carlo cammà cattedra di gastroenterologia università di palermo [email protected] roma 25...
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Carlo Cammà
Cattedra di Gastroenterologia Università di [email protected]
Roma 25 Novembre 2010
Il management del paziente difficile nelle infezioni virali croniche
Definire e trattare il paziente “difficile” HCV monoinfetto
HCV-infectedPatient
Virological Factors
Genetic factors
Severity of fibrosis
Metabolic Factors
HCV Difficult to Treat Patients
HCV-infectedPatient
Virological Factors
Genetic factors
Severity of Fibrosis
Metabolic Factors
HCV Difficult to Treat Patients
Effetto medioMega-trial
HCV Difficult to Treat Patients
The promise of personalized medicine
D. Ge, Nature , 2009
Genetics Predict Response: IL28B Genotype C/C Confers Higher SVR Rates
DL Ge et al. Nature 461, 399-401 (2009) doi:10.1038/nature08309
Rate of SVR and rs12979860 C-allele frequency in diverse ethnic groups.
Genetics Predict Response: IL28B Genotype C/C Confers Higher SVR Rates
SVR
(%
)
Gt 1 Gt 2/3 Gt 4
T/TT/T T/CT/C C/CC/C T/CT/C T/CT/CT/TT/T C/CC/C T/TT/T C/CC/C29 79 10 47 4 8114 51 22n =
C/C*
T/C*
T/T*
*Genotype of rs12979860 on chromosome 19 (Ge D et al. Nature. 2009;461:399-401).Strättermayer A et al. EASL 2010.
HCV Difficult to Treat Patients
E’ la risposta all’interferone interamente correlata al polimorfismo genetico ?
NO
IL28b and outcome of combination antiviral therapy with PEG-IFN + Riba
SNPStudy
Overall SVR
SVR in persons with indicated genotype (%)
% of SVR explained by the favorable genotype
Homozygous favorable
allele
Heterozygous or homozygous
unfavorable allele
Rs12979860 Ge et al. 56 82 40 56Rs8099917 Suppiah et al. 46 56 36 63Rauch et al. 64 74 50 68
Balagopal et al. Gastroenterology 2010
HCV-infectedPatient
Virological Factors
Genetic factors
Severity of fibrosis
Metabolic Factors
HCV Difficult to Treat Patients
233 Cirrhotic pts (ITT analysis)
Pat
ient
s w
ith v
irolo
gica
l res
pons
e(%
)
Di Marco V et al, personal data
HCV Difficult to Treat Patients
HCV Difficult to Treat Patients
E’ la risposta all’interferone interamente correlata al
polimorfismo genetico e alla fibrosi ?
NO
IDEAL study
SVR rates IL28b Genotype
CC CT TT
Overall 69% 33% 27%
HCV RNA ≤600,000 / METAVIR F0-2 86% 63% 52%
HCV RNA ≤600,000 / METAVIR F3-4 63% 25% 0%
HCV RNA >600,000 / METAVIR F0-2 70% 29% 23%
HCV RNA >600,000 / METAVIR F3-4 37% 21% 12%Gastroenterology 2010;139:120-9
HCV Difficult to Treat Patients
HCV-infectedPatient
Virological Factors
Genetic factors
Severity of fibrosis
Metabolic Factors
HCV Difficult to Treat Patients
Steatosis (± visceral obesity) and IR
hyporesponsiveness to antiviral therapy.
•(HEPATOLOGY 2006)
HCV Difficult to Treat Patients
IR and SVR in G1 Chronic Hepatitis C
ROMERO-GOMEZ et al, Gastroenterology 2005
HCV Difficult to Treat Patients
SVRLowVit D
HCV Difficult to Treat Patients
Hepatology, 2010
Villa et al., submitted
Factors Associated with SVRMV analysis in 442 Female Patients with CHC
HCV Difficult to Treat Patients
Menopause and SVR
HCV-infectedPatient
Virological Factors
Genetic factors
Severity of fibrosis
Metabolic Factors
HCV Difficult to Treat Patients
Rapid Virological Response
as Strongest Predictor of SVR
RVR
HCV Difficult to Treat Patients
Range RVR in G1 10% - 50%
RVR 24 wksPR
HCV Difficult to Treat Patients
Baseline Predictors of RVR in Naive Patients with G1 CHC
RVRAbsence of Severe Fibrosis
Lower BMI
LDL-COL
Insulin Resistance Steatosis
Vitamin D Levels
IL28B Gene
IL-28B and RVR
RVRLowVit D
IL 28
IDEAL study
HCV Difficult to Treat Patients
Peg 2-a Peg 2-b
Differences between Peg 2-a and 2-b
• Pharmacodinamic profile
Triple therapy
RVR 4 wk
DAA
DAATELAPREVIR (T)
DAABOCEPREVIR (BOC)
DAA
LEAD-IN
HCV Difficult to Treat Patients
3 scenari clinici
• IL-28B
• LEAD IN RVR
• TRIPLICE
LEAD-IN RVR PR24 wks
Naive IL28 TT
NR
TRIPLICE
40%
LEAD-IN: ???TRIPLICE
Naive IL28 TC
????
TRASFERIBILITA’ RISULTATI
MEGA-TRIAL
HCV Difficult to Treat Patients
Non tutto ciò che può essere misurato conta, e non tutto ciò che conta può essere misurato.
Albert Einstein
Disclaimer
01-13-RTG-2010-IT-4769-AV01-13-RTG-2010-IT-4769-AV
Servizio scientifico offerto alla Classe Medica da MSD Italia S.r.l.
Questa pubblicazione riflette i punti di vista e le esperienze dell’autore [o degli autori] e non necessariamente quelli della MSD Italia S.r.l.
Ogni farmaco menzionato deve essere usato in accordo con il relativo riassunto delle
caratteristiche del prodotto fornito dalla ditta produttrice.
Servizio scientifico offerto alla Classe Medica da MSD Italia S.r.l.
Questa pubblicazione riflette i punti di vista e le esperienze dell’autore [o degli autori] e non necessariamente quelli della MSD Italia S.r.l.
Ogni farmaco menzionato deve essere usato in accordo con il relativo riassunto delle
caratteristiche del prodotto fornito dalla ditta produttrice.