Neurology -- Correspondence for Ryan et al., 62 (6) 957-962

Correspondence published:

Reply to Asnis et al: Elizabeth L. Ryan, Douglas Dieterich, Susan Morgello (4 October 2004)

Neuropsychiatric impact of hepatitis C on advanced HIV: Gregory M. Asnis, Alexandra L. Migdal (4 October 2004)

Reply to Asnis et al 4 October 2004

Elizabeth L. Ryan,
Mount Sinai School of Medicine
Box 1134-MHBB One Gustave Levy Place NY, NY 10029-6574,
Douglas Dieterich, Susan Morgello
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Re: Reply to Asnis et al

elizabeth.ryan{at}mssm.edu Elizabeth L. Ryan, et al.

We appreciate the inquiry by Dr. Asnis et al as to whether the HIV/HCV coinfected patients in our study were treated with interferon (IFN). Its neuropsychiatric effects not only in patients treated for HCV but also for other disorders has been widely reported. As Dieperink et al [1] note, most reports have identified IFN-induced depression in HCV. We are unaware of any other reports (aside from ours) of IFN-induced cognitive deficits in HCV utilizing formal neuropsychological testing.
The effects we saw in our co-infected population could not be due to IFN, as the majority did not report active treatment for HCV at the time of assessment. Despite their seropositivity, most of our patients had compensated liver function as indicated. Furthermore, we do not know whether they were viremic at the time of assessment. We agree that early treatment of chronic HCV with IFN is a good idea and more likely to succeed than late.
However, until further studies of coinfected patients are performed that relate viremia to cognition, use of our study to support this indication may be premature.
References
1. Dieperink E, Willenbring M, Ho SB. Neuropsychiatric symptoms associated with hepatitis C and interferon alpha: A review. Am J Psychiatry. 2000 Jun;157:867-76.

Neuropsychiatric impact of hepatitis C on advanced HIV 4 October 2004

Gregory M. Asnis,
Montefiore Medical Center/Albert Einstein School of Medicine
Montefiore Medical Center 111 E. 210 St, Bronx, New York, 10467,
Alexandra L. Migdal
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Re: Neuropsychiatric impact of hepatitis C on advanced HIV

asnisarts{at}aol.com Gregory M. Asnis, et al.

We read with interest the article by Ryan et al which found that patients with HIV comorbid with chronic hepatitis C (CHC) had increased neuropsychiatric impairment versus HIV patients without comorbid CHC. [1] Furthermore, this additive neurocognitive burden of CHC apparently was not related to subclinical/clinical hepatic encephalopathy since this was seen in patients without significant hepatic decompensation.
The authors state that all patients were on the HAART regimen for HIV. However, the authors do not clarify whether CHC patients were being treated with interferon (IFN) for their illness. Since IFN is known to have a negative impact on neurocognition and quality of life [2], its use may have complicated the findings by Ryan et al. What seems to be a direct result of CHC may relate more to its treatment.
If these neuropsychiatric results are predominantly due to co- infection with CHC and not explained by IFN treatment, early treatment may eradicate the CHC virus with an anticipated improvement in cognitive impairment after subsequent IFN discontinuation. [3] Traditionally, IFN treatment is limited to CHC patients who have advanced liver disease. Recent studies suggest that IFN is also highly effective in early stages of CHC - normal liver enzymes and minimal fibrosis[4]; therefore,IFN might be considered in HIV/CHC patients with early or advanced liver disease.
The other reason to aggressively treat HIV/CHC patients with IFN is that CHC in these patients has a more aggressive course and over 30% of HIV patients are comorbid for CHC. [1] A clarification of the IFN status is necessary because these results may have a bearing on treatment decisions.
References
1. Ryan EL, Morgello S, Isaacs K, Naseer M, Gerits P. Neuropsychiatric impact of hepatitis C on advanced HIV. Neurology 2004;62:957-962.
2. Rasenack J, Zeuzem S, Feinman SV, et al. Peginterferon alpha-2a (40kD) [Pegasys] improves HR-QOL outcomes compared with unmodified interferon alpha-2a [Roferon-A]: in patients with chronic hepatitis C. Pharmacoeconomics 2003;21:341-349.
3. Bonkovsky HL, Woolley JM. Reduction of health-related quality of life in chronic hepatitis C and improvement with interferon therapy. The Consensus Interferon Study Group. Hepatology. 1999 Jan;29(1):264-70.
4. Zeuzem S. International, multicenter, randomized, controlled study for the treatment of patients with chronic hepatitis C and persistently normal ALT levels with peginterferon alfa-2a (40KD) (PEGASYS�) and ribavirin (COPEGUS�). Hepatology 2003; 38(suppl 1):208A.