Boceprevir-Based Triple Therapy as Initial Treatment for Acute Hepatitis C

Boceprevir-based triple therapy could be a viable treatment option for patients with acute hepatitis C virus who fail to respond to standard treatment, according to a case study out of Kansas that was presented at the American College of Gastroenterology annual meeting in San Diego, CA.

The case involved a 24-year-old woman with acute hepatitis C virus (HCV) infection who was treated with boceprevir-based triple therapy (without an interruption in therapy) after failure of treatment with combined pegylated interferon and ribavirin, said the study’s lead author Nabil Mansour, MD, of the University of Kansas School of Medicine, Wichita, KS.

Doctors typically treat acute HCV with the antiviral drug interferon, recommended for patients who do not spontaneously clear the virus within 12 weeks of diagnosis. For more than 80 percent of patients, interferon treatment alone clears the virus from the blood stream in what is called a sustained virologic response (SVR). Interferon in combination treatment with ribavirin is also standard.

For patients who don’t respond to standard treatment, recommended alternatives are scarce and the use of protease inhibitors, which were used in this case study, is not usually advocated, according to Mansour.

The young woman had abdominal pain and was vomiting and jaundiced when she was admitted to the hospital. Her laboratory tests showed that transaminases were elevated with ALT 673 and AST of 971. Further medical investigation revealed that she had positive HCV antibodies with HCV RNA viral load of 3.1 million copies and genotype 1b.

The patient had been hospitalized a month earlier and at that time HCV antibodies were negative, which indicated a recent infection with acute HCV. Eight weeks after her diagnosis her HCV RNA reading was 5760 copies, and it looked hopeful that she would spontaneously clear the virus by 12 weeks, the standard time period recommended to begin antivirals treatment if HCV is still detected. But the patient’s viral load spiked to 165,160 copies and doctors started her on combined treatment of pegylated interferon and ribavirin.

The patient did not respond to the dual therapy and in fact her HCV RNA increased to 327,000 copies. A continued lack of response prompted doctors to add the protease inhibitor boceprevir without interrupting therapy. They planned to keep the triple drug combination going for 44 more weeks. Four weeks after boceprevir was added, the patient’s viral load was undetectable and remained that way at end of treatment (pending SVR).

The main point of the case study is that immediate initiation of protease inhibitor-based triple therapy may be a reasonable treatment option in patients with acute genotype 1 HCV infection who do not respond to standard therapy, Mansour said. However, more studies to investigate efficacy and optimal duration of treatment in this patient population are recommended.