The design of the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis (HALT-C) trial has been described previously.12 (
link) Briefly, patients meeting the following criteria were entered into this study from 10 study centers in the United States between August 2000 and August 2004: lack of a sustained virologic response to previous therapy, advanced hepatic fibrosis according to liver biopsy (an Ishak fibrosis score13 (
link) of 3 or more; scores range from 0 to 6, with higher scores indicating greater degrees of fibrosis and scores of 5 or 6 indicating cirrhosis), no history of hepatic decompensation or hepatocellular carcinoma, and absence of exclusion criteria (e.g., liver disease other than hepatitis C, uncontrolled medical or psychiatric conditions, or contraindications to interferon treatment). The patients were stratified according to their Ishak fibrosis score. The non-cirrhotic-fibrosis stratum consisted of 622 patients with a score of 3 or 4, and the cirrhosis stratum consisted of 428 patients with a score of 5 or 6. The patients provided written informed consent for participation in the trial.
During the lead-in phase of the trial, all patients underwent treatment with 180
μg of subcutaneous pegylated interferon alfa-2a weekly (Pegasys, Roche; the drug had not yet been approved by the Food and Drug Administration [FDA] when the trial began) and oral ribavirin (1000 to 1200 mg daily, according to body weight) for at least 24 weeks before undergoing randomization (
Fig. 1). Randomization was stratified according to clinical center and the presence or absence of cirrhosis and was performed centrally by computer with the use of permuted blocks of random size. Patients with detectable serum HCV RNA levels at treatment week 20 were classified as having no response (<1 log
10 IU per milliliter decrease in HCV RNA level from baseline) or a partial response (≥1 log
10 IU per milliliter decrease in HCV RNA level from baseline) and were assigned for the next 3.5 years to either the maintenance-therapy group (90
μg of peginterferon alfa-2a weekly, without ribavirin) or the untreated control group. For treated patients who had unacceptable side effects, the weekly peginterferon dose was reduced to 45 μg or even lower, as needed.
Patients with undetectable serum HCV RNA at week 20 continued therapy for an additional 48 weeks, as reported previously.14 (
link) If HCV RNA was detected in a patient again after week 20, either during treatment (breakthrough) or after cessation of treatment (relapse), the patient was offered the opportunity to undergo randomization in the controlled phase of the trial (the “breakthrough or relapse” cohort). During the trial, after pegylated interferons became available for treating hepatitis C, we amended the protocol to allow patients who had been treated with peginterferon plus ribavirin outside the study but had not had a sustained virologic response to treatment to undergo randomization to the treatment or control group (the “express” cohort).
Di Bisceglie A.M., Shiffman M.L., Everson G.T., Lindsay K.L., Everhart J.E., Wright E.C., Lee W.M., Lok A.S., Bonkovsky H.L., Morgan T.R., Ghany M.G., Morishima C., Snow K.K, & Dienstag J.L. (2008). Prolonged Therapy of Advanced Chronic Hepatitis C with Low-Dose Peginterferon. The New England journal of medicine, 359(23), 2429-2441.