Proton Pump Inhibitor Usage Reduces Sustained Viral Response Rates for Veterans With HIV/HCV Coinfection on Ledipasvir/Sofosbuvir

A Real-world Study From a Multicentre VA Cohort

Tzu-Hao Lee; Austin Chan; William Bryan; Lawrence Park; Mohamed Hashem; Mary Townsend; Cynthia Moylan; Rachel Britt; Steve Choi; Susanna Naggie

Disclosures

J Viral Hepat. 2021;28(4):630-636. 

In This Article

Results

There were 10,083 veterans identified within the VA pharmacy database who filled a prescription of LDV/SOF with a minimal 8-week course and had complete SVR12 data. We excluded veterans that had either cirrhosis or prior HCV treatment but received 8 weeks of LDV/SOF, which was not considered standard therapy (Figure S1). There were 9703 veterans included in the final analysis, with a median age of 63 years old. Ninety-six percent of the patients were male, 58% were Caucasian, and 36% were African American. The prevalence of cirrhosis was 23% (defined by FIB-4 sore>3.25), and 20% had failed prior HCV treatment (Table 1).

In the study cohort, 3422 (35.3%) veterans were taking PPI, including 1159 (11.9%) on high dose PPI, 823 (8.5%) on PPI twice a day, and 348 (3.6%) were taking H2B therapy during the HCV treatment. The veterans taking PPI were similar to the veterans not on PPI in terms of age, sex, race and HCV genotype (Table 1). However, more veterans in the PPI group had failed prior HCV treatment (24% vs. 18%) or had cirrhosis (27% vs. 20%) compared to the veterans not on any acid suppression medication (Table 1).

SVR in the Overall Cohort

In the inversed probability weight analysis (IPW) model, using PPI was associated with a lower SVR (95.0% vs. 96.1%, adjusted odds ratio [OR]:0.86, 95% confidence interval [CI]: 0.74–0.99, p = .03) (Table 2). Based on the estimated effect sizes, the number needed to harm is 90.9 and the clinical significance is small. The SVR rates for veterans taking high-dose PPI, PPI twice daily or H2 blocker are similar to the no-acid suppression group (Table 2).

In our analysis, low platelet count (<150,000), cirrhosis, prior HCV treatment failure and ribavirin use were also associated with lower SVR, while female sex and higher platelet (>200,000) were associated with higher SVR (Table 3).

Stratified Subgroups: Cirrhosis and Prior HCV Treatment

We stratified the overall cohort according to the two previously reported factors associated with lower SVR: prior HCV treatment failure and cirrhosis. After adjustment, PPI (all doses) or H2B use was not associated with lower SVR rates in these subgroups (Table 2).

Stratified Subgroup: HIV/HCV Coinfection

In our study, there were 589 veterans with HIV/HCV coinfection, which was 6.1% of the total cohort. The median age of patients with HIV-HCV coinfection was 62 years old. Ninety-eight percent were male, and 65% were African American. Twenty percent of these patients had cirrhosis at the time of DAA therapy, and 15% had failed prior HCV therapy (Table 4).

In this subgroup of patients, 26% (n = 151) were taking PPI, and 3% were taking H2B (n = 17). The veterans with HIV/HCV coinfection taking PPI were similar to the veterans with HIV/HCV coinfection not on acid suppression in terms of age, sex and race. However, more veterans in the PPI group had failed prior HCV treatment (21% vs. 14%) or had cirrhosis (23% vs. 19%) compared to those not on any acid suppression medication (Table 4).

In the inverse probability weighting analysis, taking any dose of PPI was associated with a lower SVR rate (93.4% vs. 96.9%), with an adjusted OR 0.47 (95% CI: 0.26–0.85, p = .01) (Table 3). Based on the estimated effect sizes, the number needed to harm is 28.6. There were only 17 patients with HIV/HCV coinfection taking H2B. Compared to patients not taking any acid suppression medication, using an H2B was not associated with a lower SVR rate (adjusted OR 3.34 with 95% CI 0.45–443.0, p = .34) (Table 3).

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