Combination nucleos(t)ide analogue as initial treatment for chronic hepatitis B: Have we put this to rest?

C ombination nucleos(t)ide analogs (NUCs) had been advocated as the initial treatment of chronic hepatitis B when lamivudine and adefovir dipivoxil (ADV) were the only approved NUCs for hepatitis B. These drugs had weak antiviral activity and/or low barrier to resistance with rates of genotypic resistance of 70% and 29%, respectively, after 5 years of continuous treatment. Borrowing from lessons learned in development of treatment for human immunodeficiency virus infection, virologists warned that a combination of NUCs with no cross-resistance would be necessary to maintain long-term suppression of hepatitis B virus (HBV) replication. In the past 7 years, three additional NUCs have been approved for hepatitis B. Of these, entecavir (ETV) and tenofovir disoproxil fumarate (TDF) have been shown to have a very high barrier to resistance. Phase III clinical trials found that the incidence of genotypic resistance was 1.2% and 0% after 5 years of ETV and TDF monotherapy in NUC-naı̈ve patients, respectively. Among hepatitis B e antigen (HBeAg)positive patients, 94% of ETV-treated patients had HBV DNA <300 copies/mL and 97% of TDFtreated patients had HBV DNA <400 copies/mL at Year 5. Although the design of both trials left room for doubt, these data showed that monotherapy with ETV or TDF can maintain viral suppression in the vast majority of patients with chronic hepatitis B for at least 5 years. In the phase III ETV trial, only 183 of 354 patients were enrolled in the roll-over study, some patients had a short gap in treatment between Years 2 and 3, a small number of patients received a combination of lamivudine and ETV for a short duration, and all patients received a higher dose of ETV (1.0 mg) from Year 3 onward. Nevertheless, other studies in which ETV 0.5 mg was administered continuously confirmed that >90% of patients had undetectable HBV DNA and 0%-1% had genotypic resistance after 3-4 years of treatment (Fig. 1). In the phase III TDF trial, patients with confirmed HBV DNA 400 copies/mL on or after Week 72 were eligible to add emtricitabine (FTC) to TDF and 34 of 51 eligible patients did so. A multicenter field study of TDF monotherapy in Italy confirmed that HBV DNA was undetectable in 95% HBeAg-positive and in 98% HBeAg-negative patients at Year 3 in the absence of FTC rescue. These additional studies support the optimism that monotherapy with ETV or TDF would be sufficient for the vast majority of NUC-naı̈ve patients with chronic hepatitis B. A lingering question is whether this optimism can be applied to patients with high baseline viral load. In this issue of Hepatology, Gordon et al. reported the results of a subgroup analysis of the phase III TDF trial. Eligible patients (HBeAg-positive and HBeAg-negative) were randomized to receive TDF 300 mg daily or ADV 10 mg daily for 48 weeks and then open-label TDF for an additional 192 weeks. Of 641 patients enrolled in the trial, 129 (118 HBeAg-positive) had high baseline viral load (HVL) defined as HBV DNA 9 log10 copies/mL (8.24 log10 IU/mL). At Week 240 ( Year 5), 96.1% of HVL and 98.7% of non-HVL patients on treatment achieved HBV DNA <400 copies/ mL. Both groups had similar rates of histologic regression between baseline and Week 240. Patients with HVL generally took longer to achieve HBV DNA <400 copies/ mL but had caught up with the non-HVL patients by Week 96. The authors stated that no patient with baseline HVL had persistent viremia at Week 240 or amino acid substitutions associated with TDF resistance. These results are remarkable and suggest that monotherapy with a potent NUC that has a high barrier to Abbreviations: ADV, adefovir dipivoxil; ETV, entecavir; FTC, emtricitabine; HBeAg, hepatitis B e antigen; HBV, hepatitis B virus; HVL, high baseline viral load; NUCs, nucleos(t)ide analogs; TDF, tenofovir disoproxil fumarate. Address reprint requests to: Anna S.F. Lok, M.D., Division of Gastroenterology and Hepatology, University of Michigan Health System, 1500 East Medical Center Dr., 3912 Taubman Center, SPC 5362, Ann Arbor, MI 48109. E-mail: aslok@umich.edu; fax: 734-936-7392. Copyright VC 2013 by the American Association for the Study of Liver Diseases. View this article online at wileyonlinelibrary.com. DOI 10.1002/hep.26337 Potential conflict of interest: Research grants: Bristol-Myers Squibb, Gilead, Merck. Advisory panel: Gilead, GlaxoSmithKline, Novartis, Merck, Roche.