Comparison of Adefovir and Tenofovir in the Treatment of Lamivudine-Resistant Hepatitis B Virus Infection

Florian van Bommel,1 Thomas Wunsche,2 Stefan Mauss,3 Petra Reinke,4 Alexandra Bergk,1 Dirk Schurmann,2 1 and Thomas Berg1 Bertram Wiedenmann,
Adefovir dipivoxil was recently approved for the treatment of wild-type and lamivudineresistant hepatitis B virus (HBV) infection. Tenofovir disoproxil fumarate, a congender of adefovir that is used in the treatment of HIV infected patients, has recently been shown to also be effective in patients with lamivudine-resistant HBV infection. We therefore compared the two substances in a study of 53 patients dened by high HBV DNA (>6 log10 copies/mL) levels and genotypic evidence of lamivudine resistance. Thirty-ve patients received tenofovir for 72 to 130 weeks, and 18 received adefovir for 60 to 80 weeks. Changes in HBV DNA levels were followed for the complete period of 48 weeks. Early viral kinetics were compared on matched subgroups of 5 patients each. Individually, all tenofovir-treated patients showed a strong and early suppression of HBV DNA within a few weeks whether they were coinfected with HIV or were without comorbidity. In contrast, considerable individual variations in HBV DNA decline were observed in the adefovir group. Thus at week 48, only 44% of these patients had HBV DNA levels below 105 copies/mL in contrast to 100% of the tenofovir-treated patients (P .001). No severe side effects were noticed in either group. No evidence of phenotypic viral resistance could be demonstrated in the tenofovir-treated patients in the long term (up to 130 weeks). In conclusion, tenofovir may become an effective alternative for the treatment of patients with lamivudine-resistant HBV infection.(HEPATOLOGY 2004;40:14211425.) reatment of chronic hepatitis B virus (HBV) infection with the nucleoside analogue and reverse transcriptase inhibitor lamivudine has been shown to be very effective in suppressing HBV replication without major side effects.1 In view of the long half-life of

Abbreviations: HBV, hepatitis B virus; HBsAg, hepatitis B surface antigen; HIV, human immunodeciency virus; ALT, alanine aminotransferase; HBeAg, hepatitis B e antigen. From Medizinische Klinik mit Schwerpunkt 1Hepatologie und Gastroenterologie, 2Infektiologie und Asthma-Poliklinik, and 4Nephrologie und Internistische Intensivmedizin, Charite, Universitatsmedizin Berlin, Campus Virchow, Berlin, Germany; and 3Zentrum fur HIV und Hepatogastroenterologie, Dusseldorf, Ger many. Received April 23, 2004; accepted August 23, 2004. Supported in part by the German BMBF Network of Competence for Viral Hepatitis (Hep Net). Presented in part at the 54th Annual Meeting of The American Association for the Study of Liver Diseases, October 24 28, 2003, Boston, MA (Abstract 246). Address reprint requests to: PD Dr. Thomas Berg, Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charite, Campus Virchow-Klini kum, Universitatsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Ger many. E-mail: thomas.berg@charite.de; fax: (49) 30-450-553903. Copyright 2004 by the American Association for the Study of Liver Diseases. Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/hep.20464

covalently closed circular HBV DNA and the variable turnover of infected hepatocytes, long-term treatment is required to achieve complete HBV elimination (i.e., hepatitis B surface antigen [HBsAg] loss). Unfortunately, the effect of this kind of treatment is often abolished by the selection of lamivudine-resistant mutants2 followed by the reappearance of HBV DNA to baseline levels and reactivation of chronic hepatitis B. The efcacy of the acyclic nucleotide analogue adefovir dipivoxil (adefovir) in the treatment of wild-type and lamivudine-resistant HBV infection has been described, and a daily adefovir dose of 10 mg was recently approved for the treatment of chronic HBV infection.3 6 Tenofovir disoproxil fumarate, another acyclic nucleotide analogue that is the pro-drug of tenofovir, has been approved as a novel oral agent for the treatment of human immunodeciency virus (HIV) infection. Its effect in lamivudine drug resistance has been recently described by us as well as by other authors.714 In view of the close structural relationship between these two drugs, we conducted a study in patients suffering from lamivudine drug resistance to compare their ef1421

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Table 1. Baseline Characteristics of Patients Treated With Tenofovir or Adefovir

Tenofovir Group (n Group 1: HBV, No Comorbidities (n 9) Group 2: HIV/HBV Coinfected (n 21) 35) Group 3: HBV/Kidney Transplantation (n 5) Total TenofovirTreated Patients (n 35)

Baseline Features

Adefovir Group (n 18)

P Value

Age (yr) Sex (M/F) Weight (kg) Treatment with lamivudine (mo) HBV DNA (copies/mL) HBe-Ag-positive (%) Serum ALT (U/L) Serum creatinine (mg/dL)

46 79 31 3.6 157 0.9

5.9 7/2 2.3 5.6 2.9 109 67 57 0.14

47 76 22 2.5 95 0.8

1.58 21/0 3.5 6 9.4 100 35 1.3

48 73.8 34 2.2

3.72 4/1 6.7

47

2 32/3 77 2 3.5 9.3 89 26 1.0

45 71 26 0.33 88 0.96

3.7 14/4 2.7 3.7 0.18 89 36 1.2

NS NS NS NS NS NS NS NS

109

6.3 1.2 100 57 17 1.7 0.3

109

28 2.7 106 1.04

109

109

NOTE. Data are given as mean SE. *Mann-Whitney-Wilcoxon test. Difference in HBV DNA level between tenofovir group 1 and the adefovir group was not statistically signicant (P Difference in ALT levels between tenofovir group 1 and groups 2 and 3 was not statistically different (P .38).

0.22).

fect on HBV DNA suppression. Additionally, the longterm efcacy of tenofovir was demonstrated in patients who were not coinfected as well as patients suffering from HIV/HBV coinfection.

Patients and Methods

Patients. Fifty-three consecutive patients who developed lamivudine-resistant chronic HBV infection between December 2001 and April 2003 were included in this study. Inclusion criteria were: 1. Initial response to lamivudine as indicated by a decrease of HBV DNA of at least 3 log and normalization of alanine aminotransferase (ALT). 2. Genotypic as well as phenotypic resistance demonstrated via detection of lamivudine-associated mutations within the polymerase gene (YMDD) and an increase in HBV DNA to 106 copies/mL. 3. No pretreatment with either adefovir or tenofovir. 4. Exclusion of hepatitis delta virus and hepatitis C virus coinfections. All patients had been tested for HIV. Informed consent in writing was obtained from each patient prior to the treatment. The major clinical parameters are shown in Table 1. All patients were followed as outpatients. Lamivudine resistance occurred within a mean treatment period of 28.4 months (range, 6-54 months). Thirty-ve patients were treated with tenofovir at a dosage of 300 mg/d; the remaining 18 were treated with adefovir at a dosage of 10 mg/d. Tenofovir patients were divided into three groups: group 1, only HBV-infected patients (n 9); group 2, HIV/HBV coinfected patients who had received tenofovir as a part of the antiretroviral therapy (HAART) (n 21); and group 3, immunosuppressed HBV-infected patients after kidney

transplantation (n 5) (mean time after kidney transplantation, 163 118 months; range, 1-218 months). None of the adefovir-treated patients had comorbidity features. Treatment duration ranged from 72 to 130 weeks (between December 2001 and June 2004) in the tenofovir group and from 60 to 80 weeks (between November 2002 and June 2004) in the adefovir group. Lamivudine treatment was continued for 1 year in 10 of the 21 HBV/HIV coinfected patients receiving tenofovir; all other patients stopped lamivudine with the beginning of tenofovir or adefovir treatment. The patients in our study were enrolled consecutively according to the availability of tenofovir and adefovir. Consequently, the tenofovir-treated patients were included rst, whereas the adefovir-treated patients were enrolled with the start of the early access program in November 2002. In 5 of the 9 tenofovir group 1 patients and in 5 of the 18 adefovir-treated patients, HBV DNA was measured at baseline as well as days 0.5, 1, 2, 4, 7, 14, 21, 28, and 35. These patients were matched for age (48.6 years vs. 46 years), sex (all male), ALT levels (all 2 times the upper limit of normal; mean ALT 147 U/L vs. 87 U/L), hepatitis B e antigen (HBeAg) status (all HBeAg-positive), and HBV DNA level at baseline (mean, 1.3 109copies/mL vs. 0.9 109copies/mL; P values not signicant for all comparisons between the tenofovir and adefovir groups). These patients were also consecutively selected during the adefovir early access program. Methods. Serum HBV DNA was measured before and during the treatment period using the Roche Amplicor (linear dynamic range, 400 to 200,000 copies/mL; Roche Diagnostic Systems, Branchburg, NJ). Samples with HBV DNA greater than 200,000 were diluted to

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Fig. 1. Early HBV DNA kinetics during the rst 35 days in patients treated with either tenofovir (n 5) or adefovir (n 5). At day 35 the differences between the two groups were not statistically signicant (P .085). Large symbols represent mean values; small symbols show individual patient data. HBV, hepatitis B virus.

achieve the absolute level of viral DNA. For all patients, HBV DNA levels were measured at baseline and every consecutive week until week 4, then every consecutive month during treatment. YMDD mutants of HBV were detected using the Inno LiPa Line probe assay (Innogenetics, Gent, Belgium). Statistical Analysis. Statistical data analysis was performed using SPSS Inc. for Windows, release 11.0 (Chicago, IL). Correlation of continuous variables was calculated using a non-parametric test (Mann-WhitneyWilcoxon test); categorical data were analyzed using the two-sided Fisher exact test and cross tables employing Yatescorrected chi-square test. To determine changes of HBV DNA in serum, HBV DNA initially measured in copies/mL was calculated into logarithmic scales. Because of the lower limit of detection of 400 copies/mL, undetectable HBV DNA is equivalent to 2.6 log10.

patients (mean HBV DNA decline at week 48, 5.6 vs. 2.5 log10 copies/mL; P .0001). Pronounced individual variations in the decline of HBV DNA were observed in the adefovir-treated patients but not in the patients receiving tenofovir. Thus, at week 24, 5 patients (28%) from the adefovir group showed a decline of less than 1 log10, 6 patients (33%) showed a decline between 1 and 3 log10, and 7 patients (39%) showed a decline greater than 3 log10 copies/mL. At week 48, 5 patients (28%) showed a decline of less than 1 log10, 3 patients (17%) showed a decline between 1 and 3 log10, and 10 patients (55%) showed a decline greater than 3 log10 copies/mL. Individual variations of HBV decrease were not inuenced by baseline ALT levels (data not shown). ALT levels normalized more rapidly in the tenofovir group than in the adefovir group (week 24, 69% vs. 53%, P value not signicant; week 36, 87% vs. 50%, P .006; week 48, 85% vs. 57%, P .008). No major clinical side effects were reported during treatment with either tenofovir or adefovir. Creatinine levels were 0.97 0.42 mg/dL (range, 0.6-2.4) at baseline versus 1.1 0.56 (range, 0.66-2.8) at week 48 in the tenofovir group (P .12), and 0.98 0.47 mg/dL (range, 0.61-2.46) versus 1.2 0.68 mg/dL (range, 0.692.96) in the adefovir group (P .27). Phosphate levels were 1.06 0.55 (range, 0.67-2.6) at baseline versus 1.08 0.62 (range, 0.75-2.6) at week 48 in the tenofovir group (P .24) and 0.91 0.19 mg/dL (range, 0.57-

Results
Antiviral Effect of Tenofovir Versus Adefovir. Early viral kinetics were conducted in 5 of the 35 and 5 of the 18 patients receiving tenofovir or adefovir, respectively. The decline of HBV DNA levels followed for 35 days was faster in the tenofovir-treated patients (2.9 log10 vs. 1.9 log10 copies/mL at day 35; P .085) (Fig. 1). This effect of a more pronounced suppression of HBV DNA levels reached statistical signicance when all 53 patients were analyzed (Fig. 2). Thus, the percentage of patients showing a viral decline to a level of less than 105 copies/mL or below the limit of detection at weeks 12, 24, and 48 was signicantly higher in the tenofovir group than in the adefovir group (Fig. 3). These ndings were not altered when we restricted our analysis to the HBeAg-positive

Fig. 2. Comparison of the reduction of HBV DNA under therapy with adefovir or tenofovir. In the tenofovir group (n 35), the reduction of HBV DNA was faster than in the adefovir group (n 18). At weeks 12, 24, 36, and 48, the tenofovir group showed a mean HBV DNA decline of 4.5 log10 copies/mL, 5.2 log10 copies/mL, 5.4 log10 copies/mL, and 5.5 copies/mL, respectively, compared with 2.2 log10 copies/mL, 2.6 log10 copies/mL, 3.0 log10 copies/mL, and 2.8 copies/mL, respectively, in the adefovir group (P .001). Data are given as mean values; error bars indicate standard deviation. HBV, hepatitis B virus.

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Fig. 3. Percentage of adefovir- and tenofovir-treated patients with HBV DNA decline to a level of 105 copies/mL or 400 copies/mL at weeks 12, 24, 36, and 48, respectively. Statistically signicant differences (P .001) are marked with asterisks. HBV, hepatitis B virus.

1.22) versus 0.9 0.25 mg/dL (range, 0.71-1.3) in the adefovir group (P .23). No signicant individual aggravations of laboratory parameters were observed. Long-Term Effect of Tenofovir. The 35 tenofovirtreated patients were followed for up to 130 weeks. In all of these patients, HBV DNA levels became undetectable within 44 weeks of treatment and remained undetectable during the observation period. Phenotypic resistance to tenofovir could not be observed. HBeAg loss occured in 11 (35%) of 31 HBeAg-positive patients, and HBsAg loss occurred in 5 tenofovir-treated patients (14%; 2 patients each from group 1 and 2 and 1 patient from group 3) after a mean treatment duration of 44 weeks (range, 24-76 weeks) and 59 weeks (range, 36-100 weeks), respectively. In the adefovir group, 3 (19%) of 16 HBeAg-positive patients lost HBeAg and 1 patient (5.6%) lost HBsAg at weeks 56 (range, 40-68) and 60 Inuence of HIV Infection and Immunosuppressive Therapy on the Antiviral Effect of Tenofovir. No major differences in viral response between the three groups of tenofovir-treated patients could be demonstrated, although within the rst 4 weeks the viral decay slope was slower in the 5 patients after kidney transplantation (P .06). The rate of ALT normalization within the tenofovir subgroups was not signicantly different at weeks 12, 24, 36, or 48.

Discussion
The treatment options for chronic hepatitis B are still limited. The long-term application of lamivudine unfortunately is associated with a high risk of drug resistance. Adefovir has become the treatment of choice when lamivudine resistance develops. Our data suggest that tenofovir copes more effectively with the lamivudine-resistant virus population than adefovir (mean HBV DNA log decline of 5.5 at week 48 compared with a 2.8-log decline in the adefovir group). Our ndings are in accordance with

results from previous studies demonstrating a HBV DNA log decline of 3.1 to 3.65,6 and 3.8 to 4.9 in adefovir- and tenofovir-treated patients, respectively, at week 24.8 10,13 This kind of a rapid antiviral effect is of clinical interest especially in those situations in which patients develop fulminant HBV infection or severe HBV reactivation during drug resistance development.11 Complete suppression of HBV replication is an important goal for any kind of antiviral treatment to nally cure the infection (e.g., HBsAg loss). In this respect, tenofovir is superior to adefovir considering the fact that in all tenofovir-treated patients HBV DNA became negative compared with only approximately 44% of the adefovir group. Interestingly, 5 of the tenofovir-treated patients lost HBsAg. Adefovir and tenofovir are related molecules and most likely act in a similar way at the mutated polymerase of lamivudine-resistant HBV strains. Therefore, we believe that the different effects of these two drugs are rather a matter of the different dosages applied to these patients. Interestingly, a recent study treating HBV-infected patients with adefovir at 30 mg/d instead of 10 mg/d resulted in a reduction of viral load that was similar to the decline observed in our patients being treated with tenofovir at a dose of 300 mg.5 There are still some observations that are difcult to explain. Some of the patients treated with adefovir exhibited the same dynamic of viral response as the patients receiving tenofovir, while in other adefovir-treated patients the antiviral response was much weaker or even absent. One could argue that these patients simply need a higher dosage of adefovir to overcome the weakened responsiveness; however, alterations of drug absorption and metabolism must also be considered. In view of recent observations describing the development of HBV strains resistant to adefovir,15 it would certainly be of interest to evaluate whether tenofovir may be

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superior to adefovir with respect to the avoidance of drug resistance. Level of HBV DNA suppression may be critical when the chance to develop drug resistance is considered. The observed HBV kinetic during tenofovir treatment makes development of tenofovir resistance unlikely. Tolerability of tenofovir seems to be excellent independently, whether it is applied to patients with or without HIV coinfection or even in those being immunosuppressed after kidney transplantation. Regarding the strong antiviral activity of tenofovir on both HIV and HBV and the increasing importance of tenofovir in the antiviral therapy of HIV infection, tenofovir may become the treatment of choice in HIV/HBV coinfected patients. Our data suggest that tenofovir has a stronger antiviral activity than adefovir and therefore could serve as an important new therapeutic tool for the induction of complete remission in patients with lamivudine-resistant HBV infection. A large-scale clinical trial therefore seems justied to obtain more insight into the antiviral activity of tenofovir.

References
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