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To the Editor:

We read with great interest and enthusiasm the updated American Association for the Study of Liver Diseases practice guidelines, “Diagnosis, Management, and Treatment of Hepatitis C” by Strader et al., who comprehensively reviewed the current status and pointed out areas requiring more studies.1 Unfortunately, a group of hepatitis C patients— those with hepatitis B virus (HBV) coinfection—were not addressed at all. In most countries, hepatitis C patients usually have only one hepatotropic virus infection. However, in areas where HBV infection is endemic, such as Southeast Asia, Far East and southern Europe, the number of subjects infected with both hepatitis C and B is substantial.2, 3 More specifically, antibody to hepatitis C virus (anti-HCV) was present in 7% to 11% of patients with HBV-related chronic liver diseases.2, 3 If the prevalence of anti-HCV positivity is around 1% to 2% in the general population, then the number of HCV/HBV coinfection worldwide will be around 3 million to 7 million among the 350 million HBV carriers. Moreover, the HCV- and HBV-coinfected patients have been shown to carry a significantly higher risk of developing cirrhosis or hepatocellular carcinoma than those with HCV or HBV infection alone.4–6 Therefore, patients dually infected with hepatitis C and B need more attention from the medical profession, and they should be urgently treated with effective regimens. At present, unfortunately, hepatitis C and B coinfected patients are frequently neglected.

Nevertheless, some regimens have been used to treat dual chronic hepatitis C and B. A recent study reported that standard interferon 9 million units thrice weekly for 6 months could clear HCV in 31% of these patients.7 We have treated hepatitis C and B dually infected patients in a pilot study by using standard interferon in combination with ribavirin for 6 months.8 We found that a sustained HCV clearance rate in hepatitis C and B dually infected patients could be achieved to an extent comparable to that in hepatitis C alone. After a follow-up of 2 years, HCV RNA remained undetectable in 89% of patients, with sustained clearance of serum HCV RNA 6 months posttreatment. To our surprise, 21% of these patients lose serum hepatitis B surface antigen. We anticipate that the efficacy may be enhanced by pegylated interferon, and therefore we propose using pegylated interferon plus ribavirin to treat the dually infected patients. Accordingly, a multicenter clinical trial is being undertaken at present in Taiwan, and we hope our results can culminate in a better treatment for hepatitis C patients coinfected with HBV.

References

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  • 1
    Strader DB, Wright T, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C. HEPATOLOGY 2004; 39: 11471171.
  • 2
    Chen DS, Kuo GC, Sung JL, Lai MY, Sheu JC, Chen PJ, et al. Hepatitis C virus infection in an area hyperendemic for hepatitis B and chronic liver disease: the Taiwan experience. J Infect Dis 1990; 162: 817822.
  • 3
    Gaeta GB, Stornaiuolo G, Precone DF, Lobello S, Chiaramonte M, Stroffolini T, et al. Epidemiological and clinical burden of chronic hepatitis B virus/hepatitis C virus infection. A multicenter Italian study. J Hepatol 2003; 39: 10361041.
  • 4
    Yang HI, Lu SN, Liaw YF, You SL, Sun CA, Wang LY, et al. Hepatitis B e antigen and the risk of hepatocellular carcinoma. N Engl J Med 2002; 347: 168174.
  • 5
    Sun CA, Wu DM, Lin CC, Lu SN, You SL, Wang LY, et al. Incidence and cofactors of hepatitis C virus-related hepatocellular carcinoma: a prospective study of 12,008 men in Taiwan. Am J Epidemiol 2003; 157: 674682.
  • 6
    Liaw YF, Chen YC, Sheen IS, Chien RN, Yeh CT, Chu CM. Impact of acute hepatitis C virus superinfection in patients with chronic hepatitis B virus infection. Gastroenterology 2004; 126: 10241029.
  • 7
    Villa E, Grottola A, Buttafoco P, Colantoni A, Bagni A, Ferretti I, et al. High doses of α-interferon are required in chronic hepatitis due to coinfection with hepatitis B virus and hepatitis C virus: long-term results of a prospective randomized trial. Am J Gastroenterol 2001; 96: 29732977.
  • 8
    Liu CJ, Chen PJ, Lai MY, Kao JH, Jeng YM, Chen DS. Ribavirin and interferon is effective for hepatitis C virus clearance in hepatitis B and C dually infected patients. HEPATOLOGY 2003; 37: 568576.

Chun-Jen Liu*, Pei-Jer Chen* † ‡, Ding-Shinn Chen* † ‡, * Division of Gastroenterology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University, College of Medicine Taipei, Taiwan, † Graduate Institute of Clinical Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, ‡ Hepatitis Research Center, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.