PEGylated interferon alfa‐2b and ribavirin treatment in patients with hepatitis C virus–related systemic vasculitis

Abstract

Objective. Type II mixed cryoglobulinemia (MC) is a systemic vasculitis usually associated with hepatitis C virus (HCV), which may involve the skin, kidneys, and nervous system. Molecular evidence of antigen-driven B cell proliferation is definitively provided in HCVassociated type II MC, and HCV appears to be the key trigger. The present trial was established to investigate the efficacy of therapy with PEGylated interferon alfa-2b (PEG-IFN alfa-2b) plus ribavirin in patients with HCV-related MC vasculitis.Methods. Nine consecutive patients with HCVrelated MC received PEG-IFN alfa-2b (1.5 g/kg/week) subcutaneously plus oral ribavirin (800-1,200 mg/day) for at least 6 months. The response to treatment was analyzed by comparing clinical, immunologic, and virologic parameters at the initial evaluation with those observed during followup.Results. The mean ؎ SD duration of therapy with PEG-IFN alfa-2b plus ribavirin was 13.5 ؎ 2.8 months. After a mean period of 18.6 months following discontinuation of treatment, all 9 patients are alive. Seven patients (78%) had a sustained virologic response and were complete clinical responders. Serum cryoglobulin disappeared in 5 of 9 patients (56%), and complement levels normalized in 80% of the patients. One patient had a partial virologic response with a complete clinical response. In another patient, a clinical relapse of MC vasculitis occurred in association with the reappearance of HCV RNA. Treatment was well tolerated, and no patient had side effects for which discontinuation of therapy was required.Conclusion. Treatment with PEG-IFN alfa-2b plus ribavirin can achieve a complete clinical response in most patients with HCV-related MC vasculitis. Complete clinical response correlates with the eradication of HCV and requires a shorter treatment period than that previously reported for IFN␣ plus ribavirin.Mixed cryoglobulinemia (MC) is a systemic vasculitis characterized by the proliferation of B cell clones producing pathogenic IgM with rheumatoid factor (RF) activity (1). MC leads to clinical manifestations ranging from the MC syndrome (purpura, arthralgia, asthenia) to more serious lesions with neurologic and renal involvement (2). Hepatitis C virus (HCV) infection is associated with most cases of MC. Sixty to 80% of patients with MC are HCV infected (2). The primary role of HCV in the mechanism of cryoprecipitation is mainly suggested by its selective concentration in cryoglobulins (3).Limited data are available regarding the treatment of patients with HCV-related systemic vasculitis. Interferon-␣ (IFN␣) monotherapy is associated with a relatively poor response and a high relapse rate, especially in severe cases (4-7). Clinical improvement of HCV-related vasculitis correlates with virologic response, i.e., negative or significant decrease in the serum HCV RNA level. Combination therapy with IFN␣ plus ribavirin seems to provide much better short-and longterm results (8,9). In comparison with IFN␣ plus ribavirin, other treatment strategies (i.e., corticosteroids or cytotoxic ...

Hepatotropic Viral Infection Associated Systemic Vasculitides—Hepatitis B Virus Associated Polyarteritis Nodosa and Hepatitis C Virus Associated Cryoglobulinemic Vasculitis

“…59 Severe life threatening manifestations like acute nephritic or nephrotic syndrome, severe skin ulcers, or other major systemic involvement requires aggressive treatment with immunotherapy. In these patients also, anti HCV therapy is either given simultaneously or sequentially, and is an important part of therapeutic strategy.…”

Extrahepatic replication of HCV: Insights into clinical manifestations and biological consequences

“…Cutaneous vasculitis is the MC manifestation that responds best to antiviral therapy with pegylated interferon (PEG-IFN) and ribavirin (RBV). 8,9 …”

“…Nonetheless, few studies have examined the temporal relationship between HCV RNA levels in extrahepatic compartments and the development of specific extrahepatic complications, although successful treatment of HCV is frequently associated with resolution of several extrahepatic complications of HCV infection. 8,9,13,16,26 The proposed pathogenic processes by which HCV may result in the extrahepatic manifestations described above have been described in detail elsewhere. [4][5][6]107 Importantly, multiple immunologic, virologic, and environmental factors are likely involved.…”

Cryoglobulinemia (Review)

“…A suitable treatment regimen usually depends on renal function. A combination of interferon α, pegylated interferon and ribavirin is recommended (56)(57)(58)(59). Therapy recommended by the European League Against Rheumatism for patients presenting with normal renal function consists of a combination of pegylated interferon and ribavirin; however, for patients with renal insufficiency, monotherapy with interferon α is indicated since ribavirin is generally contraindicated in renal insuffiency (60).…”