Ribavirin for Chronic Hepatitis E in Transplant Patients

While there is no established therapy for hepatitis E virus (HEV), small case series and case reports have shown that a short course of pegylated interferon, or ribavirin, as monotherapy can effectively treat HEV infection. A recent study published in New England Journal of Medicine, assessed the effects of ribavirin as monotherapy for solid-organ transplant recipients with prolonged HEV [2014;370(12):1111-1120].

This retrospective, multicenter case series examined the records of 59 patients who had received a solid-organ transplant in 13 centers in France. Patients receiving the following transplants were included in the study: kidney (n=37), liver (n=10), heart (n=5), kidney and pancreas (n=5), and lung (n=2).

Data on cases of autochthonous HEV infection in solid-organ transplant recipients treated with ribavirin alone between September 10, 2009, and June 27, 2012, were collected from the participating medical centers. At these centers, all patients who had increased liver-enzyme levels that were attributed to HEV replication were treated with ribavirin monotherapy.

The median time between the HEV infection diagnosis and initiation of ribavirin therapy was 9 months. Specifically, at the time of initiation of ribavirin therapy, 34 patients had HEV for 6 months, 20 patients had HEV for 3 to <6 months, and 5 patients had been infected for <3 months.

All patients had HEV viremia when ribavirin therapy was started. The median dose of ribavirin per day was 600 mg, ranging from 29 mg to 1200 mg. Ribavirin was administered for a median of 3 months, ranging from 1 to 18 months, with 66% of the study participants receiving ribavirin for ≤3 months.

During the study, 2 patients were lost to follow-up, leaving the final participant pool at 57. HEV clearance was observed in 95% of patients by the end of therapy. At 1 month, HEV ribonucleic acid (RNA) levels were assessed in 50 patients, and the level was undetectable in 32 patients (64%). By month 3 and at the end of therapy, 56 of the 57 patients had HEV clearance. Of the 56 patients who had no detectable virus at the end of therapy, a recurrence of HEV occurred in 10 patients; therefore, 78% of patients sustained virologic response.

At 25 months follow-up—the most recent follow-up for the study—all 46 patients still did not have viremia. The rate of sustained virologic response did not differ significantly for patients who received ribavirin therapy for ≤3 months (n=39) and patients who had received the treatment for >3 months (n=20; 74% vs 85%, respectively).

In terms of adverse events for ribavirin, anemia was identified and led to a required reduction in dose in 29% of the patients, the use of erythropoietin in 54% of patients, and blood transfusions in 12%. The authors concluded that a 3-month course of ribavirin is an appropriate duration of therapy for most patients with HEV.