MXPA98007284A - Combination therapy to eradicate vhc-rna detectable in patients who have infection of hepatitis c cron - Google Patents

Abstract

The present invention relates to the use of ribavirin, interferon alpha, or a combination of ribavirin and interferon alpha, for the manufacture of a pharmaceutical composition for the treatment of a patient having chronic hepatitis C infection to eradicate detectable HCV-RNA by a method that consists of: administering an effective amount of ribavirin in association with an effective amount of interferon alfa, wherein the patient is one who has failed in his response to a previous course of therapy with interferon alfa. The compositions can be used in a method for the treatment of a patient suffering from chronic hepatitis C infection, to eradicate detectable HCV RNA, which includes a combination therapy using a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alpha. for a period from 20 to 80 weekly

Description

COMBINATION THERAPY TO ERADICATE VHC-RNA DETECTABLE IN PATIENTS WHO HAVE CHRONIC HEPATITIS C INFECTION Chronic infection with the hepatitis C virus is an insidious and slowly progressing disease, which has a significant impact on the quality of life. This can eventually lead to liver cirrhosis, decompensated liver disease or liver failure and / or hepatocellular carcinoma. To treat chronic hepatitis C infection, monotherapy with interferon alfa is commonly used. However, this treatment is not always effective and sometimes gives rise to intolerable side effects related to the dosage and duration of therapy. As a monotherapy treatment for chronic hepatitis C infection, Ribavirin has been proposed (Thomas et al AASLD Abstracts, Hepatology Vol. 20, NO-4, Pt2, Number 440, 1994). However, this monotherapy treatment by common 1Q has been found to be relatively ineffective and has its own undesirable side effects. The combination therapy of interferon alfa and ribavirin has been proposed (Lai, et al., Symposium to the 9th Biennial Scientific Meeting, Asian Pacific Association for the Study of the Liver, 1994). Preliminary results suggest that combination therapy may be more effective than any monotherapy.

Hayden FG, Shclepushikin AN, Combined interferon 2a, ri antadine hydroa loride, and ribavirin inhibition of influenza virus replication in vi tro. Anti icrob Agntes C emother. 1984; 25: 53-57. Schvarcz R, Ando Y, S xnnerbrg A, Weiland 0. With Combination treatment interferon alfa-2b and ribavirin for chronic hepatitis C in Patients Who Have Failed to Achieve sustained response to interferon alone: Swedish experience. J Hepatology. 1995; 232 (Suppl 2): 17-21. Brouwer JT,? Evens F, Michielsen P, et al. What options are left when hepatitis C does not respond to interferon? Placebo-controlled Benelux multicentre retreatment trial on ribavirin ontherapy versus combination with inteferon. J Hepatol. 1994/212 (Suppl 1): S17. Abstract WP2 / 08. Che L, Cavalletto L, Bernardinello E. et al. Response to ribavirin, to interferon and to a combination of both in patients with chronic hepatitis C and its relation to HCV genotypes. J Hepatol. 1994/212 (Suppl 1): S12. Abstract GS5 / 29. However, none have described the methods to use interferon alfa and Ribavirin, which eradicate HCV-AR? in any effective long-term way. Is there a definite need for a method for the treatment of chronic hepatitis C infection with a combination of interferon alpha and ribavirin that eradicates HCV-AR? in any effective long-term way.

SUMMARY OF THE INVENTION According to one aspect of the invention, there is provided the use of ribavirin for the manufacture of a pharmaceutical composition for treating a patient suffering from chronic hepatitis C infection to eradicate the HCV-? RN detects blc, administering an effective amount of ribavirin in association with an effective amount of interferon alfa, where the patient has not responded to a previous course of therapy with interferon alfa. According to another aspect of the invention, the use of interferon alfa for the manufacture of a pharmaceutical composition is provided to treat a patient with chronic hepatitis C infection to eradicate v, -. »- * < ---_. detectable by a method that consists of administering an effective amount of interferon alfa in association with a fnnH fi.ií. r > f: .t't ". rn? ^ r. K .v. r. rs.T. r¡ HGÍG. _ - _" > -O ... r i f > ri. "\ Q has submitted a response to a previous therapy course with intt * -e" > rti'-r-o "> r.-e '-_ rn! .a-_l1f f: a. ribavirin and alpha interferon for the manufacture of pharmaceutical compositions for treating a patient infected with chronic hepatitis C to eradicate HCV-? detcctable RN by a method comprising administering .Ifa, wherein the patient who presented no zi answer t "re >The pharmaceutical compositions are of specific utility for the treatment of a patient with chronic hepatitis C infection to eradicate the HCV-β-RNctcctablc, which consists of administering a therapeutically effective amount of ribavirin and a therapeutically effective amount thereof. effective of interferon alfa for a period of 20 to 30 approximately 30% of patients do not have HCV-RNA? l term of the period of 20 to 30 weeks, as well as no HCV-? detectable RN for at least 24 weeks after the term of administration. Preferably, at least about 40% of the patients do not have detectable VKC-RN at the end of the period of 20 to 30 weeks, as well as no VKC-RN that is detectable for at least 24 weeks after the end of administration. These may be used to treat a patient suffering from chronic hepatitis C infection to eradicate the detectable VKC-? RN, which comprises administering a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alpha, over a period of time. from 40 to 50 weeks, from .TTII 11 _Tt approximately? D. present HCV-2RN dctcctablc l term of 40 to 50 weeks, as well as no HCV-? RN detectable for at least 24 weeks after the end of administration. Preferably, that at least about 50? of the patients do not present HCV-? RN detectable at the end of the period of 40 to 50 weeks, as well as no HCV-? R? Deceptible for at least 24 weeks after the end of In another modality, these can be used to treat a patient who presents chronic hepatitis C infection to eradicate HCV-AR? detectable, which consists in the administration of a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alfa for a period of 60 to 80 weeks, so that at least about 50- of the patients do not present HCV-R? dctectablc at the end of the period of 60 to 80 weeks, as well as no VHC-? R? detected at least 24 weeks after the end of administration. Preferably, that at least approximately 60% of patients do not have HCV-? R? Detect at the end of the period of 60 to 80 weeks, as well as no VHC-? R? dctcctable for at least 24 weeks after the end of In another modality, these can be used for the treatment of a patient who has chronic hepatitis C infection with HCV genotype different from type 1 and who has a viral load less than or equal to 2 million of copies per ml of serum measured by quantitative HCV-RNA PCR to eradicate detectable HCV-RNA, which consists of administering a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alpha over a period of 20 to 30 weeks, , so that at least about 60o, and preferably, at least about 70% of the patients do not have detectable HCV-RNA at the end of the period of 20 to 30 weeks as well as no detectable HCV-RNA for at least 24 weeks after the term of administration. Preferably, at least about 80% of the patients do not have detectable HCV-RNA at the end of the period of 20 to 30 weeks, as well as no detectable HCV-RNA for at least 24 weeks after the end of administration. In another modality, these can be used for the treatment of a patient who presents chronic hepatitis C infection with HCV genotype different from type 1 and who has a viral load greater than 2 million copies, measured by the HCV-RNA / qPCR for eradicate detectable HCV-RNA, which consists of administering a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alpha for a period of 20 to 30 weeks, such that at least about 50%, do not exhibit detectable HCV-RNA at term period of 20 to 30 weeks, as well as no detectable HCV-RNA for at least 24 weeks after the end of administration. Preferably, at least about 60% of the patients do not have detectable HCV-RNA at the end of the period of 20 to 30 weeks, as well as no detectable HCV-RNA for at least 24 weeks after the end of administration. In another modality, these can be used to treat a patient who has chronic hepatitis C infection with type 1 HCV genotype and who has a viral load less than or equal to 2 million copies measured by HCV-RNA / qPCR to eradicate HCV. - Detectable RNA, which consists of administering a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alfa for a period of 20 to 30 weeks, so that at least approximately 30% of patients do not have detectable HCV-RNA at term period of 20 to 30 weeks, as well as no detectable HCV-RNA for at least 24 weeks after the end of administration. Preferably, at least about 40% of the patients do not have detectable HCV-RNA at the end of the period of 20 to 30 weeks, as well as no detectable HCV-RNA for at least 24 weeks after the end of administration. In another embodiment, a patient who has chronic HCV infection with type 1 HCV genotype and who has a viral load greater than 2 million copies measured by HCV-RNA / qPCR to eradicate HCV-RNA can be used for the treatment. detectable, which consists of administering a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alpha for a period of 20 to 30 weeks, so that at least about 15% of the patients do not have detectable HCV-RNA at the end of the period of 20 to 30 weeks, as well as no detectable HCV-RNA for at least 24 weeks after the end of administration. Preferably, at least about 20% of the patients do not have detectable HCV-RNA at the end of the period of 20 to 30 weeks, as well as no detectable HCV-RNA for at least 24 weeks after the end of administration. Preferably, the amount of ribavirin administered is from 400 to 1200 mg per day. Most preferably, the amount of ribavirin administered is 800 to 1200 mg per day. The interferon alpha administered is preferably selected from interferon alfa-2a, interferon alfa-2b, a consensus interferon, a purified interferon alpha product or a pegylated interferon alfa. More preferably, interferon alfa is selected from interferon alfa-2a, interferon alfa-2b or a purified interferon alpha product and the amount of interferon alpha administered is from 2 to 10 million Ul per week each week, TIW, QOD or daily . In a preferred embodiment, the interferon alpha that is administered is interferon alfa-2b and the amount of interferon alfa that is administered is 3 million Ul TIW. Otherwise, the interferon alfa that is administered is consensual interferon and the amount of interferon alpha administered is 1 to 20 micrograms per week, weekly, TIW, QOD or diary. In another embodiment, the interferon alpha administered is a pegylated interferon alfa-2b and the amount of interferon alpha administered is from 0.5 to 2.0 micrograms / kilogram per week weekly, TIW, QOD or daily. Otherwise, the interferon alpha administered is a pegylated interferon alfa 2a and the amount of interferon alpha administered is 20 to 250 micrograms / kilogram per week, weekly, TIW, QOD or daily. The present invention has surprisingly found that, when compared to the treatment of interferon alfa alone or ribavirin alone, therapy with a combination of a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alpha, for a period of at least 20 to 30 weeks results in 10 times more patients not having HCV-AR detectable in their serum, at least 24 weeks after finishing the therapy than with any monotherapy.

DETAILED DESCRIPTION The term "interferon alfa", when used herein, means the family of specific proteins of the species, highly homologous that inhibit viral replication and cell proliferation, and modulate the immune response. , but are not limited to, recombinant interferon alfa-2b, such as Intron-A interferon, which is commercialized by Schering Corporation, Kenilworth, NJ, recombinant interferon alfa-2a, such as interferon Roferon, available from Hoffmann-La Roche, Nutley, NJ, recombinant interferon alfa-2C, such as interferon Berofor alfa 2, available from Boehringer Ingelhei Pharmaceutical, Inc., Ridgefield, CT., Interferon alfa-nl, a purified mixture of neutral alpha interferons such as Sumiferon available from Sumitomo, Japan or as interferon alfa-nl Wellferon (INS) available from Glaxo-Wellcome Ltd., London, Great Britain, or an alpha interferon nsensual such as those described in U.S. Patent Nos. 4,897,471 and 4,695,623 (especially, Examples 7, 8 or 9 thereof) and the specific product available from Amgen, Inc., Newbury Park, CA, or interferon alpha-n3, a mixture of natural interferon alphas prepared by Inferieron Sciences and available from Purdue Frederick Co, Norwalk, CT., under the trademark Alferon. The use of interferon alfa-2a or alfa-2b is preferred. Since interferon alfa-2b, among all interferons, has the widest approval worldwide for the treatment of chronic hepatitis C infection, it is the most preferred. The manufacture of interferon alfa-2b is described in U.S. Patent No. 4,530,901. Ribavirin, 1-D-ribofuranosyl-lH-1, 2, -triazole-3-carboxamide, marketed by ICN Pharmaceuticals Inc., Costa Mesa, California, is described in the Merck Index, Compound No. 8199, 11a. edition. Its manufacture and formulation is described in U.S. Patent No. 4,211,771. By not presenting a response to a course of previous treatment "it is understood that the patient did not respond to a previous course of treatment (generally known in the art as" no response ") or that the patient responded to a course of previous treatment but subsequently it was recurrent (generally known in the art as "with unsustained response").

"Patient who is difficult to treat" means that a patient who has so far been classified as someone who does not respond easily to treatment / for example, due to high viral load or because HCV infection is a difficult genotype to treat, such as be type I, for example, type lb. For other details of the HCV classification of different genotypes, see, for example, "Classification of hepatitis C virus into six major genotypes, and a series of subtypes by pyulogenetic analysis of the NS-5 region", Simmonds, P. et al. . , J. Gen Virol (1993), 74, 231-2399 and WA Proposed System for the Nomenclature of Hepatitis C Viral Genotypes ", Simonds, P. et al., Hepatology, 19 (5) 81994), 1321-1323.A person suffering from an infection Chronic hepatitis C may present one more of the following signs or symptoms: (a) High ALT, (b) positive test for anti-HCV antibodies, (c) presence of HCV demonstrated by a positive test for HCV-RNA, (d) clinical signs of chronic liver disease, (e) hepatocellular damage.

To practice the invention, interferon alfa (hereinafter -IFN) and ribavirin are administered to the patient exhibiting one or more of the above signs or symptoms, in amounts sufficient to eliminate or at least alleviate one or more of the signs or symptoms. In a preferred embodiment, the combination therapy of the invention is administered to a patient who has not remained free of HCV-AR after monotherapy with interferon-alpha. Ribavirin is administered to the patient in association with a-IFN, that is, the dose of a-IFN is administered during the same period of time that the patient receives the doses of ribavirin. Most formulations of a-IFN are not effective when administered orally, so that the preferred method of administering α-IFN is parenterally, preferably by IV or IM injection. Ribavirin can be administered orally in the form of a capsule or tablet in association with parenteral administration of α-IFN. Of course, other types of administration of both drugs are contemplated, as they are available, such as by nasal spray, transdermal route, suppository, by its sustained release dosage form, etc. Any form of administration will work as long as the appropriate doses are administered without destroying the active ingredient.

The detectable HCV-RNA, in the context of the present invention, means that there is less than 100 copies per ml of patient serum measured by the quantitative multiple-nucleoside reverse transcriptase PCR methodology. The HCV-RNA is preferably measured in the present invention by the methodology described below. This methodology is known herein as HCV-RNA / qPCR. The RNA is extracted from the patient's serum using a mixture of guaninide thiocyanate-phenol-chloroform followed by precipitation with ethanol-ammonium acetate. The precipitated RNA is centrifuged and the resulting package is dried in a Centrivap console (Labconco, Kansas, City, MO.) The dried package is resuspended in 30 microliters of a mixture of Rnasin (Promega Corp., Madison, Wl), dithiitritol and water treated with diethyl pyrocarbonate Samples are kept at or below -20 ° C until reverse transcription of RNA (TI) and PCR To convert the entire RNA sequence into cDNA in the TI reaction, random hexadeoxyribonucleotides (Pharmacia Biotech, Piscataway, NJ) are used as primers for the synthesis of the first strand of cDNA Two aliquots of 3 microliters of the resuspended sample are added to 3 microliters of random primers in a concentration of 100 ng / 1 and denatured at 70 ° C, then reverse transcription is carried out at 40 ° C for one hour using the M-MLV reverse transcriptase (USB, Cleveland, OH) in standard buffer with a 5 mM MgCl 5 content. e TI is 26 1. PCR starts immediately after reverse transcription. A modified version of the PCR method is performed using thermostable Taq polymerase to amplify the cDNA. 75 microliters of the PCR mixture are added to the entire reaction volume of the TI (26 1) to a final MgCl concentration of 1.5 mM in a total volume of 101 L. Each sample of 101 L is then separated into 50.5 L, and a layer of mineral oil is placed on top to avoid evaporation. The PCR cycle consists of tempering for 90 seconds, extension for 90 seconds and denaturation for 90 seconds, at 55 X, 7 ° C and 94 ° C, respectively. The thermocycling samples are subjected to a final extension at 7 ° C for 10 minutes. 4 series of different cycles are used. By loading the samples in duplicate, and separating these samples uniformly after RT, we have 4 tubes of a sample. Each of the four tubes will have a different number of cycles, improving the sensitivity and precision in the quantification process. The efficiency of the thermocycling will be evaluated by satisfactory amplification of the RNA standards with a known number of copies that is included in each series of 60 tubes. For amplification, two sets of primers are used, both from the 5 'untranslated region of the HCV genome. These series of primers are highly conserved and detect all known HCV subtypes. Primer series 1: upstream or at the start 5 '-GTG GTC TGC GGA ACC GGT GAG T-3' running down 5 'TGC ACG GTC TAC GAG ACC TC-3' which produces a product of 190 bp. Primer series 2: upstream 5 'CTG, TGA GGA, ACT, ACT GTC TTC-3' downstream 5 'CCC TAT CAG GCA GTA CCA CAA-3' which produces a product of 256 bp. The amplified cDNA is then subjected to 3% agarose gel electrophoresis and transferred to a nylon membrane. The target DNA is detected by the Southern blot test and is subjected to immunostaining using a DNA probe labeled with non-radioactive digoxigenin. These procedures are performed using automated instruments for PCR thermocycling, agarose gel electrophoresis, Southern blot test for vacuum transfer, hybridization and immunostaining. Each membrane contains standards diluted in series with known number of copies, which are used to construct standard curves for the quantitative measurement of the bands of the samples. Originally the standard curves are made from carefully diluted HCV-RNA from transcribed clones. Studies of radioactive incorporation, gel electrophoresis and OD260 are performed on the transcripts to determine that they are of the expected length. After the production of the standards of clones quantified by the RNA transcripts, the "mixed" standards are generated that better represent the heterogeneous nature of HCV, which would be found in a natural infection. These mixtures are made by combining large amounts of serum or plasma from known infected individuals. The serum / plasma deposits are calibrated with PCR, against the transcripts of the clones and then diluted in known PCR-negative fluids. Finally, samples with high copy number of deposits are checked against the Quantiplex cDNA nucleic acid detection system of Chiron inc. (Emeryville, CA). Aliquots from these quantified Moble deposits are taken "and stored at minus 70 ° C. In each experiment 5,000,000, 1,000,000, 500,000, 100,000, 10,000 and 1000 copies / ml dilutions are used Each Southern blot membrane scans in a computer using a Atomized explorer / densitometer at intervals during development to determine when the standard curve is more linear The resulting electronic images are then measured for the band area and the average band density All readings are standardized for band density integrated and compared with the standard curve to obtain a numerical value of the number of viral copies for each band.The following clinical protocols were performed: Study 1: Design and general plan of the study This was a prospective study, in several centers, randomized, double blind, with parallel group. The study compared treatment with INTRON® A plus ribavirin with treatment with INTRON® A plus placebo for 24 weeks in patients with compensated chronic hepatitis C who had responded to 1 or 2 previous courses of therapy with interferon alfa (INTRON® A, Roferon ®-A or Wellferon®) (minimum of 3 MU up to a maximum of 6 MU QOD or TIW for a minimum of 20 weeks up to a maximum of 18 months) and those who had relapsed after the most recent course of therapy with interferon alfa. Eligible patients had positive chronic hepatitis C confirmed by HCV-RNA in serum, liver biopsy and laboratory tests. Patients were randomly selected for treatment with 1NTRON® A plus ribavirin or INTRON® A plus placebo. The INTRON® A dose was 3 MU SC TIW; the dose of ribavirin was 1000 or 1200 mg PO daily (based on weight) in two divided doses. The assignments of the treatment group were made in equal proportions by a Central Random Selection Center. The random selection procedure was designed in an attempt to balance treatment groups, within and between sites, with respect to the presence or absence of cirrhosis in the pre-treatment biopsy, the HCV-RNA / qPCR level in serum and the genotype of HCV. The study treatment was administered for 24 weeks. The total course of the study was 48 weeks to determine the effect of long-term treatment. During the treatment and in the follow-up after the treatment, biochemical (ALT), virological (HCV-RNA) and histological (liver biopsy) tests were used to assess the nature and duration of the response to the treatment under study. The primary efficacy variable was the general response defined as the HCV-RNA / qPCR loss (<100 copies / ml in serum) measured 24 weeks after the end of therapy associated with an improvement in liver biopsy after treatment measured by the Histological Activity Index (HAI) Knodell. The normalization of ALT was also examined as a secondary efficacy variable. The safety of the study treatments was assessed by monitoring parameters of selected laboratories and also recording and evaluating the presence of any adverse event.

Treatment regimens The treatment regimens under study were: - INTRON® A 3 MU SC TIW plus ribavirin 1000 or 1200 mg / day PO in two divided doses for 24 weeks / o - INTRON® A 3 MU SC TIW plus placebo corresponding to ribavirin PO in two divided doses for 24 weeks.

The treatment under study was administered for 24 weeks. The standard regimen of INTRON® A (interferon alfa-2b, recombinant) for hepatitis C was administered as a fixed dose of 3 MU TIW. Each patient received instructions related to the preparation and subcutaneous administration of INTRON® A. Ribavirin was administered twice a day, in the morning and in the afternoon. The dose was determined by the patient's body weight at the start visit. Patients weighing 75 kg received 1000 mg daily as two 200 mg capsules in the morning and three 200 mg capsules in the afternoon. Patients with a weight > 75 kg received 1200 mg daily as 3 capsules of 200 mg in the morning and by tarae. The random selection procedure was designed to balance the groups with respect to the following baseline characteristics: A. Liver histology prior to treatment (cirrhosis or non-cirrhosis) / B. HCV status-RNA / qPCR in serum (A. HCV-RNA / qPCR 2,000,000 or VHC-RNA / qPCR> 2,000,000 copies / ml); and C. HCV Genotype (1 or other). Patients with combined genotypes (including type 1) will be classified as type 1 for balance purposes.

Efficacy The objective of primary efficacy was the comparison of the two treatment groups with respect to the overall response rate defined as the loss of HCV-RNA / qPCR in serum 24 weeks after the end of therapy to an undetectable level or up to a level <100 copies / ml associated with an improvement in liver biopsy after treatment, as defined by Knode's AIH inflammation grade. The following endpoints of secondary efficacy were also examined: • > "> D. Portions of patients with normalization of ALT in the 24 weeks of follow-up / E. Proportions of patients with improvement in biopsy (categories I + II + III combined records) / F. Changes of the baseline in the biopsy records (records combined of the categories I + II + III); G. Response rates at the endpoint of treatment based on HCV-RNA / qPCR / H. Proportion of patients with normalization of ALT at the endpoint of treatment. I. Response rates in the 24 weeks of follow-up based on HCV-RNA / qPCR.

Virology: initial status and change from the beginning The HCV-RNA / qPCR serum tests were performed by a central laboratory. A positive result was necessary in the HCV-RNA assay at baseline, only HCV-RNA positive patients were eligible to participate. Repeated trials were scheduled for weeks 4, 12, 24 and weeks of follow-up 12 and 24. The response was rated as defined below: ">", With response: A patient was classified as having a response at a given time point if the HCV-RNA / qPCR was negative (<100 copies / ml) at this point of time. With sustained response: One patient was classified with a response if the patient had a response at 24 weeks of follow-up. Note that patients who did not meet these criteria, including patients who dropped out before the necessary HCV-RNA / qPCR evaluations were obtained, were classified as unresponsive. Total response: Based on the serum HCV-RNA / qPCR test and the change in liver histology evaluated by the HAI Knodell inflammation registry. One patient was classified as having a total response to treatment if he presented a sustained response and if his record of HAI Knodell inflammation after treatment (sum of categories I + II + III) improved in two or more units compared to the pre-treatment registry.

Liver histology Liver biopsy was necessary within six months prior to the patient's incorporation and at the week of follow-up 24. The evaluation of the biopsies was performed by a single pathologist with the use of the Knodell histology activity record. The central pathologist was deprived of information regarding the identification of the patient, the treatment group and the time in which the biopsy was obtained in relation to the treatment (before or after treatment). The efficacy of the treatments under study was evaluated by comparing the degree of inflammatory activity observed in the baseline with that present at week 24 of the follow-up.

Results 195 patients were admitted to 31 international centers and randomized for treatment with INTRON® A plus ribavirin (N = 98) or INTRON® A plus placebo (N = 97). Three patients / 2 randomized to receive INTRON® A plus ribavirin and one randomized to receive INTRON® A plus placebo were not treated / in this way, the groups with all patients treated consisted of 192 patients (96 patients for INTRON ® A plus ribavirin and INTRON® A plus placebo). Two of the three patients were not treated because they did not want to continue, the third because the protocol criteria were not met. All efficacy and safety analyzes in this report are based on data for all treated groups.

Efficacy The objectives of this study were to compare INTRON® A plus ribavirin with INTRON® A plus placebo with respect to the overall response degree and the virological response index (based on HCV-RNA (qPCR).) The primary efficacy variable for the study is the degree of general response.The conclusion of these in relation to effectiveness is as follows: J. The combination of ribavirin with INTRON® A can dramatically increase the proportion of patients who eradicate HCV-RNA and have significant reduction in liver inflammation. The degree of general response at the end of the follow-up is a compound of the loss of HCV-RNA (qPCR) in serum and the change in liver histology at the end of follow-up (24 weeks after finishing treatment). A patient was classified as having a general response if HCV-RNA (qPCR) was negative in the evaluation 24 weeks after treatment and the HAI Knodell inflammatory record (sum of categories I + II + III) had improved by two or more units in relation to the previous registration of the treatment. The virological response, the histological response and the degrees of general response at the end of the follow-up are summarized in Tables 1, 2, and 3.

Response to HCV-RNA at the end of follow-up: sustained loss of HCV-RNA 24 weeks after finishing treatment The proportion of patients with HCV-RNA eradication in serum 24 weeks after finishing treatment was 10 times higher (p < 0.001) in the group of patients treated with the combination of I? TRO? ® A plus ribavirin compared to those who received monotherapy with I? TRO? ® A. Table 1 summarizes the response of patients at the end of follow-up as Is it indicated by the HCV-AR? in serum.

Table 1 HCV-AR in serum at the end of follow-up: proportion of patients with HCV-RNA eradication 24 weeks after finishing treatment.

Number% of patients State of response INTRON® A plus INTRON® A p-value of patient ribavirin plus placebo All treated 50/96 5/96 (5) < 0.001 95% interval of (52) confidence for each treatment: 1% -10% for difference _% - 58 * between treatments: 42% -62% With response to 49/80 5/41 (12) term of (61) treatment '1 Biopsies before and after treatment were available for 81% (78/96) of patients treated with INTRON® A plus ribavirin and 77% (74/96) of those who received INTRON® A plus placebo. Table 2 summarizes the effect of treatment on liver inflammation for patients with liver biopsy results before and after treatment. As with the sustained loss of HCV-RNA replication, the proportion of patients with improvement in liver inflammation was significantly greater (p <0.001) in patients who received combination therapy, compared to those who received monotherapy with INTRQN ® A.

Table 2 Liver histology at the end of follow-up: improvement in liver histology 24 weeks after the end of treatment based on the HAI (I + II + III) Knodell registry. Number% of patients Status of the patient INTRON® A plus INTRON® A p-value ribavirin plus placebo (n = 78) (n = 74) improved biopsy "49 (51) 30 (31) <0.001 b Patients with previous biopsy and post-treatment C Fisher's Exact test d Change from pretreatment to post-treatment in the Knodell histological index record (HAI) (sum of 1+ + II + III) classified as a decrease of two or more from before of the treatment.

General response When the study was designed, it was recognized that because liver biopsy is an invasive procedure it was very unlikely that post-treatment liver biopsies were obtained for all patients. Therefore, the protocol and the statistical analysis plan specified that the analysis for the general response would be based on the data for all treated patients and would be calculated by a maximum likelihood method (MPM) for patients whose general response status does not could be determined, that is, patients with negative HCV-RNA and without biopsy evaluations (after treatment). The protocol also specified that additional analysis would be performed in patients with biopsy results prior to treatment and post-treatment (ie, patients with complete data). The general response is summarized in Table 3 based on the following analyzes: K. Calculation of the maximum probability (CPM) L. Patients with complete data (results for biopsy before and after treatment) / M. Patients with missing data (HCV and / or biopsy) treated as poor response.

Table 3 Degree of general response Analyzed data INTRON® A plus INTRON® A plus pb value ribavirin placebo Calculation of 43% 5% < 0.001 maximum probability Patients with data 39/78 (50%) 4/74 (5%) 0.001 complete '' Treatment of data 39/96 (41%) 4/96 (5%) 0.001 missing as failures " 1. CPM based on logistic regression. 1. Fisher's exact test 1. Complete data = biopsy results before and after treatment. 1. Patients who did not present virology or biopsy data or both were considered failures.

As expected from the individual results for the effect of treatment on the eradication of HCV-RNA at the end of follow-up and improvement in liver inflammation, the overall response rate in the treatment group with INTRON® A plus ribavirin was significantly higher (<0.001), with 10 to 14 times the improvement, than that observed in the INTRON® A group plus placebo for all evaluation methods. The logistic regression analysis was done on all the demographic variables of the baseline and characteristics of the disease. The only statistically significant predictive characteristic of the baseline of the sustained response at the end of the follow-up was the genotype different from 1 and the viral load from 2 million. For the number of viral copies (2 million,> 2 million), the difference was statistically significant in favor of higher response degrees in patients with 2 million copies (Table 4). When the genotype and the viral load of the baseline are combined, a hierarchy of response is observed. Patients with different genotypes of 1 and 2 million copies of the viral load in the baseline had a better response at the end of follow-up / patients with genotype 1 and > 2 million copies had a more poor response to the Monitoring Term.

Table 4 Characteristics of the disease compared with the sustained response: all patients treated Number% of patients Characteristic of INTRON® A plus INTRON® A plus disease b ribavirin (n = 96) placebo (n = 96) HCV-RNA / qPCR 2 million 24/36 (67) 5/29 (17) 2 million 26/60 (43) 0/67 (0) HCV Genotype '1 16/53 (30) 2/53 (4) other 34/43 (79) 3/19 (7) HCV-RNA / qPCR genotype / baseline other / 2 million copies 15/16 (93) 3/14 (21) other /> 2 million copies 18 / 27 (67) 0/29 (0) 1/2 million copies 8/29 (40 (0715 (0) l / > 2 million of 7/33 (2i; 0/38 (0) B copies at the beginning patients were stratified by the number of viral copies (2 million,> 2 million), genotype (1 or other) and cirrhosis (present or absent).

Study 2: Through basically the same methodology as that described in Study 1, the second Study 2 was also carried out. The results are summarized below.

Efficacy The overall response at the end of follow-up is a composite of serum HCV-RNA / qPCR loss and liver histology at the end of follow-up (24 weeks after the end of treatment). A patient was classified as having a general response if HCV-RNA (PCR) was negative in the evaluation 24 weeks after treatment and the HAI Knodell inflammation record after treatment (sum of the categories I + n + ?? i) it had improved in two or more units in relation to the pre-treatment registry. The virological response, the histological response and the general response grades at the end of the follow-up are summarized in Tables 5, 6 and 7.

HCV-AR response at the end of follow-up: sustained HCV-RNA loss 24 weeks after the end of treatment The proportion of patients with HCV-RNA eradication in serum 24 weeks after the end of treatment was 10 times (p <0.001 ), in the group of patients treated with the combination of INTRON® A plus ribavirin compared to those who received INTRON® A monotherapy. Table 5 summarizes the response of the patients at the end of follow-up as indicated by the HCV- RNA in serum.

Table 5 HCV-AR in serum at the end of follow-up: proportion of patients with HCV-RNA eradication 24 weeks after the end of treatment.

Number% of patients State of response INTRON® A plus INTRON® A p-value of patient ribavirin plus placebo All 34/77 (44) 3/76 (4) < 0.001 treated patients 95% confidence intervals for 0% -8% each treatment: 33% -56% 28% -52% for difference between treatments Table 5 (continued) State of response INTRON® A plus INTRON® A p-value of patient ribavirin plus placebo With response to the Term of 34/54 (63) 3/32 (9) Treatment '' Liver histology at the end of follow-up: Improvement in liver histology 24 weeks after the end of treatment based on the records (I + II + III) of the Knodell histological activity index (HAI) The biopsies before and after treatment were at disposition for 79% (61/77) of the patients treated with INTRON® A plus ribavirin and for 84% (64/76) of the patients who received INTRON® A plus placebo. Table 6 summarizes the effect of treatment on hepatic inflammation for patients with liver biopsy results before and after treatment. As with the loss of HCV-RNA replication, the proportion of patients with improvement in liver inflammation was significantly higher (p <0.001) in patients who received combination therapy compared to those who received monotherapy with INTRON® A .

Table 6 Liver histology at the end of follow-up: improvement in liver histology 24 weeks after the end of treatment based on the HAI (I + II + III) Kodell record. Number% of patients Status of the patient INTRON® A plus INTRON® A value pb ribavirin plus placebo (n-61) (m = 64) improved biopsy "38 (49) 27 (36) <0.001 2. Patients with previous biopsy and after the treatment 2. Fihser 's Exact 2 test. Change from pretreatment to post treatment in the registry (Sum of 1+ II + III) of the Histological Index (HAI) Knodell classified as a decrease of 2 or more from the pretreatment .

General response The general response is summarized in Table 7 based on the following analyzes: N Calculation of maximum probability (CPM) O. Patients with complete data (results of biopsy before and after treatment); P. Patients with missing data (HCV-RNA and / or biopsy) treated as a poor response.

Table 7 General response level Analyzed data INTRON® A plus INTRON® A plus pb value ribavirin ____ placebo CPM'1 36.5% 2.7% < 0.001 Patients with data 25/61 (41.0%) 2/64 (3.1%) < 0.001 completed '' Deal with missing 25/77 (32.5%) 2/76 (2.6%) < 0.001 as failures " 1. CPM based on the logistic regression. 1. Fisher's Exact test. 1. Complete data = results of the biopsy before and after treatment. 1. Patients who did not present virology or biopsy data, or both, were considered as having a poor response. As anticipated from the individual results for the effect of HCV-RNA eradication treatment at the end of follow-up and improvement in liver inflammation, the overall response rate in the INTRON® A plus ribavirin group is significantly higher (p <0.001), with 10 to 14 times the improvement, over that observed in the INTRON® A plus placebo groups for all evaluation methods. The logistic regression analysis was done on all the demographic variables of the baseline and characteristics of the disease. The only statistically significant predictive characteristic of the baseline of the sustained response to the Follow-up Term was the genotype different from 1. For the number of viral copies (2 million,> 2 million), there was a numerical difference in favor of the grades of superior response in patients with 2 million copies (Table 8). When the genotype and the viral load of the baseline are combined, a hierarchy of response is observed. Those patients with a genotype different from 1 and a viral load in the baseline of 2 million copies had a better response at the end of follow-up / patients with genotype 1 and > 2 million copies had the most deficient response to the Monitoring Term.

Table 8 Characteristics of the disease compared to the sustained response: all patients treated Number% of patients Characteristic of INTRON® A plus INTRON® A plus disease ribavirin (n = 77) placebo (n = 76) HCV-RNA / qPCR 2 million 6/9 (67), 1/12 (8) > 2 million 28/68 (41) 2/64 (3) HCV genotype 1 12/46 (28) 1/42 (2) other 21/31 (68) 2/34 (6) HCV-RNA / qPCR genotype / baseline other / 2 million copies 4/4 (100) 0/3 (0) other / > 2 million 17/27 (62) 2/31 (6) copies 2/5 (40) 1/9 (11) 1/2 million copies 11/39 (28) 0/32 (0) l / > 2 million copies ^ __ -__-- ™ -ra, Multiple modifications and variations of this invention can be made without departing from its spirit and scope, as will be apparent to those skilled in the art. The specific embodiments described herein are offered by way of example only and the invention will only be limited in the terms of the appended claims, together with the broad scope of the equivalents for which these claims are entitled.

Claims (15)

1. CLAIMS The use of ribavirin for the manufacture of a pharmaceutical composition for the treatment of a patient presenting chronic hepatitis C infection, to eradicate the detectable HCV-RNA, by a method consisting of: administering an effective amount of ribavirin associated with an amount effective interferon alfa, where the patient is the one who has failed to respond to a previous course of therapy with interferon alfa.
2. The use of interferon alfa for the manufacture of a pharmaceutical composition for the treatment of a patient presenting chronic hepatitis C infection, to eradicate the detectable HCV-RNA, by a method consisting of: administering an effective amount of interferon alfa in association with an effective amount of ribavirin, where the patient has not responded to a previous course of therapy with interferon alfa.
3. The use of ribavirin and interferon alfa for the manufacture of pharmaceutical compositions for the treatment of a patient presenting chronic hepatitis C infection, to eradicate the detectable HCV-RNA, by a method comprising: the administration of an effective amount of ribavirin association with an effective amount of interferon alfa, where the patient has failed to respond to a previous course of therapy with interferon alfa.
4. 4 * The use, as claimed in any of claims 1 to 3 wherein, in addition, the patient is a patient that presents difficulty in its treatment.
5. 5. The use, as claimed in claim 4, wherein the patient has a viral load greater than 2 million copies per milliliter of serum, as measured by quantitative PRC of HCV-RNA.
6. 6. The use, as claimed in claim 4 or claim 5, wherein the patient has difficulty treating infection of the HCV genotype.
7. The use, as claimed in claim 4 or claim 6, wherein the infection is a HCV v type genotype 1 infection.
8. 8. The use, according to any of the preceding claims, wherein the interferon alpha is selected from interferon alfa-2a, interferon alfa-2b, consensual interferon-alpha, a purified interferon alfa product or a pegylated interferon alfa.
9. 9. The use, as claimed in any of the preceding claims, wherein the interferon alpha that is employed is an interferon alpha-12b,
10. 10. The use, as claimed in any of the preceding claims, wherein the amount of ribavirin that is administered is from 400-1200 mg per day. More preferably, it is 800-1200 mg per day, and the amount of interferon alfa administered is from 2 to 10 million Ul per week, weekly, TIW, QOD per day, most preferably 3 million Ul TIW.
11. 11. The use, as claimed in any of the preceding claims, wherein the administration is carried out for a period of 20 to 30 weeks.
12. 12. The use, as claimed in claim 11, wherein the administration is further effected for a total period of 40 to 50 weeks.
13. 13. The use, as claimed in claim 11, wherein the administration is further effected for a total period of 60 to 80 weeks.
14. 14, Pharmaceuticals containing ribavirin and interferon alpha separately, but adjacent.
15. 15. The pharmaceutical products, as claimed in claim 14, wherein the alpha interferon is in a form suitable for parenteral injection, preferably subcutaneous injection, and the ribavirin is in a solid dosage form, preferably a dosage form suitable for oral administration. The pharmaceutical products, as claimed in claim 14 or 15, which contain an amount of ribavirin suitable for the treatment of 1 day and an amount of interferon alpha suitable for at least one injection of a dose. The pharmaceutical products, as claimed in claim 16, wherein the amount of ribavirin is from 400 to 1200 mg, preferably from 800 to 1200 mg, and the amount of interferon alpha is 3 million Ul, or at least 3 million Ul. The pharmaceutical products, as claimed in claims 14 or 17, in the form of a kit with injections for combinatorial use in the treatment of chronic hepatitis C infections.