Sequential therapy with entecavir and PEG-INF in patients affected by chronic hepatitis B and high levels of HBV-DNA with non-D genotypes L. Boglione*, A. D’Avolio*, G. Cariti, M. G. Milia, M. Simiele, A. De Nicolo `, V. Ghisetti and G. Di Perri Department of Infectious Diseases, Amedeo di Savoia Hospital, University of Turin, Turin, Italy Received July 2012; accepted for publication August 2012 SUMMARY. Complete eradication of hepatitis B virus (HBV) is rarely achieved. Treatment options include currently available nucleos(t)ide analogues and pegylated interferon. The aim of our exploratory study was to assess the effec- tiveness of sequential therapy for chronic hepatitis B (CHB) vs the current standard of care. We evaluated an associa- tion with entecavir and pegylated interferon alfa-2a (PEG- IFN) in 20 patients with hepatitis B, high HBV viremia and genotypes A, B, C and E. Patients received entecavir alone for 12 weeks, then entecavir and PEG-IFN for 12 weeks, lastly PEG-IFN alone for 36 weeks. The results were compared with 20 patients (control group) treated in the past with 48 weeks of PEG-IFN monotherapy. Our results show that complete sustained virological response (SVR) and partial SVR were, respectively, 60% and 80% in the study group and 10% and 30% in the control group; anti-HBe seroconversion rate were 76.9% vs 15%, and anti-HBs seroconversion were 20% vs 0%, respectively. We found a correlation among different genotypes and virolog- ical and serological outcomes – genotype C has a better virological response, while genotype A had a better sero- logical response, and E genotype had a poor response. These results show that a sequential approach is a promis- ing strategy of treatment in patients with CHB and high viremia in comparison with PEG-IFN monotherapy. The E genotype seems to have the worse rate of response and requires other treatment strategies. Keywords: entecavir, genotypes, hepatitis B virus, PEG- Interferon, sequential therapy. INTRODUCTION Hepatitis B virus (HBV) infection globally affects around 350 million people and is a leading cause of end-stage liver disease, hepatocellular carcinoma and mortality. Pro- gression of HBV-related liver disease to cirrhosis, hepatic decompensation and hepatocellular carcinoma is estimated to result in 0.5–1.2 million annual deaths [1]. The complete eradication of HBV is rarely achieved due to persistence of covalently closed circular DNA (cccDNA) in host hepatocytes [2], and the main goal of therapy is to prevent the development of cirrhosis, liver failure and hepatocellular carcinoma [3]. The most widely endpoints for assessing treatment response include HBV-DNA sup- pression (virological outcome), hepatitis B e antigen (HBeAg) loss with or without seroconversion, HBsAg loss with or without seroconversion (serological outcome), ala- nine aminotransferase (ALT) normalization (biochemical outcome) and improvement of liver histology (histological outcome) [4]. Treatment options include currently available nucleos(t) ide analogues (NA) with inhibition of the reverse transcrip- tion of the pregenomic RNA and direct antiviral effect, but without action on cccDNA and consequently on HBV erad- ication. The immunomodulatory agent interferon-alfa was the first drug used in the treatment of chronic hepatitis B (CHB), and its effect is the stimulation of T-cell cytotoxic for lysis of infected hepatocytes and the production of cyto- kines for control of viral replication [5]. Recent studies showed a relationship among interferon immunomodula- tory action, turnover of infected hepatocytes and cccDNA clearance [6]. Both treatment strategies have different advantages and side effects [7]. The main baseline predictors of response to Abbreviations: ALT, alanine aminotransferase; anti-HBe, antibody to hepatitis B e antigen; anti-HBs, antibody to hepatitis B surface anti- gen; cccDNA, closed circular DNA; CHB, chronic hepatitis B; cSVR, complete SVR; ETV, entecavir; HBeAg, hepatitis B e antigen; HbsAg, hepatitis B surface antigen; HBV, Hepatitis B virus; IFN, interferon; IQR, inter-quartile range; NA, nucleos(t)ide analogues; PEG-INF, pegylated interferon; pSVR, partial SVR; qHBsAg, quantitative hepa- titis B surface antigen; SVR, sustained virological response. Correspondence: Antonio D’Avolio, BSc, MSc, SM, Department of Infectious Diseases, Amedeo di Savoia Hospital, University of Turin, Turin, Italy. E-mail: antonio.davolio@unito.it *Both authors contributed equally to this work. © 2013 Blackwell Publishing Ltd Journal of Viral Hepatitis, 2013, 20, e11–e19 doi:10.1111/jvh.12018