MXPA01006161A - Ribavirin-pegylated interferon alfa induction hcv combination therapy - Google Patents

Abstract

The use of ribavirin and interferon alpha for the manufacture of pharmaceutical compositions for treating a patient having chronic hepatitis C infection, e.g., a patient having HCV genotype 1, 2 or 3, to eradicate detectable HCV-RNA by a method comprising administering an effective amount of ribavirin in association with an effective amount of pegylated interferon alpha, characterised in that treating patients having chronic hepatitis C infections is effected in two treatment time periods:(a) a first treatment time period of at least 20 to 30 wherein a therapeutically effective amount of ribavirin and a therapeutically effective induction dosing amount of pegylated interferon-alfa, e.g., pegylated interferon-alfa-2b sufficient to at least substantially lower, and preferably to eradicate, detectable HCV-RNA, are administered;and (b) a second treatment time period of at least 20 to 30 weeks wherein a therapeutically effective amount of ribavirin and a therapeutically effective amount of pegylated interferon-alfa are administered sufficient to maintian no detectable HCV-RNA for at least 20-30 weeks are administered after the end of the first treatment time period and to maintain no detectable HCV-RNA for at least 24 weeks after the end of the second treatment time period is disclosed.

Description

COMBINATION THERAPY FOR THE HEPATITIS C VIRUS BY INDUCTION OF RIBAVIRINA-INTERFERON ALPHA PEGILADO BACKGROUND OF THE INVENTION The present invention relates to the use of ribavirin, pegylated interferon alpha and combinations thereof, for the manufacture of pharmaceutical compositions for treating a patient with chronic hepatitis C infection to eradicate HCV RNA (Hepatitis C Virus) detectable by a method comprising administering an effective amount of ribavirin in association with an effective amount of pegylated interferon alpha, which is characterized by administering a therapeutically effective induction amount of ribavirin and a therapeutically effective induction amount of pegylated interferon alpha for a first sufficient treatment period to substantially reduce detectable HCV RNA, followed by (2) administering a therapeutically effective amount of ribavirin and a therapeutically effective amount of pegylated interferon alpha for a second treatment period sufficient to eradicate detectable HCV RNA at least at the end of the second treatment period and to keep HCV RNA undetectable, at least 24 weeks after the end of the second treatment period. Chronic infection with the hepatitis C virus is an insidious and slowly progressive disease that has a significant impact on the amount of life. It may eventually result in liver cirrhosis, liver decompensation disease and / or hepatocellular carcinoma. Int. Publication No. WO98 / 48840 discloses the use of pegylated interferon alpha to treat hepatitis C infections. Nieforth et al. (Clin Pharmacol Ther, 1996, 59: 636-646) has reported a comparison of in vivo activity of Roferon®A and Roferon®A modified with polyethylene glycol in healthy volunteers. The results, however, suggested that the conjugates could not be administered less than twice a week and therefore offered few therapeutic advantages over the unmodified counterpart. The commonly assigned co-pending patent application U.S. No. 08 / 742,305 discloses methods of administering polymeric cytokine conjugates to individuals susceptible to cytokine treatment, but does not disclose the method of this invention. Fuertges et al (Jornal of Controlled Reléase, 1990, Vol 11: 139-48) has reported the modification with polyethylene glycol of other proteins. The combination therapy of interferon alfa 2b and ribavirin to treat chronic C hepactitis for 24 weeks is revealed by Reichard et al. (Lancet 1998; 351; 83-87). T. Poynard et al. (Lancet, 1998, Vol. 352, 1426-1432) reveals that patients on chronic hepatitis C treatment, who had not been treated with interferon or ribavirin with 3 MIU of interferon alfa 2-b TIW plus 1000-1200 mg. of ribavirin per day for 48 weeks resulted in a sustained virological response at 24 weeks after treatment in 43% of patients. See also J. G. McHutchinson et al. (N. Engl. J. Med., 1998, 339: 1485-1492), G. L Davis et al. (N. Engl. Med. 339: 1493-1499) reveals that to treat patients with chronic hepatitis C who had relapsed after treatment with interferon with 3 MIU of interferon alpha 2-b Tim plus 100-1200 mg. of ribavirin per day for 48 weeks results in a higher percentage of sustained virological response than treatment with interferon alone. There is a need to provide improved therapy to treat patients with chronic hepatitis C to produce a sustained virological response at 24 weeks after treatment in a larger number of patients.

BRIEF DESCRIPTION OF THE INVENTION The present invention provides the use of ribavirin for the manufacture of a pharmaceutical composition for treating a patient having chronic hepatitis C infection to eradicate the detectable HCV RNA by a method comprising the administration of an effective amount of ribavirin in association with a effective amount of pegylated alpha interferon, characterized in that the treatment of patients who have chronic hepatitis C infections is carried out in two periods of treatment (a) a first treatment period, in which a therapeutically effective amount of ribavirin and an amount of induction dose are administered. Therapeutically effective of pegylated interferon alpha for a period sufficient to substantially decrease serum levels of the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, where a therapeutically effective amount of ribavirin and a therapeutically effective amount of pegylated interferon alfa are administered in a sufficient manner to eradicate the detectable HCV RNA, at least 20 to 30 weeks after the end of the first treatment period and to keep the HCV RNA undetectable for at least 24 weeks, after completion the second treatment period. The present invention also provides the use of pegylated interferon alpha for the manufacture of a pharmaceutical composition for treating a patient having chronic hepatitis C infection to eradicate the detectable HCV RNA by a method comprising administering an effective amount of interferon. pegylated alpha in association with an effective amount of ribavirin characterized in that the treatment of patients who have chronic hepatitis C infections is carried out in two periods of treatment (a) a first treatment period, in which a therapeutically effective amount of ribavirin is administered and a therapeutically effective induction dose amount of pegylated interferon alpha, for a period sufficient to substantially decrease the serum levels of the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, wherein an amount therapeutically effective of ribavirin and a therapeutically effective amount of pegylated interferon alpha is administered in a manner sufficient to eradicate the detectable HCV RNA for at least 20 to 30 weeks after the end of the first treatment period and to keep the HCV RNA undetectable for at least 24 weeks after the end of the second treatment period. The present invention also provides the use of ribavirin and pegylated interferon alpha for the manufacture of pharmaceutical compositions for treating a patient with chronic hepatitis C infection to eradicate detectable HCV RNA, by a method comprising administering an effective amount of pegylated alpha interferon in association with an effective amount of ribavirin in association with an effective amount of pegylated interferon alpha characterized in that the treatment of patients suffering chronic hepatitis C infections is carried out in two periods of treatment (a) a first period of treatment, in which a therapeutically effective amount of ribavirin and a therapeutically effective induction dose amount of pegylated interferon alpha are administered, for a period sufficient to substantially decrease the serum levels of the detectable HCV RNA and b) a second period of treatment of al men 20 to 30 weeks, during which a therapeutically effective amount of ribavirin and a therapeutically effective amount of pegylated interferon alpha are administered in a manner sufficient to eradicate the detectable HCV RNA for at least 20 to 30 weeks after the end of the first period of treatment and to keep HCV RNA undetectable for at least 24 weeks after the end of the second treatment period. The present invention also provides the use of ribavirin for the manufacture of a pharmaceutical composition for treating a patient having a chronic hepatitis C infection, in order to eradicate the detectable HCV RNA, by a method comprising the administration of an effective amount. of ribavirin in association with an effective amount of pegylated interferon alpha, characterized in that the treatment of patients having chronic hepatitis C infections, is carried out in two periods of treatment (a) a first treatment period, in which a therapeutically effective amount of ribavirin and a therapeutically effective amount of induction dose are administered. effective pegylated alpha interferon for a period sufficient to eradicate the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, during which a therapeutically effective amount of ribavirin and a therapeutically effective amount of Pegylated alpha interferon, in a form sufficient to keep HCV RNA undetectable, for at least 20 to 30 weeks after the end of the first treatment period and to keep HCV RNA undetectable for at least 24 weeks, after end the second treatment period. The present invention also provides the use of pegylated interferon alpha for the manufacture of a pharmaceutical composition for treating a patient having a chronic hepatitis C infection, in order to eradicate the detectable HCV RNA, by a method comprising the administration of a effective amount of pegylated interferon alpha in association with an effective amount of ribavirin, characterized in that the treatment of patients who have chronic hepatitis C infections is carried out in two periods of treatment (a) a first treatment period, in which they are administered a therapeutically effective amount of ribavirin and a therapeutically effective induction dose amount of pegylated interferon alpha for a period sufficient to eradicate the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, during which time administer a therapeutically effective amount of ribavirin and a therapeutically effective amount of pegylated interferon alpha, in a form sufficient to maintain the non-detectable HCV RNA, for at least 20 to 30 weeks after the end of the first treatment period and for keeping the HCV RNA undetectable for at least 24 hours. weeks after finishing the second treatment period. The present invention also provides the use of ribavirin and pegylated interferon alpha for the manufacture of pharmaceutical compositions for treating a patient having a chronic hepatitis C infection, in order to eradicate the detectable HCV RNA, by a method comprising administration of an effective amount of ribavirin in association with an effective amount of pegylated interferon, characterized in that the treatment of patients having chronic hepatitis C infections is carried out in two periods of treatment (a) a first treatment period, in the which a therapeutically effective amount of ribavirin and a therapeutically effective induction dose amount of pegylated interferon alpha are administered for a period sufficient to eradicate the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, during which is administered a therapeutically effective amount of ribavirin and a therapeutically effective amount of pegylated interferon alga, in a manner sufficient to maintain the non-detectable HCV RNA, for at least 20 to 30 weeks after the end of the first treatment period and to keep the HCV RNA undetectable during at least 24 weeks, after the end of the second treatment period. The present invention also provides the use of both ribavirin and pegylated interferon alpha for the manufacture of pharmaceutical compositions for the treatment of a patient having chronic hepatitis C infection to eradicate the detectable HCV RNA, by a method comprising the administration of an effective amount of ribavirin in association with an effective amount of pegylated interferon alpha characterized by the treatment of patients who have chronic hepatitis C infections, a first treatment period of approximately four weeks is carried out in two treatment periods (1), in which approximately 400-1200 mg are administered. - per day, preferably approximately 800-1200 mg. per day, of ribavirin and approximately 1.5 micrograms per kilogram of pegylated interferon alfa-2b twice a week; 2) a second treatment period of approximately up to forty-four weeks, during which approximately 800-1200 mg are administered. per day of ribavirin and approximately 1.0 to 1.5 micrograms per kilogram of pegylated interferon alfa-2b twice a week. The present invention also provides for the use of both ribavirin and pegylated interferon alpha for the manufacture of pharmaceutical compositions for the treatment of a patient having chronic hepatitis C infection to eradicate detectable HCV RNA by a method comprising the administration of an effective amount of ribavirin in association with an effective amount of pegylated interferon alpha characterized in that the treatment of patients having chronic hepatitis C infections is effected in two periods of treatment (1) a first treatment period of approximately at least four a approximately twelve weeks, during which period approximately 400-1200 mg are administered. per day, preferably about 800-1200 mg. per day, of ribavirin and approximately 1.5 micrograms per kilogram of pegylated interferon alfa-2 twice a week; 2) a second treatment period of approximately from about thirty-six to about forty-four weeks, during which approximately 800-1200 mg are administered. per day of ribavarin and approximately 0.5 to 1.5 micrograms per kilogram once a week, preferably approximately 1.0 to 1.5 micrograms per kilogram of pegylated interferon alfa-2b once a week.

DETAILED DESCRIPTION The present method of treating patients who have chronic hepatitis C infection comprises two periods of treatment. In the first treatment period, a therapeutically effective induction dosing amount of ribavirin and a therapeutically effective induction dosage amount of pegylated interferon alba are administered during a first treatment period sufficient to substantially decrease serum levels in the RNA of the detectable HCV, preferably by a power of 10, more preferably by at least two powers of 10, ie, at least 102, less than the initial serum level of HCV RNA. In a preferred embodiment of the present invention, the HCV RNA is eradicated (ie, it is decreased to less than 100 copies / ml), during the first treatment period. In the second treatment period, the method comprises administering a therapeutically effective amount of ribavirin and an effective therapeutic amount of pegylated interferon alpha to eradicate the HCV RNA at least at the end of the second treatment period and to maintain the HCV RNA not detectable, for at least 24 weeks after the end of the second treatment period. In a preferred embodiment of the present invention, HCV RNA is eradicated (i.e., decreased to less than 100 copies / ml) during the second treatment period and more preferably at the end of the first treatment period; in this preferred embodiment, the level of HCV RNA is not detectable during the second treatment period. The sum of the periods of the first and second treatment is approximately 40-50 weeks, preferably 48 hours. The amount of administrative ribavirin in the first treatment period is 400 to 1600 mg per day, preferably 600 to 1200 mg / day or approximately 800 to 1200 mg / day and more preferably approximately 1000 to 1200 mg / kg per day. . The amount of ribavirin administered in the second treatment period is in the range of about 800 to 1200 mg per day, preferably about 1000 to 1200 mg per day. The following preferred embodiments are presented for administering pegylated interferon alpha. When the pegylated interferon alpha administered is a pegylated alpha 2 -b interferon, the amount of induction dose of pegylated interferon alfa-2b that is provided in the first treatment period is in the range of 0.5 to 1.5 micrograms per kilogram twice a week (BIW) for at least twelve weeks, and the amount of pegylated interferon alfa-2b administered in the second treatment period is in the range of 0.5 to 1.5 micrograms per kilogram once a week (QW) for thirty-six to forty-four weeks. When the pegylated interferon alfa administered is a pegylated alpha 2 -b interferon, the amount of induction dose of pegylated interferon alfa-2 administered in the first treatment period is in the range of 0.5 to 1.5 micrograms per kilogram twice per week (BIW) for twelve weeks and the amount of pegylated interferon alfa-2b administered in the second treatment period is in the range of 0.5 to 1.5 micrograms per kilogram once a week (QW) for thirty-six weeks When the pegylated interferon alpha that is administered is a pegylated alpha 2 -b interferon, the amount of induction dose of pegylated interferon alfa-2b administered in the first five-week treatment period is in the range of 0.5 to 1.5 micrograms per kilogram (BIW) (preferably 1.5 microgram per kilogram of BIW) for one week, followed by 0.5 to 1.0 microgram per kilogram of BIW (preferably 1.0 microgram per kilogram of BIW) for four weeks and the amount of pegylated interferon alfa.2b administered in the second treatment period of forty-three weeks, it is in the range of 0.5 to 1.5 micrograms per kilogram once a week, preferably 0.5 to 1.0 micrograms per kilogram once a week.

When the pegylated alpha interferon administered is a pegylated alpha 2 -b interferon, the amount of induction dose of pegylated interferon alfa-2b administered in the first treatment period is in the range of 1.5 micrograms per kilogram of BIW for four weeks and the amount of pegylated interferon alfa.2b administered in the second treatment period is in the range of 0.5 micrograms per kilogram once a week for up to forty-four weeks. When the pegylated interferon alfa administered is a pegylated interferon alfa-2b, the amount of induction dose of pegylated interferon alfa-2b administered in the first treatment period of five weeks is in the range 1.5 micrograms per kilogram BIW for one week, followed by 1.0 micrograms per kilogram BIW for four weeks and the amount of pegylated interferon alfa-2b administered in the second treatment period from thirty-six to forty-four weeks, is in the range of 0.5 at 1.0 micrograms per kilogram once a week. When the pegylated interferon alfa administered is a pegylated alpha 2 -b interferon, the amount of induction dose of pegylated interferon alfa-2b administered in the first treatment period is 1.5 micrograms per kilogram BIW for twelve weeks and the amount of Pegylated interferon alfa-2b administered in the second treatment period is in the range of 1.0 micrograms per kilogram once a week for thirty-six weeks. When the pegylated interferon alpha that is administered is a pegylated alpha 2-a interferon, the amount of induction dose of pegylated interferon alfa-2a administered in the first treatment period is in the range of 20 to 250 micrograms BIW, preferably 90 at 180 micrograms BIW, for at least four weeks and the amount of pegylated interferon alfa-2b administered in the second treatment period is in the range of 20 to 250 micrograms once a week (QW), preferably 90 at 180 micrograms QW for up to forty four weeks. When the pegylated interferon alpha that is administered is a pegylated alpha 2-a interferon, the amount of induction dose of pegylated interferon alfa-2a administered in the first treatment period is in the range of 20 to 250 micrograms BIW, preferably 90 at 180 micrograms BIW, for at least four to twelve weeks and the amount of pegylated interferon alfa-2b that is administered in the second treatment period, is in the range of 20 to 250 micrograms once a week, preferably 90 a 180 micrograms QW for thirty six to forty four weeks. When the pegylated interferon alpha administered is a pegylated alpha 2-a interferon, the amount of induction dose of pegylated interferon alfa-2a administered in the first treatment period is in the range of 20 to 250 micrograms BIW for one week, preferably from 90 to 180 micrograms BIW for one week, followed by 20 to 200 micrograms BIW for four weeks, preferably 90 to 180 micrograms BIW for four weeks and the amount of pegylated interferon alfa-2a administered in the second treatment period , is in the range of 20 to 250 micrograms once a week (QW), preferably 90 to 180 micrograms QW for forty-three weeks. When the pegylated interferon alpha administered is a pegylated alpha 2-a interferon, in the first treatment period, the amount of induction dose of pegylated interferon alfa-2a administered is in the range of 20 to 250 micrograms BIW, preferably from 90 to 180 micrograms BIW for twelve weeks and the amount of pegylated interferon alfa-2a administered in the second treatment period is in the range of 20 to 250 micrograms per week on a weekly basis (QW), preferably from 90 to 180 micrograms QW for thirty six weeks. The term "pegylated interferon alpha" as used in the present invention, means conjugates of interferon alpha modified with polyethylene glycol, preferably interferon alpha-2 a and -2 b. The preferred conjugate polyethylene glycol-interferon to a! Fa-2b is PEG? 20oo-interferon alpha-2b. The phrases "conjugated alpha interferon of polyethylene glycol with molecular weight 12,000" and "PEG12000-IFN alpha", as used in the present invention, mean conjugates such as are prepared according to the methods of the international application No. WO 95 / 13090 and containing urethane linkages between the amino groups of interferon alfa-2a or -2b and polyethylene glycol having an average molecular weight of 12,000. The preferred interferon alpha-2b PEG12000 is prepared by adhesion of a PEG polymer to the epsilon amino group of a lysine residue in the IFN alpha-2b molecule. A single PEG12000 molecule is conjugated to free amino groups in an IFN alpha-2b molecule via a urethane linkage. This conjugate is characterized by the molecular weight of PEG-α20 or adhered. The PEG? 20oo-IFN alpha-2b conjugate is formulated by a lyophilized powder for injection. The goal of conjugation of IFN alpha with PEG is to improve the administration of the protein to significantly prolong the half-life of the plasma and thus provide an extensive amount of IFN alpha. The term "interferon alpha", as used in the present invention, means the family of specific proteins of highly homologous species that inhibit viral replication and cell proliferation and modulate the immune response. Typical alpha alpha interferons include, but are not limited to, recombinant interferon alfa-2b, such as Intron-A interferon available from Schering Corporation, Kenilworth, NJ, recombinant interferon alfa-2a, such as the interferon Roferon available from Hoffmann-La Roche, Nutley, NJ recombinant interferon alpha-2c, such as interferon alpha 2 Berofor from Boeheringer Ingelheim Pharmaceutical, Inc. Ridgefield, CT., interferon alpha-n1, a purified combination of natural alpha interferons, such as Sumiferon available from Sumitomo, Japan, or as interferon alfa-n1 Wellferon (INS) available from the Glaxo-Wellcome Ltd., London, Great Britain, or a consensus alpha interferon, such as those described in the US patent Nos. 4,897,471 and 4,695,623 (especially examples 7, 8 and 9 thereof) and the specific product available from Amgen, Inc. Newbury Park, CA or interferon alfa-n3 a mixture of natural alpha interferons manufactured by Interferon Sciences and available of Purdue Frederick Co. Norwalk, CT, under the Alferon brand. It is preferable to use interferon alfa-2a or alfa 2b. Because alpha interferon 2b, among all interferons, has the widest approval worldwide for treating chronic hepatitis C infection, it is the most preferred. The manufacture of interferon alfa 2b is described in the patent E.U.A. 4,530,901. Other alpha interferon conjugates can be prepared by coupling an alpha interferon to a water soluble polymer. A limited list of such polymers includes other polyalkylene oxide homopolymers, such as polypropylene glycols, polyoxyethylenated polyols, copolymers thereof and block copolymers thereof. As an alternative to the polyalkylene oxide-based polymers, effectively non-antigenic materials such as dextran, polyvinyl pyrrolidones, polyacrylamides, polyvinyl alcohols, carbohydrate-based polymers and the like can be used. Said alpha-polymeric interferon conjugates are described in U.S. Patent No. 4,766,106, U.S. Patent No. 4,917,888, EP Application No. 0236987, EP Application No. 0510356, 0563868, and 0809996 (Pegylated Interferon-alpha 2a), International Publication No. WO. 95/13090. The pharmaceutical composition of the pegylated interferon alpha suitable for parenteral administration can be formulated with a suitable buffer, for example Tris-HCL, acetate or phosphate, such as sodium dibasic phosphate / sodium phosphate monobasic buffer and pharmaceutically acceptable excipients (eg sucrose), vehicle (eg, serum albumin), toxicity agents (eg, NaCl), preservatives (eg, thimerosol, cresol) or benzyl alcohol) and surfactants (e.g., tween or polysorbates) in sterile water for injection. Pegylated interferon alpha can be stored as lyophilized powders under refrigeration at 2 ° -8 ° C. The reconstituted aqueous solutions are stable when stored at 2 ° to 8 ° C and used within 24 hours of reconstitution. See, for example, the E.U.A. Nos. 4,492,537; 5,762,923 and 5,766,582. The term "patient who has chronic hepatitis infections C ", as used in the present invention, means any patient with chronic hepatitis C and includes the treatment of" naive "patients, recurrent patients and patients who do not respond to treatment.These patients with chronic hepatitis C include those who are infected with chronic hepatitis C. multiple genotypes of HCV including type 1, as well as those infected with, inter alia, HCV genotypes 2 and / or 3, as well as HCV genotypes 2, 3, 4, 5 and / or 6 and other genotypes of VHC possible.

The term "naive patient treatment", as used in the present invention, means patients with chronic hepatitis C who were never treated with ribavirin or with any interferon, including without limitation interferon alpha, or pegylated interferon alpha. The term "recurrent", as used in the present invention, means patients with chronic hepatitis C who have had a relapse after the initial response to prior treatment with any interferon alone, or in combination with ribavirin. The term "unresponsive" patient as used in the present invention means patients with chronic hepatitis C who have not responded to a previous treatment with no interferon alone, or in combination with ribavirin. A person suffering from chronic hepatitis C infection may exhibit one or more of the following signs or symptoms: a) elevated ALT, b) positive test for anti-HCV antibodies, c) presence of HCV as demonstrated by a positive test for verify the presence of HCV RNA in the serum; d) clinical stigmas of chronic liver disease; and e) hepatocellular damage. In order to practice the invention, the combination therapy of pegylated interferon alpha and ribavirin is administered to the patient exhibiting one or more of the preceding signs or symptoms in the first and second periods of treatment in sufficient quantities to eliminate or at least alleviate one or more than the signs or symptoms. Ribavirin is administered to the patient in association with pegylated interferon alfa, ie the dose of pegylated interferon alfa is administered during the same period of time as the doses of ribavirin that the patient receives. Pegylated interferon alpha formulations are not effective when administered orally, therefore the preferred method for administering the pegylated interferon alpha is parenteral, preferably subcutaneously, IV, IM, injection. Ribavirin can be administered in capsule or oral tablet form in association with parenteral administration of pegylated interferon alpha. Of course, other types of administration of both drugs are contemplated as available, such as nasal spray, transdermally, by suppository, by sustained release dosage form, and by lung inhalation. Any form of administration will work to the extent that the appropriate doses are administered without destroying the active ingredient. The term "non-detectable HCV RNA" in the context of the present invention means that there are less than 100 copies of HCV RNA per ml of the patient's serum, as measured by Reverse Transcriptase (RT) RCP methodology. multiple cycle. The HCV RNA is preferably measured in the present invention by the methodology described below. This methodology is referred to in the present invention as HCV RNA / RCPq. The lower limit of detection of HCV RNA is 100 copies / ml. The RNA is extracted from the patient's serum using a mixture of guaninide thiocyanate-phenol-chloroform followed by precipitation of ethanol-ammonium acetate. The precipitated RNA is centrifuged and the resulting granule is dried in a Centrivap console (Labconco, Kansas City, Mo). The anhydrous granule is then resuspended in 30 microliters of a mixture of water treated with Rnasin (Promega Corpo, Madison, Wl), dithiitritol and diethyl pyrocarbonate. Samples are maintained at a temperature of -20 ° C or less from this temperature (preferably below -70 ° C) to reverse transcription of RNA (TI) and PCR. In order to convert the entire RNA sequence into cDNA in the TI ratio, random hexadeoxiribunucleotides (Pharmacia Biotech, Pisscataway, NJ) are used as primers for the synthesis of the first strand of cDNA. Two aliquots of 3 microliters of resuspended sample are added to 3 microliters of 100 ng / μl random primers and denatured at 70 ° C, then reverse transcribed at 40 ° C for one hour using inverse M-MLV reverse transcriptase (USB , Cleveland, OH) in standard buffer containing 5 mM MgCl2. The final reaction volume of TI is 26 μl. CPR begins immediately after reverse transcription. A modified version of the PCR method is developed using heat stable Taq polymerase to amplify the cDNA. 75 microliters of PCR mixture is added to the complete TI reaction volume (26 μl) at a final MgCl 2 concentration of 1.5 nM in a total volume of 101 μl. Each sample of 101 μl. It is then divided into 50.5 μl. And a layer of mineral oil is placed on top to prevent evaporation. The CPR cycle includes "alignment" for 90 seconds, during a period of 90 seconds. And denaturation of 90 sec., At 55 ° C, 74 ° C and 94 ° C, respectively. The thermocycling samples are subjected to a final extension of 74 ° C for 10 minutes. Four sets of different cycles are used. The sample is loaded in duplicate and these samples are divided evenly after the IT, there are four tubes for a sample. Each of the four tubes is given a different cycle number, increasing sensitivity and accuracy in the quantization process. The effectiveness of thermocycling can be evaluated by means of a satisfactory amplification of RNA standards by number of known copies that are included in each set of 60 tubes. The two sets of primers are used for amplification, both from the 5 'untranslated region of the HCV genome. These sets of primers are highly conserved and detect all known subtypes of HCV. Set of initiators 1: Upstream 5'-GTG GTC TGC GGA ACC GGT GAG T-3 '; downstream 5'-TGC ACG GTC TAC GAG ACC TC-3 'which produces a product of 190 bp. Set of initiators 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 electrophoresed on a 3% agarose gel and transferred to a nylon membrane. The target DNA is detected by Southern blotting and immunostaining using a DNA probe labeled with dihoxygenin. These procedures are developed using automatic instruments for PCR thermocycling, agarose gel electrophoresis, Southern blotting with vacuum transfer, hybridization and immunostaining. Each membrane contains standards serially diluted from the known number of copies that are used to interpret standard curves for the quantitative measurement of specimen bands. Original standard curves are made from carefully diluted HCV RNA from transcribed clones. The studies of radioactive incorporation, gel electrophoresis, and OD 260 are developed in the transcripts to determine that they are of the expected length. After the production of RNA transcripts will quantify clone standards, the combined standards that better represent the heterogeneous nature of HCV, which one would encounter in a natural infection, are generated. These standards are made by combining large amounts of serum or plasma from known infected individuals. These serum / plasma combinations are calibrated with PCR, against the transcripts of clones and then diluted in the known negative PCR-fluids. Finally, samples of higher copy numbers of the combined standards are checked against the quantiplex nucleic acid detection system of the cDNA from Chiron Inc. (Emeryville, CA). These double quantified combined standards are aliquoted and maintained at -70 ° C. Dilutions of 5,000,000, 1, 000,000, 5,000,000, 100,000, 10,000 and 1000 copies / ml are used in each experiment. Each Southern blotting membrane is scanned into a computer using an automatic scanner / densitometer, at intervals during development to determine when the standard curve is more linear. The resulting electronic images are then measured for average band density and band area. All readings are standardized at integrated band density and compared with the standard curve to obtain a numerical value of the number of viral copies for each band. The term "sustained virological response" as used in the context of the present invention means that there is no detectable HCV RNA in patients treated according to the present invention for at least 24 weeks after the end of the combination therapy treatment. Preferably, the period of sustained virological response will be at least one year or longer after the end of treatment. For the HCV genotype, a second-generation INNO-L PA VHC assay (Innogenetics, Zeijmaurde, Belgium) can be used. The following clinical protocol can be used to administer the combination therapy of the present invention: Complete design and study plan A parallel group can be used, distributed at random, multi-center, double invisible. Two treatment regimens were used. Study No. 1 compares the treatment with PEGylated Intro A, 1.5 micrograms per kilogram SC once a week (QW) in combination with ribavirin, 1000 to 1200 mg. Per day PO for four weeks followed by PEGylated Intro, 0.5 micrograms per kilogram SC once a week, in combination with ribavirin, 1000 to 1200 mg, per day PO for forty-four weeks of treatment with pegylated Intron A, 1.5 micrograms per kilogram SC in combination with ribavirin, 1000-1200 mg / day PO for forty-four weeks of treatment. Study No. 2 compares the treatment of pegylated Intron A 1.5 micrograms per kilogram SC BIW in combination with ribavirin, 1000-1200 mg / day PO for four weeks followed by Intro A 1, 5 micrograms / kilogram SC QW in combination with ribavirin, 1000-1200 mg / day PO for forty-four weeks for the REBETRON Combination Therapy treatment (Intron A, 3 MIU SC TIW in combination with ribavirin, 1000 to 1200 mg., Per PO day) for forty-eight weeks in patients with compensated chronic hepatitis C. Eligible patients are those 18-65 years of age, male and female subjects who would have chronic hepatitis C confirmed by positive HCV RNA, liver biopsy and laboratory tests. Assignments in treatment groups must be done in a randomization center (Central Randomization Center). The randomization procedure should be designed to balance the treatment groups, within the transverse sites, with respect to the presence or absence of cirrhosis in pretreatment liver biopsy, serum level of HCV / RCPq RNA and genotype of the VHC. During the follow-up of the treatment and after-treatment, biochemical (ALT), virological (HCV RNA) and histological (liver biopsy) tests should be performed in order to analyze the nature and duration of response to study the treatment. The variable of primary efficacy will be the complete response defined as loss of serum HCV / RCPq RNA (<100 copies / ml) as measured at 24 weeks after the end of therapy. In addition, the decrease in liver inflammation, improvement in post-treatment liver biopsy as measured by the Knodell Histology Activity (HAI) index and the normalization of ALT as extreme points of secondary efficacy will also be examined. The safety of the study treatments will be evaluated by monitoring selected laboratory parameters and also recording and evaluating the occurrence of any adverse event.

Treatment regimens There are two studies, each with two treatment regimens Study No. 1 1.- (a) INTRON ® A pegylated, 1.5 micrograms per kilogram SC once a week (QW) plus ribavirin 1000-1200 mg / kg / day PO in two divided doses for 5 weeks; followed by (b) INTRON ® A pegylated, 0.5 micrograms per SC INTRON ® A pegylate once a week (QW) plus ribavirin 1000-1200 mg / kg / day PO in two divided doses for 44 weeks. 2. (a) INTRON ® A pegylated, 1.5 micrograms per kilogram SC INTRON ® A pegylated once a week (QW) plus ribavirin 1000-1200 mg./kg./day PO in two divided doses for 44 weeks.

Study No. 2 3) (a) INTRON ® A pegylated, 1.5 micrograms per kilogram twice a week (BIW) plus ribavirin 1000-1200 mg./kg./day PO in two divided doses for 4 weeks; followed by (b) INTRON ® A pegylated, 1.5 micrograms per kilogram INTRON ® A pegylated once a week (QW) plus ribavirin 1000-1200 mg./kg./day PO in two divided doses for 44 weeks. 4. (a) INTRON ® A 3 MIU SC three times a week (TIW) plus ribavirin 1000-1200 mg./kg./day PO in two divided doses for 48 weeks. Studies 1 and 2 include treatments 1 and 2 and 3 and 4 should be administered for 48 weeks.

Exclusion criteria Patients who have chronic hepatitis C who should be excluded from treatment in accordance with the present invention include, inter alia, pregnant or breastfeeding women, those with hypersensitivity to pegylated interferon alfa or ribavirin; those with normal ALT in the screening or admission visit, as well as with any known pre-existing condition (for example, the pre-existing psychiatric condition, especially serious depression or a history of severe psychiatric disorder) that in the opinion of the intervening clinician interfered with the participation of the subject and the finalization of the protocol. The random distribution procedure can be designed to balance the groups with respect to the following baseline characteristics. - pretreatment liver histology (cirrhosis or non-cirrhosis); - HCV / RNA / RCPq status (HCV / RNA / RCPq <2,000,000 or VHC / RNA / RCPq (HCV / RNA / RCPq <2,000,000 copies / ml.) and - HCV / 1 genotype other). Patients with mixed genotypes (including type 1) are classified as type 1 for balance purposes.

Efficacy The primary efficacy objective is the proportion of sustained virological response as loss of HCV / RCPq RNA from the serum (detectable) measured at 24 weeks, after the end of therapy at a non-detectable level or at a level of < 100 copies / ml. The following extreme points of secondary efficacy will be examined: Extreme points of secondary efficacy: - proportion of patients with normalization of ALT at 24 weeks of follow-up. - proportion of patients with improvement in biopsy (categories l + II + III of combined results); - change of line due to the results of the biopsy (Categories l + II + III of combined results); - proportion of responses in the endpoints of nasal treatment in HCV / RCPq RNA; - proportion of patients with normalization of ALT at the extreme point of treatment. - response rate at n24 weeks of follow-up based on HCV / RCPq RNA.

Virology: income status and income change The HCV / RCPq RNA test of the serum and genotype test will be carried out by a central laboratory. The RNA test result of the Positive HCV will be necessary at the baseline; only patients who give positive HCV RNA will be eligible to participate. Repeat trials will be scheduled at weeks 4, 12, 24, 36, and 48. All patients will have repeat trials scheduled for weeks 12 and 24. The responses will be evaluated, as defined below. A patient is classified as someone who responds in a sustained manner if the patient has responded at 24 weeks of follow-up. It should be noted that patients who do not meet these criteria, including patients who interrupt the treatment before the required HCV / RCPq RNA evaluations are obtained, will be considered as patients who have not responded. Taking into account serum HCV / RCPq RNA and the change in liver histology, according to the Knodell HAI Inflamrnation Score, a patient will be classified as having given a complete response to the treatment if he / she responds in a sustained manner and the result of its Knodell HAI Inflammation Score post treatment (sum of categories l + ll + lll) improved 2 or more units in relation to the pretreatment result.

Liver histology A liver biopsy will be required within six weeks prior to patient registration and at week 24 of follow-up for all patients. The evaluation of the biopsies will be developed by a single pathologist using the Knodell Histology Activity Score method. The central pathologist will not know the identification of the patient, treatment group, the time in which the biopsy has to be obtained with respect to the treatment (pre or post treatment). The efficacy of the study treatments will be evaluated in comparison with the degree of inflammatory activity observed in the baseline with that present in the week 24 segment. Patient weight and disease characteristics of the baseline (genotype) of HCV and initial viral load) for all patients will be measured before the start of the study. HCV genotypes will be performed on patient serum samples subject to the HCV / RCPq RNA test. This increased efficacy that included all aspects of the disease resulted in: - Sustained eradication of detectable HCV RNA; - Improvement of liver inflammation; - Standardization of ALT; - Improvement in HQL.

Claims (25)

NOVELTY OF THE INVENTION CLAIMS

1. The use of ribavirin for the manufacture of a pharmaceutical composition for treating a patient having chronic hepatitis C infection to eradicate the detectable HCV RNA, by a method comprising administering an effective amount of ribavirin in association with an effective amount of pegylated interferon alfa, characterized in that the treatment of patients who have chronic hepatitis C infections are carried out in two periods of treatment (a) a first treatment period, in which a therapeutically effective amount of ribavirin and a dosage amount are administered of therapeutically effective induction of pegylated interferon alpha for a period sufficient to substantially decrease the serum levels of the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, where a therapeutically effective amount of ribavirin and a therapeutically effective amount of and pegylated interferon alpha are administered in a manner sufficient to eradicate the detectable HCV RNA, at least 20 to 30 weeks after the end of the first treatment period and to keep the HCV RNA undetectable for at least 24 weeks, after completion the second treatment period.

2. The use of pegylated interferon alpha for the manufacture of a pharmaceutical composition for treating a patient having chronic hepatitis C infection to eradicate the detectable HCV RNA by a method comprising the administration of an effective amount of pegylated interferon alpha in association with an effective amount of ribavirin, characterized in that the treatment of patients who have chronic hepatitis C infections are carried out in two periods of treatment (a) a first treatment period, in which a therapeutically effective amount of ribavirin and a the therapeutically effective induction dose amount of pegylated interferon alpha for a period sufficient to substantially decrease the serum levels of the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, where a therapeutically effective amount of ribavirin and a therapeutically amount effective pegylated interferon alpha are administered in a manner sufficient to eradicate detectable HCV RNA, at least 20 to 30 weeks after the end of the first treatment period and to keep HCV RNA undetectable for at least 24 weeks, after end the second treatment period.

3. The use of ribavirin and pegylated interferon alpha for the manufacture of pharmaceutical compositions for treating a patient having chronic hepatitis C infection to eradicate the detectable HCV RNA by a method comprising administering an effective amount of ribavirin in association with an effective amount of pegylated interferon alpha, characterized in that the treatment of patients who have chronic hepatitis C infections are carried out in two treatment periods (a) a first treatment period, in which a therapeutically effective amount of ribavirin and a therapeutically effective induction dose amount of pegylated interferon alpha for a period sufficient to substantially decrease the serum levels of the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, where a therapeutically effective ribavirin and a tera amount The pharmaceutically effective pegylated interferon alpha is administered in a manner sufficient to eradicate the detectable HCV RNA, at least 20 to 30 weeks after the end of the first treatment period and to keep the HCV RNA undetectable for at least 24 weeks, then to end the second treatment period.

4. The use of ribavirin for the manufacture of a pharmaceutical composition for treating a patient who has chronic hepatitis C infection to eradicate the detectable HCV RNA, by a method comprising the administration of an effective amount of ribavirin in association with an effective amount of pegylated interferon alpha, characterized in that the treatment of patients who have chronic hepatitis C infections are carried out in two treatment periods (a) a first treatment period, in which a therapeutically effective amount of ribavirin and a therapeutically effective induction dose amount of pegylated interferon alpha are administered, for a period sufficient to eradicate the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, where a therapeutically effective amount of ribavirin and a therapeutically effective amount of pegylated interferon alpha are administered in a manner sufficient to keep the HCV RNA undetectable for at least 20 to 30 weeks after the end of the first period of treatment and to maintain the HCV RNA n or detectable for at least 24 weeks, after the end of the second treatment period.

5. The use of pegylated interferon alfa for the manufacture of pharmaceutical composition to treat a patient having chronic hepatitis C infection to eradicate the detectable HCV RNA, by a method comprising administering an effective amount of pegylated interferon alfa. in association with an effective amount of ribavirin, characterized in that the treatment of patients who have chronic hepatitis C infections are carried out in two treatment periods (a) a first treatment period, in which a therapeutically effective amount of ribavirin and a therapeutically effective induction dose amount of pegylated interferon alpha for a period sufficient to eradicate the detectable HCV RNA, and b) a second treatment period of at least 20 to 30 weeks, where a therapeutically effective amount of ribavirin and a therapeutically effective amount of interferon alfa pegylate or, they are administered in a manner sufficient to keep HCV RNA undetectable for at least 20 to 30 weeks, after the end of the first treatment period and to keep HCV RNA undetectable for at least 24 weeks, after the end of treatment. second period of treatment.

6. The use of both ribavirin and pegylated interferon alfa for the manufacture of pharmaceutical compositions for treating a patient having chronic hepatitis C infection to eradicate the detectable HCV RNA by a method comprising administering an effective amount of ribavirin in association with an effective amount of pegylated interferon alpha, characterized in that the treatment of patients who have chronic hepatitis C infections is carried out in two treatment periods (a) a first treatment period, in which a quantity is administered therapeutically Effectiveness of ribavirin and a therapeutically effective induction dose amount of pegylated interferon alpha for a period sufficient to eradicate the detectable HCV RNA and b) a second treatment period of at least 20 to 30 weeks, where a therapeutically effective amount of ribavirin and a therapeutically effective amount of pegylated alpha interferon are administered in a manner sufficient to keep the HCV RNA undetectable, for at least 20 to 30 weeks after the end of the first treatment period and to keep the HCV RNA undetectable for at least 24 weeks, after end the second treatment period.

The use of any of the preceding claims, wherein the amount of ribavirin administered in the first and second periods of the treatment is 400 to 1600 mg. per day, and preferably is 600 to 1600 mg. per day or is 800 to 1200 mg. per day, and more preferably is from 1000 to 1200 mg. per day.

8. The use of any of the preceding claims, wherein the pegylated interferon alfa administered is pegylated interferon alfa-2a or pegylated interferon alfa-2b.

9. The use of any of the preceding claims, wherein the pegylated interferon alfa administered is a pegylated alpha-2b interferon and wherein the dosage amount of induction of pegylated interferon alfa-2b administered in a first treatment period is in the range of 0.5 to 1.5 micrograms per kilogram BIW for at least four weeks, and the amount of pegylated interferon alfa-2b administered in the second treatment period is in the range of 0.5 to 1.5 micrograms per kilogram per week per week on a Weekly up to forty-four weeks.

10. The use of any of the preceding claims, wherein the pegylated interferon alpha that is administered is pegylated interferon alfa-2b and wherein the dosage amount of induction of the pegylated interferon alfa-2b administered in a first treatment period is in the range of 0.5 to 1.5 micrograms per kilogram BIW for at least four to twelve weeks and the amount of pegylated interferon alfa-2b administered in the second treatment period is in the range 0.5 to 1.5 micrograms per kilometer per week over a Weekly basis from thirty-six to forty-four weeks.

11. The use of any of the preceding claims, wherein the pegylated interferon alpha that is administered is pegylated interferon alfa-2b and wherein the dosing amount of induction of pegylated interferon alfa-2b administered in a first treatment period is in the range 0.5 to 1.5 micrograms per kilogram BIW for one week, followed by 0.5 to 1.0 micrograms per kilogram BIW for four weeks and the amount of pegylated interferon alpha-2b administered in the second forty-three week treatment period is It is in the range of 0.5 to 1.5 micrograms per kilogram per week on a weekly basis.

12. The use of any of the preceding claims, wherein the pegylated alpha interferon administered is a pegylated interferon alfa-2b and wherein the dosage amount of induction of pegylated interferon alfa-2b administered in the first treatment period it is in the range of 0.5 to 1.5 micrograms / kilogram BIW for twelve weeks and the amount and pegylated interferon alfa-2b that is supplied in the second treatment period is in the range of 0.5 to 1.5 micrograms / kilograms per week on a weekly basis for thirty-six weeks.

13. The use of any of the preceding claims, wherein the pegylated interferon alfa administered is a pegylated interferon alfa-2b and wherein the amount of induction dosage of pegylated interferon alfa-2b administered in the first treatment period is in the range of 0.5 to 1.5 micrograms / kilogram BIW for one week and the amount of pegylated interferon alpha-2b that is supplied in the second forty-three week treatment period is in the range of 0.5 to 1.0 microgram / kilogram per Week on a weekly basis.

14. The use of any of the preceding claims, wherein the pegylated interferon alpha is administered in a pegylated interferon alfa-2b and wherein the dosage dosage amount of pegylated interferon alfa-2b administered in the first treatment period is 1.5 micrograms / kilograms BIW for twelve weeks and the amount of pegylated interferon alfa-2b administered in the second treatment period is 1.5 micrograms / kilograms per week on a thirty-six week basis.

15. The use of any one of the preceding claims, wherein the pegylated alpha interferon administered is a pegylated interferon alfa-2a and wherein the amount of pegylated interferon alfa-2a administered is a metering amount of interferon alfa induction. -2a pegylated administered which is in the range of 20 to 250 micrograms BIW, preferably 90 to 180 micrograms BIW, for at least four weeks, and the amount of pegylated interferon alfa-2a administered in the second treatment period is in the range of 20 to 250 micrograms per week on a weekly basis (QW), 90 to 180 micrograms QW, for up to forty-four weeks.

16. The use of any one of the preceding claims, wherein the pegylated interferon alfa administered is a pegylated interferon alfa-2a and wherein the amount of pegylated interferon alfa-2a administered is a dosing amount of pegylated interferon alfa-2a administered which is in the range of 20 to 250 micrograms BIW, preferably 90 to 180 micrograms BIW, for at least four weeks, and the amount of pegylated interferon alfa-2a administered in the second treatment period is in the range of 20 at 250 micrograms per week on a weekly basis (QW), 90 to 180 micrograms QW, for up to forty-four weeks.

17. The use of any of the preceding claims, wherein the pegylated alpha interferon administered is a pegylated interferon alfa-2a and where in the first treatment period, the pegylated interferon alfa-2a induction dosing amount administered is from a range of 20 to 250 micrograms BIW, preferably 90 to 180 micrograms BIW, for a week followed by 20 to 200 micrograms BIW, preferably 120 to 180 micrograms BIW for four weeks, and the amount of interferon alpha-2a PEGylated that is administered in the second treatment period is in the range of 20 to 250 micrograms per week on a weekly basis (QW), preferably 90 to 180 micrograms QW, for forty-three weeks.

18. The use of any of the preceding claims, wherein the pegylated interferon alpha is administered in a pegylated interferon alfa-2a and where in the first treatment period, the amount of induction of pegylated interferon alfa-2a administered is from a range of 20 to 250 micrograms BIW, preferably 90 to 180 micrograms BIW, for twelve weeks and the amount of pegylated interferon alfa-2a administered in the second treatment period is in the range of 20 to 250 micrograms per week on a weekly basis (QW), preferably 90 to 180 micrograms QW, for forty-six weeks.

19. The use of any of the preceding claims wherein patients who have chronic hepatitis C are infected with HCV genotypes including type 1

20. The use of any of the preceding claims wherein patients who have chronic hepatitis C are infected with HCV Genotype 2 and / or 3 genotypes.

21. The use of any of the preceding claims wherein the patient is a "naive" treatment patient.

22. The use of both ribavirin and pegylated interferon alpha for the manufacture of pharmaceutical compositions for the treatment of a patient having chronic hepatitis C infection to eradicate detectable HCV RNA, by a method comprising the administration of an amount Effectiveness of ribavirin in association with an effective amount of pegylated interferon alpha characterized in that the treatment of patients having chronic hepatitis C infections is carried out in two treatment periods (1) a first treatment period of approximately four weeks, in the which are administered approximately 400-1200 mg.- per day, preferably approximately 800-1200 mg. per day, of ribavirin and approximately 1.5 micrograms per kilogram of pegylated interferon alfa-2b twice a week; 2) a second treatment period of approximately up to forty-four weeks, during which approximately 800-1200 mg are administered. per day of ribavirin and approximately 1.0 to 1.5 micrograms per kilogram of pegylated interferon alfa-2b once a week.

23. The use of both ribavirin and pegylated interferon alfa for the manufacture of pharmaceutical compositions for the treatment of a patient having chronic hepatitis C infection to eradicate the detectable RNA and HCV, by a method comprising the administration of an amount Effectiveness of ribavirin in association with an effective amount of pegylated interferon alpha characterized in that the treatment of patients who have chronic hepatitis C infections is carried out in two treatment periods (1) a first period of approximately four weeks, in which they administer approximately 400-1200 mg.- per day, preferably approximately 800-1200 mg. per day, of ribavirin and approximately 1.5 micrograms per kilogram of pegylated interferon alfa-2b twice a week; 2) a second treatment period of approximately thirty-six to forty-four weeks, during which approximately 800-1200 mg per day of ribavirin and approximately 1.0 to 1.5 micrograms per kilogram of pegylated interferon alfa-2b are administered per week.

24. The use of claims 22 or 23, wherein patients who have chronic hepatitis C infection are "naive" treatment patients who have genotype 1, 2 or 3 of HCV.

25. The use of claims 22 or 23, wherein the dosage amount of induction of pegylated interferon alpha 2b administered in a second period is 1.5 micrograms / kilogram.