Research Article

Response-guided peginterferon therapy in patients

with HBeAg-positive chronic hepatitis B: A randomized
controlled study
Jian Sun1,y, Hong Ma2,y, Qing Xie3, Yao Xie4, Yongtao Sun5, Hao Wang6, Guangfeng Shi7, Mobin Wan8,
Junqi Niu9, Qin Ning10, Yanyan Yu11, Huijuan Zhou3, Jun Cheng4, Wenzhen Kang5, Yi Xie12,
Rong Fan1, Lai Wei6, Hui Zhuang13, Jidong Jia2, Jinlin Hou1,
1
State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious
Diseases, Nanfang Hospital, Southern Medical University, Guangdong Province, China; 2Liver Research Center, Beijing Friendship Hospital,
Capital Medical University, Beijing, Xicheng District, China; 3Department of Infectious Diseases, Shanghai Ruijin Hospital, Jiaotong University
School of Medicine, Shanghai, China; 4Liver Disease Department, Beijing DiTan Hospital, Beijing, Chongyang District, China; 5Department of
Infectious Diseases, Tangdu Hospital, The Fourth Military Medical University, Xian, Shaanxi Province, China; 6Peking University
Peoples Hospital, Peking University Hepatology Institute, Beijing, China; 7Department of Infectious Diseases, Huashan Hospital affiliated to
Fudan University, Shanghai, China; 8Department of Infectious Diseases, Shanghai Changhai Hospital, Shanghai, China; 9Department of Liver,
First Hospital of Jilin University, Changchun, Jilin Province, China; 10Department of Infectious Diseases, Wuhan Tongji Hospital affiliated to
Huazhong Technology University, Tongji Medical College, Wuhan, Hubei Province, China; 11Department of Infectious Diseases,
Peking University First Hospital, Beijing, China; 12Shanghai Roche Pharmaceuticals Co Ltd, Shanghai, China; 13Department of Microbiology
and Infectious Disease Center, Peking University, Health Science Center, Beijing, China

Background & Aims: Response-guided therapy has been con-
firmed to be an effective strategy for the treatment of chronic
hepatitis C in the pegylated interferon (PegIFN) era, but no ran-
domized trial utilizing this strategy has been conducted in
chronic hepatitis B.
Methods: In this open-label, multicenter, randomized trial,
HBeAg positive patients were treated with PegIFN (180 lg/week)
for 24 weeks. Early responders (HBsAg <1500 IU/ml and HBV
DNA <105 copies/ml at week 24) received PegIFN for a further
24 weeks (arm A), while non-early responders were randomized
to PegIFN for another 24 weeks (arm B), another 72 weeks (arm
C) or PegIFN for another 72 weeks plus adefovir for 36 weeks
(arm D). The primary endpoint was the change of quantitative
HBsAg from baseline to the end of follow-up (EOF).
Results: For non-early responders, 96-week PegIFN monotherapy
did not lead to a greater reduction of HBsAg from baseline to EOF,
compared with 48-week PegIFN (0.71 vs. 0.67 log10 IU/ml,
Keywords: Antiviral therapy; Hepatitis B; Clinical trial.
Received 13 January 2016; received in revised form 21 April 2016; accepted 13 May
2016; available online 26 May 2016
Corresponding author. Address: Hepatology Unit, Nanfang Hospital, Southern
Medical University, Guangzhou 510515, China. Tel.: +86 20 61641941; fax: +86
20 62786530.
E-mail address: jlhousmu@163.com (J. Hou).
y
These authors contributed equally as joint first authors.
Abbreviations: ADV, adefovir; AEs, adverse events; ALT, alanine aminotransferase;
BMI, body mass index; CHB, chronic hepatitis B; EOF, end of follow-up; EOT, end
of treatment; ETV, entecavir; HBV, hepatitis B virus; HBeAg, hepatitis B e antigen;
HBeAb, hepatitis B e antibody; HBsAb, hepatitis B surface antibody; HBsAg,
hepatitis B surface antigen; ITT, intention to treat; NAs, nucleot(s)ide analogs;
PEIU, Paul Ehrlich international units; PegIFN, pegylated interferon; RGT,
response-guided therapy; ULN, upper limit of normal.
P = 0.407). The rate of HBeAg seroconversion with HBV DNA
<2000 IU/ml at EOF were similar for arms B, C and D (17.9%,
23.9% and 25.0% respectively). For patients with HBsAg
<1500 IU/ml or HBV DNA <105 copies/ml at week 24, 38.4% and
37.0% achieved HBeAg seroconversion with HBV DNA <2000 IU/
ml at EOF respectively.
Conclusions: Patients with HBsAg <1500 IU/ml or HBV DNA
<105 copies/ml at week 24 would benefit from continued PegIFN
treatment. Extending the duration of PegIFN with or without add-
ing adefovir did not show superiority over 48 weeks PegIFN
monotherapy.
Lay summary: Extending the duration of pegylated interferon
(PegIFN) alfa-2a is not recommended in HBeAg positive patients
as treatment extension beyond 48 weeks did not show convinc-
ing benefit. Patients who achieved HBsAg <1500 IU/ml or HBV
DNA <105 copies/ml after 24-week PegIFNa-2a showed satisfac-
tory outcome after the withdrawal of finite PegIFNa-2a
treatment.
Clinical Trial Number: NCT01086085.
2016 European Association for the Study of the Liver. Published
by Elsevier B.V. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Chronic hepatitis B (CHB) caused by hepatitis B virus (HBV) infec-
tion is a major public health problem that affects more than
350 million people worldwide. Liver cirrhosis, liver failure and
hepatocellular carcinoma are well-known sequelae of CHB [1].

Journal of Hepatology 2016 vol. 65 j 674682


At present, pegylated interferon (PegIFN) which stimulates the
immune response to HBV, and nucleot(s)ide analogs (NAs), which
directly suppress viral replication, are the two main first-line
therapies recommended by international guidelines [24].
Approximately 3040% of hepatitis B e antigen (HBeAg) posi-
tive CHB patients show a sustained response to PegIFN therapy
leading to a relatively high hepatitis B surface antigen (HBsAg)
seroclearance rate [5,6]. However, the remaining 6070% of
patients show an incomplete or partial response. Broadly, two
strategies have been proposed for the patients treated with
PegIFN: (1) Identification of biomarkers, at baseline or in the
early phase of treatment, that can help to identify complete
responders and encourage them to complete the standard dura-
tion of PegIFN therapy [7]; and (2) Development of strategies
for increasing treatment efficacy for incomplete or partial respon-
ders, including extending treatment duration or combining with
NAs [8]. These strategies originated from the concept of
response-guided therapy (RGT), which has been successfully
applied in the management of chronic hepatitis C in the PegIFN
era [9]. However, to the best of our knowledge, this approach
has not been studied in CHB patients with PegIFN therapy.
Post-hoc analysis of the PegIFNa-2a registration and
NEPTUNE studies revealed that 5457% of HBeAg positive
patients who had HBsAg <1500 IU/ml at week 24 achieved HBeAg
seroconversion and 7% to 12% of these patients achieved HBsAg
loss 6 months after discontinuation of PegIFNa-2a therapy
[10,11]. These patients should be encouraged to complete
standard PegIFN treatment.
The more challenging job is to optimize the efficacy of PegIFN
in the non-early responders. Various treatment strategies have
been tried in the past with different outcomes. The global phase
3 PegIFNa-2a registration study failed to show the benefit of
combination with lamivudine at the end of follow-up (EOF) in
both HBeAg positive and HBeAg negative patients [12,13]. Simi-
larly, combination of PegIFN with entecavir (ETV) or sequential
treatment with ETV, followed by PegIFN, did not show any added
benefit over PegIFN monotherapy [14]. Extending the duration of
PegIFNa-2a treatment in HBeAg negative patients from 48 weeks
to 96 weeks resulted in improved virological responses (12% vs.
29%) at one-year post-treatment [8]. However, the above-
mentioned studies testing alternate optimization strategies were
conducted on overall treatment nave patients, and did not take
into account on-treatment HBsAg levels.
In this study, we employed quantitative assays for HBsAg and
HBV DNA at week 24 as the criteria for evaluating the early
response in Chinese HBeAg positive CHB patients. We tried to
explore the possibility of applying RGT strategy to the manage-
ment of patients with PegIFN treatment and to assess whether
it is possible to improve the outcomes of non-early responders
by extending PegIFN treatment from 48 weeks to 96 weeks,
and/or by adding adefovir (ADV).
Materials and methods
Study design and treatment protocol
In this phase IV, prospective, randomized, open-label study (ClinicalTrials.gov
number: NCT01086085), all enrolled patients received PegIFNa-2a (Pegasys,
Roche, Basel, Switzerlands) 180 lg/week for 24 weeks prior to randomization.
Serum HBV DNA and HBsAg level were measured at week 24. Early responders
were defined as patients with HBsAg <1500 IU/ml and HBV DNA <105 copies/ml
Journal of Hepatology 2016 vol. 65 j 674682
JOURNAL OF HEPATOLOGY
(17,182 IU/ml, approximately 20,000 IU/ml) at week 24. Early responders (arm
A) continued PegIFNa-2a 180 lg/week for a further 24 weeks (total 48 weeks).
Non-early responders were randomly assigned in a 1:1:1 ratio to arms B, C and
D at week 28, by using a block size of 6 according to a computer-generated ran-
dom schedule using SAS software package version 9.1.3. The fax system was
used to assign the treatment to each subject.
In arm B, treatment with PegIFNa-2a (180 lg/week) was continued for
another 24 weeks (total 48 weeks). Patients in arm C continued treatment with
PegIFNa-2a (180 lg/week) for another 72 weeks (total 96 weeks). In arm D, treat-
ment with PegIFNa-2a (180 lg/week) was continued for another 72 weeks (total
96 weeks) in combination with ADV (Hepsera; GSK, Brentford, UK) (10 mg/day),
from week 29 to week 64 (Fig. 1). All subjects were followed up for 24 weeks after
the end of treatment (EOT). Evaluations were conducted at treatment weeks 0, 2,
4, 8, 12, 20, 24, 28, 36, 40 and 48 (all patients). Patients in arms C and D were also
evaluated at treatment weeks 56, 64, 72, 84 and 96. Follow-up assessments were
conducted at weeks 12 and 24 (6 months) after treatment. The study protocol
was approved by independent ethics committees at all the participating institu-
tions in accordance with the Declaration of Helsinki. Written informed consent
was obtained from all subjects prior to initiating any study-specific procedures.
Patients
Patients aged between 18 to 65 years were eligible if HBsAg positive for at least
6 months, HBeAg positive and hepatitis B e antibody (HBeAb) negative, HBV DNA
>105 copies/ml, alanine aminotransferase (ALT) P2x upper limit of normal (ULN)
but <10x ULN at two consecutive time points 14 days apart before enrollment.
Patients who had received antiviral treatment within the prior 6 months were
excluded. Other major exclusion criteria were co-infection with hepatitis A, hep-
atitis C, hepatitis D and/or human immunodeficiency virus infection, evidence of
decompensated liver disease (Child-Pugh score >5), chronic liver disease other
than viral hepatitis (e.g., hemochromatosis, autoimmune hepatitis, metabolic
liver disease, alcoholic liver disease, toxin exposure, thalassemia), signs or symp-
toms of hepatocellular carcinoma, a neutrophil count <1500 cells/mm3 or platelet
count <90,000 cells/mm3, hemoglobin <11.0 g/dl for females and <12.0 g/dl for
males, and serum creatinine level >1.5x ULN.
Measurements
Biochemical, virological, and hematological assessments were performed in each
center according to locally validated procedures with the exception of HBV DNA,
HBV genotype, HBsAg/hepatitis B surface antibody (HBsAb), and HBeAg/HBeAb.
ALT levels quantified at each center were transformed to ULN with the centers
normal range used as reference. Serum HBV DNA levels were measured centrally
using the COBAS TaqMan HBV Test (Roche Molecular Diagnostics, Pleasanton,
California, USA; limit of detection 12 IU/ml, 1 IU/ml = 5.82 copies/ml) at commer-
cial laboratory (Clearstone, Beijing). HBV genotypes were determined by poly-
merase chain reaction sequencing and alignment as reported previously [15].
HBsAg levels were quantified centrally using the Abbott Architect HBsAg assay
Early responders
A PegIFN- 2a
Follow- up
180 g/week
Non-early responders (randomised 1:1:1)
B PegIFN- 2a
PegIFN- 2a
180 g/week 180 g/week
Follow- up
C
R PegIFN-2a 180 g/week Follow-up
D
PegIFN-2a 180 g/week Follow-up
ADV 10 mg
once daily
0 24 24 29 48 64 72 96 120
Week
Fig. 1. Schematic representation of the study design. PegIFN, pegylated
interferon; ADV, adefovir.
675
Research Article
(Abbott Ireland Diagnostics Division, Sligo, Ireland; dynamic range 0.05250.0 IU/
ml). Samples with HBsAg >250.0 IU/ml were retested after a dilution of 1:500.
Efficacy assessment
The efficacy analysis included all patients who fulfilled the inclusion criteria and
were randomized at week 24 (modified intention to treat [mITT] population). Per-
protocol analysis included patients who finished the predefined treatment and
follow-up without major protocol deviation. The primary endpoint was the
change of quantitative HBsAg from baseline to EOF. The secondary endpoints
included the changes from baseline of HBV DNA, rates of ALT normalization,
HBeAg loss, HBeAg seroconversion, HBsAg loss and HBsAg seroconversion, HBeAg
seroconversion with HBV DNA <2,000 IU/ml at EOT and EOF.
Sample size estimation
The alternative hypothesis of this study was the mean change from baseline of
quantitative HBsAg at EOF in either arms C or D was superior to that in arm B.
For arms C vs. B and arms D vs. B in the change of quantitative HBsAg from base-
line to EOF, the differences was estimated to be 0.8 log10 IU/ml and the standard
deviation was 1.62 log10 IU/ml according to the data from HBeAg positive
patients with PegIFN treatment in Chinese population [14]. The level of signifi-
cance was set at 0.05, with power of 80%. Therefore, the estimated sample size
was 65 each in arms B, C and D, which was rounded up to 72 to allow for a
10% withdrawal rate (subtotal 216 in arms B, C and D). For arm A, it was esti-
mated that 15% of the subjects could achieve response criteria. Therefore, the
sample size for arm A would be 42 (taking into account 10% withdrawal rate).
The total sample size required for this study was thus calculated to be 258.
Safety assessments
Safety parameters included clinical adverse events (AEs), laboratory test results,
vital signs and physical and ophthalmological examinations during treatment.
The safety analysis was conducted on all patients who had received at least 1 dose
of study medication.
Statistical analysis
Statistical analyses were performed using the SAS software package version
9.1.3. Quantitative changes of HBsAg and HBV DNA level, from baseline to EOF,
were assessed using an analysis of covariance (ANCOVA) model with treatment
arms (B, C and D) and center as fixed factors and baseline levels as covariate.
For the statistical analyses of binary efficacy endpoints, a logistic model incorpo-
rating treatment effects in arms (B, C, and D) and the corresponding baseline vari-
ables (baseline HBV DNA for HBV DNA negative; baseline HBeAg for HBeAg loss/
HBeAg seroconversion; baseline HBsAg for HBsAg loss/HBsAg seroconversion;
both baseline HBeAg and HBV DNA for combined response) were used. For the
continuous variables included in the efficacy evaluation, the last observation car-
ried forward procedure was used to impute the missing data pertaining to the
treatment period. However, for the missing data pertaining to the follow-up per-
iod, no imputation was conducted. For the binary efficacy endpoints, missing val-
ues were considered as failures. If the subject received other antiviral therapies,
the efficacy data from the start of therapies was set to missing, and no imputation
was conducted and was considered as failures for the binary efficacy endpoints.
Safety data were summarized using descriptive statistics.
Results
Patient disposition
A summary of subject disposition is presented in Fig. 2. A total of
373 patients were screened and 265 HBeAg positive CHB patients
were enrolled across 11 clinical centers between April 2010 and
October 2010. The reasons of 108 patients with screen failure
were as following (subjects may have multiple reasons): not
meeting inclusion criteria (N = 44), meeting exclusion criteria
(N = 69) and others (N = 10). One patient opted out from the study
before week 24 (i.e., prior to randomization), therefore, the mITT

Screened
N = 373

Enrollment
N = 265
Withdraw consent n = 1
Completed first 24
week treatment
N = 264

Randomization

Arm A Arm B Arm C Arm D

N = 66 N = 67 N = 67 N = 64
Other n = 1 AEs n = 2 AEs n = 2
Withdraw consent n = 1 Lost to follow-up n = 3
Protocol deviations n = 1 Others n = 1
Lost to follow-up n = 5
Lack of efficacy n = 1
Others n = 1
Completed therapy Completed therapy Completed therapy Completed therapy
N = 65 N = 67 N = 56 N = 58
AEs n = 1 AEs n = 1 AEs n = 1 AEs n = 1
Withdraw Withdraw consent n = 1 Lost to follow-up n = 2 Withdraw consent n = 1
consent n = 1 Lost to follow-up n = 1 Other n = 1 Lost to follow-up n = 2
Others n = 1 Lack of efficacy n = 1

Completed follow-up Completed follow-up Completed follow-up Completed follow-up

N = 62 N = 64 N = 52 N = 53

Fig. 2. Subject disposition of the study. AE, adverse events.

676 Journal of Hepatology 2016 vol. 65 j 674682


population for our efficacy analyses was 264 patients. Among the
mITT population, 66 patients (25.0%) achieved an early response
(HBsAg <1500 IU/ml and HBV DNA <105 copies/ml) at week 24
and were assigned to arm A. The remaining 198 patients were ran-
domly assigned to arms B, C or D. A total of 246 patients (93.2%)
completed the treatment, 231 patients (87.5%) completed
24 weeks follow-up. The overall dropout rates at EOT and EOF
were higher in arms C and D (EOT: 1.5%, 0%, 16.4% and 9.4%,
p <0.001; EOF: 6.1%, 4.5%, 22.4% and 17.2%, p = 0.003; in arms A,
B, C and D respectively). Taking into consideration of the >20%
drop out rate in arm C, a per-protocol analysis was included as
supplementary results.
Baseline characteristics of mITT population
The baseline (Week 0) characteristics of the mITT population
were not balanced as they were not randomized at baseline
(Table 1). Patients in arm A had lower baseline HBsAg, HBeAg
and HBV DNA but higher ALT than patients in other groups.
Patient characteristics in arms B, C and D were comparable,
except for slightly higher HBeAg and HBV DNA level in arm B.
With respect to the genotype distribution, more patients in arm
A were infected with genotype B HBV.
Week 24 characteristics of non-early responders
As the non-early responders were randomized according to the
response at week 24, the characteristics at week 24 among arms
JOURNAL OF HEPATOLOGY
B, C and D were balanced in terms of mean HBV DNA, ALT,
HBsAg quantitation, HBeAg loss and seroconversion rate
(Table 2). The decline of HBsAg from baseline at week 24 was
0.40, 0.36, 0.45 log10 IU/ml (p = 0.756) for arms B, C and D,
respectively.
Efficacy in early responders (Arm A)
In the first 24 weeks, the mean reduction of HBsAg was signifi-
cantly greater in early responders (arm A, 1.52 log10 IU/ml),
compared with the other three arms (Fig. 3A). The overall reduc-
tion of quantitative HBsAg from baseline to EOF was 1.15 log10
IU/ml in arm A compared to 0.67 log10 IU/ml in the non-early
responders (p = 0.038) (Fig. 3A).
At week 24, 25.8% (17/66) and 25.8% (17/66) of patients
achieved HBeAg loss and HBeAg seroconversion at week 24, com-
pared with 34.8% (23/66) and 33.3% (22/66) at EOT (week 48).
The increase of response rate from week 24 to week 48 was lim-
ited (HBeAg loss, +9.0%, p = 0.256; HBeAg seroconversion +7.5%,
p = 0.340)
At EOF, 51.5% and 47.0% of early responders achieved HBeAg
loss and seroconversion, that was significantly greater than
that observed in non-early responders (p = 0.016 and p = 0.047,
respectively). Rates of HBV DNA undetectability, HBeAg
seroconversion with HBV DNA <2000 IU/ml were also higher in
the early responders as compared to non-early responders
(Table 3).

Table 1. Characteristics of the enrolled subjects at baseline.

Total Arm A Arm B Arm C Arm D p value

(N = 264) (N = 66) (N = 67) (N = 67) (N = 64) (B vs. C vs. D)
Male, n (%) 209 (79.2) 57 (86.4) 53 (79.1) 52 (77.6) 47 (73.4) 0.757
Age, years 28.9 6.7 28.2 6.7 28.6 6.7 28.2 6.2 30.8 7.2 0.057
BMI, kg/m2 22.5 3.2 21.9 3.0 22.3 3.1 23.6 3.8 22.3 2.6 0.033
Genotype, n (%) 0.864
B 93 (35.2) 32 (48.5) 19 (28.4) 22 (32.8) 20 (31.3)
C 169 (64.0) 34 (51.5) 47 (70.1) 44 (65.7) 44 (68.8)
Other 2 (0.8) 0 1 (1.5) 1 (1.5) 0
HBsAg, log10 IU/ml 4.0 0.7 3.7 0.9 4.2 0.7 4.1 0.7 4.1 0.6 0.706
HBsAg <1500 IU/ml, n (%) 30 (11.4) 17 (25.8) 3 (4.5) 5 (7.5) 5 (7.8) 0.695
HBeAg, log10 PEIU/ml 2.4 1.0 2.1 1.2 2.8 0.8 2.4 0.9 2.4 1.0 0.035
HBV DNA, log10 copies/ml 8.5 1.2 8.0 1.4 8.9 0.9 8.4 1.3 8.6 1.2 0.033
ALT, ULN 4.3 3.7 5.4 5.5 4.3 2.7 4.0 3.0 3.4 2.4 0.151

Table 2. Characteristics of the randomized patients at week 24.

Total Arm B Arm C Arm D p value

(N = 198) (N = 67) (N = 67) (N = 64) (B vs. C vs. D)
HBsAg decline, log10 IU/ml -0.40 -0.40 -0.36 -0.45 0.756
ALT, ULN 1.9 2.2 2.1 2.4 1.8 1.6 1.9 2.6 0.709
HBV DNA, log10 copies/ml 6.2 2.0 6.3 2.0 6.1 1.9 6.2 2.0 0.870
HBsAg, log10 IU/ml 3.7 0.6 3.8 0.5 3.7 0.7 3.7 0.7 0.777
HBsAg <1500 IU/ml, n (%) 20 (10.1) 7 (10.4) 9 (13.4) 4 (6.3) 0.392
HBeAg, log10 PEIU/ml 1.3 1.1 1.5 1.2 1.2 1.1 1.3 1.1 0.420
HBeAg loss, n (%) 11 (5.5) 3 (4.5) 4 (6.0) 4 (6.3) 0.892
HBeAg seroconversion, n (%) 11 (5.5) 3 (4.5) 4 (6.0) 4 (6.3) 0.892

Journal of Hepatology 2016 vol. 65 j 674682 677

Research Article
p <0.001
A 3.5 p <0.001
p = 0.001 p = 0.038
Arm A
B 7.0 p <0.001
p = 0.108

Arm B p <0.001

Mean ( SD) decline of HBV DNA

Mean ( SD) decline of HBsAg

3.0 6.0
from baseline, log10 IU/ml

Arm C

from baseline, log10 cps/ml

p <0.001 Arm D
2.5 5.0

2.0 4.0

1.5 3.0

1.0 2.0

0.5 1.0

0.0 0.89 0.33 0.28 0.34 1.52 0.40 0.36 0.45 1.53 0.87 0.72 0.87 1.15 0.67 0.71 0.64
0.0 3.60 2.38 2.09 1.83 4.82 2.62 2.27 2.45 4.79 3.18 3.01 3.72 3.28 2.34 2.68 2.83
Week 12 Week 24 EOT EOF Week 12 Week 24 EOT EOF
No. of subjects being followed: No. of subjects being followed:
66 67 67 64 66 67 67 64 65 67 56 58 62 64 52 53 66 67 67 64 66 67 67 64 65 67 56 58 62 64 52 53

Fig. 3. Mean decline of HBsAg (A) and HBV DNA (B) from baseline to 24 weeks post-treatment. p value was calculated from a Students t test between early responder
and non-early responder. Last observation carried forward procedure was used to impute the missing data pertaining to the treatment period. EOT, end of treatment; EOF,
end of follow-up.

Table 3. Summary of treatment responses at EOT and 24 weeks post-treatment.

Early responders Non-early responders p value p value p value

Arm A Arm B Arm C Arm D (C+D vs. B) (C vs. B) (D vs. B)
(n = 66) (n = 67) (n = 67) (n = 64)
End of treatment
HBsAg reduction (log10 IU/ml) -1.53 -0.87 -0.72 -0.87 0.655 0.746 0.461
HBeAg loss, n (%) 23 (34.8) 10 (14.9) 19 (28.4) 23 (35.9) 0.010 0.142 0.022
HBeAg seroconversion, n (%) 22 (33.3) 9 (13.4) 18 (26.9) 20 (31.3) 0.015 0.116 0.041
HBV DNA undetectable, n (%) 24 (36.4) 6 (9.0) 11 (16.4) 10 (15.6) 0.195 0.301 0.303
HBsAg loss, n (%) 4 (6.1) 0 1 (1.5) 2 (3.1) 0.552 0.962 0.960
HBsAg seroconversion, n (%) 3 (4.5) 0 0 2 (3.1) 0.550 1.000 0.926
ALT normalization, n (%)a 27 (43.5) 29 (43.3) 27 (41.5) 36 (59.0) 0.374 0.898 0.057
End of follow-up
HBsAg reduction (log10 IU/ml) -1.15 -0.67 -0.71 -0.64 0.964 0.407 0.552
HBeAg loss, n (%) 34 (51.5) 21 (31.3) 23 (34.3) 25 (39.1) 0.459 0.777 0.786
HBeAg seroconversion, n (%) 31 (47.0) 21 (31.3) 23 (34.3) 22 (34.4) 0.671 0.883 0.865
HBV DNA undetectable, n (%) 9 (13.6) 3 (4.5) 3 (4.5) 4 (6.3) 1.000 0.967 0.672
HBeAg seroconversion with HBV DNA 26 (39.4) 12 (17.9) 16 (23.9) 16 (25.0) 0.297 0.395 0.322
<2000 IU/ml, n (%)
HBsAg loss, n (%) 3 (4.5) 0 1 (1.5) 2 (3.1) 0.552 0.962 0.959
HBsAg seroconversion, n (%) 1 (1.5) 0 1 (1.5) 2 (3.1) 0.552 0.962 0.959
ALT normalization, n (%)a 37 (59.7) 28 (41.8) 28 (43.1) 32 (52.5) 0.439 0.832 0.189
a
The rate of ALT normalization is defined as number of subjects with ALT >1 ULN at baseline but ALT 61 ULN at end of treatment (or end of follow-up) divided by number of
subjects with abnormal ALT at baseline.

Efficacy in Non-early responders (Arms B, C and D) and 26.9%), as compared to arm B (14.9% and 13.4%) but without
statistical significance. When we combined the arm C and arm D,
At the end of treatment i.e., all patients with 96 weeks PegIFN therapy, the HBeAg loss
From week 24 to EOT, further decline of HBsAg was observed in and HBeAg seroconversion rate was significantly higher com-
the three groups (0.47 log10 IU/ml, 0.36 log10 IU/ml and pared to the group of patients receiving the 48 weeks regimen
0.42 log10 IU/ml in arms B, C and D, respectively). There was (arm B).
no significant difference in the decrease of HBsAg from baseline Adding on ADV from week 29 to week 64 resulted in a tempo-
to EOT in arm B, when compared with that observed in arms C rary improvement of viral suppression with a higher HBV DNA
and D, respectively (B vs. C, p = 0.746; B vs. D, p = 0.461). reduction from baseline to week 72 (arm C vs. Arm D, 2.49 vs.
At EOT, 96 weeks of therapy with PegIFNa-2a in combination 3.99 log10 copies/ml, p <0.001). However, the HBV DNA unde-
with ADV (arm D) resulted in a significantly higher proportion of tectability rate at EOT was similar between arms C and D.
patients achieving HBeAg loss (35.9% vs. 14.9%, p = 0.022) and
seroconversion (31.3% vs. 13.4%, p = 0.041) compared with At the end of follow-up
48 weeks PegIFNa-2a monotherapy in arm B (Table 3). The rates Partial rebound of quantitative HBsAg from EOT to EOF was
of HBeAg loss and seroconversion were higher in arm C (28.4% observed in each arm after the stop of PegIFN (Fig. 3A). There

678 Journal of Hepatology 2016 vol. 65 j 674682


was no significant difference in the decrease of HBsAg from base-
line to EOF in arm B, when compared with that observed in arms
C and D, respectively (B vs. C, p = 0.407; B vs. D, p = 0.552). In
addition, there were no differences in HBeAg loss and seroconver-
sion for arms B, C and D (Table 3). The rate of HBsAg loss was 0%,
1.5% and 3.1% in arms B, C and D respectively. Partial rebound of
HBV DNA level was observed in each arm from EOT to EOF. The
mean HBV DNA decline from baseline to EOF was 2.34, 2.68
and 2.83 log10 copies/ml in arms B, C and D, respectively
(Fig. 3B). There was no significant difference between arm C vs.
arm B or arm D vs. arm B in terms of HBV DNA undetectability,
HBeAg seroconversion with HBV DNA <2000 IU/ml (Table 3).
Per-protocol analysis also showed that the response at EOF
among arms B, C and D were not different (Supplementary
Table 1).
Prediction of response
Fig. 4 shows the chance of response according to the levels
of HBsAg (<1500 vs. P1500 IU/ml) and/or HBV DNA (<5 vs.
JOURNAL OF HEPATOLOGY
P5 log copies/ml) at week 24. 38.4% of patients with HBsAg
<1500 IU/ml at week 24 achieved HBeAg seroconversion with
HBV DNA <2000 IU/ml at EOF, similarly, 37.0% of patients with
HBV DNA <5 log copies/ml at week 24 also achieved this response
at EOF. When we combined HBsAg and HBV DNA levels at week
24, only patients with HBsAg >1500 IU/ml plus HBV DNA >5 log
copies/ml showed relatively poor response (HBeAg seroconver-
sion with HBV DNA <2000 IU/ml rate 13.6% at EOF). Patients
infected with genotype B had a numerically higher rate of HBeAg
seroconversion with HBV DNA <2000 IU/ml compared with those
infected with genotype C; however, this difference was not statis-
tically significant (Supplementary Fig. 1).
Notably, 17.7% (8/45) of patients with HBsAg >20,000 IU/ml at
week 12 and 14.3% (5/35) of patients with HBsAg >20,000 IU/ml
at week 24 still achieved HBeAg seroconversion with HBV DNA
<2000 IU/ml at EOF. When we only included patients with
48 weeks PegIFN treatment, 17.6% (3/17) of patients with HBsAg
>20,000 IU/ml at week 12 and 7.7% (1/13) of patients with HBsAg
>20,000 IU/ml at week 24 achieved HBeAg seroconversion with
HBV DNA <2000 IU/ml at EOF.

Safety

%
The safety analysis included 265 patients who received at least 1
50
HBV DNA <2000 IU/ml at EOF

dose of study drug. Treatment was generally well tolerated. A

Rate of HBeAg seroconversion

38.8% total of 262 patients (98.9%) experienced AEs with more AEs
40 38.4% 37.0% 36.8%
35.0% being mild to moderate in severity. Four patients discontinued
combined with

treatment due to AEs (two each in arms C and D) and four

30
patients discontinued follow-up due to AEs (one each in arms
20.8% A, B, C and D). No deaths were reported during the study period
20 16.8%
13.6% (Table 4). The most common AEs were pyrexia and decreased
10
neutrophil count. Arm D (with ADV) was associated with a higher
incidence of leucopenia, neutropenia, thrombocytopenia, and
0 increased ALT levels than arms B and C. All of the serious AEs
33/86 37/178 47/127 23/137 26/67 7/19 21/60 16/118 resolved by the end of study.
24W HBsAg Y N - - Y Y N N
<1500 IU/ml
24W HBV DNA - - Y N Y N Y N
Discussion
<5 log copies/ml

Fig. 4. Rates of response at end of follow-up according to HBsAg and/or HBV RGT is a promising approach which has been successfully applied
DNA at week 24. to the treatment of chronic hepatitis C. To the best of our

Table 4. Summary of adverse events (AEs) (ITT).

N (%) Arm A Arm B Arm C Arm D Total

(N = 66) (N = 67) (N = 67) (N = 64) (N = 265)
1 reported AEs 66 (100.0) 67 (100.0) 66 (98.5) 62 (96.9) 262 (98.9)
1 reported serious AEs 3 (4.5) 4 (6.0) 5 (7.5) 1 (1.6) 13 (4.9)
Discontinuations from planned treatment due to AEs 0 0 2 (3.0) 2 (3.1) 4 (1.5)
Discontinuations from 24 week follow-up due to AEs 1 (1.5) 1 (1.5) 1 (1.5) 1 (1.6) 4 (1.5)
The most common AEs, n (%)
Pyrexia 50 (75.8) 50 (74.6) 37 (55.2) 33 (51.6) 171 (64.5)
Neutropenia 38 (57.6) 33 (49.3) 44 (65.7) 47 (73.4) 162 (61.1)
Leucopenia 32 (48.5) 27 (40.3) 37 (55.2) 43 (67.2) 139 (52.5)
Thrombocytopenia 17 (25.8) 17 (25.4) 18 (26.9) 23 (35.9) 76 (28.7)
Asthenia 20 (30.3) 18 (26.9) 16 (23.9) 16 (25.0) 71 (26.8)
Alopecia 11 (16.7) 19 (28.4) 18 (26.9) 14 (21.9) 62 (23.4)
Increased ALT 9 (13.6) 12 (17.9) 6 (9.0) 19 (29.7) 46 (17.4)
Neutrophil percentage decreased 8 (12.1) 10 (14.9) 11 (16.4) 12 (18.8) 41 (15.5)
Increased AST 6 (9.1) 10 (14.9) 4 (6.0) 8 (12.5) 28 (10.6)

Journal of Hepatology 2016 vol. 65 j 674682 679

Research Article
knowledge, this is the first randomized, controlled study to apply
the concept of RGT in CHB. For patients who achieved HBsAg
<1500 IU/ml or HBV DNA <105 copies/ml at week 24, the
response was optimal with 38.4% and 37.0% respectively achiev-
ing HBeAg seroconversion with HBV DNA <2000 IU/ml at EOF.
Extending PegIFN treatment duration or adding on ADV, did not
show superiority over 48 weeks PegIFN monotherapy.
On-treatment HBsAg levels have been shown in retrospective
analyses to be strongly related with post-treatment response to
PegIFN. However, this rationale has not been confirmed by any
prospective study. Our study is the first study which prospec-
tively demonstrated that patients with HBsAg <1500 IU/ml at
week 24 gained favorable sustained response to PegIFN treat-
ment. Taken together, for 86 patients with HBsAg <1500 IU/ml
at week 24, the sustained response rate (HBeAg seroconversion
with HBV DNA <2000 IU/ml at EOF) was 38.4%. The rationale
for combining HBsAg quantitation with HBV DNA level for defin-
ing early response at week 24 originated from the study by Fried
et al. [16] which showed that 53% of patients with HBV DNA
<5 log copies/ml at week 24 achieved HBeAg seroconversion at
24 weeks post-treatment. Our study results also confirmed that
week 24 HBV DNA as well as week 24 HBsAg level can predict
the outcomes at EOF. It is reasonable to infer that combining
these two strong efficacy predictors may be helpful for patient
management. In our study, for patients achieving HBV DNA
<105 copies/ml plus HBsAg <1500 IU/ml at week 24, 38.8%
showed sustained response at EOF with HBeAg seroconversion
and HBV DNA <2000 IU/ml. However, the response rate is compa-
rable to patients with HBV DNA <105 copies/ml or HBsAg
<1500 IU/ml at week 24 (Fig. 4). Only for patients with 24-
week HBsAg >1500 IU/ml and HBV DNA >5 log10 copies/ml was
the response rate relatively lower. Therefore, patients with HBsAg
<1500 IU/ml or HBV DNA <5 log10 copies/ml should be encour-
aged to continue PegIFN treatment since they have a high chance
of achieving sustained response off-treatment.
Interestingly, in early responders in our study, 24 weeks of
treatment resulted in HBsAg reduction of 1.52 Log10 IU/ml,
25.8% HBeAg loss and HBeAg seroconversion rate. Another
24 weeks PegIFN treatment from week 24 to week 48 did not
provide significant additional benefit for these patients, with no
further decline of HBsAg, and minimal increase of HBeAg loss
and seroconversion rate. It merits further study to compare short
duration of 24 weeks vs. 48 weeks for the early responders. We
will present the in-depth analysis result in a future publication
to propose which patients could benefit from a shortened therapy
period of 24 weeks based on rapid response as early as week 12.
Trying to increase response rate for non-early responders is
always difficult. In this study, extending PegIFN from 48 weeks
to 96 weeks with or without combining adefovir, did not lead
to more benefit for non-early responders in terms of primary or
secondary endpoints at EOF. Several studies have demonstrated
the potential benefit of extending interferon treatment duration,
mainly focused on HBeAg negative patients [8,17]. Lampertico
et al. reported significantly higher virological response rates
(HBV DNA <2000 IU/ml) at EOF after extending PegIFNa-2 ther-
apy from 48 weeks to 96 weeks, in a cohort of HBeAg negative
CHB patients [8]. Of note, there was no significant difference in
virological response at EOT. The benefit of extending PegIFN
duration in HBeAg negative patients is aimed at decreasing
relapse rate after PegIFN withdrawal. However, extending treat-
ment duration in HBeAg positive patients is a different story from
680 Journal of Hepatology 2016 vol. 65 j 674682
HBeAg negative patients. In our study in HBeAg positive patients,
extending the treatment duration from 48 weeks to 96 weeks in
non-early responders (arm C + D vs. arm B) resulted in higher
HBeAg loss and seroconversion response at EOT, but not at EOF.
This result suggested that extending PegIFN therapy in HBeAg
positive patients just speeded up the HBeAg seroconversion,
but did not increase the overall off-treatment response.
Currently, combination therapy of NAs with PegIFN is not rec-
ommended by international guidelines because of unproven
superior efficacy [18]. In the present study, for treatment-
experienced patients who do not achieve early response to
PegIFN, addition of ADV only resulted in transient reduction of
HBV DNA level, which rebounded after stopping ADV. The addi-
tion of ADV did not improve other efficacy endpoints either, such
as HBsAg reduction, HBeAg seroconversion and HBeAg loss. For
treatment nave patients, most studies testing the efficacy of
combination therapy of PegIFNa-2a plus NAs in HBeAg positive
CHB have shown disappointing results. The classical PegIFNa-
2a and alfa-2b global registration study failed to demonstrate
the benefit of combination with lamivudine at EOF [13,19]. Fur-
thermore, a recent Chinese multicenter study demonstrated no
additional benefit in terms of serological and virological response
with PegIFN plus ETV regimen, or PegIFN therapy with ETV pre-
treatment, over that attained with PegIFN monotherapy [14].
On the contrary, the result of a recent study showed that PegIFN
combined with tenofovir could achieve greater decline of HBsAg
level, as well as higher rate of HBsAg loss, but the benefit is not
significant when we only focused on patients with genotype B
and C [20]. Therefore, based on the above results, we proposed
that the benefit of adding on NAs during PegIFN treatment for
non-responders is limited, which is not encouraged, especially
in patients infected with genotype B or C.
Stopping rules have been proposed recently to guide PegIFN
treatment in HBeAg positive patients based on HBsAg level at
week 12 or 24 according to different genotypes [7]. Treatment
discontinuation is indicated in all patients with HBsAg
>20,000 IU/ml at week 24, irrespective of HBV genotype. How-
ever, this rule did not work very well in our region. In our study,
14.3% of patients with HBsAg >20,000 IU/ml at week 24 still
achieved HBeAg seroconversion with HBV DNA <2000 IU/ml at
EOF. This has also been illustrated previously by the PegIFNa
2a registration study which showed that 16% patients achieved
HBeAg seroconversion even if HBsAg was >20,000 IU/ml at week
24 [10]. As the genotype distribution differs among regions, we
need more careful evaluation of the stopping rule in Chinese
HBeAg positive patients with validation data from different
studies.
Extending PegIFNa-2a duration and combination of PegIFNa-
2a with ADV were both well tolerated. The safety assessment did
not reveal any major concerns and the reported AEs were consis-
tent with the know safety profile of PegIFN and ADV [13,21]. A
few subjects (4.9%) experienced serious AEs, however, no deaths
were reported. Totally, 33 patients dropped out before EOF, but
only 8 of them were due to AEs. Non-compliance was an impor-
tant issue for the PegIFN extension groups.
As this was the first attempt to try RGT strategy in CHB
patients, some limitations in our study were inevitable. Using
HBsAg reduction as primary endpoint was perhaps a suboptimal
primary endpoint. However, if we kept the same study design
and used HBeAg loss or seroconversion as the primary endpoint,
the estimated sample size requirement would have been over

800, which was not feasible owing to the budgetary constraints.
In addition, HBsAg quantitation has been extensively studied in
patients treated with PegIFN [7,10,11,22,23]. Several pivotal
studies have shown that greater reduction of HBsAg levels indi-
cated better treatment outcomes [2224]. HBsAg reduction is
also the prerequisite to achieve HBsAg clearance. Based on this
rationale, HBsAg reduction is still a meaningful endpoint, espe-
cially in future study designs targeting HBsAg clearance. Another
shortcoming was the high dropout rate observed in the study
group treated with 96 weeks PegIFNa-2a. This probably underes-
timated the benefit of extending treatment duration since all
cases with incomplete data were considered as treatment failure.
However, a per-protocol analysis was also performed, which
showed consistent results to that the ITT analysis. A reduction
in the dosage of PegIFNa-2a to 135 microgram per week in the
period from 48 weeks to 96 weeks could probably improve
treatment compliance [8]. Finally, adefovir is not the preferred
first-line anti-HBV drug according to international guidelines.
However, as this study is the first proof of concept study trying
to optimize the treatment outcome by combining PegIFN with
NAs in patients who did not achieve early response to PegIFN,
the finding from the present study are important for the design
of future studies combining PegIFN with other NAs.
To conclude, this study proved that RGT was practical for CHB
patients. Extending the duration of PegIFN in non-early respon-
ders is not recommended in Chinese HBeAg positive patients as
treatment extension beyond 48 weeks did not show convincing
benefit in terms of serologic or virologic response. Patients who
achieved an early response defined as HBsAg <1500 IU/ml or
HBV DNA <105 copies/ml at week 24 showed satisfactory out-
come after the withdrawal of finite PegIFN treatment.
Financial support
This study was funded by National Science and Technology Major
Project (2012ZX10002003) and F. Hoffmann-La Roche Ltd, Basel,
Switzerland.
Conflict of interest
QX and QN have received consulting fees from Roche, Novartis,
GlaxoSmithKline, Bristol-Myers Squibb and have received grant/
research support from Roche. JQN and JC has received honoraria
as a speaker for Roche, Merck Sharp & Dohme, Bristol-Myers
Squibb, GSK, and Novartis. JDJ has acted as a consultant for
Novartis, Bristol-Myers Squibb, GSK, Roche and Merck Sharp &
Dohme. LW has received consulting fees from Abbvie, Bristol-
Myers Squibb, Gilead, Merck, Novartis, Roche, and have received
grant/research support from Bristol-Myers Squibb and Roche. JLH
has received grant/research support from Roche, Novartis and
GSK. The other authors declared that they do not have anything
to disclose regarding funding or conflict of interest with respect
to this manuscript.
Authors contributions
JS, LW, HZ, JDJ, JLH were involved in the study design. JS, HM, QX,
YX, YTS, HW, GFS, MBW, JQN, QN, YYY, HJZ, JC, WZK, YX collected
Journal of Hepatology 2016 vol. 65 j 674682
JOURNAL OF HEPATOLOGY
data. JS, HM, RF, JJD and JLH analyzed and interpreted the data
and wrote the manuscript. All the authors had full access to the
final version of the report and agreed to the submission.
Acknowledgements
Parts of this study were presented at the 62nd American Associa-
tion for the Study of Liver Diseases annual meeting (AASLD 2011),
Nov 4-8, San Francisco; the 47th annual meeting of the European
Association for the Study of the Liver (EASL 2013), April 24-28,
Amsterdam; and the 48th annual meeting of the European Asso-
ciation for the Study of the Liver (EASL 2014), April 9-13, London.
We would like to thank all the patients, their families, the inves-
tigators and the nurses who participated in this trial. Medjaden
Bioscience Limited provided writing assistance which was spon-
sored by Shanghai Roche Pharmaceuticals.
Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.jhep.2016.05.
024.
References
[1] Trpo C, Chan HLY, Lok A. Hepatitis B virus infection. Lancet
2014;384:20532063.
[2] Lok ASF, McMahon BJ. Chronic hepatitis B: update 2009. Hepatology
2009;50:661662.
[3] Liaw Y-F, Kao J-H, Piratvisuth T, Chan H, Chien R-N, Liu C-J, et al. Asian-
Pacific consensus statement on the management of chronic hepatitis B: a
2012 update. Hepatol Int 2012;6:531561.
[4] European Association for the Study of the Liver. EASL Clinical Practice
Guidelines: management of chronic hepatitis B virus infection. J Hepatol
2012;57:167185.
[5] Buster EHCJ, Flink HJ, Cakaloglu Y, Simon K, Trojan J, Tabak F, et al. Sustained
HBeAg and HBsAg loss after long-term follow-up of HBeAg-positive patients
treated with peginterferon a-2b. Gastroenterology 2008;135:459467.
[6] van Zonneveld M, Honkoop P, Hansen BE, Niesters HG, Darwish Murad S, de
Man RA, et al. Long-term follow-up of alpha-interferon treatment of patients
with chronic hepatitis B. Hepatology 2004;39:804810.
[7] Sonneveld MJ, Hansen BE, Piratvisuth T, Jia JD, Zeuzem S, Gane E, et al.
Response-guided peginterferon therapy in hepatitis B e antigen-positive
chronic hepatitis B using serum hepatitis B surface antigen levels. Hepatol-
ogy 2013;58:872880.
[8] Lampertico P, Vigano M, Di Costanzo GG, Sagnelli E, Fasano M, Di Marco V,
et al. Randomised study comparing 48 and 96 weeks peginterferon alpha-2a
therapy in genotype D HBeAg-negative chronic hepatitis B. Gut
2013;62:290298.
[9] European Association for the Study of the Liver. EASL Clinical Practice
Guidelines: management of hepatitis C virus infection. J Hepatol
2014;60:392420.
[10] Piratvisuth T, Marcellin P, Popescu M, Kapprell H-P, Rothe V, Lu Z-M.
Hepatitis B surface antigen: association with sustained response to pegin-
terferon alfa-2a in hepatitis B e antigen-positive patients. Hepatol Int
2013;7:429436.
[11] Liaw YF, Jia JD, Chan HLY, Han KH, Tanwandee T, Chuang WL, et al. Shorter
durations and lower doses of peginterferon alfa-2a are associated with
inferior hepatitis B e antigen seroconversion rates in hepatitis B virus
genotypes B or C. Hepatology 2011;54:15911599.
[12] Marcellin P, Lau GKK, Bonino F, Farci P, Hadziyannis S, Jin R, et al.
Peginterferon Alfa-2a alone, lamivudine alone, and the two in combination
in patients with HBeAg-negative chronic hepatitis B. N Engl J Med
2004;351:12061217.
[13] Lau GKK, Piratvisuth T, Luo KX, Marcellin P, Thongsawat S, Cooksley G, et al.
Peginterferon Alfa-2a, lamivudine, and the combination for HBeAg-positive
chronic hepatitis B. N Engl J Med 2005;352:26822695.
681
Research Article
[14] Xie Q, Zhou H, Bai X, Wu S, Chen J-J, Sheng J, et al. A randomized, open-label
clinical study of combined pegylated interferon Alfa-2a (40KD) and ente-
cavir treatment for hepatitis B e antigen-positive chronic hepatitis B. Clin
Infect Dis 2014. http://dx.doi.org/10.1093/cid/ciu702.
[15] Sugauchi F, Orito E, Ichida T, Kato H, Sakugawa H, Kakumu S, et al. Hepatitis
B virus of genotype B with or without recombination with genotype C over
the precore region plus the core gene. J Virol 2002;76:59855992.
[16] Fried MW, Piratvisuth T, Lau GKK, Marcellin P, Chow W-C, Cooksley G, et al.
HBeAg and hepatitis B virus DNA as outcome predictors during therapy with
peginterferon alfa-2a for HBeAg-positive chronic hepatitis B. Hepatology
2008;47:428434.
[17] Gish RG, Lau DT, Schmid P, Perrillo R. A pilot study of extended duration
peginterferon alfa-2a for patients with hepatitis B e antigen-negative
chronic hepatitis B. Am J Gastroenterol 2007;102:27182723.
[18] Lampertico P. The royal wedding in chronic hepatitis B: The haves and the
have-nots for the combination of pegylated interferon and nucleos(t)ide
therapy. Hepatology 2015;61:14591461.
[19] Janssen HLA, van Zonneveld M, Senturk H, Zeuzem S, Akarca US, Cakaloglu Y,
et al. Pegylated interferon alfa-2b alone or in combination with lamivudine
for HBeAg-positive chronic hepatitis B: a randomised trial. Lancet
2005;365:123129.
682 Journal of Hepatology 2016 vol. 65 j 674682
[20] Marcellin P, Ahn SH, Ma X, Caruntu FA, Tak WY, Elkashab M, et al.
Combination of tenofovir disoproxil fumarate and peginterferon alfa-2a
increases loss of hepatitis B surface antigen in patients with chronic
hepatitis B. Gastroenterology 2015. http://dx.doi.org/10.1053/
j.gastro.2015.09.043.
[21] Marcellin P, Chang TT, Lim SG, Tong MJ, Sievert W, Shiffman ML, et al.
Adefovir dipivoxil for the treatment of hepatitis B e antigen-positive chronic
hepatitis B. N Engl J Med 2003;348:808816.
[22] Moucari R, Mackiewicz V, Lada O, Ripault M-P, Castelnau C, Martinot-
Peignoux M, et al. Early serum HBsAg drop: A strong predictor of sustained
virological response to pegylated interferon alfa-2a in HBeAg-negative
patients. Hepatology 2009;49:11511157.
[23] Sonneveld MJ, Rijckborst V, Boucher CAB, Hansen BE, Janssen HLA. Predic-
tion of sustained response to peginterferon alfa-2b for hepatitis B e antigen
positive chronic hepatitis B using on-treatment hepatitis B surface antigen
decline. Hepatology 2010;52:12511257.
[24] Rijckborst V, Hansen BE, Ferenci P, Brunetto MR, Tabak F, Cakaloglu Y, et al.
Validation of a stopping rule at week 12 using HBsAg and HBV DNA for
HBeAg-negative patients treated with peginterferon alfa-2a. J Hepatol
2012;56:10061011.