Sequential combination therapy with interferon, interleukin-2 and therapeutic vaccine in entecavir-suppressed chronic hepatitis B patients: the Endeavor study
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Switching from nucleos(t)ide analogues to interferon (IFN) improves hepatitis B surface antigen (HBsAg) loss. We aimed to evaluate whether combining immunomodulators such as interleukin-2 (IL-2) and therapeutic vaccine with IFN enhances HBsAg loss in entecavir (ETV)-suppressed patients.
Ninety-four patients exhibiting virological suppression and hepatitis B e antigen (HBeAg) loss following ETV treatment were randomized 1:1:1 to receive ETV (group I) or IFN (group II) for 48 weeks, or IFN and vaccine for 48 weeks plus IL-2 for 12 weeks (group III). The primary endpoint was HBsAg loss at week 48. Peripheral natural killer (NK) cells and regulatory T cells (Treg) were measured as immune checkpoint indicators.
Mean HBsAg decline at week 48 was significantly greater in group III (0.85 log 10 IU/mL) and group II (0.74 log 10 IU/mL), than in group I (0.13 log 10 IU/mL). At week 48, 9.38%, 3.03%, and 3.70% of subjects in group III, II, and I, respectively, achieved HBsAg loss. Among patients with baseline HBsAg titers ranging from 100 to 1500 IU/mL, HBsAg loss rate was 27.3, 7.1, and 0% in group III, II, and I, respectively. Responders in group III showed a significantly higher increase in CD56bright CD16−NK cells from week 24 to 36, and a significant decline in Treg from week 12 to 24 than non-responders.
For ETV-suppressed patients, particularly those with low baseline HBsAg levels, combination therapy with IFN and other immunomodulators may enhance HBsAg loss, while successful response correlates with partial restoration of NK cells and Tregs.
KeywordsHepatitis B surface antigen loss Interferon Entecavir Combination therapy
Chronic hepatitis B
Covalently closed circular DNA
Hepatitis B e antigen
Hepatitis B surface antigen
Hepatitis B virus
- NK cell
Natural killer cell
Regulatory T cell
Upper limit of normal
The authors would like to thank all the patients in this study, and the nurses who assisted in the patient management and the collection of serum samples. Data management and clinical trial monitoring were provided by Hangzhou Tigermed Consulting Co., Ltd.
QN, DW, and MH developed the concepts and designed the experiments. DW, and PW analyzed and interpreted the data. DW drafted the manuscript. YC, XC, QX, WY, CZ, QX, JJ, LW, DT, XD, YY, and JH were involved in patient recruitment, and data collection. QN, DW, XL, MH, and XW revised the manuscript.
This work was supported by grants from the Chinese National Twelfth Five Years Project in Science and Technology (2013ZX10002003), the Chinese National Thirteenth Five Years Project in Science and Technology (2017ZX10202201) and Hubei Provincial Natural Science Foundation of China (2018CFB206).
Compliance with ethical standards
Conflict of interest
The authors declare no conflict of interest.
The study was performed in accordance with Good Clinical Practice and the Declaration of Helsinki principles for ethical research. The study protocol was approved by the independent central ethics committee of Tongji Medical College at Wuhan. Written informed consent was obtained from each participant. ClinicalTrials.gov Identifier: NCT02360592. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).
Informed consent was obtained from all patients for being included in the study.
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