September 6, 2013

Sensitivity of a Ribavirin Resistant Mutant of Hepatitis C Virus to Other Antiviral Drugs

Provided by PLoS ONE

Research Article

Kathleen B. Mihalik, Dino A. Feigelstock



While ribavirin mono-therapy regimens have minimal effect on patients with chronic hepatitis C virus (HCV) infections, they can be efficacious when combined with interferon. Clinical studies show that interferon-free combination therapies containing ribavirin are also efficacious, suggesting that an interferon-free therapy could be adopted in the near future. However, generation of drug resistant mutants and cross resistance to other drugs could impair the efficacy of the treatment. Therefore, understanding the mechanism of HCV resistance to ribavirin and cross resistance to other antiviral drugs could be of major importance.


We tested the ability of a J6/JFH1 derived HCV ribavirin resistant mutant to grow in tissue cultured Huh7D cells in the presence of the mutagen 5-Fluorouracil and the nucleoside analog 2′-C-Methylcytidine. Virus replication was assessed by detecting HCV antigens by immunofluorescence and by titrating virus present in the supernatants. Recovered viruses were amplified by RT-PCR and sequenced.


The sensitivity of HCV-RR relative to parental J6/JFH1 to the tested drugs varied. HCV-RR was more resistant than J6/JFH1 to 5-Fluorouracil but was not more resistant than J6/JFH1 to 2′-C-Methylcytidine. Growth of HCV-RR in 5-Fluorouracil allowed the selection of an HCV-RR derived mutant resistant to 5-Fluorouracil (HCV-5FU). HCV-5FU grows to moderate levels in the presence of high concentrations of 5-Fluorouracil and to parental levels in the absence of the drug. Sequence of its genome shows that HCV-5FU accumulated multiple synonymous and non-synonymous mutations.


These results indicate that determinants of resistance to ribavirin could also confer resistance to other anti-HCV drugs, shedding light toward understanding the mechanism of action of ribavirin and highlighting the importance of combination drug selection for HCV treatment. The results also show that it is possible to select a 5-Fluorouracil HCV resistant mutant that replicates to levels similar to parental virus when grown in the absence of 5-Fluorouracil.

Citation: Mihalik KB, Feigelstock DA (2013) Sensitivity of a Ribavirin Resistant Mutant of Hepatitis C Virus to Other Antiviral Drugs. PLoS ONE 8(9): e74027. doi:10.1371/journal.pone.0074027

Editor: Hak Hotta, Kobe University, Japan

Received: April 19, 2013; Accepted: July 26, 2013; Published: September 5, 2013

This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Funding: This work was supported by internal funding from the Food and Drug Administration. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Continue here to read the full article ……

Management of Depression Induced by Interferon Hepatitis Therapies

Provided by

Hema Shah, MD; Snehal Kadia, MD; Radhika Bawa, MD; and Steven Lippmann, MD

Submitted: October 9, 2012; accepted May 3, 2013.

Published online: September 5, 2013.

Corresponding author: Steven Lippmann, MD, ACB Clinic, First Floor, 550 South Jackson St, Louisville, KY 40202 (


Objective: Treatment with interferon therapy for hepatitis can induce depression and/or recurrence of affective illness, which could result in cessation of interferon treatment. This article reviews treatment for interferon-induced depression, including antidepressant drugs that may diminish associated symptoms.

Data Sources: English-language literature with no date restrictions on the treatment of interferon-induced depression was reviewed via PubMed and MEDLINE using the key words hepatitis, interferon, hepatitis C, interferon-induced depression, pharmacotherapy of interferon-induced depression, and depression prevention. Fourteen of the most pertinent references are cited.

Data Extraction: Escitalopram is the most prominently noted pharmaceutical prescribed for treating mood symptoms in hepatitis patients with interferon-induced depression. Other antidepressant medicines may have utility as well.

Results: Antidepressant drugs can be efficacious in diminishing mood disorders during hepatitis therapies. It remains controversial as to whether antidepressant medications can provide prophylaxis against newly developing interferon-induced depressions in individuals with no past history of a mood disorder.

Conclusions: Antidepressant medicines can be effective at improving mood in patients undergoing interferon treatment for hepatitis.

Prim Care Companion CNS Disord 2013;15(5):doi:10.4088/PCC.12r01487

© Copyright 2013 Physicians Postgraduate Press, Inc.


Effects of lifestyle changes including specific dietary intervention and physical activity in the management of patients with chronic hepatitis C – a randomized trial


Emilia Rusu123, Mariana Jinga24, Georgiana Enache1, Florin Rusu34, Andreea Diana Dragomir23, Ioan Ancuta25, Ramona Draguţ12*, Cristina Parpala1, Raluca Nan12, Irina Sima1, Simona Ateia2, Victor Stoica35, Dan Mircea Cheţa123 and Gabriela Radulian123

* Corresponding author: Ramona Draguţ

Author Affiliations

1“Prof. N. Paulescu” National Institute of Diabetes, Nutrition and Metabolic Diseases - Bucharest, Romania

2“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

3 Healthy Nutrition Foundation, Bucharest, Romania

4“Dr. Carol Davila” Clinical Central Military Emergency Hospital, Bucharest, Romania

5 Dr. I. Cantacuzino Clinical Hospital, Bucharest, Romania

For all author emails, please log on.

Nutrition Journal 2013, 12:119 doi:10.1186/1475-2891-12-119

The electronic version of this article is the complete one and can be found online at:

Received: 29 January 2013, Accepted: 7 August 2013, Published: 14 August 2013

© 2013 Rusu et al.; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



In patients with chronic hepatitis C (CHC), obesity is involved in the pathogenesis of insulin resistance, fatty liver disease and progression of fibrosis. The objective of this study was to compare a normoglucidic low-calorie diet (NGLCD) with a low-fat diet (LFD) among participants with CHC. Aimed to measure the impact of dietary changes in reduction of insulin resistance, obesity but also in steatosis and fibrosis.


Randomized, controlled trial in three medical centers with assessments at baseline, 6 months and 12 months. Participants were patients over 35 years with chronic hepatitis C (n = 120) with BMI over 25 kg/m2. We evaluated the effects of NGLCD vs. LFD in weight management and metabolic improvement. The primary endpoint was to measure the impact of dietary changes through nutritional intervention in reversibility of insulin resistance, obesity, steatosis, and fibrosis. We performed anthropometric measurements, fasting glucose profile, serum lipids, liver profile, blood count at baseline, 6 and 12 months. Steatosis was evaluated using ultrasonographic criteria. Liver fibrosis was non-invasively assessed.


After 6 and 12 months of intervention, both groups had a significant decrease in caloric consumption. At 6 months, weight loss was greater in the NGLCD group (−5.02 ± 3.43 kg vs. −4.1 ± 2.6 kg; p = 0.002) compared to the LFD group. At 1-year, however, weight loss was similar in both groups (−3.9 ± 3.3 kg vs. −3.1 ± 2.6 kg; p = 0.139). At 12 months, fasting plasma glucose, fasting plasma insulin, and HOMA-IR had significant improvements in both groups. With both diets aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT) decreased with significant differences; also there were significant improvements in AST/ALT ratio, Forns fibrosis index. The two diets were associated with reduction of both the prevalence and the severity of steatosis (all p < 0.001). At 12 months, total cholesterol, HDL-cholesterol, triglycerides improved in both groups (all p < 0.05).


The present study establishes the benefits of low-calorie diet and low-fat diet in management of patients with hepatitis C regarding improvement of insulin resistance, steatosis and also fibrosis.

Overweight or obese patients with CHC undergoing a lifestyle intervention (specific dietary intervention and physical activity) for 1-year had significant improvements in body weight, lipid and hepatic profile.

Trial registration PNCI2-3343/41008/2007

Keywords: Hepatitis C; Diet; Lifestyle change; HOMA-IR; Body mass index


The prevalence of hepatitis C virus (HCV) infection worldwide is estimated at 3% [1]. World Health Organization estimates that the prevalence of HCV in Europe is 1% [1]. In Romania, statistics show that there are 1 million people (4.5% of the population) infected with HCV [2].

Chronic hepatitis C (CHC) can be considered a metabolic liver disease which implies: insulin resistance (IR), increased prevalence of impaired glucose tolerance or type 2 diabetes mellitus (T2DM), changes in lipid metabolism, and a high prevalence of steatosis [3].

As obesity is involved in the pathogenesis of hepatic steatosis and fibrosis progression, one of the important objectives of nutrition management is weight control.


Trial design

This multicenter, randomized controlled trial was conducted from September 2007 to December 2010.


Participants were recruited from three hospitals from Bucharest, Romania. The inclusion criteria were: age over 35 years, BMI over 25 kg/m2 diagnosis of chronic hepatitis C (CHC infection was defined by the presence of anti-HCV antibodies for a least 6 months and a positive HCV-viremia).

The exclusion criteria were: patients with other etiology of chronic liver disease, hepatitis B, autoimmune liver disease, hemochromatosis, HIV infection, patients with history of hepatotoxic or steatosis-inducing drug use, currently on interferon treatment or during the last 12 months, patients having an alcohol consumption of more than 20 g/day for women and 30 g/day for men, history of pancreatitis.

Study setting

The study was conducted in Bucharest, the most important commercial urban setting of Romania, with a population of 2 million and an estimated CHC rate of 3.35% in adults (data as of 2007).

Trial overview

The DIADIPOHEP (Adipocitokynes, link between virus C hepatitis and type 2 diabetes mellitus)) study was approved by the Romanian National Authority for Scientific Research. Written informed consent was obtained from all participants.

Enrollment began in September 2007 and ended in December 2010. Participants were recruited from three hospitals. Eligibility was established through a screening visit that included a physical examination and a review of the patient's medical history. Following completion of baseline assessments, participants were randomized to a normoglucidic low-calorie diet (NGLCD) group, or to a low-fat diet (LFD) group, both with a lifestlye management program.

Outcome measures

The primary endpoint was to measure the impact of dietary changes in reduction of insulin resistance as well as hepatic steatosis and fibrosis through nutritional intervention. Secondary endpoints included changes in weight, lipid profile (total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides), blood pressure (systolic and diastolic), hepatic profile, and renal function (estimated glomerular filtration rate [eGFR]).


We performed anthropometric measurements (weight, height, BMI (body mass index), waist circumference, waist to hip ratio (WHR)) every month.

Body mass index (BMI) was calculated as weight (in kilograms) divided by height (in meters squared). Based on the World Health Organization classification, overweight was defined as BMI between 25 and 29.9 kg/m2, and obesity was defined as BMI over 30 kg/m2[4]. We also measured waist circumference (in centimeters) at the mid-point of the distance between the 12th rib and iliac crest and hip circumference at the greater trochanters with the legs brought together.

Arterial blood pressure was measured three times at the end of the physical examination with the subject in the sitting position. Participants whose average blood pressure levels were greater or equal to 140/90 mmHg or receiving antihypertensive medication were classified as hypertensive subjects [5].

Laboratory assays

Fasting blood samples were drawn between 7:00 a.m. and 10:00 a.m.

The biochemical analyses, including fasting serum lipids (total cholesterol (TC), triglyceride (TG), high-density lipoprotein-cholesterol (HDL-C)), glucose profile (fasting plasma glucose (FPG), fasting plasma insulin (FPI), glycated hemoglobin (HbA1c)), liver function tests (aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase, bilirubin, albumin, total protein, International Normalized Ratio (INR)), were performed at baseline, 6 and 12 months with commercially available kits from Roche-Hitachi Systems which were analyzed on a Hitachi 917 autoanalyser. Low-density lipoprotein cholesterol (LDL-C) was calculated using the Friedwald formula (LDL-C = TC − TG/5 + HDL-C) [6].

Serum C-peptide was measured through an electrochemiluminescence immunoassay (Modular Analytics, Roche Diagnostics) with intra- and interassay coefficients of variation of 4.5% and 6.9%, respectively.

Insulin concentration was determined through RIA (Abbott Axsym System, Chicago IL), with intra- and interassay coefficients of variation of 4.5% and 6.9%, respectively.

FPI and C peptide were measured at baseline and 12 months. Insulin resistance (IR) was determined using Homeostasis model assessment (HOMA-IR)(fasting insulin level (mUI/l)x fasting glucose level (mg/dl)/405 [4]; a HOMA-IR index value of more than 2.0 was considered as the criteria of insulin resistance [7].

The oral glucose tolerance test (OGTT) was performed in patients with HbA1c higher than 5.5%. For OGTT, a glucose load equivalent to 75 g anhydrous glucose was given in a total water volume of 250 –300 ml [8]. The glucose drink was consumed over 5 min. Timing for the rest of the test started at the beginning of ingestion. A further blood sample was collected 2 h after the glucose load in order to measure the glucose concentration. Diabetes diagnostic was made according to ADA 2003 criteria [9].

The definition of the metabolic syndrome (MetS) was based on the IDF criteria (central obesity defined as waist circumference over 94 cm in men, over 80 cm in women or BMI over 30 kg/m2 plus any two of the following factors: 1. triglycerides (TG) ≥1.695 mmol/l (150 mg/dl) or treatment; 2. high density lipoprotein-cholesterol (HDL-C) lower than 40 mg/dl in men, 50 mg/dl in women or treatment; 3. blood pressure ≥130/85 mmHg or medication; 4. fasting blood glucose ≥ 5.6 mmol/l (100 mg/dl) or medication for diabetes [10].

Liver fibrosis was non-invasively assessed using the Forns fibrosis index (FI) [11]; a value < 4.2 excludes liver fibrosis and a value > 6.9 is a predictor for significant fibrosis. Forns fibrosis index was calculated according to formula: 7.811–3.131 ln[platelet count (109/l)] + 0.781 ln[gamma-glutamyl transpeptidase (GGT) (UI/l)] + 3.467 ln[age (years)] − 0.014[cholesterol (mg/dl)]. The presence of significant fibrosis was predicted with a 96% negative predictive value (NPV) and 66% positive predictive value (PPV) [11].

The AST to platelet ratio index (APRI) was calculated by dividing the AST level (UI/l), expressed as the number of times above the upper limit of normal (ULN), by the platelet count (109/l): AST (/ULN) × 100/platelet count (109/l) [12]. APRI is simpler to use than most of the other indices with similar performance to that of the Fibrotest (FT) and the Forns fibrosis index. This index has been validated in HCV patients [12]. An 86% NPV and an 88% PPV were reported to predict the presence of significant fibrosis and a 98% NPV and a 57% PPV were reported to predict the presence of cirrhosis [12].

Hepatic steatosis (HS) was evaluated using ultrasonographic criteria. Hepatic ultrasound is a sensitive procedure for detecting liver fat (sensitivity 91–100, specificity 93–100) [13]. The severity of echogenicity was graded as follows: grade 0, normal echogenicity; grade 1, slight, diffuse increase in fine echoes in liver parenchyma with normal visualization of diaphragm and intrahepatic vessel borders; grade 2, moderate, diffuse increase in fine echoes with slightly impaired visualization of intrahepatic vessels and diaphragm; grade 3, marked increase in fine echoes with poor or nonvisualization of the intrahepatic vessel borders, diaphragm, and posterior right lobe of the liver.

Estimated glomerular filtration rate (eGFR) was made according to CKD-EPI equation [14]. The CKD-EPI equation, expressed as a single equation, is: GFR = 141 X min(Scr/κ,1)α X max(Scr/κ,1)-1.209 X 0.993Age X 1.018 [if female] X 1.159 [if black].


Independently done computer randomization was used to allocate numbers and divide the patients into two groups. Randomization was done by block design to ensure equal numbers in each group for every 4 subjects recruited.


All patients received nutrition counseling (NGLCD or LFD) in individual sessions every week in the first 6 months and every month thereafter until 12 months, with biological reevaluation at 6 and 12 months. All patients were required to submit a food journal at the baseline visit (before group allocation), as well as subsequent journals prior to the 6 month, 12 month, and each monthly visit. The food journal covers a 4 day period that includes 2 working days and 2 free days/weekend. Foods were measured using standard measuring cups and spoons and weight for 100 g; the input accuracy of the food journals was confirmed by using food-frequency questionnaires.

No supplements were allowed in this period. Patients who missed more than 30% of dietitian appointments or did not complete the food journals were considered noncompliant and were excluded from final analysis.

Macronutrient intake was calculated using the United States Department of Agriculture's food database (National Nutrient Database for Standard Reference, Release 16–1 and 17, Release dates July 2003 and 2004, Beltsville, MD) [15].

Subjects were required to limit alcohol intake to <20 g/week during the intervention period. Alcohol intake was averaged and recorded as grams per week.

Normoglucidic low-calorie diet

Dietitian doctors instructed participants to follow a diet comprising approximately 50-60% of daily caloric intake from carbohydrates [16], 25-35% of total calories from fat (less than 7% of total calories from saturated fat, less than 1% trans fatty acids, 10% monounsaturated fatty acids, 5-10% polyunsaturated fatty acids (PUFAs) and less than 300 mg cholesterol per day), proteins 15% of total calories (1.0 to 1.2 g/kg/day) [17], and <5% of caloric intake from simple sugars. Nutrient-rich choices that included whole grains, vegetables and fruit were prioritized. NGLCD was defined as a normoglucidic, normolipidic, normoproteic, low-calorie diet (100–500 kcal less than estimated energy needs).

Low-fat diet

Restriction of fat intake to 20% of total daily energy uptake with avoidance of trans-fat and saturated fat, up to 20% of the total calories from proteins and 60-65% carbohydrates. Further recommendation included increasing fibre uptake to 30 g per day, and avoiding liquid mono- and disaccharides. Moreover, patients were advised to consume at least 250 to 300 g of fruits, 125 to 150 g of vegetables, and 25 to 50 g of walnuts per day; in addition, they were also encouraged to consume 400 g of whole grains (rice, maize, and wheat) daily and to increase their consumption of olive oil. Compared with normoglucidic low-calorie diet, low-fat diet was defined by a low intake of fat (up to 20% of caloric intake), increased carbohydrate intake up to 60-65% of daily caloric intake, increased fiber intake (30 g/day), and protein intake up to 20%.

Physical activity

A healthy lifestyle includes regular physical activity (PA). Regular physical activity included 30 minutes of moderate intensity physical activities (e.g. brisk walking, jogging, cycling) for 3–7 days a week, recommended for persons with hepatitis C virus infection without advanced cirrhosis or other metabolic complications [18].

Energy needs

A high-energy diet is normally recommended for HCV-infected persons [19,20]. Measured energy needs of patients with HCV infection, even in the absence of cirrhosis, are on average higher per unit of lean body mass than the needs of healthy individuals [21]. The following provides two reasonable estimates of energy needs for patients undergoing physiological stress, such as those with infection: 25 to 40 kcal/kg, based on dry weight or an adjusted ideal weight [22] or add 20% to 40% to basal energy expenditure (BEE) using the Harris-Benedict equation [23].

In patients with overweight or obesity, the energy intake was individualized to be 100–500 kcal less than estimated energy needs because we designed it to induce at least a 5-10% weight loss at 6 months and to maintain this weight loss in the subsequent 6 months.


Results for continuous normally distributed data were expressed as mean ± standard deviations (SD). Tests of normality used were Kolmogorov-Smirnov with a Lilliefors significance correction and Shapiro-Wilk statistic. The comparison of mean value at baseline, 6 months and 12 months was performed with paired t-test. For continuous nonnormal distribution we used Wilcoxon's rank-sum tests, and data were reported as median ± interquartile ranges. Pearson's χ2 tests were used to compare changes in continuous variables from beginning categorical baseline characteristics. Wilcoxon's rank-sum tests were also used to compare changes in continuous variables from baseline to the 12 month. P-value less than 0.05 was considered significant. All statistical analyses were performed using SPSS 19 (copyright IBM).

The primary analysis was intention-to-treat and involved all patients who were randomly assigned [24]. Two patients in the NGLCD group and eight patients in LFD groups were lost to follow up; thus data from 110 patients were available for the intention-to-treat analysis.


The flow chart for study participants is presented in Figure 1[25]. The completion rate was 91.6%; 10 of the 120 subjects (8.3%) participating at baseline did not complete the 1-year intervention: 2/60 (3.3%) in the NGLCD group and 8/60 (8.3%) in the LFD group. The dropout rate in the LFD group was significantly greater than that in the NGLCD (p = 0.047). At baseline, in both groups, there were no statistically significant differences between patients who completed the study and those who dropped out.


Figure 1. Participant flow diagram.

The baseline characteristics of participants who completed the 1-year intervention are presented in Table 1; participants were similar in sex distribution, smoking, glycemic state, hypertension, dyslipidemia (Table 1). There were no significant differences between the groups (data not shown) for demographic characteristics, marital status, environment, occupation. In both groups, compared with women, men had a higher mean baseline BMI (mean difference 1.96 kg/m2 [95% CI 0.13, 3.79]) in NGLCD group and 2.1 kg/m2 [95% CI 0.33, 4.06]) in LFD group. All patients were affected by genotype 1.

Table 1. (click to view) Demografic and clinical characteristics at baseline

The average age was 54.3 ± 8.6 years in NGLCD group and 54.2 ± 9.3 years in LFD group (p = 0.51).

Overweight was present at baseline in 60.3% (n = 35) patients in NGLCD group and in 55.8% (n = 29) patients in LFD group; the other patients had obesity (p = 0.53 between groups). Overweight was present at 12-months in 55.2% (n = 32) patients in NGLCD group and in 57.7% (n = 30) patients in LFD group; obesity was present in 20.7% (n = 12) patients in NGLCD group and in 23.1% (n = 12) patients in LFD group.

The prevalence of MetS at baseline was similar between groups (61.5% in NGLCD (n = 36) vs. 61.5% in LFD (n = 32), p = 0.55) but higher in men from LFD group than in women from the same group (85.7% (n = 18) vs. 45.2% (n = 14), p = 0.003).

Kilocalories and macronutrients

At baseline, analysis of the 4-day food journal showed that calorie intake of the two groups was not significantly different (2247 ± 160 Kcal/day vs. 2213 ± 157 Kcal/day in the NGLCD and LFD, p = 0.261). The results were similar for the baseline protein (16.2 ± 1.6% vs. 16.3 ± 1.6%, p = 0.506), lipid (33.9 ± 3.52% vs. 33.2 ± 3.51%, p = 0.1) and carbohydrate intake (49.8 ± 3.4% vs. 50.2 ± 3.3%, p = 0.8) in the NGLCD and LFD group, respectively.

Significant reduction in carbohydrate, protein and lipid intake was observed in the NGLCD group both at 6 months and 12 months (all p < 0.001) (Table 2). In LFD group we observed a significant reduction of calories and lipid intake and an increase of protein and carbohydrates intake during the intervention period (all p < 0.001 at 12 months) (Table 2).

Table 2. (click to view) Kilocalories and macronutrients, comparison at baseline and after 6 and 12 months

After 6 and 12 months of intervention, both groups had a significant decrease in caloric consumption (Table 2), without differences between groups (p = 0.839 at 6 months, and p = 0.96 at 12 months); at 12 months, fat consumption in LFD patients was significantly lower (43.3 ± 7.04 g/day vs. 61.4 ± 8.1 g/day).

Weight loss

At 6 months, weight loss was greater in the NGLCD group (−5.02 [95% CI −5.9, -4.1]kg vs. −4.1 [95% CI −4.8, -3.3]kg; p = 0.002) compared to the LFD group. At 1-year, however, weight loss was similar in both groups (−3.9 [95% CI −4.8, -3.1]kg vs. −3.1 [95% CI −3.8, -2.3]kg; p = 0.139). Most of the weight loss occurred in the first 6 months. After 12 months, patients slowly regained weight after no longer being under observation on a regular basis. We also found no significant sex differences for changes in weight. A total of 18 patients in LFD group (34.6%) and 21 patients in NGLCD group (36.2%) continued to lose weight from 6 months to 1 year. At 1 year, 29.3% (n = 17) patients in NGLCD group and 30.8% (n = 16) patients in LFD group had lost between 5-10% of their initial body weight; 10.3% (n = 6) patients in NGLCD group and 1.9% (n = 1) patients in LFD group lost over 10% of their initial weight (p = 0.33).

There were no significant differences between the groups in body weight changes, BMI, waist circumferences at 12 months (Table 3).

Table 3. (click to view) Metabolic syndrome parameters

Physical activity

Before the start of the study all patients were sedentary, not involved in any form of regular exercise (in NGLCD, PA was 28.7 ± 18.7 min/week, in LFD, PA was 29.5 ± 19.3 min/week).

The degree of PA increased in the first 6 months in both groups statistically significant; even if in the next 6 months PA decreased, the difference between baseline and 12-months remained significant in both groups (for NGLCD the difference was 56.5 min/week [95% CI, 46.4, 66.6] and 39 min/week [95% CI 28.7, 49.3] for LFD.

Comparing the two groups, significant differences were found only at the 12-months visit, when patients in the NGLCD group continued to be more active (16.7 min/week [95% CI 1.8, 31.5]).

Effect of diet programs on insulin resistance

In NGLCD group, after the 12-month intervention we have seen reductions of 5.5% (95% CI 3.4, 7.6) in FPG and of 27.4% (95% CI 20.3, 34.5) in FPI; in LFD group we also observed a reduction of 5.2% (CI95% 2.9, 7.4) for FPG and of 21.6% (95% CI 15.3, 28) for FPI, respectively. Pairwise analyses test showed significant differences in changes of FPG and FPI for the two groups (Table 4).

Table 4. (click to view) Glucose metabolism parameters

Insulin resistance determined through HOMA-IR improved by 31.5% (95% CI 24.6, 38.5) in the NGLCD group; HOMA-IR improved also in the LFD group (25.7% (CI95% 19.3, 32.1) (p = 0.219 between groups).

There were no significant differences in the 12-month percentage changes in FPG, FPI, C peptide, homeostasis model assessment for insulin resistance and homeostasis model assessment for β-cell function, between groups. After adjustment for body weight lost, HOMA-IR showed an improvement with both diets (p = 0.026, respectively p = 0.03).

Effects of diet programs on hepatic profile

The liver function tests at baseline and after 12 months for NGLCD and LFD groups are presented in Table 5.

Table 5. (click to view) Parameters for hepatic function

With both diets AST, ALT, GGT decreased with significant differences; also AST/ALT ratio, APRI score and Forns index had significant improvements. Albumin and bilirubin levels were not significantly changed (Table 5).

In order to assess the effects of weight loss on liver function parameters patients were stratified according to degree of weight loss (weight gain, 1-5% weight loss, 5-10% weight loss, and more than 10% weight loss). Both diets proved to be efficacious in the improvement of liver function parameters.

In NGLCD patients group

In patients with less than 5% loss of baseline weight (n = 30) (−2.1 kg [95% CI −2.5, -1.75]) there was an improvement of ALT levels (−15.1 [95% CI −22.8, - 7.5]), GGT levels (−6.4 [95% CI [−10.9, -1.9]), AST/ALT ratio (−0.07 [95% CI, -0.002, -0.14]) and Forns index (−0.17 [(95% CI, -0.005, -0.28]) (Table 6).

Table 6. (click to view) Groups of weight loss and liver function parameters in patients with NGLCD

In patients who lost between 5-10% of baseline weight (n =17, 29.3%) there was an improved GGT, alkaline phosphatase, Forns index, and APRI (Table 6).

In patients from NGLCD group who have lost more than 10% of the body weight (n = 6) there was a significant improvement of non-invasive index of liver fibrosis (Forns index) (Table 6).

In LFD patients group

In patients with weight gain (n = 4, 7.7%) we observed a slight improvement of Forns index, probably obtained in the context of reduced fat consumption (Table 7).

Table 7. (click to view) Groups of weight loss and liver function parameters in patients with LFD

In those with less than 5% loss of baseline weight (n = 31, 59.6%) we found improvements in AST, ALT, total bilirubin, INR, Forns index, APRI (Table 7).

In patients with 5-10% loss of baseline weight (n = 16, 30.8%) we found significant improvements in GGT and Forns index, with an improvement in the remaining parameters, but it was not statistically significant (Table 7).


Fatty liver disease is common in patients with CHC. In our study 52.7% patients (n = 58) presented hepatic steatosis, 60.3% (n = 35) patients in NGLCD group and 46.2% (n = 24) patients in LFD group (p = 0.097).

The two diets were associated with reduction of both prevalence and severity of steatosis (all p < 0.001) without significant differences between groups; in NGLCD group - mild: 68.6% vs. 77.4%, moderate: 25.7% vs. 22.6%, severe: 5.7% vs. 0%; in LFD group - mild: 58.3% vs. 76.2%, moderate: 29.2% vs. 23.8%, severe: 12.5% vs. 0%.

This reduction in prevalence and severity of liver steatosis resulted in a significant diminution of serum triglycerides in NGLCD and of serum ALT levels in LFD group (p = 0.045, respectively p = 0.03). Such regression of steatosis occurred even in absence of weight normalization.

Effects of diet programs on metabolic syndrome parameters and fasting lipid profiles

At baseline, metabolic syndrome (≥3 criteria) was present in 62.1% (n = 36) patients in NGLCD and in 61.5% (n = 32) patients in LFD (p = 0.55). At 12 months, all parameters associated with the metabolic syndrome improved in both groups (all p < 0.005). At 12-months only 25.9% (n = 15) form patients receiving NGLCD and 26.9% (n = 14) form patients receiving LFD showed MetS; we did not find differences between groups at baseline and 12 months (Table 3).

Effects of diet programs on renal profile

There were no differences between the two diets regarding the changes in renal function (eGFR, creatinin, urea). In both groups, there were no associations between the changes in protein intake (g/day) and the change in eGFR (r = 0.04, p = 0.29) or creatinin (r = 0.07, p = 0.34).


This RCT demonstrated the benefits of both normoglucidic low-calorie and low-fat diets in individuals with CHC. Our results indicated that after 1 year, overweight and obese patients with CHC had similar weight reduction with both diets. The dropout rate in LFD was significantly greater than that in NGLCD. Similar to prior studies, we observed a faster weight loss after initiation of a NGLCD and equivalent weight loss after 1 year [26].

This study demonstrated that lifestyle changes (NGLCD or LFD and physical activity) improved the anthropometric parameters, glucose parameters and lipid and liver profiles. Further improvement was noted in the results of non-invasive liver fibrosis testing, as well as improvement of the prevalence and severity of hepatic steatosis.

The prevalence of MetS in our study was higher than previously published in Romania [27] and in Europe, most likely because we included overweight patients (BMI over 25 kg/m2). At baseline 61.5% of patients belonging to the NGLCD group and 61.5% to the LFD group presented MetS. In the largest retrospective survey (239 HCV-positive subjects) 16.7% had metabolic syndrome [28]. In other studies [29,30], the prevalence of metabolic syndrome in chronic HCV-infected patients ranged from 4.1 to 44% [31].

Even the weight loss at 12 months wasn’t spectacular (−3.9 [95% CI −4.8, -3.1]kg in NGLCD vs. −3.1 [95% CI −3.8, -2.3]kg in LFD) there was a reduction in MetS prevalence (25.9% in NGLCD group and 26.9% in LFD group). In CHC patients lifestyle changes through medical nutritional therapy and physical activity led to an improvement in all metabolic parameters: reduced insulin resistance, lower blood glucose, lower triglycerides, total serum cholesterol, LDL-C, increased HDL-C, reducing systolic and diastolic blood pressure.

Modest weight loss of 5–10% body weight is known to reduce insulin resistance in obese individuals [32].

In our study a normoglucidic low-calorie diet (with limited refined carbohydrates and sugar intake, and increased fruits, vegetables and whole grains intake) was accompanied by improvement in insulin resistance (HOMA-IR) lipid and liver profile.

The metabolic changes induced by the low-fat, high carbohydrate, high protein diet were associated with similar weight losses, improved lipid and glucose profiles, however there were no adverse changes in renal function parameters but the compliance to this diet was lower (drop out rate was almost double).

Thus, even if macronutrient intake was different, there were similar improvements in glycemia and insulin resistance, indicating that in the context of tolerable diets and weight loss, mild variations in nutrient fuels have limited impact on glucose metabolism.

In overweight/obese patients with steatosis who subsequently lost weight, liver-related abnormalities improved [33]. Although weight loss may be difficult to achieve and sustain, the patients who did manage to lose weight showed a reduction in steatosis and abnormal liver enzymes as well as improvement in liver fibrosis, despite the persistence of the virus [34]. Lifestyle changes are deemed to be additive to proper antiviral treatment schedules, which remain the standard of care [31].

The effects of lifestyle changes on hepatic inflammation and fibrosis varied [35,36], only one study showed significant improvement [36].

In patients with steatosis, lifestyle changes (diet and exercise) were associated with improvement of ALT levels [35] and steatosis [35,36].

Recently a semiquantitative index used to assess steatosis was validated against histology [37] and proved useful in the specific setting of lifestyle interventions [38].

Limitations of the study are: we used non-invasive methods to estimate steatosis and fibrosis in patients with CHC, and these indices are less sensitive and specific in these patients; the analysis and presentation of only detailed food journals may bias the estimate of food intake; recruited patients were overweight (BMI > 25 kg/m2) thus the prevalence of MetS was higher.

At this point only lifestyle interventions can be recommended to improve metabolic syndrome and obesity associated with chronic hepatitis C, but their effect on treatment response and long term outcome requires further study.

Moderate exercise is recommended for all persons with hepatitis C who did not experience advanced cirrhosis or other metabolic complications [17,39,40]. In the present study, changes in food intake and the increase of physical activity were sustainable, associated with long-term metabolic benefits. In some studies, patients with CHC who participated in light or moderate exercise programs reported an improvement in some symptoms such as nausea, fatigue, depression and appetite [17,35,36].

An important issue related to long-term of dietary interventions is that adherence decreases over time and therefore achieving the treatment goals involves an individualized education program, structured and continuously adapted to the socio-biological and family environment, with patient’s involvement in his own treatment.

Long-term benefits can be confirmed only by large studies over a longer period of time, where the patient has adopted the habit of an optimal lifestyle.


The present study establishes the benefits of the low-calorie diet and low-fat diet in management of patients with hepatitis C regarding improvement of insulin resistance, steatosis and also liver fibrosis.

Overweight or obese patients with hepatitis C undergoing a lifestyle intervention (specific dietary intervention and physical activity) for 1-year had significant improvements in body weight, lipid and hepatic profiles.


ALT: Alanine aminotransferase; APRI: AST to platelet ratio index; AST: Aspartate aminotransferase; BMI: Body mass index; DBP: Diastolic blood pressure; FI: Forns fibrosis index; FPG: Fasting plasma glucose; FPI: Fasting plasma insulin; GGT: Gamma-glutamyl transpeptidase; HbA1c: Glycosylated hemoglobin; HDL: High density lipoproteins; HOMA-IR: Homeostasis model assessment of insulin resistance; IFG: Impaired fasting glucose; IGT: Impaired glucose tolerance; LFD: Low-fat diet; MetS: Metabolic syndrome; NGLCD: Normoglucidic low-calorie diet; SBP: Systolic blood pressure; WC: Waist circumference; NGLCD: Normoglucidic low-calorie diet.

Competing interest

The authors declare that they have no competing interest.

Authors’ contributions

Conception and design: ER; Providing study materials and inclusion of patients: ER, GR, FR, GE, ADD, MJ, IA, RD, CP, RN, IS, SA, VS, DMC, GR; Data collection and assembly: GE, FR, ER, ADD; Data analysis and interpretation: ER, DMC, MJ, GR; Manuscript elaboration: ER; Final approval of the manuscript: ER, MJ, GE, FR, ADD, IA, NC, PA, RN, IS, SA, VS, DMC, GR. All authors read and approved in the final manuscript.


This study was supported by the Romanian National Authority for Scientific Research as a part of the PNCDI 2 program DIADIPOHEP 41-008/2007.


The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors wish to thank Dr. Lawrence C. Nwabudike for improving the style and the language of the manuscript.



Firms Spar Over Hepatitis Drug

Provided by Chemical and Engineering News

Volume 91 Issue 36 | p. 16 | News of The Week
Issue Date: September 9, 2013 | Web Date: September 5, 2013

Patents: Merck & Co., too, claims a stake in hepatitis C drug from Gilead

By Lisa M. Jarvis


As Gilead prepares for the launch of sofosbuvir, a small-molecule hepatitis C treatment that is expected to rake in billions of dollars annually, competitors are angling for a piece of the action. The latest firm to come forward is Merck & Co., which alleges that sofosbuvir’s structure is covered by patents generated in its search for hepatitis C treatments.

According to the Centers for Disease Control & Prevention, roughly 3.2 million Americans are infected with the hepatitis C virus (HCV). Battling it traditionally required a harsh, nearly yearlong regimen involving daily doses of the antiviral medication ribavirin and weekly injections of interferon. In 2011, Merck and Vertex Pharmaceuticals both launched second-generation antivirals that, when added to the combination therapy, significantly shorten treatment time.

Sofosbuvir, which came to Gilead through its 2012 acquisition of Pharmasset, would be part of the first all-oral treatment for HCV. With the Food & Drug Administration likely to approve using the drug with ribavirin before the end of the year, analysts believe Gilead could see more than $2 billion in sales in 2014 and even more in the years ahead.

“If our projections for peak sales are accurate (over $10 billion), we are not surprised that many companies have pursued complaints against Gilead to either prevent launch or receive royalties,” Deutsche Bank stock analyst Robyn Karnauskas said in a note to investors.

In a letter dated Aug. 5, Merck notified Gilead that it would grant the firm a license to two patents related to sofosbuvir in exchange for a 10% royalty on sales of the drug. Merck asked for a reply by Aug. 31; Gilead filed a preemptive lawsuit on Aug. 30.

The Merck suit comes as litigation between Gilead and Idenix Pharmaceuticals winds through the courts. Merck and Idenix both claim that sofosbuvir is covered by their patents for families of nucleoside derivatives that block RNA viral polymerase.

Analysts think Merck and Idenix are unlikely to prevail. Sofosbuvir’s activity is due to a 2'-methyl, 2'-fluoro substitution on the sugar piece of the nucleoside, a specific feature that does not seem to be in either company’s patents, says Howard Liang of investment firm Leerink Swann. Indeed, Idenix lost the latest round of its legal fight against Gilead.

Chemical & Engineering News

ISSN 0009-2347

Copyright © 2013 American Chemical Society


Also See:

Galectin Therapeutics Receives FDA Fast Track Designation for GR-MD-02 for Fatty Liver Disease with Advanced Fibrosis


Norcross, GA -- (SBWIRE) -- 09/02/2013 -- Galectin Therapeutics, the leading developer of therapeutics that target galectin proteins to treat fibrosis and cancer, today announced that the U.S. Food and Drug Administration (FDA) has granted GR-MD-O2 (galactoarabino-rhamnogalacturonate) Fast Track designation for non-alcoholic steatohepatitis (NASH) with hepatic fibrosis, commonly known as fatty liver disease with advanced fibrosis.

Galectin Therapeutics is currently conducting a Phase 1 clinical trial to evaluate the safety, tolerability and exploratory biomarkers for efficacy for single and multiple doses of GR-MD-02 over four weekly doses of GR-MD-02 treatment in patients with fatty liver disease with advanced fibrosis. The study will enroll 8 patients in each dose escalation cohort and there will be at least three cohorts and potentially up to 5 cohorts, with a maximum of 40 patients at six clinical sites in the US, which each have extensive experience in clinical trials in liver disease. More information on the first-in-man Phase 1 clinical study of GR-MD-02 is available at

“Our preclinical data has shown that GR-MD-02 has robust treatment effects in reversing fibrosis and cirrhosis. Fast Track designation enables us to expedite the compound’s development and review process, with the ultimate goal of bringing a first-in-class treatment to the millions of Americans suffering from fatty liver disease with advanced fibrosis," said Dr. Peter G. Traber, President, Chief Executive Officer, and Chief Medical Officer of Galectin Therapeutics Inc. “We are very pleased that the FDA sees the clinical value of GR-MD-02 and seriousness of fatty liver disease, and we look forward to working closely with the FDA throughout this process."

The FDA's Fast Track program is designed to expedite the review of new drugs that are intended to treat serious or life-threatening conditions and demonstrate the potential to address unmet medical needs.

About GR-MD-02
GR-MD-02 is a complex carbohydrate drug that targets galectin-3, a critical protein in the pathogenesis of fatty liver disease and fibrosis. Galectin proteins play a major role in diseases that involve scaring of organs such as cancer, and inflammatory and fibrotic disorders. The drug binds to galectin proteins and disrupts their function. Preclinical data has shown that GR-MD-02 has robust treatment effects in reversing fibrosis and cirrhosis in kidney, lung, and liver.
About Fatty Liver Disease with Advanced Fibrosis

Non-alcoholic steatohepatitis (NASH), also known as fatty liver disease, has become a common disease of the liver with the rise in obesity rates, estimated to affect nine to 15 million people, including children, in the US. Fatty liver disease is characterized by the presence of fat in the liver along with inflammation and damage in people who drink little or no alcohol. Over time, patients with fatty liver disease can develop fibrosis, or scarring of the liver, and it is estimated that as many as three million individuals will develop cirrhosis, a severe liver disease where liver transplantation is the only current treatment available. Approximately 6,300 liver transplants are done on an annual basis in the US. There are no drug therapies approved for the treatment of liver fibrosis.

About Galectin Therapeutics
Galectin Therapeutics is developing promising carbohydrate-based therapies for the treatment of fibrotic liver disease and cancer based on the Company's unique understanding of galectin proteins, key mediators of biologic function. We are leveraging extensive scientific and development expertise as well as established relationships with external sources to achieve cost effective and efficient development. We are pursuing a clear development pathway to clinical enhancement and commercialization for our lead compounds in liver fibrosis and cancer. Additional information is available at

Forward Looking Statements
This press release contains, in addition to historical information, forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. These statements relate to future events or future financial performance, and use words such as “may,” “estimate,” “could,” “expect” and others. They are based on our current expectations and are subject to factors and uncertainties which could cause actual results to differ materially from those described in the statements. These statements include those regarding plans, expectations and goals, expectations and goals regarding the clinical trial, our FAST TRACK submission and the potential benefits of a FAST TRACK designation, potential therapeutic uses and benefits of our Galectin inhibitors and further related studies and potential partnerships.

Factors that could cause our actual performance to differ materially from those discussed in the forward-looking statements include, among others, that the receipt of a FAST TRACK designation from FDA is no guarantee that we avoid delays in the development of our drug product and provide no assurance of FDA approval of our drug development plans and of the grant of marketing approval for our drug product. Future clinical studies may not begin or produce positive results in a timely fashion, if at all, and could prove time consuming and costly. Plans regarding development, approval and marketing of any of our drugs are subject to change at any time based on the changing needs of our company as determined by management and regulatory agencies. Regardless of the results of current or future studies, we may be unsuccessful in developing partnerships with other companies that would allow us to further develop and/or fund any studies or trials.

To date, we have incurred operating losses since our inception, and our ability to successfully develop and market drugs may be impacted by our ability to manage costs and finance our continuing operations For a discussion of additional factors impacting our business, see our Annual Report on Form 10-K for the year ended December 31, 2012, and our subsequent filings with the SEC. You should not place undue reliance on forward-looking statements. Although subsequent events may cause our views to change, we disclaim any obligation to update forward-looking statements.

For more information on Galectin Therapeutics, please visit:

Galectin Therapeutics is represented by Eclectic Media Productions National PR firm. Website:


A Randomized Controlled Trial Adding Fluvastatin to Peginterferon and Ribavirin for Naïve Genotype 1 Hepatitis C Patients

Journal of Viral Hepatitis

T. Bader, L. D. Hughes, J. Fazili, B. Frost, M. Dunnam, A. Gonterman, M. Madhoun, C. E. Aston

J Viral Hepat. 2013;20(9):622-627.

Abstract and Introduction


Fluvastatin or simvastatin has demonstrable antiviral activity against hepatitis C virus (HCV) as monotherapy. The safety and efficacy of adding fluvastatin or simvastatin to peginterferon/ribavirin for 48 weeks was tested in HCV genotype 1 naïve-to-treatment veterans. Thirty-seven naïve-to-treatment genotype 1 HCV patients were randomized to either a control group (n = 20) to receive peginterferon alfa plus ribavirin or an experimental group (n = 18) to similarly receive peginterferon alfa plus ribavirin as well as fluvastatin 20 mg/day. In addition, seven patients who presented for HCV treatment already were on simvastatin and could not be withdrawn. These simvastatin users were not randomized but were entered into a concurrent prospective pilot arm. There were no unique safety issues with fluvastatin or simvastatin when these drugs were given with peginterferon/ribavirin for 48 weeks. Thirteen of 25 statin patients achieved sustained viral response (SVR), while 5 of 20 control patients achieved SVR. Analysis of SVR by intention-to-treat showed P = 0.078. In this phase 2 study, there were no safety issues with the addition of fluvastatin or simvastatin to peginterferon and ribavirin for 48 weeks. There was a trend towards improvement in SVR when fluvastatin or simvastatin was administered with peginterferon/ribavirin. The size of the groups did not reach the prestudy size thought needed to show significant difference (type II error). These results support the significant results of two other larger randomized controlled trials reported using the same dose of fluvastatin in naïve-to-treatment genotype 1 HCV patients.


Brown and Goldstein won the Nobel Prize in 1985 for their work on isolating and characterizing low-density lipoprotein (LDL). Brown and Goldstein also were the first to suggest that a statin, lovastatin, possessed an anti-HCV effect in a hepatitis C virus (HCV) replicon culture system.[1] Ikeda et al.[2] then performed an in vitro dose vs antiviral effect for all available statins. They reported that fluvastatin had the strongest anti-HCV activity.

Under a phase 1 Food and Drug Administration (FDA), USA licence, we previously were able to demonstrate an antiviral dose for fluvastatin in humans infected with chronic hepatitis C virus.[3] The FDA-approved doses of fluvastatin for use against hypercholesterolaemia are 20–80 mg/day. As Ikeda et al. had suggested that higher concentrations of statin in vitro possessed more anti-HCV activity, we tested doses up to 4 × the upper limit approved by the FDA for hypercholesterolaemia (i.e. 320 mg/day). Paradoxically, we determined that the lowest approved dose of fluvastatin, 20 mg/day, was the most active anti-HCV dose in humans when used as monotherapy. The anti-HCV effect with fluvastatin monotherapy is modest with decrements of HCV RNA in the range of 0.5–1.0 logs. It usually lasts a few days to a few weeks, although one patient experienced a 3-log HCV RNA drop 1 year later.[3] For comparison, this direct antiviral effect of fluvastatin monotherapy is significantly stronger and longer-lasting than the direct antiviral effect of ribavirin used alone.[4, 5]

Our phase 1 FDA monotherapy trials of statins in patients with chronic HCV did not show safety problems. Specifically, we did not note any symptomatic or laboratory evidence of myopathy, although our numbers were small (n = 50). Unexpectedly, we saw uniform improvement in abnormal alanine aminotransferase (ALT) values that often normalized and lasted the duration of the statin use.[3, 6]

The primary purpose of this phase 2 FDA-licensed trial was to examine safety issues occurring when fluvastatin was combined with peginterferon/ribavirin over 48 weeks. Phase 2 trials are small so as to limit exposure of subjects and not sized to prove efficacy as in the case of phase 3 trials. The FDA does not require randomization of subjects for phase 2 trials, but reviewers permit it. We randomized the cohort to better compare the development of safety issues. A secondary prestudy goal was to evaluate efficacy by intention-to-treat with the realization that our enrolment may not achieve an adequate size to reduce type 2 error below the typically accepted level of 20%.


Study Design

The entire study took place within the gastrointestinal section of the Oklahoma City Veteran's Administration Medical Center. Patients were enrolled from 20 July 2007 until 20 October 2010. All genotype 1 HCV patients were eligible for entry if they were between the ages 18 and 70 and had never been treated with interferon or peginterferon before. Patients were excluded for the following reasons: (i) decompensated cirrhosis, (ii) severe cardiopulmonary disease, (iii) chronic renal insufficiency (GFR < 50 mL/min), (iv) HIV positivity, (v) hepatitis B surface antigen positivity and/or (vi) significant unexplained chronic muscle pain. Figure 1 shows the flow of patients through the study. Thirty-eight patients were not taking a statin upon enrolment and were randomized to either the control arm (n = 20) treated with peginterferon alfa-2a plus weight-based ribavirin or the experimental arm (n = 18) treated with the same regimen plus 20 mg/day fluvastatin. In addition, seven patients presented for HCV treatment already on simvastatin for their hypercholesterolaemia and could not be exposed to withdrawal of statin with randomization. The dose of simvastatin ranged from 10 to 80 mg/day. These simvastatin users were entered into a concurrent prospective pilot arm and analysed together with the fluvastatin arm as the statin group (n = 25).


Figure 1. Flow chart of the study. PEG IFN, peginterferon; RBV, ribavirin; FLV, fluvastatin; SIM, simvastatin; SVR, sustained viral remission; ITT, intention-to-treat.

Laboratory Measurements

The endpoint for efficacy was sustained viral response (SVR) measured as an undetectable HCV RNA 24 weeks after the end of treatment. All HCV RNA samples were analysed using an in-house real-time Roche Cobas® PCR measurement machine that was leased and periodically upgraded for the latest technical advancements in measuring HCV RNA. Over the time period of the study, the lower limit of signal detection for HCV RNA at our institution was 20 IU/mL. As placebos do not influence HCV RNA levels in chronic hepatitis C patients, medicines were administered in an open-label format.

In addition to standard monitoring of patients on peginterferon and ribavirin, creatine kinase levels in all patients were measured periodically throughout the study. Reporting of side effects followed the National Cancer Institute's Criteria for Adverse Events, version 3.0 (2003), located at

Statistical Analysis

Results were expressed as means ± SD. Differences between groups were analysed by Student's t-test for continuous measures and Fisher's exact test for categorical measures. An intention-to-treat analysis for SVR results was carried out. A nominal significance level of 5% was assumed for the two-tailed tests. The a priori sample size of 40 for each group was determined to allow for 80% power to detect a minimal difference of 35% in SVR between the groups with maximum allowable type I error of 5%. SAS computer statistical package, version 9.1 (SAS Institute Inc, Cary, NC, USA), was used to analyse the data.

Oversight and Approvals

This was an investigator-initiated trial. The principal investigator responsible for the trial was TB. The FDA Investigational New Drug licence number was 75605. The clinical trial registration number was NCT00487318. Institutional review board study approval was under the auspices of The University of Oklahoma Health Sciences Center Institutional Review Board and the VA Research and Development Committee, Oklahoma City, OK.


The baseline characteristics of the statin and control groups are given in Table 1. The 44 subjects were all male veterans, ranging in age from 34 to 65 years.

Table 1Clinical and demographic profile of the patients' outcome

Statin (n = 25) Control (n = 20) P value
Age (years) 54 ± 6 54 ± 5 0.99
Race: # white 20 (80%) 15 (75%) 0.73
Weight (lbs) 215 ± 44 220 ± 35 0.68
Diabetes mellitus 4 (16%) 3 (15%) 0.99
Platelet count (×103) 213 ± 48 197 ± 46 0.25
AST (IU/L) 50 ± 31 56 ± 31 0.51
HCV RNA (IU/mL) 3721236 ± 3187349 3852940 ± 3760296 0.90
LOG HCV RNA (IU/mL) 6.3 ± 0.6 6.3 ± 0.6 0.90
LDL cholesterol (mg/dL) 95 ± 32 102 ± 28 0.46
Total cholesterol (mg/dL) 154 ± 35 156 ± 27 0.82
Outcome SVR 13 (52%) 5 (25%) 0.078

AST, aspartate aminotransferase; HCV, hepatitis C virus; LDL, low-density lipoprotein; SVR, sustained viral response.


The primary purpose of this phase 2 trial was to observe unfamiliar side effects when fluvastatin was added to peginterferon/ribavirin for 48 weeks. There were no unique side effects noted beyond the usual adverse effects with the combination of peginterferon and ribavirin. Creatine kinase levels were checked an average of 3× per patient throughout the study. Enquiry about symptoms of unexplained muscle pain was monitored for the possibility of statin-induced myopathy. No patient reported an episode of unexplained muscle pain. The highest multiple of the upper limit of normal for creatine kinase that occurred in the fluvastatin, simvastatin and control arms was 2.5, 1.4 and 1.7, respectively. Perhaps the best overall safety assessment for the study was the very low drop-out rate in any arm for any reason. None of the 25 statin group patients discontinued treatment, while only one of the 20 controls did.


Figure 1 and list the outcome of efficacy when measured with intention-to-treat. Thirteen of 25 statin patients achieved SVR, while five of 20 controls did (P = 0.078).

There were seven African American men: two in the fluvastatin arm, two in the simvastatin arm and three in the control arm. Only one African American achieved SVR while taking 80 mg/day simvastatin.



The primary purpose of the trial was to evaluate the safety issues involved when fluvastatin or simvastatin was added to peginterferon/ribavirin for 48 weeks. When we combined either fluvastatin or simvastatin prospectively with peginterferon/ribavirin in 25 patients for 48 weeks, we did not observe any unique difficulty and no patient discontinued therapy. Other groups who have combined 20 mg/day of fluvastatin with peginterferon/ribavirin in larger randomized control trials (RCTs) (noted later) also have failed to report any unique side effects or the occurrence of myopathy with the use of fluvastatin. The worldwide prospective RCT experience with 20 mg/day fluvastatin when combined with peginterferon/ribavirin and used against HCV for 48-week therapy now totals 181 patients for 8 688 weeks of drug exposure without incident. The latter fluvastatin total does not include our seven simvastatin patients or nonrandomized prospective studies of fluvastatin/peginterferon/ribavirin.[7]


When fluvastatin or simvastatin was added to peginterferon/ribavirin, 13 of 25 (52%) obtained sustained viral response (SVR), whereas in the control group using peginterferon/ribavirin, 5 of 20 (25%) reached SVR (P = 0.078). This indicates a strong trend favouring the addition of fluvastatin. We did not reach our enrolment goal of 80 patients that was based on the results of a retrospective study of patients who by chance took a statin along with peginterferon and ribavirin.[8] Thus, it is likely that an insufficient sample was accumulated. Enrolling patients became difficult when the promise of direct antiviral agents became a reality. Notably, maintaining the observed proportion of SVR in each group and artificially increasing the total sample size to 80 gave P = 0.021.

As with any RCT, a positive statistical effect favouring the intervention can be disguised by poor performance of the control group. Our current control group achieved a 25% SVR rate. This is identical to our previous retrospective report of naïve-to-treatment genotype 1 patients not on a statin of 25% (16/65).[8] The national VA database for this same classification of genotype 1 patients (n = 20 477) has been reported to have an SVR rate of 26%.[9] Thus, our control group performed the same as our own published historical group or the national VA database.

The 52% SVR rate for the statin group in the current report compares similarly to our retrospective SVR report of 55%. Throughout the time period encompassed by both the retrospective database and prospective trial, the statin used almost exclusively for hypercholesterolaemia in the VA system was simvastatin. Accordingly, 20 of 25 HCV patients in the retrospective statin report were taking simvastatin.[8]

In any case, our results serve to support the results of two other RCTs of fluvastatin published that have tested the addition of our discovered dose of 20 mg/day of fluvastatin to peginterferon/ribavirin. Georgescu et al. gave fluvastatin 20 mg/day combined with peginterferon/ribavirin in an RCT to 104 naïve-to-treatment genotype 1 patients and compared the outcome with 105 control patients. The SVR rates were 63.5% and 49.5% (P = 0.05), respectively. When the 50 patients with metabolic syndrome (as defined by National Cholesterol Education Program Adult Treatment Panel III criteria) were subtracted from each arm in a post hoc analysis, the SVR rates were 74.4% and 58.4%, respectively (P = 0.049).[10]

The second trial reported by Kondo et al.[11] also used 20 mg/day of fluvastatin with peginterferon/ribavirin in 94 naïve-to-treatment genotype 1b patients with high viral loads. The reported SVR rates in the fluvastatin and control arms were 63% and 42% (P = 0.047), respectively.

Combining all three studies (Georgescu et al., Kondo et al. and ours, total sample size = 348), the reported SVR rates in the fluvastatin and control arms were 62% and 45% (P = 0.0018).

When our trial is viewed together with the two other RCTs using fluvastatin at 20 mg/day, the evidence is growing that fluvastatin improves the SVR rate when given to naïve-to-treatment genotype 1 HCV patients.

The mechanism of statin action against hepatitis C is poorly understood. Hypothetically, if the effect is related to changes in extracellular cholesterol, one has to account for the observation that fluvastatin is the weakest LDL-lowering statin and yet it has the strongest anti-HCV effect of all the statins tested.[2] Moreover, it is at the lowest approved dose for hypercholesterolaemia, 20 mg, for which fluvastatin has the greatest anti-HCV effect.[3] In retrospective analysis, some have tried to relate outcomes of peginterferon alfa/ribavirin double therapy to the baseline serum LDL or baseline total cholesterol. In the largest post hoc analysis of statin and serum cholesterol (IDEAL trial), statin use was determined to be an independent factor from cholesterol as a predictor of response to peginterferon/ribavirin.[12] Later analysis of a smaller group from the IDEAL trial suggested that serum LDL cholesterol was strongly associated with the IL28B genotype and that it was this latter parameter that was more directly related to SVR outcome with peginterferon/ribavirin than cholesterol.[13] In our prospective work that delineated fluvastatin to have the strongest anti-HCV effect at 20 mg/day, we were unable to relate baseline LDL or changes in serum LDL to antiviral effect[3] In the current work, there were no differences between groups in regard to baseline serum LDL or total cholesterol (Table 1).

The limitations of our study include a time period before which IL28B genotypes were appreciated or commercially available. As with many VA studies, ours tested only men. Liver biopsies were not performed; however, platelet counts are a practical surrogate, and these counts did not differ between groups. Based upon our retrospective study of statins8, we planned an enrolment of 80 patients to reduce the possibility of type 2 error below the typically accepted level of 20%. With the prospective advent of protease inhibitors, it became increasingly difficult to enrol patients. Our closing study number was 45. Finally, the data reported for simvastatin are only preliminary in nature.

The relevance of the addition of fluvastatin to peginterferon/ribavirin in the era of HCV protease inhibitors may be greatest as cost-effective improvement in SVR for resource-limited areas. The current price for adding only the cost of the tablets for boceprevir or telaprevir ranges from US $28 000 to $55 000 per treated patient, respectively.[14] This does not include the cost of the peginterferon/ribavirin component or the expense of medical management. In contrast, the 20-mg capsule of fluvastatin was approved in generic form by the FDA on 13 April 2012. Prices for the generic version are not immediately available, but will likely become a US dollar per capsule as in other countries.[15] The 48-week cost of fluvastatin will then be US $336. There has not been a noninferiority head-to-head trial of fluvastatin triple therapy vs protease inhibitor triple therapy to compare SVR outcome.

Development of fluvastatin for HCV purposes has been slowed by the nonproprietary status of the drug and the persisting mythological paradigm of statin-induced hepatotoxicity.[16–19] It is relevant that the FDA recently revised all statin labels to state that monitoring of statins with liver tests is no longer recommended.[19] The 20-mg dose of fluvastatin has thus far been shown to be safe in HCV patients either alone or when added to peginterferon/ribavirin for 48 weeks.

The future of hepatitis C treatment seems to be heading towards combinations of oral antiviral agents. Given the positive results of the three randomized controlled trials reported here, further studies of fluvastatin for use against HCV as part of a multidrug regimen are needed.


  1. Ye J, Wang C, Sumpter R, Brown M, Goldstein J, Gale M. Disruption of hepatitis C virus RNA replication through inhibition of host protein geranylgeranylation. Proc Natl AcadSci U S A 2003; 100(26): 15865–15870.

  2. Ikeda M, Abe K, Yamada M, Dansako H, Naka K, Kato N. Different anti-HCV profiles of statins and their potential for combination therapy with interferon. Hepatology 2006; 44: 117–125.

  3. Bader T, Fazili J, Madhoun M et al. Fluvastatin inhibits hepatitis C replication in humans. Am J Gastroenterol 2008; 103: 1383–1389.

  4. Pawlotsky J-M, Dahari H, Neumann AU et al. Antiviral action of ribavirin in chronic hepatitis C. Gastroenterology 2004; 126(3): 703–714.

  5. Bader T. Rosuvastatin compared to fluvastatin, simvastatin, and ribavirin for anti-HCV activity in vitro. JHepatol 2010; 52(suppl): S289.

  6. Madhoun MF, Bader T. Statins improve ALT values in chronic hepatitis C patients with abnormal values. Dig Dis Sci 2010; 55(3): 870–871.

  7. Sezaki H, Suzuki F, Akuta N et al. An open pilot study exploring the efficacy of fluvastatin, pegylated interferon and ribavirin in patients with hepatitis C virus genotype 1b in high viral loads. Intervirology 2009; 52(1): 43–48.

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Brain Damage Caused by Drinking Alcohol Could Be Reversed by Aerobic Exercise

Dr. Douglas Fields

Neurobiologist and author, 'The Other Brain'

Posted: 09/04/2013 2:28 pm

There is no doubt that alcohol abuse causes brain damage and several other health problems, including cancer and liver disease. Some of the brain injury associated with alcohol abuse can be seen on a brain scan (MRI) as physical changes in brain structure and loss of brain tissue in wide-spread regions throughout the brain.

One of the most prominent changes associated with alcohol consumption involves the massive bundles of nerve fibers that interconnect neurons in different regions of the brain into functional circuits. These fibers are coated with a white-colored electrical insulation, called myelin, which is essential for transmission of electrical signals. These tracts of white matter streaking through the brain are the brain's information highways, and damage to them will impair any cognitive function that depends on information transmission through the communication cables. Loss of memory, slowed thinking, impaired problem solving and decision making are especially vulnerable to damage caused by alcohol consumption, because it disrupts white matter connections to the cerebral cortex and deep brain structures necessary for these mental functions.

Remarkably, a large body of new research has revealed that aerobic exercise not only builds muscle, it builds brain tissue. Aerobic exercise stimulates the birth of new neurons in specific parts of the brain where neurons can still divide in adults, including the hippocampus, which is involved in learning. Exercise protects against cognitive decline in aging and neurological diseases, including Alzheimer's, and it strengthens the integrity of white matter tracts to the extent that the beneficial changes can be seen on an MRI.

These recent discoveries motivated researchers Hollis Karoly and colleagues at the University of Colorado to ask whether aerobic exercise could prevent the damaging effects of heavy alcohol consumption on white matter in the human brain. Identifying any new treatment that could reverse brain damage caused by alcohol consumption would have profound health benefits for tens of thousands of individuals who consume alcohol. According to this new study, there is an effective treatment that requires no medication and has no negative side effects -- aerobic exercise.

To answer this intriguing hypothesis, the researchers compared the level of alcohol consumption in a population of men and women between the ages of 21-55 with the integrity of their white matter. This was accomplished by using an MRI brain imaging method that is highly sensitive to white matter integrity, called diffusion tensor imaging (DTI). Three conclusions were supported by the data, two of them confirming what was already shown in the literature, and the new finding reported here.

(1) White matter tracts in the brain are strongly affected by alcohol consumption. This was seen throughout the brain, but it was especially pronounced in some fiber tracts known to be necessary for higher level thinking and memory and other functions impaired in those who abuse alcohol. For example, the external capsule (EC) and superior longitudinal fasciculus (SLF) were especially sensitive to damage caused by drinking alcohol. When white matter integrity is graphed against the total number of alcoholic drinks consumed in 60 days (or other measures of alcohol consumption), white matter integrity drops in direct proportion to the amount of alcohol consumed.

(2) Conversely, white matter integrity increased in people who reported doing aerobic exercise in the last three months, and greater improvements were seen in those who did more than the average amount of exercise.

Both of these effects confirm and extend the result of other studies. The third result was that in people who exercised, the loss of white matter integrity caused by alcohol consumption was prevented or reduced, depending on how much exercise was done and which particular white matter tract in the brain is examined.

For example, in people who reported doing a moderate amount of aerobic exercise in the last three months (that is, the average amount of aerobic exercise among all participants), the integrity of the EC white matter tract was maintained even for the heaviest drinkers. Even better results in preserving white matter integrity were seen in subjects reporting an above average level of aerobic exercise. The steep, straight-line drop in white matter integrity plotted against the amount of alcohol consumption, leveled out completely in those participating in high levels of aerobic exercise; that is, no deleterious effects of alcohol consumption at any level of consumption could be seen in the white matter tracts of these people. Again, the magnitude of the effects differed somewhat in different white matter tracts, but in general the beneficial effects of exercise were evident throughout many white matter tracts in the brain.

The study also sorted the data according to self-reporting of cannabis use and tobacco smoking, because both of these have been implicated in white matter damage. Even accounting for these other effects on white matter structure, the beneficial effects of aerobic exercise on white matter integrity were still seen. The researchers conclude that the most damaging effects of alcohol consumption on white matter integrity are seen in those people who do not exercise regularly, "alcohol consumption did not appear to be associated with white matter damage among individuals who exercised regularly."

The design of this experiment can only provide correlative data. The associations revealed here must be tested in further experiments to show that there is a causal link between exercise and protection against white matter damage caused by drinking alcohol, and to uncover the biological mechanisms for the protection. However, these findings revealing the protective effects of aerobic exercise on preventing white matter brain damage in drinkers are compelling and valuable, regardless of whatever biological link to explain this correlation may be found in the future.


All of the facts stated in this article are documented by citations to the scientific literature in the following paper reporting these new results:

Karoly, H.C., et al., (2013, in press) Aerobic exercise moderates the effect of heavy alcohol consumption on white matter damage. Alcoholism: Clinical and Experimental Research. Published on-line in advance of print.

For additional information on white matter see:

Fields, R.D. (2008) White Matter Matters, Scientific American, 298: 42-9.

Fields, R.D. (2008) White matter in learning, cognition and psychiatric disorders. Trends Neurosci. 31: 361-70.