Intravenous silibinin monotherapy shows significant antiviral

20 Pages·2012·0.94 MB·English

by  Zoe Mariño

Accepted Manuscript
Intravenous silibinin monotherapy shows significant antiviral activity in HCV-
infected patients in the peri-transplantation period
Zoe Mariño, Gonzalo Crespo, Massimo D’Amato, Nadia Brambilla, Giampaolo
Giacovelli, Lucio Rovati, Josep Costa, Miquel Navasa, Xavier Forns
PII: S0168-8278(12)00768-4
DOI: http://dx.doi.org/10.1016/j.jhep.2012.09.034
Reference: JHEPAT 4435
To appear in: Journal of Hepatology
Received Date: 7 August 2012
Revised Date: 7 September 2012
Accepted Date: 10 September 2012
Please cite this article as: Mariño, Z., Crespo, G., D’Amato, M., Brambilla, N., Giacovelli, G., Rovati, L., Costa, J.,
Navasa, M., Forns, X., Intravenous silibinin monotherapy shows significant antiviral activity in HCV-infected
patients in the peri-transplantation period, Journal of Hepatology (2012), doi: http://dx.doi.org/10.1016/j.jhep.
2012.09.034
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Intravenous silibinin monotherapy shows significant antiviral activity in
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2 HCV-infected patients in the peri-transplantation period.
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7 Zoe Mariño1, Gonzalo Crespo1, Massimo D’Amato2, Nadia Brambilla2,
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9 Giampaolo Giacovelli2, Lucio Rovati2, Josep Costa3, Miquel Navasa1, Xavier
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12 Forns1
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17 1 Liver Unit, Hospital Clinic. CIBERehd, IDIBAPS. Barcelona, Spain;
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19 2 Rottapharm SpA, Monza, Italy;
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3 Microbiology Unit, Hospital Clinic. CIBERehd, IDIBAPS. Barcelona, Spain.
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29 Address correspondence to:
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Xavier Forns, MD
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Liver Unit
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34 Hospital Clinic
35 Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de
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Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas
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(CIBERehd)
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Villarroel 170
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40 08036
41 Barcelona
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[email protected]
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46 Electronic word count: 3713
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48 Number of Tables: 2
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Number of Figures: 2
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Abbreviations: HCV: hepatitis C virus; SIL: silibinin; IV: intravenous; LT: liver
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55 transplantation; VL: viral load; RNA: ribonucleic acid; CVR: complete virological
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57 response; SVR: sustained virological response; PVR: partial virological
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59 response; PCR: Polymerase Chain Reaction; LOQ: limit of quantification; LOD:
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limit of detection; SAEs: serious adverse events; AEs: adverse events; NS5B:
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non-structural protein 5B; MELD: model for end-stage-liver-disease.
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6 Conflicts of interest: The authors of this manuscript have no conflicts of
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8 interest to disclose. XF received unrestricted grant support from Roche and
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MSD. Co-authors Massimo D’Amato, Nadia Brambilla, Giampaolo Giacovelli,
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13 Lucio Rovati are scientists from the Department of Clinical Pharmacolog y of
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Rottapharm|Madaus and agreed individually to be listed as co-authors due to
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18 their involvement in the study and in the manuscript preparation; there was no
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other involvement of the sponsor as a corporate entity in the manuscript
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23 preparation.
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Financial support: ZM received foundation by CIBERehd and Fundación
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28 BBVA. CIBERehd is funded by the Instituto de Salud Carlos III and the
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30 Ministerio de Economía y Competitividad, Spain. GC was supported by Hospital
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Clínic (Ajut a la Recerca Josep Font) and Fundación BBVA. MN and XF
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35 received support, in part, by grants from the Instituto de Salud Carlos III,
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Ministerio de Economía y Competitividad (PI 10/01551 and PI11/01907), co-
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40 funded by the European Regional Development Fund (ERDF), Unión Europea,
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Una manera de hacer Europa. Rottapharm|Madaus is the sponsor of the study
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45 and the manufacturer of the preparation tested in this study. This was a trial
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47 conducted for regulatory purposes and received therefore full financial support
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from the sponsor Rottapharm|Madaus.
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Abstract
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2 Background and Aims: Hepatitis C recurrence after liver transplantation (LT)
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is the main problem of most transplant programs. We aimed to assess the
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7 antiviral activity and safety of intravenous silibinin (SIL) administered daily
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during the peri-transplant period. Methods: This was a single-centre,
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12 prospective, randomized, double-blind, placebo-controlled study including 14
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HCV-infected patients awaiting LT. Eleven patients received SIL and 3 placebo,
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17 for a maximum of 21 days before LT and 7 days after LT. Results: Among the
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19 patients who received more than 14 days of pre-LT treatment, the median
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decrease in viral load (VL) was 2.31 log (range 0.6-4.2) in the SIL-treated
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24 group (n=9) versus 0.30 log (0.1-0.6) in the placebo group (n=3) (p=0.016).
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During the post-LT treatment, HCV-RNA levels were consistently and
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29 significantly (p=0.002) lower in the SIL group compared to placebo and
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decreased below the limit of quantification in 2 patients and below the limit of
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34 detection in 2 additional patients (all in the SIL-treated group). Peri-transplant
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36 treatment with SIL was well tolerated. Conclusions: This proof-of-concept
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study in patients in the waiting list for LT indicates that daily intravenous silibinin
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41 has evident antiviral properties and is well tolerated in the peri-LT period. A
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longer treatment regimen with silibinin (alone or in combination with other
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46 agents) should be assessed in clinical trials for the prevention of hepatitis C
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recurrence.
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Introduction
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Liver transplantation (LT) is the treatment of choice for HCV-infected patients
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7 with end-stage liver disease or hepatocellular carcinoma. Unfortunately,
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infection of the graft occurs universally in patients with detectable HCV-RNA at
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12 the time of LT [1]. Moreover, hepatitis C recurrence leads to graft cirrhosis in a
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significant proportion of patients within the first years after transplantation [2].
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17 Eradication of hepatitis C virus before, or inhibition of HCV replication after LT,
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19 are among potential strategies to prevent hepatitis C recurrence in the graft [3].
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Nevertheless, pegylated interferon and ribavirin therapy in patients awaiting LT
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24 has a low applicability and efficacy, as well as numerous adverse events (some
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of them life-threatening) [4, 5]. In addition, interferon cannot be administered
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29 immediately following LT.
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34 Ferenci et al [6] have recently shown potent dose-dependent antiviral activity of
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intravenous silibinin in patients with chronic hepatitis C not responding to prior
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standard antiviral therapy. Moreover, treatment was safe, with only a transient
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41 increase in serum bilirubin levels in accordance to that observed in different
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publications [7, 8].
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In this study, we explored the antiviral efficacy and safety of intravenous silibinin
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Patients and methods
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2 This is a single-centre, prospective, randomized, double-blind, placebo-
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controlled study (NCT01535092). HCV-infected patients enlisted for LT due to
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7 end-stage liver disease or hepatocellular carcinoma were considered to
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participate in the study protocol. Detailed inclusion and exclusion criteria are
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12 shown in the supplemental methods section. The aim of the study was to
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determine if Legalon® SIL was effective in the prevention of HCV graft infection,
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17 i.e. to induce a complete virological response [CVR] (defined as undetectable
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19 HCV at any time during the study, potentially including sustained virological
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response - SVR), or at least, to induce a partial virological response (PVR, ≥ 2
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24 log viral load decrease). Finally, we aimed to assess the safety profile and
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tolerability of the drug.
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Patients were randomized to receive 20 mg/kg/day IV Legalon® SIL
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34 (Rottapharm|Madaus, Monza, Italy) or placebo according to a 3:1 active: control
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ratio for a maximum of 21 consecutive days before LT (Pre-LT treatment
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period). Treatment was started when, based on the historical data of our center
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41 waiting list, we estimated that LT was likely to occur in less than one month.
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The latter was considered likely when patients from blood groups 0 and A
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46 reached the second or third position in the waiting list. At this point, patients
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were given information and were asked to consent to study participation. In
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51 addition to pre-LT treatment, patients received treatment for further 7 days after
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LT starting on the same day of the surgical procedure (from day 0 to day 6 after
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56 LT; Post -LT treatment period), totalling a maximum of 28 days of treatment with
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58 Legalon® SIL/ placebo. Infusions were administered daily in the hospital over 2-
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4 hours under the supervision of a nurse. Clinical and laboratory assessments
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2 were performed daily during the treatment period; viral load (VL) was
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determined at every visit by real time PCR (COBAS TaqMan HCV Test, v2.0
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7 Roche Molecular System Inc Branchburg, NJ 08876 USA; LOQ 25 IU/mL, LOD
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15 IU/mL) according to the protocol schedule (see supplemental methods
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12 section). Patients were then followed up for 24 weeks after LT (Follow-up
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period). The study was approved by the Ethics Committee of the Hospital Clinic
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17 of Barcelona and all patients gave written informed consent before screening.
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During the study period (September 2010- October 2011) 46 HCV-infected
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24 patients underwent LT in our unit; 16 patients consented to participate and were
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screened for the study. Out of the 16 patients included, 14 were randomized to
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29 receive IV SIL (n=11) or placebo (n=3) and they all received at least one dose
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of study medication (median: 20 days, range 1- 21). Twelve of these patients (9
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34 SIL; 3 placebo) were treated for ≥14 consecutive days during the pre-LT period.
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Three (3) patients randomized to SIL withdrew from the study before LT: 1
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patient died due to hepatocellular carcinoma progression and 2 others withdrew
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41 due to a serious adverse event (SAE) (n= 1) or an adverse event (AE) (n= 1)
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(Table 2). Therefore, 11 of the 14 patients underwent LT. One (1) additional
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46 patient was then withdrawn from the study 2 days after LT due to primary graft
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failure, leading to 10 randomized patients undergoing LT and completing the
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51 post-LT period. These 10 patients constitute the prospectively defined Intention-
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to-Treat Population (subgroup of Transplanted patients) for the efficacy analysis
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medication (Safety Population) (Figure 1). The key characteristics of the study
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7 Results
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Efficacy analysis
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12 The median VL decrease from baseline to the end of pre-LT treatment in the
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SIL group (n=9) was 2.31 log (0.6-4.2) versus 0.30 log (0.1-0.6) for the
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17 placebo group (n=3) (p=0.016, Mann-Whitney U test). Interestingly, at the end
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19 of the pre-LT treatment period 6 (67%) patients in the SIL group achieved a ≥ 2
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22 log decrease in viral load (PVR) versus no patient in the placebo group (p=
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24 0.18, Fisher Exact Test). In one patient HCV-RNA levels decreased below the
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LOD and in a second one below the LOQ, both in the SIL group (Figure 1 and
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29 Table 1).
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The time interval between the end of pre-LT treatment and LT ranged between
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34 0 and 38 days. Only 3 patients (all in SIL group – Table 1 and Figure 2)
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underwent LT while on therapy. In those patients in whom there was a gap
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39 between pre-LT and post-LT treatment, the VL increased again (Figure 2A).
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Already with the first infusion after LT (day 0 = day of LT), VL was lower in the
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44 SIL group (n=7) compared to placebo (n=3) and remained consistently lower
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measurements ANOVA) (Figure 2B). At the end of the post-LT treatment period
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51 VL was 1.95±1,13 (log UI/mL, mean ± SD) in SIL and 3.87±1.57 in placebo
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treated patients; in other words, VL was ≥2 log lower than at the screening time
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Exact Test, p=0.008). Interestingly, VL was below LOQ in 4 of the 7 SIL-treated
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patients versus none in the placebo group, with 2 patients being even below
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As depicted in Figure 2B, VL increased after the end of the short post-LT
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7 treatment and, although numerically lower in the SIL group compared to
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placebo at all study time points (weeks 1-4, 8, 12 and 24 after LT), the
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12 differences were not statistically significant. No patient achieved SVR at the end
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of the study.
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19 Safety analysis
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Safety was analyzed in all 14 randomized patients receiving at least one dose
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24 of the study medication. The number and profile of AEs observed in this study
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was in line with those anticipated in patients awaiting LT or with the known
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29 pattern for SIL (e.g. heat sensation, chills, abdominal pain). Most of AEs were
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mild (76%) or not related to the study drug (74%) and more frequently reported
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34 during the pre-LT period (56%) (Table 2).
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A transient and reversible increase in bilirubin was observed in 1 patient that
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could be attributable to SIL. Overall, while bilirubin values in the placebo group
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41 (n= 3) remained fairly constant over time before LT, in patients in the SIL group,
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bilirubin levels increased from 3.8±3.7 at baseline to 4.7±4.0 mg/dl at the time of
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46 LT. Following LT, mean bilirubin values at the end of treatment were
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numerically higher in patients who received SIL than those receiving placebo
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study, total bilirubin values were similar between groups.
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Discussion
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Ferenci et al have recently shown potent dose-dependent antiviral activity of
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6 intravenous silibinin in patients with chronic hepatitis C not responding to prior
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8 standard antiviral therapy [6]. Moreover, HCV infection of the graft has been
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prevented by the administration of IV silibinin during the peritransplant setting in
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13 2 patients (one infected with genotype 3 and another with mixed 1a/4, bo th with
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baseline VL below 30000 UI/ml) [7, 8]. In vitro, silibinin has been shown to exert
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18 anti-HCV effects by direct inhibition of NS5B polymerase activity [9], as well as
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by blocking virus entry and transmission by targeting the host cell [10]. In a
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23 recently published study [11], viral kinetics modelling based on daily
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measurements of HCV VL in patients receiving IV SIL has supported both in
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28 vitro findings [9, 10], and suggested a major dose-dependent effect of silibinin
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cell spread). Thus, it appeared reasonable to explore the safety and efficacy of
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in a controlled study.
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41 Our study confirmed the potent antiviral activity of SIL in difficult to treat patients
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(i.e. decompensated cirrhotics). Viral load decreased > 2 log in two thirds of
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46 patients who underwent at least 2 weeks of SIL therapy before LT and reached
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levels below the LOQ in two of them. Due to logistics and safety reasons, pre-
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small proportion of patients underwent LT while on therapy. As expected, in a
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