Drug resistance to nucleoside and nucleotide analogs in chronic hepatitis B and its management

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1 nfect Dis nfo, Vol. 26, No. 1, February 28, [ ] 4 nucleoside and nucleotide analogs, NAs chronic hepatitis B, CHB CHB HBV NAs HBV NAs [ ] [ ] [ ] A [ ] (2013) Drug resistance to nucleoside and nucleotide analogs in chronic hepatitis B and its management Experts Attending the Discussionon Hepatitis B Virus Drug esistance corresponding author. ZHUANG Hui, Department of Microbiology and nfectious Disease Center, chool of Basic Medical ciences, Peking University Health cience Center, Beijing , China, zhuangbmu@126.com; WENG Xin-hua, Department of nfectious Disease, Huashan Hospital, Fudan University, hanghai , China, xinhua_weng@fudan.edu.cn [Abstract] Four nucleos(t)ide analogs (NAs) have been approved by the Food and Drug Administration, China for treatment of patients with chronic hepatitis B (CHB). The patients can be successfully treated using NAs, but drugresistant hepatitis B virus (HBV) mutants frequently arise, leading to treatment failure and progression of the disease. This paper has reviewed the mechanisms of resistance to NAs, and consensus on the management and prevention of HBV resistance to NAs. [Key words] hepatitis B, chronic; drug resistance; nucleoside and nucleotide analogs; management nucleoside and nucleotide analogs, NAs HCC 1 NAs 4 LAM ADV LdT ETV NAs TDF [1-4] 2008 NAs genetic barrier [5] [6] 2009 LAM 1 24% 5 70% [7-9] LdT 2 HBeAg 25% 11% [10-11] ADV 5 HBeAg nfection nternational electronic edition 42% 29% [12-13] ADV HBeAg % [14] [ ], ETV 3 1.7% 1.2% [15-16] E- mail zhuangbmu@126.com E- mail wengxinhua@fudan.edu.cn TDF 2 426

2 nfect Dis nfo, Vol. 26, No. 1, February 28, HBeAg 250 HBeAg TDF % HBV DNA ~120 TDF 20 4 HBV DNA 400 /ml 69 U/ml 10 1 [27] 72~96 /ml 69 U/ml 2.6 multidrug resistance 2 NAs [26] [17] 2.7 primary non-response NAs NAs 3 12 HBV DNA <1 lg U/ml [4-5] 2.8 partial virological response NAs 6 24 NAs 80%~90% HBV DNA >1 lg U/ml [4] 81% NAs NAs 30% LAM 35% ADV NAs LAM LdT NAs ETV LAM 39.6% [18] [2] TDF complete virological response [3] NAs HBV DNA 2.10 biochemical response [19-21] ung [21] ALT 2 [2] LAM ULN ALT HCC 78% virological breakthrough HBV DNA HCC 1 lg U/ml 1 2 [ ] [5, 26] 2.12 biochemical breakthrough ALT ALT ULN [28] virological rebound 2.1 primary drug resistance mutation HBV DNA [29] 2.14 hepatitis flare ALT [26] 2.2 secondary drug resistance mutation compensatory drug resistance mutation [27] [26] 2.3 genotypic resistance HBV ~10 13 [27] [27] EC cross resistance 1 PC ALT 2 菖 ULN >5 菖 ULN >3 ALT [30] ALT HCV 2.4 phenotypic resistance HV HBV HBV 1 1

3 nfect Dis nfo, Vol. 26, No. 1, February 28, HBV 1.4~3.2 菖 10-5[31] 3.2 HBV [27 32] quasispecies NAs HBV DNA [ ] HBV T HBV [26-27] NAs L LdT LAM LdT D ETV GLOBE HBV DNA ADV TDF 3 5 NAs 1 HBV DNA<9 lg /ml HBeAg HBV DNA<7 lg /ml HBeAg 2 / NaseH (rt1) 692(rt344) 845a.a. F_V_LLAQ_YMDD (G) (F) A B C D E L LAM LdT rta181t/v rtm204v/ rtm204\// rtm204 ADV TDF rta181t/v rtn236t D ETV rt169 rtt184 rtm204\// rt202 rtm250 1 ( [2] [31] [32]) Figure 1 Common primary resistance mutations of NAs (refer to [2], [31] and [32]) [36] HBV 47%~49% 1 HBV 19%~24% [16] [37-38] HBV [39-40] NAs [32] [23-27] % [28] Chotiyaputta [41] LAM ADV ETV TDF 3 LAM LdT ADV 1 1 ETV 95% 39.7% 46.1% 3

4 nfect Dis nfo, Vol. 26, No. 1, February 28, 2013 [42-44] TDF ADV rta181t/sw172 * [44-45] HV HBV TDF rtl180m rta194t rtm204v [46] HCC LAM 1 ETV 5 ( ) [42-43] LAM ETV 5 51% [47] 5.1 L rt204 rtm204v/ L LAM LdT D ETV ADV [42-43, 57] 5.2 rt236 LAM LdT rtn236t ADV [43] TDF 5.3 rt181 L ADV TDF ADV TDF TDF 40% ADV [4-5] 5% LAM 5.4 rta181t/v rtn236t [23] L LAM LdT 4 HBV 5.5 ETV rtl180m rtm204v/ OF rt169 rtt184 rt202 rtm250 1 NAs 3 ETV [19] HBV NAs HBsAg 1 HBsAg [48-51] 1 HBV Table 1 Cross-resistance of the most common antiviralresistant HBV strains HBV rta181t rtm204 sw172 * sw196 * 1 HBV rta181t/sw172 * M204V M204 N236T L180M+M204V/±169T±V173L±M250V [52] L180M+M204V/±T184G±202/G [52-55] 5 [5 32] ADV TDF [44] L180M+M204V A181T/V [56] HCC 6 NAs NAs LAM / LdT ETV ADV TDF LAM. LdT. ETV. ADV. TDF....

5 nfect Dis nfo, Vol. 26, No. 1, February 28, [26] NAs Villet [43] 1 LAM LAM ADV LAM ADV rtv173l L180M A181V N236T LAM ADV LAM ADV PC HBV DNA [27] [58] 7 1PC [61] 90% PC 20% 20% [ ] [62] NAs 2PC PC [4 27] 10~30 [60] PC 8 3 FLP [27] 8.1 HBV DNA HBV DNA 5% PC 4 HBV DNA U/ml NNO-LiPA [63-66] 1 U/ml 5~6 /ml 5% [ ] NAs HBV DNA HBV DNA 9.1 3~6 1 [4] NAs 8.2 LAM [4] HBV T LAM 4 NAs NAs ADV 1 NAs ETV TDF NAs LAM LdT ETV LAM LdT ADV TDF

6 nfect Dis nfo, Vol. 26, No. 1, February 28, 2013 NAs NAs Peg FN [70] LdT Peg FN [2 4-5] [71] 2 LAM LdT 24 ADV 2 TDF ADV 48 Table 2 Treatment options when resistance to antiviral therapy occurs 1 NAs HBV DNA LAM LdT TDF ADV ETV ADV ETV TDF LAM LdT LAM LdT LAM TDF 24 HBV DNA ETV TDF ADV 2~4 Keeffe [67] TDF ETV LAM LdT LAM NAs 24 HBV DNA LAM. LdT. ETV. ADV. TDF. EFFOT NH NCT NAs [68] 76 LAM LdT ADV 74.0% vs 61.1% P=0.001 NAs ETV 1.4% vs11.4% P<0.001 TDF ETV TDF 48 HBV DNA 48 HBV DNA HBV DNA 10 >2 菖 10 7 U/ml HBV DNA [ ] LAM ETV ADV 200 TDF NAs NAs ETV NAs NAs NAs ADV NAs NAs [27] HBV DNA 1 HBV DNA NAs ETV TDF [5-6 72]

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