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Opinion Article
Revised

Statin (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor)-based therapy for hepatitis C virus (HCV) infection-related diseases in the era of direct-acting antiviral agents

[version 3; peer review: 2 approved]
PUBLISHED 25 Jan 2017
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Abstract

Recent improvements have been made in the treatment of hepatitis C virus (HCV) infection with the introduction of direct-acting antiviral agents (DAAs). However, despite successful viral clearance, many patients continue to have HCV-related disease progression. Therefore, new treatments must be developed to achieve viral clearance and prevent the risk of HCV-related diseases. In particular, the use of pitavastatin together with DAAs may improve the antiviral efficacy as well as decrease the progression of liver fibrosis and the incidence of HCV-related hepatocellular carcinoma. To investigate the management methods for HCV-related diseases using pitavastatin and DAAs, clinical trials should be undertaken. However, concerns have been raised about potential drug interactions between statins and DAAs. Therefore, pre-clinical trials using a replicon system, human hepatocyte-like cells, human neurons and human cardiomyocytes from human-induced pluripotent stem cells should be conducted. Based on these pre-clinical trials, an optimal direct-acting antiviral agent could be selected for combination with pitavastatin and DAAs. Following the pre-clinical trial, the combination of pitavastatin and the optimal direct-acting antiviral agent should be compared to other combinations of DAAs (e.g., sofosbuvir and velpatasvir) according to the antiviral effect on HCV infection, HCV-related diseases and cost-effectiveness.

Keywords

Hepatitis C virus (HCV) infection, HCV infection-related diseases, statins, replicon system, human hepatocyte-like cells from human induced pluripotent stem cells, direct-acting antiviral agents (DAAs)

Revised Amendments from Version 2

All of the author names were updated to correct them and the order of the authors was also corrected.

See the authors' detailed response to the review by Joel D. Baines

Introduction

Hepatitis C virus (HCV) infection is an important public health problem worldwide, as many HCV-infected patients develop liver cirrhosis and/or hepatocellular carcinoma (HCC)1.

Recent improvements in the treatment of HCV infection have focused on the use of direct-acting antiviral agents (DAAs)1. However, despite successful viral clearance, many patients with advanced fibrosis continue to have HCV-related disease progression2,3. Therefore, new treatments must be developed to achieve viral clearance and prevent the risk of HCV-related diseases.

Statins (inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase) have been proposed as a new candidate for the treatment of HCV infection. According to previously conducted clinical studies using statins in HCV-infected patients48, the antiviral effect of statins on HCV infection depends on the type of statin used. Among various statins, pitavastatin showed the highest antiviral efficacy against HCV genotype 1b infection in vitro9. Therefore, pitavastatin represents a novel candidate for the treatment of HCV infection.

Clinical trials for pitavastatin against HCV infection

After performing a search of the PubMed database, we identified three clinical trials using pitavastatin for the treatment of HCV infection7,8,10.

When Shimada et al.7 considered two reports published in 2010 investigating the antiviral efficacy of pitavastatin against HCV infection in vitro9,11, they conducted a randomized controlled trial7. The proof-of-concept studies demonstrated the antiviral efficacy and safety of pitavastatin against HCV infection using a replicon system and human hepatocyte-like cells from human induced pluripotent stem cells (hiPSCs)9,11, and these effects of pitavastatin were confirmed in the randomized controlled trial7,12. Indeed, this series of studies7,9,11 would be the first to report the clinical applications of hiPSCs12. After the clinical trial performed by Shimada et al.7, the antiviral efficacy and safety of pitavastatin against HCV infection were further confirmed in two clinical studies8,10. Thus, investigating the antiviral efficacy and safety of pitavastatin against HCV infection using a replicon system and human hepatocyte-like cells from hiPSCs9,11 constitutes a rational approach to discover new drugs and/or new therapeutic methods.

Clinical trials to investigate the management methods of HCV-related diseases in the era of DAAs

Butt et al.13 showed that statin use was associated with improved antiviral efficacy as well as decreased progression of liver fibrosis and a reduced incidence of HCC among a large cohort of HCV-positive veterans. Furthermore, the use of statins among patients with HCV and compensated cirrhosis (n=40,512) was associated with a more than 40% lower risk of cirrhosis decomposition and death14. Moreover, statin users showed a significant reduction in the incidence of HCC15. In addition, pitavastatin showed anti-cancer effects against human hematoma cell lines1618.

DAAs in combination with statins have been shown to generate increased antiviral efficacy against HCV infection19. However, concerns have been raised about the drug interactions between various statins and DAAs20. For instance, simvastatin and lovastatin should be avoided in patients with HCV infection who are using boceprevir or telaprevir as a DAA21. Atorvastatin should be avoided in patients with HCV infection who are using telaprevir21, and pravastatin plus boceprevir may also pose risks21. Although rosuvastatin could be considered for use in combination with telaprevir and boceprevir21, the drug interactions between pitavastatin and DAAs remain unknown.

Furthermore, according to our search of the PubMed database and UMIN Clinical Trials Registry System (http://www.umin.ac.jp/icdr/index.html), no clinical trial has been conducted for the combination of statins and DAAs. Therefore, although there is likely only a minimal additive benefit for viral clearance using statins, as new combinations of DAA (sofosbuvir and velpatasvir) therapy have shown sustained virologic response (SVR) rates above 95%22, conducting a clinical trial for the combination of pitavastatin and DAAs may be meaningful to investigate management methods to prevent fibrosis and cirrhosis or the development of HCC and other HCV-related diseases in the era of DAAs. However, in pre-clinical trials, the antiviral effects of the combination of pitavastatin and DAAs should be evaluated using a replicon system9. Furthermore, hepatotoxicities should also be evaluated for the combination of pitavastatin and DAAs using human hepatocyte-like cells from hiPSCs11. Using a replicon system and human hepatocyte-like cells from hiPSCs in a pre-clinical trial9,11, an optimal direct-acting antiviral agent could be selected for use in the combination of pitavastatin and DAAs. After the pre-clinical trial, the combination of pitavastatin and the optimal direct-acting antiviral agent should be compared with other DAA combinations (e.g., sofosbuvir and velpatasvir) according to their antiviral efficacy against HCV infection and prevention of HCV-related diseases. Furthermore, because the cost for DAA combination treatment is very high ($83,000 to $153,000 per course of treatment)22, the new and effective hepatitis C treatments seem beyond the reach of low- and middle-income countries23. However, the cost ($0.79 to $2.59 per day) of pitavastatin (2mg)7 is low (http://www.pharmacychecker.com/generic/price-comparison/pitavastatin/2+mg/). Therefore, the above-mentioned comparison should also be investigated in light of cost-effectiveness.

On the other hand, a replicon system in hepatocellular cells is not likely to duplicate the full gamut of potential side effects seen in patients with HCV infection receiving pitavastatin and DAAs. The risks (potential side effects) that will not be revealed in a pre-clinical trial using this system should be acknowledged. Therefore, in order to identify the risk (potential side effects) that will not be revealed in a pre-clinical trial using this system, the evaluations using human neurons and human cardiomyocytes from hiPSCs24,25 should also be done in pre-clinical trials.

In conclusion, a pre-clinical trial investigating the combination of pitavastatin and DAAs against HCV infection using a replicon system, human hepatocyte-like cells, human neurons and human cardiomyocytes from hiPSCs9,11,24,25 represents a rational approach for discovering a new therapeutic method.

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VERSION 3 PUBLISHED 26 Feb 2016
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Kishta SS, Kishta SA and El-Shenawy R. Statin (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor)-based therapy for hepatitis C virus (HCV) infection-related diseases in the era of direct-acting antiviral agents [version 3; peer review: 2 approved]. F1000Research 2017, 5:223 (https://doi.org/10.12688/f1000research.7970.3)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
VERSION 2
PUBLISHED 07 Jul 2016
Revised
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Reviewer Report 15 Aug 2016
Joel D. Baines, LSU School of Veterinary Medicine (SVM), Louisiana State University, Baton Rouge, LA, USA 
Approved
VIEWS 174
The revisions address my ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Baines JD. Reviewer Report For: Statin (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor)-based therapy for hepatitis C virus (HCV) infection-related diseases in the era of direct-acting antiviral agents [version 3; peer review: 2 approved]. F1000Research 2017, 5:223 (https://doi.org/10.5256/f1000research.9843.r15693)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 1
VERSION 1
PUBLISHED 26 Feb 2016
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Reviewer Report 07 Jun 2016
Joel D. Baines, LSU School of Veterinary Medicine (SVM), Louisiana State University, Baton Rouge, LA, USA 
Approved with Reservations
VIEWS 246
This article would be improved with statements quantifying how common progression to disease occurs in patients treated with anti-HCV compounds in the absence of other drugs. The main point of the article, that there should be pre-clinical trials to test for efficacy ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Baines JD. Reviewer Report For: Statin (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor)-based therapy for hepatitis C virus (HCV) infection-related diseases in the era of direct-acting antiviral agents [version 3; peer review: 2 approved]. F1000Research 2017, 5:223 (https://doi.org/10.5256/f1000research.8578.r13945)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 07 Jul 2016
    Sara Kishta, Medical Biotechnology Lab, Microbial Biotechnology Department, National Research Center, Egypt, Cairo, Egypt
    07 Jul 2016
    Author Response
    First of all, thank you very much for your suggestions. We think that your comments were very helpful. We agree with your suggestions. If you agree with our revisions, we ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 07 Jul 2016
    Sara Kishta, Medical Biotechnology Lab, Microbial Biotechnology Department, National Research Center, Egypt, Cairo, Egypt
    07 Jul 2016
    Author Response
    First of all, thank you very much for your suggestions. We think that your comments were very helpful. We agree with your suggestions. If you agree with our revisions, we ... Continue reading
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253
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Reviewer Report 11 May 2016
Susana N. Asin, White River Junction, Veterans Affairs Medical Center, White River Junction, VT, USA 
Approved
VIEWS 253
Recent improvements in treatment strategies for Hepatitis C virus infected patients have been successful at reaching sustained virological responses yet did not prevent liver fibrosis and progression to hepatocellular carcinoma.
 
The idea proposed in this paper that new treatments must be ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Asin SN. Reviewer Report For: Statin (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor)-based therapy for hepatitis C virus (HCV) infection-related diseases in the era of direct-acting antiviral agents [version 3; peer review: 2 approved]. F1000Research 2017, 5:223 (https://doi.org/10.5256/f1000research.8578.r13680)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 26 Feb 2016
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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