encephalopathy, HCC), enlisting for orthotopic liver transplantation (OLT). The following laboratory values were registered: alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, creatinine, international normalized ratio (INR), blood count and albumin, alpha-1-fetoprotein. Comorbidities were classified according to Harboun and Ankri,²⁰ and the possible interaction of co-administered drugs with the DAA to be prescribed were checked by the Liverpool HEP interactions.²¹

Measurement of fibrosis and classification of cirrhosis

Evaluation of liver fibrosis was made by histology or elastometry (FibroScan©); one of the two evaluations was carried out within two months before starting therapy. Advanced fibrosis was defined at histology by a Metavir score of F3 or a FibroScan ≥ 10 kPa but < 14 kPa. Cirrhosis was defined by a Metavir score of F4, or by a FibroScan ≥ 14 kPa or in presence of clinical, laboratory and ultrasound (US) parameters of clinical apparent cirrhosis. Portal hypertension was defined by the presence of esophago-gastro varices at endoscopy and/or detection of collateral veins at ultrasound.

For cirrhotic patients, Child-Pugh-Turcotte (CPT) classes and Model for End-Stage Liver Disease (MELD) scores were calculated. Cirrhotic patients were further stratified into five classes according to D’Amico classification.²² They were classified as follows: compensated cirrhotics without or with endoscopic evidence of varices were included in class 1 or 2, respectively; decompensated cirrhotics were those with a history of variceal bleeding (stage 3), a previous, single episode of ascites or encephalopathy in the absence of esophageal bleeding (stage 4), and those with multiple, recurrent episodes of decompensation, including a bleeding event (stage 5).

Efficacy assessment and outcomes

Patients were reviewed monthly during the antiviral treatment and virological response was assessed by quantitative HCV-RNA at week 4, at the end of treatment, and at four and 12 weeks following the end of treatment. The SVR, defined as the persistent absence of detectable HCV-RNA in serum 12 weeks after the end of treatment (SVR12), was used as the primary outcome in this study. The secondary outcome was the identification of baseline characteristics that could predict treatment failure.

Meta-analysis

With the intent to delineate a treatment schedule with the new DAAs that would offer the higher chance of SVR to patients with HCV genotype 3, a systematic search of the literature data was implemented and the retrieved information was pooled and evaluated by a meta-analytical approach.

Selection of primary studies

Electronic, systematic review of the available evidence in the published literature, conducted in line with the Cochrane Handbook for Systematic Reviews of Interventions,²³ was undertaken to identify all studies. Secondly, the proceedings of the 2015 and 2016 Annual Meetings of the American Association for the Study of Liver Diseases and of the European Association for the Study of the Liver were hand-searched. The systematic literature review was performed via Medline from 2012 to 2016 by the following search keys: HCV Genotype 3 AND [(DAA)OR (sofosbuvir)OR(daclatasvir)OR(Ledipasvir)OR(Velpatasvir)]. The last search was on December 2016. Manual searching included reading through reference lists of relevant papers to capture missing studies that met our inclusion criteria. Three independent reviewers (FM, ML, RG) scanned every identified study to determine eligibility. Studies were excluded if they were in languages other than English, or reported data on HIV- or HBV-co-infected patients. Phase II and dose-finding studies were also excluded, as were duplicate publications, narrative reviews, and editorials. The studies may be focused only on genotype 3 patients or be studies with patients infected with all HCV genotypes; in this event, only data regarding for HCV genotype 3-infected patients were extracted and pooled into the analysis.

Data extraction and management

All information was extracted using a standardized data abstraction form. Retrieved data included: study characteristics (clinical trials or interventional studies); baseline patient characteristics, treatment history (naïve or treatment experienced); treatment regimens, including dose and duration; use of RBV; efficacy of therapy as ascertained by SVR12. Data were extracted by a single review author and checked by a second independent reviewer. Any disagreement was resolved through discussion.

Data synthesis

The primary efficacy outcome was SVR12 (undetectable HCV-RNA levels 12 weeks after the end of therapy). Separate analyses were performed in non-cirrhotic and cirrhotic patients, for each treatment regimen, and for subpopulations based on prior treatment experience (whether naïve or previously exposed to peg-IFN and RBV), on the concomitant use or not of RBV, and duration of therapy (12 or 16 or 24 weeks).

Statistical analysis

Baseline characteristics of patients were assessed with standard descriptive statistics. Categorical variables were reported as percentages and compared using chi-square (or Fisher’s exact test, when needed). Variables with a p < 0.05 were included in a multivariate stepwise logistic regression model. Regarding meta-analysis, proportions were the measure of interest and subgroup analyses were carried out. Random rather than fixed-effects models were used to estimate pooled proportions in order to account for heterogeneity. All analyses were performed using SPSS software, version 13.0 (SPSS Inc, Chicago, IL, USA) and Comprehensive Meta-analysis software (Version 2.2064, Biostat, Englewood, NJ, USA).

Results

Patients

A total of 233 HCV genotype 3 patients who met the inclusion criteria were extracted from the database of the collaborative ITAL-C consortium. Enrolled patients were adults with a median age of 52 years. The great majority of patients were males (82.0%) with liver disease progressed to the stage of cirrhosis (83.7%). Two-thirds of them were naïve to antiviral treatment. Eighty percent (157/195) of patients were in CPT class A, 15.4% (30/195) in class B, and the remaining eight patients (4.1%) in class C. On the basis of MELD scoring, 188 patients (96.4%) had a score <16, and seven patients (3.6%) a score ≥16. According to cirrhosis stage 98/195 (50.2%) patients were classified as class 1 (no signs of portal hypertension or previous decompensating events), while the remaining cirrhotic patients had clinically apparent cirrhosis.

Baseline characteristics of patients and the corresponding SVR12 rates are shown in Table 1. In the entire population, the SVR rate was achieved by 205 individuals (88.0%). A successful treatment outcome was documented in 79.0% of patients treated with sofosbuvir in combination with RBV, in 92.0% of those who received sofosbuvir/daclatasvir with or without RBV, and in all seven patients treated with sofosbuvir/ledipasvir with or without RBV.

Table 1.

Univariate analysis of factors affecting treatment outcome to DAAs in 233 HCV genotype 3-infected patients.

	Treatment failures		Treatment success		p value
	N	%	N	%
Overall	28	12	205	88
Gender
Male	27	14	164	86	0.035
Female	1	2	41	98
Age (years)
<70	28	12	199	88	1.000
≥70	–	–	6	100
BMI
<30	19	10	171	90	0.047
≥30	9	21	34	79
Liver disease
Advanced fibrosis	5	13	33	87	0.813
Cirrhosis	23	12	172	88
Albumin (g/dl)
>3.5	20	11	164	89	0.296
≤3.5	8	16	41	84
INR
≤1.7	25	11	195	89	0.207
(1.7–2.2)	3	23	10	77
Bilirubin (mg/dl)
<2	23	11	186	89	0.161
≥3	5	21	19	79
Comorbidities (no.)
0	21	15	123	85	0.125
≥1	7	8	82	92
Pre-therapy status
Naïve	15	10	138	90	0.151
Tx experienced	13	16	67	84
Treatment schedules
SOF + RBV	17	21	63	79	0.011
SOF + DCV ± RBV	11	8	135	92
SOF + LDV ± RBV	–	–	7	100
Ribavirin
Without	8	10	70	90	0.558
With	20	13	135	87
Duration of therapy
12 weeks	7	19	29	81	0.136
24 weeks	21	11	176	89

DAAs: direct-acting agents; HCV: hepatitis C virus; BMI: body mass index; INR: international normalized ratio; Tx: therapy; SOF: sofosbuvir; RBV: ribavirin; DCV: daclatasvir; LDV: ledipasvir.

At the univariate analysis, baseline predictors of the SVR12 were gender (female patients being more responsive than males), BMI <30 and the treatment schedule. Of relevance, age, stage of liver disease (whether advanced fibrosis or cirrhosis), RBV use, and treatment length were irrelevant to SVR12. At the stepwise logistic regression analysis, the only two factors independently associated with SVR12 were regimens containing sofosbuvir in combination with daclatasvir or ledipasvir (odds ratio (OR) = 4.25; 95% confidence interval (CI): 1.81–9.97; p = 0.001), and BMI < 30 (OR = 2.64; 95% CI: 1.04–6.72; p = 0.041). Although SVR12 rates between cirrhotic and non-cirrhotic patients were not different at the prior analysis, we performed a separate analysis for the 195 cirrhotic patients; see Table 2. The overall SVR12 rate was 88.2%, and only 23 patients failed to respond. All 31 female patients cleared the HCV infection, while the SVR12 rate in males was 86.0% with a significant difference in comparison to females (p = 0.029). None of the three different staging systems for cirrhosis (CPT, MELD and the D’Amico system),²² had a significant impact on SVR12 rates, but numerically lower rates were noted in CPT class C and in patients with a ≥16 MELD score. As to treatment schedule, the inclusion of RBV did not ameliorate the SVR12 rates. The regimen of sofosbuvir in combination with RBV yielded significantly lower rates than the sofosbuvir-containing regimens in combination with daclatasvir or ledipasvir (p = 0.030). At the multivariate analysis, these latter regimens and BMI were the only two independent predictors of a favorable outcome, with the respective OR of 4.09 (95% CI: 1.60–10.47; p = 0.003), and 3.89 (95% CI: 1.45–10.47; p = 0.007).

Table 2.

Univariate analysis of factors affecting treatment outcome to DAAs in 195 HCV genotype 3-infected cirrhotic patients.

	Treatment failures		Treatment success		p value
	N	%	N	%
Overall	23	12	172	88
CPT
A	17	11	140	89	0.109
B	3	10	27	90
C	3	38	5	63
MELD score
<16	21	11	167	89	0.161
≥16	2	29	5	71
Gender
Male	23	14	141	86	0.029
Female	–	–	31	100
BMI
<30	14	9	142	91	0.024
≥30	9	23	30	77
Pre-therapy status
Naïve	13	10	114	90	0.356
Tx experienced	10	15	58	85
Treatment schedules
SOF + RBV	13	21	48	79	0.030
SOF + DCV ± RBV	10	8	118	92
SOF + LDV ± RBV	–	–	6	100
Ribavirin
Without	7	11	58	89	0.754
With	16	12	114	88
Duration of therapy
12 weeks	2	25	6	75	0.237
24 weeks	21	12	166	88

DAAs: direct antiviral agents; HCV: hepatitis C virus; CPT: Child-Pugh-Turcotte; MELD: Model for End-Stage Liver Disease; BMI: body mass index; Tx: therapy; SOF: sofosbuvir; RBV: ribavirin; DCV: daclatasvir; LDV: ledipasvir.

Meta-analysis

Figure 1 presents the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for the selection of primary studies. Seventeen full text records (11 randomized controlled trials (RCTs) and six observational cohorts),^{6–8,11,13,14,24–34} the present investigation and two abstracts^15,35 were retained for analysis. Main clinical features of the 3311 patients treated with different schedules of the DAAs are shown in Table 3, and the meta-analytical data in Figure 2. Overall, the mean weighted SVR12 rate was 84.4% (95% CI: 80.4–87.8). The three schedules of antiviral treatment yielded numerically different SVR12 rates, which varied from 79.0% (95% CI: 70.9–85.3) in the regimen comprising sofosbuvir with RBV, to 83.7% (95% CI: 66.2–93.1) when sofosbuvir was given in combination with ledispavir, and 88.2% (95% CI 83.3–91.7) with a combination of sofosbuvir with daclatasvir.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram for the processing of literature data.

Table 3.

Outcomes following treatments in 3316 HCV genotype 3-infected patients.

	RBV	Duration of therapy (weeks)	TOTAL		CIRRHOTIC		NO CIRRHOTIC		NAIVE		EXPERIENCED
DRUG First author, year^ref	RBV	Duration of therapy (weeks)	nSVR	TOT	nSVR	TOT	nSVR	TOT	nSVR	TOT	nSVR	TOT
SOF + RBV
Feld, 2016²⁴	Yes	24	107	178	43	96	64	82	63	94	44	84
Foster, 2015²⁵	Yes	16	128	181	29	57	99	124	70	91	58	90
	Yes	24	153	182	44	56	109	126	83	94	70	88
Butt, 2016²⁶	Yes	12/24	166	201	72	95	94	106	126	144	40	57
Lawitz, 2013⁶	Yes	12	102	183					102	183
Foster, 2015²⁵	Yes	24	221	275	55	83	163	187	174	201	44	69
Jacobson, 2013⁷	Yes	12	60	98	3	14	57	84
	Yes	12	19	64	5	26	14	38			19	64
	Yes	16	39	63	14	23	25	40			39	63
Zeuzem, 2014⁸	Yes	24	213	250	41	60	172	190	99	105	114	145
Wu, 2015²⁷	Yes	24	25	31	10	12	15	19
Satsangi, 2017²⁸	Yes	24	75	76	25	26	50	50	71	72	4	4
Isakov, 2016²⁹	Yes	16	26	30	5	6	21	24	26	30
	Yes	24	28	31	3	5	25	26	28	30
Shah, 2017³⁰	Yes	16	29	29	7	7	22	22
	Yes	24	28	30	6	7	22	23
Present study	Yes	12	15	19	4	4	11	15	10	12	5	7
	Yes	24	48	62	44	58	4	4	32	39	16	23
TOT			1482	1983	410	635	967	1160	884	1095	453	694
SOF + LDV
Gane, 2015³¹	No	12	16	25					16	25
	Yes	12	67	76	22	28	45	48	26	26	41	50
Foster, 2016³²	Yes	12	38	59	38	59
Present study	Yes	24	5	5	5	5			2	2	3	3
	No	12	1	1			1	1			1	1
	No	24	1	1	1	1			1	1
Alonso, 2016³³	Yes	12	9	9	9	9
	No	12	3	3	3	3
	Yes	24	59	64	59	64
	No	24	1	1	1	1
TOT			200	244	138	170	46	49	45	54	45	54
SOF + DCV
Nelson, 2015¹¹	No	12	135	152	20	32	105	120	91	101	44	51
Hezode, 2015¹⁵	Yes	12	5	5	4	4	1	1
	No	12	47	58	23	33	24	25
	Yes	24	43	53	39	48	4	5
	No	24	147	166	116	135	29	29
Welzel, 2016¹⁴	Yes	24	49	56	41	46	4	5	23	25	26	31
	No	24	33	37	29	33	1	1	12	12	21	25
Leroy, 2015¹³	Yes	12	21	24	15	18	6	6	6	6	15	18
	Yes	16	24	26	16	18	8	8	7	7	17	19
Foster, 2016³²	Yes	12	83	115	83	115
Sulkowski, 2014³⁴	No	24	6	6					6	6
	Yes	24	5	5					5	5
Koskinas, 2016³⁵	No	12/24	33	40
	Yes	12/24	59	65
Present study	Yes	12	6	6	2	2	4	4	4	4	2	2
	No	12	8	11	0	2	8	9	8	9	0	2
	Yes	24	61	64	59	62	2	2	40	42	21	22
	No	24	64	69	60	65	4	4	43	46	21	23
Alonso, 2017³³	Yes	12	29	32	29	32
	No	12	5	5	5	5
	Yes	24	70	73	70	73
	No	24	19	21	19	21
TOT			952	1089	630	744	200	219	245	263	167	193

HCV: hepatitis C virus; SVR: sustained virological response; SOF: sofosbuvir; RBV: ribavirin; DCV: daclatasvir; LDV: ledipasvir; TOT: total.

Figure 2.

Weighted estimates of SVR12 rates in all clinical trials evaluating the efficacy of the different antiviral regimens with the new direct-acting agents in patients with HCV genotype 3 infection. The results are broken down according to administered regimen.

The impact of RBV administration, treatment duration (12, 16 or 24 weeks), presence of advanced fibrosis or cirrhosis, and the status prior to current therapy (whether naïve or treatment experienced) was evaluated separately for each therapeutic regimen. Results are shown in Table 4.

Table 4.

Weighted estimates of SVR12 rates of 3311 HCV genotype 3-infected patients, broken down by treatment regime.

	SVR 12	Naive	Experienced	Cirrhotics	Non-cirrhotics
SOF/RBV
Overall	0.701 (0.629–0.764)	0.849 (0.766–0.907)	0.650 (0.550–0.739)	0.659 (0.555–0.749)	0.826 (0.754–0.881)
12 weeks	0.560 (0.452–0.663)	0.671 (0.360–0.881)	0.463 (0.135–0.826)	0.529 (0.034v0.973)	0.610 (0.487–0.720)
24 weeks	0.832 (0.753–0.889)	0.883 (0.795–0.937)	0.704 (0.586–0.800)	0.718 (0.601–0.812)	0.874 (0.824–0.911)
SOF/DCV
Overall	0.879 (0.852–0.901)	0.919 (0.879–0.947)	0.858 (0.798–0.902)	0.851 (0.793–0.896)	0.887 (0.834–0.925)
RBV yes	0.887 (0.811–0.935)	0.933 (0.859–0.970)	0.865 (0.775–0.923)	0.878 (0.802–0.927)	0.868 (0.694–0.950)
RBV no	0.877 (0.847–0.902)	0.912 (0.859–0.946)	0.839 (0.685–0.925)	0.816 (0.700–0.894)	0.891 (0.833–0.930)
12 weeks	0.841 (0.759–0.899)	0.901 (0.834–0.943)	0.807 (0.612–0.917)	0.743 (0.642–0.823)	0.889 (0.829–0.929)
24 weeks	0.909 (0.863–0.940)	0.937 (0.882–0.968)	0.870 (0.785–0.925)	0.905 (0.844–0.944)	0.938 (0.461–0.996)
SOF/LDV
Overall	0.745 (0.608–0.846)	0.851 (0.419–0.978)	0.824 (0.698–0.904)	0.837 (0.675–0.927)	0.938 (0.823–0.980)
RBV yes	0.854 (0.656–0.948)	0.946 (0.636–0.994)	0.824 (0.698–0.904)	0.835 (0.656–0.931)	–
RBV no	0.679 (0.497–0.819)	0.640 (0.440–0.801)	–	0.875 (0.266–0.993)	–
12 weeks	0.779 (0.581–0.899)	0.881 (0.217–0.995)	0.820 (0.689–0.904)	0.750 (0.550–0.880)	–
24 weeks	0.924 (0.835–0.966)	0.833 (0.194–0.990)	0.875 (0.266–0.993)	0.923 (0.833–0.966)	–

SVR: sustained virological response; HCV: hepatitis C virus; SOF: sofosbuvir; RBV: ribavirin; DCV: daclatasvir; LDV: ledipasvir.

Eleven studies, including the present investigation,^{6–8,24–30} evaluated the regimen of sofosbuvir plus RBV, administered to a total of 1983 patients: The SRV12 rates were higher when treatment lasted for 24 weeks, in naïve patients compared to experienced patients, and in non-cirrhotics compared with those with cirrhosis.

Information on the outcome following treatment with sofosbuvir/daclatasvir with or without RBV was retrieved from eight studies^{11,13–15,32–35} and the present investigation; a total of 1089 patients received this therapeutic regimen. The inclusion of RBV in the schedule did not affect the therapeutic outcome in the different subgroups of patients, whether naïve or treatment experienced, whether cirrhotics or non-cirrhotics. Treatment duration did not influence the outcome in the subgroups of naïve patients and in those without cirrhosis, whereas prolongation of treatment to 24 weeks produced higher SVR12 rates in treatment-experienced patients and in those with liver cirrhosis.

The combination of sofosbuvir/ledispavir has been evaluated to date in only 244 patients enrolled in three studies^31–33 and in the present investigation. With this therapeutic regimen, higher SVR rates were registered when RBV was included in the therapeutic schedule and when therapy lasted for 24 weeks. When patients treated with this combination therapy were subdivided by difference in the administered regimen, the value of adding RBV was documented only in naïve patients, and the benefit of 24 weeks’ treatment duration persisted only in those with cirrhosis.

Discussion

The optimal regimen of the new DAAs for patients with HCV genotype 3, and especially for those who have progressed to liver cirrhosis, is still an unsolved issue. The regimen containing sofosbuvir in combination with RBV is currently recommended;^17,19 however, this schedule may ensure an optimal outcome for non-cirrhotic patients treated for 24 weeks, but remains far from ideal in cirrhotic patients, whether naïve or treatment experienced. Real-life studies or compassionate use programs have reported better outcome when a combination of two DAAs was administered to HCV genotype 3-infected patients.^14,15 In these programs, SVR rates as high as 86% were reported in cirrhotic patients, whether naïve or treatment experienced, using a 24-week regimen.^14,15 These promising results, however, emerged from studies with a limited number of genotype 3 patients, so that the information cannot be considered conclusive.

Our study enrolled a large cohort (n = 233) of patients infected by the HCV genotype 3, the majority of them presenting with liver cirrhosis. A merit of this investigation is the simultaneous evaluation of the outcome following therapy with all available DAA schedules: Indeed, only 34.3% (80/233) of our patients were treated only with an NS5B inhibitor (sofosbuvir) in combination with RBV, whereas for the remaining two-thirds of patients, two NS5A inhibitors (daclatasvir or ledipasvir) were administered in combination with sofosbuvir, with or without RBV. We found an overall SVR12 rate of 88.0%, without difference in non-cirrhotic vs cirrhotic patients (87.0% vs 88.0%), and in treatment-naïve vs experienced patients (90.0% vs 84.0%). The SVR rates differed in relation to BMI (favoring BMI < 30) and to the schedule of treatment used (favoring sofosbuvir in combination with daclatasvir or ledispavir).The most relevant finding of our study was the demonstration of a similar high efficacy of schedules containing an NS5A inhibitor (daclatasvir or ledipasvir) in association with sofosbuvir, and independently from the use of RBV in cirrhotic vs non-cirrhotic patients (92.2% vs 94.4% for daclatasvir, and 100% vs 100% for ledipasvir).Of relevance, the prior two schedules independently predicted an SVR in the entire cohort of patients, as well as in the cirrhotic cohort. This finding is in contrast with data coming from registration trials using the same schedule of drugs but showing significant different rates of SVR in non-cirrhotic (96%) and cirrhotic patients; in the latter subset of patients the reported rates varied from 63% to 83% for a treatment duration of 12 weeks, to 89% for 16 weeks of treatment.^11,13 No information from registration trials is available concerning a prolonged treatment of 24 weeks. On the other hand our results seem to be consistent with and even better than those observed in real-life studies. In particular, the European and French Expanded Access Program showed an improvement of the rate of SVR, ranging between 81% and 88% when the treatment with sofosbuvir + daclatasvir was extended to 24 weeks, with no difference between RBV-free and RBV-containing regimens.^14,15 Overall, our data, in agreement with prior observations, sustain the possibility that the high rate of relapse previously observed in cirrhosis HCV-3 patients might be related to the use of sub-optimal schedules of therapy (sofosbuvir and RBV) and indicate as an optimal schedule the use of sofosbuvir in combination with either of the two NS5A inhibitors.

It is important to note that in our survey the stage of cirrhosis did not represent a factor influencing the rate of SVR, even if a numerically lower rate of success was obtained in Child C class (63.0%). Although the number of Child C patients in our study was low, our results are similar to the figure from larger studies focused on decompensated cirrhosis.^14,15,32

HCV infection is known to be associated with hepatic steatosis. In the case of genotype 3 infection, this is clearly a cytopathic effect of the virus because it is present in approximately two-thirds of infected individuals and can resolve completely in patients who achieve an SVR to therapy.³⁶ In the era of IFN-based therapies, liver steatosis was a known negative predictor of SVR, while its role in DAA-based therapies is not established. Unfortunately steatosis was not a variable included in the original database; therefore, although it would have been interesting data we cannot speculate on this matter and further studies are needed.

With the aim to reinforce the identification of the best IFN-free DAA regimens to be administered to patients with genotype 3 infection, we conducted a systematic review of the literature and combined data from 20 studies (including the present one) on a total of 3311 HCV-genotype 3 patients. In our meta-analysis we did not include the schedule with sofosbuvir in association to the third-generation NS5A inhibitor velpatasvir, as only a single trial has been made available so far.¹² The results per regimen demonstrated that the combination that achieved the highest SVR12 rate for the overall population of HCV 3-infected patients was the combination of sofosbuvir/daclatasvir, which achieved SVR12 rates ∼90% in naïve non-cirrhotic patients with a short treatment duration of only 12 weeks, and without the need for RBV co-administration. However, this regimen needs to be administered for 24 weeks in patients with cirrhosis and in those who failed a previous course of antiviral therapy. The large number of patients treated with this therapeutic schedule (n = 1989) lends support to our conclusions.

In our meta-analysis we also considered the therapeutic outcome after treatment of 1983 genotype 3-infected patients with the still recommended schedule of sofosbuvir with RBV. The registered SVR12 rates in these patients were inferior to those seen when two DAAs (sofosbuvir and daclatasvir) were administered. Unacceptably low rates were registered when the sofosbuvir/RBV regimen was given for 12 weeks, whereas the rates improved by extending treatment duration to 24 weeks; however, this could remain a therapeutic option only for the subset of genotype 3-infected patients naïve to therapy and who have progressed to a non-cirrhotic stage. Based on this evidence, we would suggest this schedule should no longer be considered for these patients, considering the availability of more effective regimens.

Finally, we also had the opportunity to review the data on the efficacy of the regimen contemplating the use sofosbuvir in combination with ledispavir. The registered SVR12 rates following this schedule were superior to the results achieved with the administration of sofosbuvir/RBV but numerically inferior to those with the combination of sofosbuvir and daclatasvir. From the available information it seems that the sofosbuvir/ledispavir combination would be effective whenever RBV was included in the schedule and treatment prolonged to 24 weeks. However, we acknowledge the small number of patients evaluated in our investigation (n = 244) and the large range of CIs for several sub-analyses on different subgroups of genotype 3 patients treated with this last combination of two DAAs. Previous limitations did not allow us to draw a firm conclusion on the efficacy of this therapeutic regimen. Further evaluation of this regimen in HCV genotype 3 patients is warranted.

In conclusion, the results of this investigation further reinforce the concept that HCV genotype 3-infected patients, and in particular those who have progressed to cirrhosis, should no longer be considered difficult-to-treat individuals, provided that an optimal therapeutic schedule is applied. According to the presented data, the optimal therapeutic regimen for HCV genotype 3-infected patients without cirrhosis appears to be the combination of sofosbuvir with daclatasvir, administered for 12 weeks, without the use of RBV. In difficult-to-treat patients the results coming from meta-analysis suggest extending therapy to 24 weeks with or without ribavirin.

Footnotes

Acknowledgments

Co-authors of the ITAL-C consortium: Maria Guarino (Gastroenterology Unit, Department of Clinical Medicine and Surgery, University “Federico II” of Naples); Michele Barone (Section of Gastroenterology, Department of Emergency and Organ Transplantation, AOU Policlinico, University of Bari);Vito Carretta (Liver Unit, Department of Internal Medicine, Hospital of Venosa); Immacolata Carraturo (Division of Infectious Diseases “Fazzi” Hospital, Lecce); Giuseppe Cuccorese (Division of Internal Medicine, “Monsignor Dimiccoli” Hospital, Barletta).

Ethics approval

The study protocol was approved July 27, 2016 by the Ethics Committee of the Casa Sollievo della Sofferenza Hospital, in San Giovanni Rotondo, Italy. Each patient included in the study provided a written informed consent. All the study’s procedures were conducted according with the provisions of the Declaration of Helsinki and Good Clinical Practice Guidelines.

Informed consent

Written consent was obtained from the patient for publication.

Conflict of interest

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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