All baseline characteristics of the two groups are shown in Table 1. Almost all clinical data from the two groups were comparable. All patients were HBsAg positive, with an HBV viral load >500 IU/ml, no participant had decompensated liver cirrhosis.
Table 1. Baseline clinical data of the two study groups
Variables
|
NAs monotherapy(n=56)
|
Combination
Therapy(n=73)
|
P value
|
Age(Year)
|
45.5±12.7
|
42.9±12.2
|
0.489
|
Male(%)
|
35(62.5%)
|
48(65.75%)
|
0.367
|
BMI
|
23.1±3.1
|
23.4±2.9
|
0.536
|
ALT(U/L)
|
79.5±64.9
|
92.4±104.2
|
0.447
|
ALT>40U/L
|
15(26.78%)
|
23(31.51%)
|
0.560
|
AST(U/L)
|
60.8±38.9
|
69.1±66.7
|
0.435
|
AST>40U/L
|
14(25%)
|
21(28.77%)
|
0.633
|
TBil(umol/L)
|
14.5±6.9
|
14.8±8.8
|
0.791
|
AFP(ng/ml)
|
23.4±77.3
|
33.3±96.9
|
0.839
|
LSM(KPa)
|
20.0±13.4
|
17.2±13.2
|
0.323
|
PLT(10^9/L)
|
127.3±50.8
|
122.8±53.1
|
0.643
|
HBV DNA(log10IU/ml)
|
5.68±1.23
|
5.56±1.44
|
0.636
|
HBeAg positive
|
28(50%)
|
32(43.8%)
|
0.612
|
Data are shown as the mean± standard deviation (SD) or n (%) and they were compared using the independent-sample test or a chi-square test.
Abbreviations: BMI, Body Mass Index; ALT, alanine aminotransferase; AST, aspartate aminotransferase; TBil, total bilirubin; AFP, alpha-fetoprotein; LSM, liver stiffness measurement ;PLT, platelet; HBeAg, hepatitis B e antigen
Clinical efficacy of two groups
The clinical efficacy was different between the two groups at different time points, as shown in Table 2. Baseline and endpoint treatment variables were also compared in each group (Table 3). These results indicated that at week 52, the monotherapy group had better liver function recovery compared with the add-on treatment group (ALT: 26.0±12.1 U/L vs. 37.4±34.4, P=0.029; AST: 26.8±7.0 U/L vs. 36.4±23.6 U/L, P=0.007), but there was no significant difference in ALT and AST levels between the two groups at week 104. The results also showed that the monotherapy group might have favorable AFP decrease compared with the combination therapy group (2.4±0.84 ng/mL vs. 4.7±5.7 ng/mL, P=0.011). At the end of 2 years, the mean ALT and AST levels and the transient elastography value decreased significantly in each group compared with baseline data.
Table 2. On-treatment laboratory examination comparative results at different time points between the two groups
Variable
|
group
|
Baseline
|
26
weeks
|
P
|
52
weeks
|
P
|
78
weeks
|
P
|
104
Weeks
|
P
|
ALT(U/L)
|
monotherapy
|
79.5±64.9
|
30.5±16.1
|
0.927
|
26.0±12.1
|
0.029*
|
24.4±9.5
|
0.158
|
24.8±11.5
|
0.2
|
|
Add on
|
92.4±104.2
|
30.8±17.6
|
|
37.4±34.4
|
|
29.9±24.6
|
|
40.1±62.7
|
|
ALT>40U/L
|
monotherapy
|
15(26.8%)
|
8(14.3%)
|
0.738
|
6(10.7%)
|
0.469
|
1(1.8%)
|
0.228
|
4(7.1%)
|
0.948
|
|
Add on
|
23(31.5%)
|
12(16.4%)
|
|
11(15.1%)
|
|
6(8.2%)
|
|
5(6.8%)
|
|
AST(U/L)
|
monotherapy
|
60.8±38.9
|
31.2±16.1
|
0.956
|
26.8±7.0
|
0.007*
|
25.8±6.2
|
0.108
|
25.4±7.5
|
0.403
|
|
Add on
|
69.1±66.7
|
31.3±13.1
|
|
36.4±23.6
|
|
29.3±13.7
|
|
28.5±18.2
|
|
ALB (g/L)
|
monotherapy
|
46.8±5.5
|
45.3±2.9
|
0.799
|
45.3±2.1
|
0.208
|
46.5±4.3
|
0.91
|
48.2±4.7
|
0.774
|
|
Add on
|
42.5±4.9
|
45.4±3.8
|
|
44.4±4.3
|
|
45.1±4.1
|
|
47.8±6.3
|
|
TBil(umol/L)
|
monotherapy
|
14.5±6.9
|
14.3±5.4
|
0.781
|
15.9±7.0
|
0.649
|
14.3±5.5
|
0.292
|
20.6±32.7
|
0.143
|
Add on
|
14.8±8.8
|
14.0±6.2
|
|
18.4±38.6
|
|
13.2±5.8
|
|
12.4±5.0
|
|
AFP(ng/ml)
|
monotherapy
|
23.4±77.3
|
3.5±1.7
|
0.221
|
3.3±2.8
|
0.058
|
2.4±0.84
|
0.011*
|
2.4±0.9
|
0.07
|
Add on
|
33.3±96.9
|
6.8±19.1
|
|
4.4±3.2
|
|
4.7±5.7
|
|
4.3±5.5
|
|
LSM
measurement
|
monotherapy
|
20.0±13.4
|
12.9±7.9
|
0.853
|
12.3±8.3
|
0.195
|
11.1±10.7
|
0.357
|
12.8±13.9
|
0.037*
|
Add on
|
17.2±13.2
|
13.3±12.4
|
|
10.5±5.9
|
|
9.5±5.9
|
|
7.5±3.4
|
|
HBV DNA
(log10IU/ml)
|
monotherapy
|
5.68±1.23
|
3.07±0.94
|
0.759
|
3.11±0.41
|
0.552
|
|
|
/
|
/
|
Add on
|
5.56±1.44
|
3.01±0.48
|
|
2.95±0.04
|
|
|
|
/
|
|
Note: Data were mean ± SD and were compared by Independent-Sample Test. *: P value of <0.05 was defined as statistically significant. Monotherapy means that patients in this group only received ETV treatment. Add on means that patients in this group received add-on pegylated interferon alfa-2a to ongoing ETV treatment. There were few patients HBV DNA viral load > 500 IU/ml at week 78 and week 104,so the data was not comparable.
Table 3. Clinical efficacy at baseline and at the end of the study in each group
Variable
|
monotherapy
|
P
|
combination therapy
|
P
|
|
Baseline
|
2years
|
|
Baseline
|
2years
|
|
ALT(U/L)
|
79.5±64.9
|
24.8±11.5
|
0.000
|
92.4±104.2
|
40.1±62.7
|
0.007
|
AST(U/L)
|
60.8±38.9
|
25.4±7.5
|
0.000
|
69.1±66.7
|
28.5±18.2
|
0.001
|
ALB (g/L)
|
46.8±5.5
|
48.2±4.7
|
0.32
|
42.5±4.9
|
47.8±6.3
|
0.000
|
TBil(umol/L)
|
14.5±6.9
|
20.6±32.7
|
0.207
|
14.8±8.8
|
12.4±5.0
|
0.142
|
AFP(ng/ml)
|
23.4±77.3
|
2.4±0.91
|
0.149
|
33.3±96.9
|
4.3±5.5
|
0.085
|
LSM( KPa)
|
20.0±13.4
|
12.8±13.9
|
0.035
|
17.2±13.2
|
7.5±3.4
|
0.000
|
HBV viral load
|
5.68±1.23
|
<500
|
<0.05
|
5.56±1.44
|
<500
|
<0.05
|
Liver histology
|
|
Inflammation grades
|
2(2,3)
|
1(1,1)
|
0.000
|
2(2,3)
|
1(1,1.25)
|
0.001
|
Fibrosis stage
|
3(2,4)
|
1.5(1,3)
|
0.021
|
3(2,4)
|
1.5(1,3.25)
|
0.011
|
Ishak fibrosis score
|
4(1,4)
|
2(1,3.75)
|
0.47
|
4(3,4)
|
1.5(1,3.25)
|
0.001
|
Note: All data are presented as the mean±SD, or median (IQR: 1st, 3rd quartiles) as appropriate. *P value of <0.05 was defined as statistically significant.
HBsAg/HBeAg clearance or seroconversion results
At week 26, patients in both groups only received ETV for treatment, and none of them showed HBsAg loss, whereas some patients began to lose and/or seroconvert HBeAg.
At week 52, one patient in the monotherapy group but none in the combination therapy group had lost HBsAg. In both groups, another three patients had lost and/or seroconverted HBeAg. The patient who had lost HBsAg in the monotherapy group also had an undetectable HBV viral load, but his liver function test results remained abnormal during the treatment. Additionally, before receiving ETV monotherapy treatment, the patient had already been followed-up in our department for 2 years with slightly high ALT and AST levels and HBV viral load.
At week 78, one patient from combination group had lost and/or seroconverted HBsAg.
At the end of our study, there was altogether one patient who lost HBsAg in the monotherapy group while three patients in the combination therapy group showed HBsAg clearance (1.79% (1/56) vs 4.11% (3/73), P=0.632). All data are presented in Table 4. Additionally, Figure 2A and 2B provide supplementary information about the total number of patients who lost HBsAg, HBeAg and/or seroconverted with the respective antibody formation at different time points. Data are presented as n (%). Figure 2C shows the change of HBsAg levels. Figure 2D presents the results of sustained suppression of HBV DNA. There was no significant difference in sustained suppression of HBV DNA between the two groups.
Table 4. The number of patients who had HBsAg, HBeAg clearance, and/or seroconversion with emerging antibody during the research period
Variable
|
group
|
0
weeks
|
26
weeks
|
52
weeks
|
78
weeks
|
104
Weeks
|
HBsAg lost
|
monotherapy
|
0
|
0
|
1
|
1
|
1
|
|
Add on
|
0
|
0
|
0
|
1
|
3
|
HBsAb acquire
|
monotherapy
|
0
|
0
|
1
|
1
|
1
|
|
Add on
|
0
|
0
|
3
|
3
|
3
|
HBeAg lost
|
monotherapy
|
0
|
1
|
4
|
5
|
7
|
|
Add on
|
0
|
2
|
5
|
6
|
8
|
HBeAb acquire
|
monotherapy
|
0
|
1
|
4
|
4
|
6
|
|
Add on
|
0
|
1
|
4
|
5
|
7
|
Note: Data are presented as the number of patients.
Complementary liver histology results
Combination therapy showed better histology improvement than the monotherapy group (mean liver stiffness value 7.5±3.4 kPa [SD 1.9] vs. 12.8±13.9 kPa [SD 1.9], P=0.037). The liver stiffness value decreased significantly in each group compared with baseline data. Liver histology improved remarkably in both groups after 2 years. The results are shown in Figs 3 and 4.
Supplement Table: Changes of liver histological evaluations
Fibrosis stage
|
Monotherapy
|
Combination therapy
|
|
Baseline
|
2 years
|
Baseline
|
2 years
|
G1S1
|
0
|
9
|
0
|
12
|
G1S2
|
13
|
7
|
12
|
9
|
G2S2
|
6
|
5
|
6
|
6
|
G2S3
|
6
|
3
|
15
|
6
|
G2S4
|
5
|
2
|
10
|
5
|
G3S2
|
6
|
2
|
3
|
3
|
G3S3
|
6
|
3
|
3
|
3
|
G3S4
|
14
|
4
|
24
|
6
|
Note:Not all patients agreed second liver biopsy after 2 years of treatment.
Adverse events
During treatment, three patients showed thyroid dysfunction (one patient in monotherapy) and two patients had granulopenia (both in the combination therapy group). Six patients had a fever in the combination therapy group after they received their treatment. One patient felt fatigue in the ETV monotherapy group.
Table 5. Incidence of discontinuation of treatment and adverse events
Variable
|
Monotherapy(N=56)
|
Combination therapy(N=73)
|
Discontinuation
|
|
|
For safety reasons
|
4(7.14%)
|
5(6.85%)
|
For other reasons
|
8(14.28%)
|
3(2.81%)
|
Adverse events
|
|
|
thyroid dysfunction
|
1(1.79%)
|
0
|
granulopenia
|
0
|
2(2.74%)
|
fever
|
0
|
6(8.22%)
|
fatigue
|
1(1.79%)
|
0
|