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Thalidomide in the Treatment of Chronic Hepatitis C Unresponsive to Alfa-Interferon and Ribavirin
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(Am J Gastroenterol Feb 2006;101:399-402)
Case Reports
Laura Milazzo, M.D.1, Mara Biasin, Ph.D.2, Nadia Gatti, M.D.1, Luca Piacentini, Ph.D.2, Fosca Niero, M.D.3, Barbara Zanone Poma, Ph.D.1, Massimo Galli, M.D.1, Mauro Moroni, M.D.1, Mario Clerici, M.D.2, and Agostino Riva, M.D.1
Immunomodulation of thalidomide is represented by the antiinflammatory effect through inhibition of tumor necrosis factor a and costimulatory effect on human CD8+ T cells. We investigated the efficacy and safety of a 24-wk course of thalidomide at a dosage of 200 mg/day in eight patients with HCV chronic hepatitis nonresponders to interferon a plus ribavirin. We observed a significant mean decrease of serum aminotransferases and τ-glutamyltransferases of 39% and 61%, respectively (p= 0.017 and 0.02). Tumor necrosis factor-ain vitro production in mononuclear cells decreased with thalidomide in all the subjects (p= 0.028). Perforin- and granzyme-specific mRNA expression increased under thalidomide without statistical significance. A positive correlation between biochemical and immunological parameters was observed with higher increase of granzyme and perforin values in patients showing reduction of aminotransferases. Finally upregulation of T-helper 1 cytokine expression as mean interferon τ/IL-10 ratio was evidenced. Thalidomide was well tolerated. In conclusion, thalidomide was able to reduce liver enzymes in six out of eight patients with chronic hepatitis C and to reduce tumor necrosis factor a production, representing a promising new approach for the treatment of HCV infection.
INTRODUCTION
The immunopathogenesis of liver damage in chronic hepatitis C is due to cytolytic and noncytolytic mechanisms mediated by cytotoxic T lymphocytes (CTL) and inflammatory cytokines (1, 2). Thalidomide exerts antiinflammatory activity primarily by the inhibition of tumor necrosis factor (TNF)-a; a potent costimulatory effect of thalidomide on human CD8+ T cells in vitro has been also described (3, 4). Its immunomodulating effects include increased production of IL-12, IL-2, and IFN-τ (5, 6).
We evaluated the safety and the effects of thalidomide in the treatment of eight subjects with HCV chronic hepatitis.
PATIENTS AND METHODS
Eight HCV-infected patients with active chronic hepatitis, nonresponders or relapsers to a previous treatment with IFN-a and ribavirin, were treated with thalidomide at a daily dose of 200 mg for 24 wk. They had no HBV or HIV coinfection and had stopped IFN and ribavirin at least 6 months before enrollment.
A liver biopsy was performed within 3 months of enrollment; serum liver enzymes were monitored monthly during the study period and serum quantitative HCV-RNA was measured every 3 months. The study was approved by our Institutional Ethical Committee, a written informed consent was obtained from all the patients.
Evaluation of mRNA Specific for Cytolytic Molecules and Cytokines
Total RNA was extracted from peripheral blood mononuclear cells (PBMC) and was reverse transcribed. Perforin, granzyme, IL-10, and IFN-τ were evaluated by RealTime PCR, were expressed as ∇∇Ct and presented as ratios between the target gene mRNA and the GAPDH housekeeping mRNA.
TNF-a Production
PBMC were cultured with PMA at a concentration of 1 ng/mL and ionomycin at a concentration of 500 ng/mL for 48 h. TNF-a was measured by enzyme-linked immunosorbent assay (ELISA, Amersham Biosciences, UK).
Statistical Analysis
Continuous data were analyzed by the Student's t-test and by Wilcoxon nonparametric test.
RESULTS
The characteristics of the patients are shown in Table 1. High prevalence of HCV genotype 1 (75%) and high degree of fibrosis were detected (mean ± standard deviation (SD) Knodell activity score: 6.2 ± 2.4; mean ± SD Knodell fibrosis score: 4.4 ± 1.5). The mean ± SD ALT level before thalidomide was 164.9 ± 66 IU/L.
Thalidomide was generally well tolerated; the majority of the patients referred constipation and drowsiness and one patient (No. 2) developed mild peripheral neuropathy.
We observed a mean decrease of serum ALT of 39% at wk 24 compared to pretreatment levels (from mean value ± SD of 164.9 ± 66 IU/L to 100.6 ± 25 IU/L, p= 0.017 95% CI: 19.1-109.3; Fig. 1A). Gamma-glutamyl-tranferases (GGT) showed a mean decrease of 61% (from mean value ± SD of 127.6 ± 87 IU/L to 49 ± 28 IU/L, p= 0.02; 95% CI: 14.8-128.1 Fig. 1B). Six of the eight patients showed a decrease of serum transaminases, the remaining two did not show significant change of liver enzymes. It is noteworthy that after interruption of thalidomide the mean values of ALT and τGT returned close to pretreatment levels (Fig. 2).
No significant change of serum HCV-RNA was observed.
No detectable histologic modification for both necroinflammatory and fibrosis scores was evidenced in the four patients who accepted to undergo liver biopsy at the end of treatment.
Immunological Results
Granzyme- and perforin-specific mRNA levels increased after 24 wk of thalidomide without reaching statistical significance (Fig. 3A and B). A higher increase of granzyme and perforin values were observed in patients with reduction of ALT: from 3,952 N fold to 6,889 N fold (p= 0.028, 95% CI: 691-5176) and from 1,920 N fold to 2,405 N fold (p= 0.46), respectively, while no increase was observed in subjects without biochemical response. Moreover, therapy resulted in an upregulation of Th1 cytokine expression as mean ± SD IFN-τ/IL-10 ratio changed from 8.1 ± 5 to 13.0 ± 14.7 (p= 0.43; Fig. 3C).
Finally in vitro TNF-a production decreased from a mean ± SD value of 3,530 ± 2,224 pg/mL to 2,397 ± 1,905 pg/mL at wk 24 of treatment. (p= 0.028, 95% CI: 170.3-2094.2; Fig. 3D).
DISCUSSION
To our knowledge this is the first study to employ thalidomide in the treatment of hepatitis C. We observed a significant decrease of ALT and τGT levels during a 24-wk course of treatment. No effect on HCV viremia and no histological improvement were observed.
At the dosage of 200 mg/day thalidomide was well tolerated and no rise of aminotransferases was seen after starting the drug, as previously reported in one patient (7).
Interestingly the most significant decrease of ALT was observed in patients with higher pretreatment levels. These data could be explained by the antiinflammatory activity on nonspecific immune activation responsible of liver damage and possibly by the costimulatory effect that thalidomide determines on activated CTL immune response (3, 4, 8).
We found an increased IFN-τ/IL-10 mRNA ratio with thalidomide administration, suggesting a cytokine shift from Th2 to Th1, although the limited number of patients and the high individual variability do not allow a conclusive interpretation.
A recent study has shown that etanercept, an anti-TNF agent, used as an adjuvant to interferon and ribavirin therapy seems to enhance viral clearance in chronic hepatitis C (9). Several studies have demonstrated the anti-TNF activity of thalidomide in vitro and in vivo and we accordingly detected a reduced TNF-a production by stimulated PBMC in vitro. Moreover thalidomide was reported to accelerate the recovery from experimental cirrhosis in rats, probably mediated by TNF-a suppression in the liver (10). We did not find histologic improvement in the four follow-up liver specimens, but longer follow-up might be necessary to determine a late beneficial effect.
Thalidomide due to its immunomodulatory characteristics might represent a new pharmacologic approach to chronic HCV infection. Future investigations might focus on the association of thalidomide with IFN or possibly with IFN and ribavirin to evaluate the potential improvement of the current therapeutic regimens.
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