Gut 1996; 38: 603-609

Low dose oa interferon therapy can be effective inchronic active hepatitis C. Results of amulticentre, randomised trial

JM Sanchez-Tapias, X Forns, S Ampurdanes, L Tito, R Planas, JM Viver, D Acero,M Torres, P Mas, R Morillas, M Forne, J Espinos, J M Llovet, J Costa, E Olmedo,F X L6pez-Labrador, M T Jimenez de Anta, J Rodes

Liver UnitJ M Sanchez-TapiasX FomsS AmpurdanesL Tit6J Rodes

and Service ofMicrobiologyJ CostaE OlmedoF X L6pez-LabradorMT Jimenez de Anta

Hospital Clinic,University ofBarcelona, Spain

Service of InternalMedicine, Hospital deL'Esperit Sant, SantaColoma de Gramenet,SpainL Tit6M Torres

Service of DigestiveDiseases, HospitalGermans Trias,Badalona, SpainR PlanasR MorillasJM Llovet

Service of DigestiveDiseases, HospitalMutua de Tarrasa,SpainJ M ViverM Fomr

Service of DigestiveDiseases, Hospital deGirona, SpainD Acero

Service ofInternalMedicine, HospitalParc Tauli, Sabadell,Barcelona, SpainP MasJ Espin6s

Correspondence to:Dr JM Sanchez-Tapias,Liver Unit, Hospital Clinic,Villarroel 170, 08036Barcelona, Spain.Accepted for publication9 October 1995

AbstractBackground-There is some controversyconcerning the efficacy of low dose ainterferon therapy in chronic hepatitis C.Aims-To evaluate the effectiveness oftreatment with low doses ofa interferon inchronic hepatitis C.Patients-One hundred and forty onepatients with anti-HCV positive chronicactive hepatitis C from six hospitals wereenrolled in the study.Methods-Patients were randomised totreatment with 5 MU (group A) or 1-5 MU(group B) injections. The dose wasreduced in responders from group A orincreased in non-responders from groupB to maintain treatment with the miniimaleffective dose. Patients were treated for 48weeks and followed up for 24 additionalweeks with no treatment. Normalisationof alanine aminotransferase (ALT) wasused to evaluate response.Results-A sustained response was seen ineight patients from group A (12%) and in15 (21%) from group B. This differencewas not statistically significant. In-creasing the dose of interferon led to sus-tained response in only five of 58 patients(90/o) from group B who did not respond to1-5 MU injections. In contrast, 15 of 21patients (71%) in whom ALT remainednormal with 1.5 MU injections developeda sustained response. By multivariateanalysis sustained response seemedassociated with young age and was morefrequent in patients with genotype 3 HCVinfection. Sustained response was pre-ceded by a rapid normalisation of ALTand was inversely related to the amount ofa interferon necessary to maintain ALT atlow values during treatment.Conclusions-Some patients with chronichepatitis C are very sensitive to a inter-feron and can be successfully treated withlow doses. Treatment with higher dosesmay be effective in a minority of patientswho do not respond to low doses.(Gut 1996; 38: 603-609)

Keywords: hepatitis C therapy, hepatitis C virus,interferon.

Chronic infection with the hepatitis C virus(HCV) is the main cause of chronic hepatitis inWestern countries and in Japan.1-3 Chronic

hepatitis C is a serious condition because itmay lead to development of cirrhosis of theliver and hepatocellular carcinoma.4-7

Administration of ao interferon is currentlyaccepted as a treatment for chronic hepatitis Cbecause ao interferon inhibits HCV replicationand induces remission of the activity of thedisease in some cases.8-12 Eradication of theinfection after a interferon therapy has recentlybeen reported.'3

However, important problems concerning axinterferon therapy in chronic hepatitis Cremain unsolved. Many patients do notrespond to this treatment and many othersrelapse almost immediately after withdrawal ofthe treatment. In addition, ax interferon isexpensive and often causes adverse reactions,which occasionally are serious.14As most of the unwanted side effects of inter-

feron are dose related,'5 treatment with lowdoses might be preferable. However, it is uncer-tain if low dose interferon therapy is effective inchronic hepatitis C. In a multicentre study,Davis et al observed that treatment with 1 MUper injection three times a week for six monthswas less effective than treatment with 3 MUinjections.16 Similar findings arose from twosmaller studies carried out in France.'7 18 Incomparison with lower doses, however, theadvantages of treatment with 3 MU injectionswere less clear in a large Italian study'9 and,recently, Reichen et al showed that treatmentwith 15 MU three times a week for 12 monthsproduced results in the range of those obtainedwith higher interferon doses.20 Indeed, treat-ment with minimal amounts of ax interferon, aslow as 0-25 MU three times a week2' or weekly6MU injections22 can produce beneficial effectsin some patients.

This multicentre randomised study aimed toevaluate the effectiveness of low dose inter-feron therapy in chronic hepatitis C. To thispurpose, a large number of patients were ran-domised to be treated with decreasing orincreasing doses of interferon depending onthe response to comparatively high (5 MU perinjection) or low (1-5 MU) doses given ini-tially, respectively.

Methods

PATIENTSOne hundred and forty one consecutivepatients with chronic active hepatitis C partici-pated in the study. They were recruited in six

603

Sanchez-Tapias, Foms, Ampurdanes, Tito, Planas, Viver, et al

hospitals located in the Barcelona area fromOctober 1989 to January 1991. Admissioncriteria included: (a) increased alanine amino-transferase (ALT) serum concentrations above2.5 times the normal value (40 IU/l) on at leasttwo separate occasions during the six monthperiod preceding randomisation and (b)chronic active hepatitis with or without cirrho-sis confirmed by percutaneous liver biopsy.Evidence of hepatitis C virus infection was nota criteria for selection because specific testswere not universally available at the beginningof enrolment. Anti-HCV antibodies were posi-tive, however, in all the cases when testedretrospectively with a second generationenzyme linked immunosorbent assay (ELISA)test (Ortho Diagnostic Systems, Raritan, NJ,USA).

Patients with current HBV infection (posi-tive HBsAg), alcohol abuse, autoimmunehepatitis (presence of antinuclear, antimito-chondrial, antismooth muscle, or anti-LKMnon-organ specific autoantibodies with a titrevalue higher than 1:40), drug induced or meta-bolic liver disease were not considered forinclusion. Other exclusion criteria were: agelower than 18 years or higher than 65 years,HIV infection, histological diagnosis of chronicpersistent hepatitis or minimal liver lesions,past or current hepatic decompensation, pre-vious treatment with antiviral or immuno-

modulatory agents, leucocyte count below3x 106/1, platelet count below 75x 106/1, preg-

nancy or presence of any significant pathologi-cal condition other than hepatitis.

Randomisation and treatment schedulesAccording to histological features, patientswere stratified in three categories: chronicactive hepatitis, chronic active hepatitis withbridging fibrosis, or bridging necrosis andchronic active hepatitis with cirrhosis. Patientsfrom each histological category were ran-

domised to treatment with decreasing doses ofinterferon (group A) or with increasing doses(group B) by computer generated randomnumbers.

Group A - interferon aL2b was given bysubcutaneous injection three times per weekduring 48 weeks. Treatment was started with 5MU injections. After 12 weeks oftreatment thedose of interferon was adjusted according toindividual response. In patients who showed a

decrease of serum ALT greater than 50°/O thepretreatment values the dose of interferon wasreduced to 3 MU three times a week, whichwas given during the next 12 weeks. In patientswith sustained response to 3 MU of interferonthe dose was further reduced to 1.5 MU perinjection for 24 additional weeks. In patientswho had another increase in ALT upon dosereduction, the previously effective dose was

reintroduced and this dose was maintaineduntil the end of the treatment period with no

further modification. Treatment was stoppedin patients who did not show a 50O/o decreaseofALT after 16 weeks of treatment with 5 MUthree times a week.

Group B - interferon was also given three

times a week during 48 weeks. Treatmentstarted with 1.5 MU injections. This dose wasmaintained during the entire treatment periodin patients who achieved a 50% or greaterreduction of ALT. In patients who did notrespond to 1-5 MU injections after eight weeksof treatment, the dose was increased to 3 MUthree times a week for eight additional weeks.The dose was then reduced to 1-5 MU orincreased to 5 MU according to response. Asin group A, treatment was maintained with theminimal effective dose. Treatment wasstopped if a 500/o decrease of ALT did notoccur after 16 weeks of treatment with 5 MUinjections.

ExaminationsComplete clinical and biochemical examina-tion, including liver function tests, serumglucose, creatinine, blood urea nitrogen, totalprotein, albumin, prothrombin time, and fullblood cell count were carried out weeklyduring the first month of treatment and at leastevery four weeks during the remaining periodof treatment and during the six months followup after treatment.

Pretreatment serum samples from all thepatients recruited at one of the participatingcentres (Hospital Clinic, Barcelona) werescreened for the presence of specific antibodiesagainst HCV types 1, 2, and 3. Testing wasperformed at the Department of MedicalMicrobiology of the University of Edinburghwith an ELISA test in which synthetic peptidesderived from the NS4 region of the HCVgenome were used as antigen, as described.23HCV-RNA in serum was examined in serial

serum samples taken at baseline, after 12 and48 weeks of treatment, and at the end ofpost-treatment follow up. Investigation wasperformed by polymerase chain reactionaccording to Simmonds et al, with minormodifications.24 In brief, RNA was extractedfrom 200 ,ul of serum by the phenol/chloro-form method25 and reverse transcribed tocDNA with random primers. cDNA wasamplified by nested polymerase chain reactionusing the two pairs of primers of the 5'UTR ofthe HCV genome described by Garson et al.26

TABLE I Pretreatment characteristics ofpatients includedin the study*

Group A Group BVariable (n= 70) (n= 71)

Age (y) 49 (12) 46 (13)Sex

males n (/) 39 (56) 41 (58)females n (/) 31 (44) 30 (42)

Presumed source of infectionblood transfusion n (%) 22 (31) 20 (28)intravenous drug abuse n (O/o) 2 (3) 9 (13)unknown n (o/O) 46 (66) 42 (59)

Aspartate aminotransferase (IU/l) 133 (72) 139 (73)Alanine aminotransferase (IU/l) 236 (146) 272 (177)y Glutamyltranspeptidase (IU/1) 62 (39) 73 (67)Platelet count (X 106/l) 174 (51) 179 (63)White blood cell count (X 106/l) 5-9 (1-9) 6-1 (1-8)Liver histologyCAH n (%) 33 (47) 37 (52)CAH with bridging n (/) 28 (40) 24 (34)CAH with cirrhosis n (%) 9 (13) 10 (14)

*Quantitative data are expressed as mean (standard deviation).CAH: Chronic active hepatitis.

604

Low dose a interferon therapy can be effective in chronic active hepatitis C

TABLE II Relation between interferon dose and response in patients from group A

Total No No Sustaineddose of Response response Relapse response

Interferon dose (MU) cases n (%/°) n (%o) n (%/o) n (%/o)Maintained at 5 MU* 240 17 0 17 (100) 0 0Reduced to 3 MU with later increase to 5 MU 648 15 4 (27) 11 (73) 3 (20) 1 (7)Reduced to 3 MU and to 1-5 MU with later increase to 3 MU 450 21 8 (38) 13 (62) 6 (29) 2 (9)Reduced to 3 MU and to 1-5 MU 396 17 8 (47) 9 (53) 3 (17) 5 (30)Total 70 20 (29) 50 (71) 12 (17) 8 (12)

*Treatment was withdrawn in patients who did not respond after 16 weeks of treatment.

Definition of types of responseResponse was defined by normalisation ofALT only when it was sustained until the endof the treatment period. Depending on eventsduring follow up after treatment, two cate-gories of response were defined: sustainedresponse, defined by normalisation of ALTpersisting until the end of the post-treatmentfollow up, and transient response, defined bynormalisation of ALT at the end of treatmentfollowed by relapse. Lack of normalisation ofALT at the end of treatment was consideredno response.

Statistical analysisQuantitative variables were expressed as mean(SD). The two tailed Student's t test was usedto compare continuous variables between twogroups. Differences between dichotomousvariables were evaluated with x2 analysis orFisher's exact test depending on the size of thesample. A multivariate analysis by stepwiselogistic regression was performed to identifyfactors independently associated withresponse. Analysis was performed on an inten-tion to treat basis and all calculations weremade using a SPSS computer program.The study protocol was approved by the

ethics committee of each participating hospitaland all patients gave their informed consentprior to randomisation.

ResultsOf 141 patients enrolled in the study, 70 wererandomised to receive treatment with decreas-ing doses of interferon (group A) and 71 toreceive increasing doses of interferon (groupB). The demographic, clinical, biochemical,and histological features of both groups weresimilar (Table I).Twenty eight patients from each group did

not complete 48 weeks of treatment. In 17cases in group A and in 18 in group B the treat-ment was interrupted after 16 weeks at thehighest dose (5 MU three times a week)because ALT did not decrease to below 50%pretreatment values, as scheduled in the study

TABLE III Relation between interferon dose and response in patients from group B

Total No No Sustaineddose of Response response Relapse response

Interferon dose (MU) cases n (%) n (%/°) n (%/o) n (%)

Maintained at 1-5 MU 216 27 13 (48) 14 (52) 3 (11) 10 (37)Increased to 3 MU 396 24 10 (42) 14 (58) 6 (25) 4 (17)Increased to 5 MU 588 20 2 (10) 18 (90) 1 (5) 1 (5)Total 71 25 (35) 46 (65) 10 (14) 15 (21)

protocol. Treatment was interrupted becauseof development of side effects, including neu-tropenia, thrombocytopenia, severe depressionor hyperthyroidism, in seven patients fromgroup A and in five from group B. Treatmentwas interrupted for other reasons, such as sub-jective intolerance, travelling abroad or trafficaccident in nine additional patients, four fromgroup A and five from group B. No patientwithdrawn from treatment was excluded fromthe study.Of 70 patients included in group A, 20

(29%) fulfilled the criteria for response definedabove and 50 (71%) did not (Table II).Response was transient in 12 (17%) and sus-tained in eight (12%). Corresponding figuresfor the 71 patients in group B were: 25 (35%)for response, 46 (66%) for no response, 10(14%) for transient response, and 15 (21%) forsustained response (Table III). Thus, therewas a trend for better response in patientstreated with lower dose of interferon but thedifference did not reach statistical significance.

Complete normalisation ofALT at the end oftreatment seemed inversely related to theamount of interferon necessary to induce adecrease of ALT below 50/o of the pretreat-ment values. This was particularly evident ingroup B, where the proportion of respondersseen among patients treated exclusively with1.5 MU injections (total dose 216 MU) wassignificantly greater than in patients whorequired an increase in the amount of interferongiven per injection up to 5 MU (total dose 588MU) to keep ALT low (48% v 1.0%; Fisher'sexact test, p=0005) (Table III). In group Athere was also a trend for better response amongpatients treated with 1.5 MU injections only(total dose of 396 MU) than in those requiringtreatmnent with 3 MU or 5 MU injections (totaldose 450 to 648 MU) (Table II).The proportion of patients with sustained

response after interferon withdrawal was alsohigher among patients treated with low inter-feron dose. In group A, sustained response wasrecorded in five of 17 patients (30%) in whominterferon administration could be reduced to1.5 MU per injection (total dose 396 MU) butin only three of 36 (8%) who received greateramounts of interferon (total dose 450 or 648MU) (p=0*05, Fisher's exact test) (Table II).In group B, sustained response was seen in 10of 27 patients (370/o) treated exclusively with1.5 MU injections (total dose 216 MU) and infive of 44 (13%) treated with higher doses(total dose 396 or 588 MU) (p=0 01, Fisher'sexact test) (Table III).

In contrast, relapse upon interferon with-drawal seemed directly related to the amount

605

Sanchez-Tapias, Forns, Ampurdanis, Tito, Planas, Viver, et al

TABLE IV Relation between nornalisation ofserumalanine aminotransferase (ALT) early during treatmentand the type of response

Patients with normalALT

No of At 4 weeks At 8 weekscases n (%0) n (%)

Non-responders 96 3 (3)* 4 (4)Responders 45 21 (47) 31 (69)Sustained responders 23 13 (56) 18 (78)Transient responders 22 8 (36) 13 (59)

*Non-responders v responders at 4 weeks: difference betweenproportions=0435, 95% CI 0-286 to 0-585, p<0000; at 8weeks: difference between proportions=0647, 95% CI 0-506to 0-788, p<0000.

of interferon that was necessary to maintainlow ALT values during treatment. In group A,relapse occurred in three of eight (37%)patients who maintained response with 1-5MU doses and in nine of 12 (75%) patientswho required 3 MU or 5 MU doses (Table II).In group B, relapse occurred in three of 13(23%) patients with normal ALT while treatedwith 1-5 MU dose and in seven of 12 (58%)who required three or five MU doses (TableIII). These differences were not statisticallysignificant. When responders from both groupswere pooled, however, it became apparent thatrelapse occurred in six of 21 patients (29%)who maintained response with 1.5 MU and in16 of 24 patients (67%) who required higherdose of interferon to maintain ALT at normalvalues during treatment (Fisher's exact test,p=0O01).

Rapid normalisation of ALT after the startof treatment was associated with response.Normalisation ofALT after four or eight weeksof treatment was more frequent in responders(47% and 69% respectively), particularly inthose with sustained response (56% and 78%),than in non-responders (3% and 4%). Thesedifferences were statistically significant. Thefrequency of rapid normalisation of ALT insustained responders was somewhat greaterthan in transient responders but the differencewas not statistically significant (Table IV).

Responders and non-responders werecompared to investigate factors associated withresponse (Table V). Univariate analysis showedthat responders were significantly younger than

TABLE V Factors associated with response to interferon therapy*

Responders Non-responders p(n=45) (n=96) DBM 95% CI Value

Age (y) 41-8 (14-6) 50-1 (11-3) 8-30 3-86 to 12-7 0.001Sex NSmales n (/) 30 (66) 52 (54)females n (%) 15 (33) 44 (46)

Presumed source of infection 0.009blood transfusion n (%) 13 (29) 30 (31)use of intravenous drugsn (%) 8 (18) 3 (3)

unknown n (%) 24 (53) 63 (66)Platelet count (X 106/1) 196 (60) 167 (53) 29 9-24 to 48-8 0.005WBC count (X106/l) 6.5 (2.3) 5-7 (1-5) 0-8 0-16 to 1.44 0-025AST (IU/l) 142 (89) 133 (63) NSALT (IU/l) 282 (198) 241 (143) NSAST/ALT 0.55 (037) 0-60 (020) NSyGT (IU/1) 56 (66) 73 (48) NSHistology NSCAH n (%) 27 (60) 44 (46)CAH with bridging n (%) 13 (29) 38 (39)CAH with cirrhosis n (%) 5 (11) 14 (15)

*Quantitative data are expressed as mean (SD). Responders includes patients with sustained ortransient response. DBM, difference between means for quantitative variables. WBC=whiteblood cell, yGT=-y glutamyltranspeptidase, CAH=chronic active hepatitis.

non-responders. History of intravenous drugabuse in the past was more common in respon-ders. No significant differences in serum aspar-tate aminotransferase (AST) nor ALT activitywere found but platelet and whiteblood cell counts were significantly higher inresponders. The degree of histological severitywas similar in responders and non-responders.Multivariate analysis showed that only age hadindependent predictive value of response.

Univariate analysis of baseline features dis-closed several differences between patients withand without sustained response. Sustainedresponders were younger and their plateletcount and AST/ALT ratio were higher than innon-sustained responders. History of intra-venous use of drugs was more frequent in sus-tained responders. The degree of histologicalseverity was similar in both groups (Table VI).Sustained response occurred, however, in 16 of71 patients (23%) with preserved lobular archi-tecture but in only seven of 70 (10%) withchanged lobular architecture by the presence ofbridging fibrosis or cirrhosis (difference be-tween proportions 0. 125, 95% confidence inter-vals 00054 to 0.245, p=0.04). Multivariateanalysis showed that only age was indepen-dently associated with sustained response.

Fifty four patients recruited at a singlecentre were screened for specific antibodiesagainst HCV genotypes 1, 2, and 3. Thirty two(59%) reacted for type 1, one (2%) for type 2,five (9%) for type 3, five (9%) for genotypes 1,and two and 11 (20%) did not react or gavenon-type specific reaction. The response tointerferon in these 54 patients did not differfrom that seen in the remaining 87 non-screened patients recruited in other centres.Table VII shows the relation between HCVserotype and response to treatment. The pro-portion of patients who showed sustainedresponse was significantly higher in patientswith HCV genotype 3 or with an unidentifiedHCV genotype than in those infected withgenotype 1 (Fisher's exact test, p=0.0048 andp=0*012 respectively). Of the 10 patients withsustained response, seven were treated withlow dose interferon and four of them wereinfected by serotype 3 of HCV. In patientsinfected with HCV serotype 1, a sustainedresponse after treatment with 1.5 MU injec-tions was achieved in one case only.HCV-RNA was investigated in serum

samples taken before, during, and after treat-ment in the 54 patients screened for HCVserotypes. HCV-RNA was positive in all thecases before treatment. The proportion ofpatients in whom HCV-RNA became negativewas greater in responders than in non-responders (Table VIII) although threepatients with sustained biochemical responsestill had detectable HCV-RNA in serum bynested polymerase chain reaction six monthsafter completion of treatment. However,HCV-RNA became negative when thesepatients were re-tested one year later.The rate of negative values of HCV-RNA

seen after 12 weeks of treatment, at the end oftreatment, and at the end of follow up ingroups A and B was similar.

606

Low dose a interferon therapy can be effective in chronic active hepatitis C

TABLE VI Factors associated with sustained response to interferon therapy*

Sustainedresponders Others p(n=23) (n=118) DBM 95% CI Value

Age (y) 37-5(16-2) 49.5 (11-4) 12 6-46 to 17-5 0-002Sex NSmales n (O/o) 14 (61) 68 (58)females n (/) 9 (39) 50 (42)

Source of infection 0-021blood transfusion n (O/o) 7 (30) 36 (31)use of intravenous drugsn (%) 5 (22) 6 (5)

unknown n (%) 11 (48) 76 (64)Platelet count (X 106/) 203 (72) 171 (53) NSWBC count (X106/l) 6-8 (2.9) 5-8 (1.8) 1 0-092 to 1.91 0-042AST (IU/A) 147 (101) 134 (65) NSALT (IUI1) 319 (235) 242 (144) NSAST/ALT 0-46 (0.09) 0-61 (0.28) 1-50 0.033 to 0-267 0.000yGT (IU/l) 51 (41) 71 (57) NSHistology NSCAH n (O/o) 16 (70) 55 (47)CAH with bridging n (%) 5 (22) 46 (39)CAH with cirrhosis n (°/°) 2 (8) 17 (14)

*Quantitative data are expressed as mean (SD). Abbreviations as in Table V.

DiscussionThe potential value of a interferon therapy forthe treatment of chronic non-A, non-Bhepatitis was recognised in 1986, several yearsbefore the identification of HCV as the agentresponsible for this disease.27 To assess theeffectiveness of this treatment several con-trolled trials were set up and a recent metaanalysis of these studies showed that a inter-feron can induce remission of the disease inabout one half of treated patients although onehalf of responders will relapse when the treat-ment is stopped.28

In this study only 22 of 141 patients (1 5.6%)had a sustained response. This low proportionof responders is possibly due to patient selec-tion because this study did not include patientswith a low index of histological activity orchronic persistent hepatitis, who are believedto respond better to interferon.29 30 In fact,about one half of the patients selected forinclusion had either cirrhosis or chronic activehepatitis with bridging fibrosis and distortedlobular architecture, which are factors associ-ated with a poor response to interferontherapy.29 31 32

Previous studies have suggested that, besidethese histopathological features, the response toa interferon therapy may also be related to othercircumstances. Among host related factors, oldage,173334 long duration of the disease,3235excessive body weight,3035 increased y gluta-myltranspeptidadse,34 36 and iron overload33have all been associated with diminishedresponse to interferon. Recently, factors directlyrelated to the causative agent, such as HCVgenotype37 38 or the amount of HCV-RNA

TABLE VII Relation between HCVserotype and the typeof response to interferon therapy

Type of response

No of Sustained Transient AbsentHCVserotype cases n (°/°) n (%o) n (%)Type 1 32 4 (12) 7 (22) 21 (66)Type2 1 0 0 1(100)Type 3 5 4 (80) 0 1 (20)Type 1+2 5 1 (20) 1 (20) 3 (60)Not identified 11 1 (9) 4 (36) 6 (55)Total 54 10 (19) 12 (22) 32 (59)

detected in serum1039 have also emerged asimportant determinants of response.The dose of interferon and the duration of

treatment can also influence the effectivenessof the treatment. The probability of perma-nent response seems greater if treatment isgiven for at least 12 months4041 and a highrate of sustained response in patients treatedfor 60 weeks has recently been reported.42The influence on response of the dose ofinterferon is more controversial because theresults of studies showing that low dose is lesseffective than high dose therapy16-18 do notagree with other findings.'9 2041 To evaluatethe influence of the dose administered on thefinal result of the treatment is an importantissue because a interferon is expensive andoften produces undesirable side effects, whichare dose related.The main objective of this study was to

compare the effectiveness of two differentschedules of a interferon therapy given for 48weeks. To this purpose, a large group ofpatients with chronic active hepatitis C wererandomised to receive a interferon at increas-ing or decreasing doses, starting from 1.5 MUor 5 MU per injection respectively, accordingto response. In contrast with other studiesaimed at comparing fixed doses of interferon,the design of this trial permitted the adminis-tration of increasing amounts of interferon inthose patients who failed to respond to lowerdoses, according to a strategy that may beeffective in some patients.43There were no differences in the rate of

response seen in patients treated with low,increasing dose in comparison with thosetreated with high, decreasing dose. In fact, theproportion of patients who responded, eithertransiently or permanently, was slightlygreater in patients who started treatment witha low dose of interferon. As patients fromboth groups were comparable, it may be sug-gested that the effectiveness of the two thera-peutic schedules evaluated in this study wassimilar.

Beside the possible role of low dose inter-feron therapy in chronic hepatitis C, otheraspects of this study deserve further comment.Firstly, about two thirds of the patients whodeveloped a sustained response were able torespond or to maintain ALT, or both below theupper normal limit with 1.5 MU injections ofinterferon. Secondly, sustained response wasstrongly associated with a rapid fall ofALT, aspreviously noted by others.44 In this study,ALT became normal within the eight initialweeks of treatment in 78% of the patients whodeveloped later a sustained response, includingthose who started treatment with low doses of

TABLE VIII Detectability ofHCV-RNA in serum before,during, and after interferon therapy according to the type ofbiochemical response

Sustained Transient Absent(n=10) (n= 12) (n=32)

Before therapy n (%) 10 (100) 12 (100) 32 (100)At week 12 of therapy n (%) 5 (50) 8 (67) 27 (84)At the end of therapy n (%/o) 5 (50) 9 (75) 27 (84)At the end of follow up n (%/o) 3 (30) 12 (100) 29 (91)

607

608 Sanchez-Tapias, Forns, Ampurdanes, Tito, Planas, Viver, et al

interferon. In contrast, rapid normalisation ofALT was very rare in non-responders from thetwo study groups.

These findings suggest that some patientswith chronic HCV infection are very sensitiveto interferon whereas other patients are refrac-tory to this treatment. Distinction betweenthese two categories has important implica-tions. In this study the small number ofpatients who presented a sustained response tolow dose interferon made difficult the identifi-cation of the features that characterise sus-tained responders. Comparison of sustainedresponders, most of whom achieved responsewith low dose treatment, with non-sustainedresponders, showed that young age, obviousparenteral exposure to infection, and particu-larly hiptory of addiction to intravenous drugsin the past, high AST/ALT ratio, and pre-served lobular architecture were associatedwith complete response. Each of these vari-ables has been recognised as a marker offavourable response in previous studies wherepatients received higher doses of interferon.30In this study, however, logistic regressionanalysis showed that only young age wasindependently related to good response.The influence of virological factors on the

response to treatment was analysed in morethan one third of the patients by testing forHCV serotype and serum HCV-RNA.Sustained response, even to low dose of inter-feron, seemed associated with infection withHCV serotype 3 whereas most patientsinfected with HCV serotype 1 did not respondor relapsed. These findings are in agreementwith recent observations from other largeserological surveys of patients with chronichepatitis C treated with different interferonschedules.45-47 In these studies it has beenshown that aL interferon therapy is less effectivein patients with chronic hepatitis caused byserotype 1 HCV than in patients infected byother HCV serotypes.There is increasing evidence that a low level

of viraemia is associated with longtermresponse to interferon therapy in chronichepatitis C.10 39 48 Unfortunately, serumHCV-RNA was not assessed because properlyprocessed and stored serum samples49obtained at baseline were not available frommany patients. We have recently reported,however, a good correlation between lowHCV-RNA serum concentration and a satis-factory response to interferon in a large seriesof patients from our hospital who otherwisepresented similar features to those included inthis study.50 Therefore, the presence of lowlevels of viraemia in sustained responders fromthe present series is likely.As noted previously,'9 serum HCV-RNA

sequences were detected by nested polymerasechain reaction despite sustained biochemicalremission in three of 10 patients. Althoughthese subjects cleared HCV-RNA when testedone year later, the meaning and the prognosticimplications of the presence of HCV-RNA inpatients undergoing normalisation of ALTunder interferon therapy is currently uncer-tain.

In summary, administration of 1-5 MU of oxinterferon three times a week for 48 weeks wassufficient to induce sustained biochemicalremission in about 15% of patients withchronic active hepatitis C in an area wheregenotype 1 is highly prevalent. Response tosuch a low dose of interferon can be expectedin young patients infected with HCV genotype3 and, possibly, low level of viraemia.Sustained response was heralded by rapid nor-malisation of ALT. Increasing the dose ofinterferon induced response in some patientswho did not respond rapidly to low doses butmost of them relapsed upon interferon with-drawal. Initial treatment with 5 MU injectionsfollowed by tapered doses in respondingpatients did not increase the efficiency of treat-ment with 1X5 MU initial doses. Failure of aLinterferon therapy is likely in patients withchronic active hepatitis C who do not respondrapidly to low dose ax interferon therapy. Inthese patients, treatments other than at inter-feron given alone must be prospectively inves-tigated. As relapse may still occur in patientsresponding to 48 week low dose therapy, treat-ment for longer periods of time deservesfurhier evaluation.This study was supported in part by grants 91/360 and 94.848from Fondo de Investigaciones Sanitarias del Ministerio deSanidad. X Forns, F X L6pez-Labrador, and E Olmedo receivegrants from Hospital Clinic, Ministerio de Educaci6n y Ciencia,and Fundaci6 Catalana per L'Estudi del Fetge respectively.The authors are grateful to Dr P Simmonds for serotyping

studies.

1 Sanchez-Tapias JM, Barrera JM, Costa J, Ercilla MG, ParesA, Comalrrena 1U, et al. Hepatitis C virus infection in non-alcoholic chronic liver diseases. Ann Intern Med 1990;112: 921-4.

2 Jeffers LJ, Hasan F, de Medina M, Reddy R, Parker T, SilvaM, et al. Prevalence of antibodies to hepatitis C virusamong patients with cryptogenic chronic hepatitis andcirrhosis. Hepatology 1992; 15: 187-90.

3 Hosoda K, Omata M, Yokosuka 0, Kato N, Ohto M. Non-A, non-B chronic hepatitis is chronic hepatitis C: a sensi-tive assay for detection of hepatitis C virus RNA in theliver. Hepatology 1992; 15: 777-81.

4 Hopf U, M6ller B, Kuiter D, Stemerowicz R, Lobeck H,Ludtke-Handjery, et al. Long-term follow up of posttrans-fusion and sporadic chronic hepatitis non-A, non-B andfrequency of circulating antibodies to hepatitis C virus(HCV).7 Hepatol 1990; 10: 69-76.

5 Tremolada F, Casarin C, Alberti A, Drago C, Tagger A,Ribero ML, et al. Long term follow-up of non-A, non-B(type C) post-transfusion hepatitis. Jf Hepatol 1992; 16:273-81.

6 Di Bisceglie AM, Goodman ZD, Ishak KG, Hoofnagle JH,Melpolder j, Alter HJ. Long tern clinical and histopatho-logical follow-up of chronic posttransfusion hepatitis.Hepatology 1991; 14: 969-74.

7 Kiyosawa K, Akahane Y, Nagata A, Furata S.Hepatocellular carcinoma after non-A, non-B posttrans-fusion hepatitis. Am J Gastroenterol 1984; 79: 777-81.

8 Shindo M, DiBisceglie AM, Cheung L, Shih WK, CristianoK, Feinstone SM, et al. Decrease in serum hepatitis Cvirus RNA during alpha interferon therapy for chronichepatitis C. Ann Intern Med 1991; 115: 700-4.

9 Chayama K, Saitoh S, Arase Y, Ikeda K, Matsumoto T,Sakai Y, et al. Effect of interferon administration on serumhepatitis C virus RNA in patients with chronic hepatitis C.Hepatology 1991; 13: 1040-3.

10 Hagiwara H, Hayashi N, Mita E, Takehara T, Kasahara A,Fusamoto H, et al. Quantitative analysis of hepatitis Cvirus RNA in serum during interferon alpha therapy.Gastroenterology 1993; 104: 877-83.

11 David E, Pucci A, Palladin D, Saracco G, Garello E, PintusC, et al. Histologic changes in liver biopsy specimens pro-duced by recombinant interferon alpha-2b therapy forchronic non-A, non-B viral hepatitis. A randomizedcontrolled trial. AmJffClin Pathol 1992; 98: 397-401.

12 Marcellin P, Boyer N, Martinot-Peignoux M, Areias J,Giostra E, Degott C, et al. Long-term histologicalimprovement and persistent HCV replication in patientswith chronic hepatitis C having responded to recombinantalpha interferon. In: Nishioka K, Suzuki H, Mishiro 5,Oda T, eds. Viral hepatitis and liver disease. Tokyo:Springer-Veriag, 1994: 635-7.

13 Romeo R, Pol 5, Berthelot P, Brechot C. Eradication ofhepatitis C virus RNA after alpha-interferon therapy. AnnIntern Med 1994; 121: 276-7.

Low dose a interferon therapy can be effective in chronic active hepatitis C 609

14 Janssen HLA, Brouwer JT, Nevens F, Sanchez-Tapias JM,Craxi A, Hadzyannis SJ. Fatal hepatic decompensationassociated with interferon alpha. BMJ 1993; 306: 107-8.

15 Renault PF, Hoofnagle JH. Side effects of alpha interferon.Semin Liver Dis 1989; 9: 273-7.

16 Davis GL, Ballart LA, Schiff ER, Lindsay K, BodenheimerHC, Perrillo RP, et al. Treatment of chronic hepatitis Cwith recombinant interferon alpha. A multicentre ran-domized controlled trial. N Engl J Med 1989; 321:1501-6.

17 Causse X, Godinot H, Ouzan D, Chevalier M, ChossegrosP, Zoulim F, et al. Comparison of 1 or 3 MU of interferonalpha-2b and placebo in patients with chronic non-A,non-B hepatitis. Gastroenterology 1991; 101: 497-502.

18 Marcellin P, Boyer N, Giostra E, Degott C, Courouce AM,Degos F, et al. Recombinant human a-interferon inpatients with chronic non-A, non-B hepatitis: a multi-centre randomized controlled trial from France.Hepatology 1991; 13: 393-7.

19 Saracco G, Rosina F, Abate ML, Chiandussi L, Gallo V,Cerutti E, et al. Long-term follow-up of patients withchronic hepatitis C treated with different doses of inter-feron a-2b. Hepatology 1993; 18: 1300-5.

20 Reichen J, Solioz M, Buhler H, Gonvers JJ, Knoblauch M,Lavanchy D, et al. Low-dose interferon in chronic non-A,non-B hepatitis: effects on quantitative liver function andstructure in a randomized, controlled, multicentre trial.Clin Investig 1993; 71: 888-93.

21 Varagona G, Brown D, Kibbler H, Scheuer P, AshrafzadehP, Sherlock S, et al. Response, relapse and re-treatmentrates and viremia in chronic hepatitis C treated with a-2binterferon alpha: A phase III study. European Journal ofGastroenterology and Hepatology 1992; 4: 701-12.

22 Kagawa T, Morizane T, Saito H, Miyaguchi S, TsunematsuS, Tada S, et al. A randomized, controlled trial of lym-phoblastoid interferon in patients with chronic hepatitisC.JHepatol 1993; 17: 91-6.

23 Simmonds P, Rose KA, Graham S, Chan SW, Lin CK,McOmish F, et al. Mapping of serotype-specific, immun-odominant epitopes in the NS-4 region of hepatitis virus(HCV): use of type-specific peptides to serologically dif-ferentiate infections with HCV type 1, 2 and 3. Jf ClinMicrobiol 1993; 31: 1493-503.

24 Simmonds P, Zhang LQ, Watson HG, Rebus L, FergusonED, Balfe P, et al. Hepatitis C quantification and sequenc-ing in blood products, haemophiliacs, and drug users.Lancet 1990; 336: 1469-72.

25 Chomczynski P, Sacchi N. Single-step method ofRNA iso-lation by acid guanidium thiocyanate-phenol-chloroformextraction. Ann Biochem 1987; 162: 156-9.

26 Garson JA, Ring C, Tuke P, Tedder RS. Enhanced detec-tion by PCR of hepatitis C virus RNA [Letter]. Lancet1990; 336: 878-9.

27 Hoofnagle JH, Mullen KD, Jones DB, Rustgi V, DiBisceglie A, Peters M, et al. Treatment of chronic non-A,non-B hepatitis with recombinant human alpha-inter-feron. A preliminary report. N Engl J Med 1986; 315:1575-8.

28 Tine F, Magrin S, Craxi A, Pagliaro L. Interferon for non-A, non-B chronic hepatitis: a meta-analysis of randomizedclinical trials. J Hepatol 1991; 13: 192-9.

29 Iino S, Yasuda K, Sainokami S, Hino K. Treatment ofchronic hepatitis C with interferon-a. In: Nishioka K,Suzuki H, Mishiro S, Oda T, eds. Viral hepatitis and liverdisease. Tokyo: Springer-Verlag, 1994: 607-9.

30 Davis GL. Prediction of response to interferon treatment inchronic hepatitis C. JHepatol 1994; 21: 1-3.

31 Jouet P, Roudot-Thoraval F, Dhumeaux D, Metreau JM,and Le Groupe Francais pour l'Etude du Traitement desHepatites Chroniques NANB-C. Comparative efficacy ofinterferon alfa in cirrhotic and non-cirrhotic patients withnon-A, non-B, C hepatitis. Gastroenterology 1994; 106:686-90.

32 Pagliaro L, Craxi A, Cammaa C, Tine F, Di Marco V, LoIacomo 0, et al. Interferon-a for chronic hepatitis C: ananalysis of pretreatment clinical predictors of response.Hepatology 1994; 19: 820-8.

33 Perez R, Pravia R, Linares A, Gonzalez M, Rodriguez M,

Lombrafia JLS, et al. Treatment of chronic hepatitis Cwith recombinant interferon alfa-2b for nine months. Gut1992; 34 (suppl): S136-8.

34 Serfati L, Giral P, Loria A, Andreani T, Legendre C,Poupon R. Factors predictive of the response to interferonin patients with chronic hepatitis C. Jf Hepatol 1994; 21:12-7.

35 Weiland 0, Schvarcz R, Wejstal R, Norkrans G, Fryden A.Therapy ofchronic post-transfusion non-A, non-B hepati-tis with interferon alfa-2b: Swedish experience. Jf Hepatol1990; 11 (suppl 1): S57-62.

36 Battezzati PM, Podda M, Bruno S, Zuin M, Crosignani A,Camisasca M, et al. Factors predicting early response totreatment with recombinant interferon alpha-2a inchronic non-A, non-B hepatitis. Preliminary report of along term trial. ItalJ7 Gastroenterol 1992; 24: 481-4.

37 Yoshioka K, Kakumu S, Wakita T, Ishikawa T, Itoh I,Takayanagi M, et al. Detection of hepatitis C virus bypolymerase chain reaction and response to interferonalpha therapy: relationship to genotypes of hepatitis Cvirus. Hepatology 1992; 16: 293-9.

38 Tsubota A, Chayama K, Ikeda K, Yasuji A, Koida I, SaitohS, et al. Factors predictive of response to interferon-ettherapy in hepatitis C virus infection. Hepatology 1994; 19:1088-94.

39 Mita E, Hayashi N, Hagiwara H, Ueda K, Kanazawa Y,Kasahara A, et al. Predicting interferon therapy efficacyfrom hepatitis C virus genotype and RNA titer. Dig Dis Sci1994; 39: 977-82.

40 Chemello L, Pontiso P, Rose KA, Simmonds P, Bonetti P,Cavalletto L, et al. The long-term response (LTR) tointerferon-alfa (IFN-2A) in chronic hepatitis C is influ-enced by dose and duration of treatment and the HCVserotype [Abstract]. Jf Hepatol 1993; 18 (suppl 1): S10.

41 Bellobuono A, Mondazzi L, Tempini S, Bellati G, CassaraL, Lombino M, et al. Efficacy of different regimens of a-interferon in chronic hepatitis C and relationship betweenresponse and HCV genotype [Abstract]. J7 Hepatol 1994;21 (suppl 1): S35.

42 Reichard 0, Foberg U, Fryden A, Mattsson L, Norkrans G,Sonnerborg A, et al. High sustained response rate andclearance of viremia after treatment with interferon-alpha2b for 60 weeks. Hepatology 1994; 19: 280-5.

43 Bosch 0, Tapia L, Quiroga JA, Carreflo V. An escalating doseregime of recombinant interferon-alpha-2A in the treat-ment of chronic hepatitis C. JHepatol 1993; 17: 146-9.

44 Camps J, Cris6stomo S, Garcia-Granero M, Riezu-Boj JI,Civeira MP, Prieto J. Prediction ofthe response of chronichepatitis C to interferon alfa: a statistical analysis of pre-treatment variables. Gut 1993; 34: 1714-7.

45 Chemello L, Alberti A, Rose K, Simmonds P. Hepatitis Cserotype and response to interferon therapy [Letter]. NEnglJ Med 1994; 330: 143.

46 Dusheiko G, Alberti A, Colombo M, Craxi A, Frost C,Prieto J, et al. The influence of serotypes of hepatitis Cvirus on sustained response to alpha interferon treatment[Abstract]. Jf Hepatol 1994; 21 (suppl 1): S 1 7.

47 Ampurdanes S, Vilella A, Olmedo E, Maluenda MD,L6pez-Labrador FX, Costa J, et al. Hepatitis C virusserotype and response to interferon in chronic hepatitis C[Abstract]. J Hepatol 1994; 21 (suppl 1): S23.

48 Suzuki T, Tanaka E, Matsumoto A, Urushihara A,Sodeyama T. Usefulness of simple assays for serum con-centration of hepatitis C virus RNA and HCV genotype inpredicting the response of patients with chronic hepatitisto interferon-a2a therapy. J Med Virol 1995; 46: 162-8.

49 Davis GL, Lau JY, Urdea MS, Neuwald PD, Wilber JC,Lindsay K, et al. Quantitative detection of hepatitis Cvirus (HCV) RNA by a solid-phase signal amplificationmethod: definition of optimal conditions for specimencollection and clinical application in interferon treatedpatients. Hepatology 1994; 19: 1337-41.

50 Olmedo E, Forns X, Ampurdanes S, Maluenda MD,Lopez-labrador FX, Costa J, et al. Evaluaci6n de la repli-caci6n del virus de la hepatitis C (VHC), su relaci6n conel genotipo viral, la gravedad de la enfermedad y larespuesta al tratamiento [Abstract]. Gastroenterol Hepatol1995; 18: 266.