Best Practice & Research Clinical Gastroenterology 31 (2017) 321e327

Contents lists available at ScienceDirect

Best Practice & Research Clinical Gastroenterology

journal homepage: https://ees.elsevier.com/ybega/default.asp

10

Hepatitis delta infection e Current and new treatment options

Menashe Elazar, PhD, Senior Research Scientist a, 1,
Christopher Koh, MD, MHSc, Associate Professor d, 2,
Jeffrey S. Glenn, MD, PhD, Associate Professor of Medicine and Microbiology &
Immunology a, b, c, *
a
Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 269 Campus Drive, Stanford, CA 94305,
USA
b
Department of Microbiology & Immunology, Stanford University School of Medicine, Stanford, CA 94305, USA
c
Veterans Administration Medical Center, Palo Alto, CA, USA
d
Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, NIH, 10 Center Drive, CRC, 5-2740 Bethesda, MD 20892 USA

a b s t r a c t
Keywords: In humans, hepatitis D virus (HDV) infection only occurs in the presence of a concomitant hepatitis B
Hepatitis delta virus virus (HBV) infection, and induces the most severe form of human viral hepatitis. Even though HDV is
Treatment
spread worldwide and is endemic in some regions, screening and treatment has been often neglected in
Novel therapies
part due to the lack of an effective therapy. Moreover, HDV prevalence rates are increasing in many
countries driven by immigration from areas of high endemicity. Currently, no FDA-approved anti-HDV
therapy is available, although interferon (IFN) alpha therapy has demonstrated benefit in a minority of
patients. In this review, we present a current view of our understanding of the epidemiology, molecular
virology and management of HDV infection. We additionally discuss new treatment approaches in
development and describe the most promising results of recent and ongoing clinical trials of these new
potential agents.
© 2017 Elsevier Ltd. All rights reserved.

Introduction infectiondeither as a de novo co-infection of an HBV naïve patient,

Hepatitis Delta virus (HDV) was identified in 1977 in a cohort of
hepatitis B virus (HBV) patients presenting with severe hepatitis.
Liver biopsies from these patients revealed a novel immunostaining
pattern [1]. This apparent new antigenic moiety was termed d an-
tigen and was present in liver cell nuclei from chronic HBV patients.
Although at first considered a new antigenic moiety of HBV, it was
quickly recognized as a separate antigen that was associated with
HBsAg [1]. Further characterization identified the d antigen as an
antigen of an infectious agent distinct from HBV that was associated
with a low molecular weight RNA genome [2]. HDV infection was
found to always occurs in the presence of an accompanying HBV
or as a superinfection of a patient already chronically infected with
HBV e a fact explained by HDV's molecular virology (see below).
The presence of HDV is generally associated with worse clinical
outcomes compared to HBV monoinfection, both in terms of the
severity of acute disease as well as accelerating the rate of devel-
opment of the sequelae of chronic disease, including cirrhosis, liver
failure, HCC, or death [3]. Here, we will briefly review the molecular
virology, epidemiology and pathogenesis of HDV infection and will
focus on current and new therapeutic approaches that are under
clinical investigation.
Molecular virology

* Corresponding author. Departments of Medicine, Division of Gastroenterology
and Hepatology and Microbiology & Immunology, Stanford University School of
Medicine, Stanford, CA, USA. Fax: þ1 650 723 3032.
E-mail addresses: menashe@stanford.edu (M. Elazar), Christopher.Koh@nih.gov
(C. Koh), jeffrey.glenn@stanford.edu (J.S. Glenn).
1
Fax: þ1 650 723 3032.
2
Fax: þ1 301 480 6303.
HDV is a single-stranded (-)RNA virus with a 1.7 kb circular
genome that forms a collapsed rod structure by the self-annealing
of 74% of its nucleotides [4]. The viral genome codes for one protein
that exists in two forms, known as small and large delta antigen
(SHDAg and LHDAg), respectively. These proteins are identical
except that the large delta antigen contains an extra 19 amino acids

http://dx.doi.org/10.1016/j.bpg.2017.05.001
1521-6918/© 2017 Elsevier Ltd. All rights reserved.
322 M. Elazar et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 321e327
at its carboxyl terminus. This extension is the result of a specific
RNA editing event that occurs during replication of the genome [5].
The addition of these 19 amino acids change the carboxy terminus
of the protein to possess a CXXX-box motif (where C ¼ cysteine, and
X ¼ one of the last 3 amino acids at the carboxy terminus) that
renders the protein a substrate for farnesyltransferase, an enzyme
that adds a farnesyl group to the cysteine of the CXXX-box [6]. This
farnesylation reaction is an essential modification for virion as-
sembly [7]. The complete HDV virus particle consists of a complex
of the viral genome and both delta antigen isoforms, all encapsu-
lated by a lipid envelope decorated with HBV surface antigens (S, M
and L HBsAg) proteins, which are provided by a co-infecting HBV
[8]. The HBV proteins present in the lipid envelope provide the
means for HDV particle exit and entry into the cell [8]. This
dependence on HBV for a source of envelope proteins provides the
molecular explanation for why HDV infection is always accompa-
nied by HBV co-infection. This supply of HBV surface antigens is the
only helper function provided by HBV.
HDV genome replication proceeds entirely through RNA-
dependent RNA replication. There are no DNA intermediates and
there is no archiving of HDV into DNA, yet HDV does not code for
its own RNA-dependent RNA-polymerase. Rather HDV depends on
host cell polymerases for its replication. Interestingly, the virus
appears to recruit Pol-II, a host DNA-dependent RNA polymerase
to replicate its RNA genome in a RNA dependent manner [9]. It has
been hypothesized that the double stranded-like structure of the
HDV genomic RNA provides a template akin to double stranded
DNA that enables the recruitment of Pol-II [10]. Following HDV
entry and uncoating, the incoming HDV RNA genome is trans-
ferred into the nucleus. The RNA is replicated through a so-called
double rolling circle mechanism by Pol-II associated with the
SHDAg to generate linear multimeric copies of antigenomic RNA,
which undergo cleavage by the antigenomic ribozyme to form
linear monomers that are then ligated, forming closed circular
antigenomes that serve as templates for production of genomic
RNA in a similar mechanism [9]. As replication proceeds, an RNA
editing event, mediated by ADAR1, occurs on the antigenomic RNA
that modifies the amber stop codon of the reading frame encoding
SHDAg. This results in translation proceeding to the next down-
stream stop codon, adding an extra 19 amino acids and yielding
expression of the LHDAg [11]. These extra 19 amino acids
dramatically change the function of the delta antigen. For
example, while the SHDAg is required for HDV RNA genome
replication, the LHDAg acts as a potent transdominant inhibitor of
HDV replication [12]. Moreover, only the LHDAg isoform is able to
mediate assembly with HBsAg envelope proteins. Thus the above
RNA editing event represents an important molecular switch in
the virus life cycle, serving to turn off RNA replication and turn on
packaging of newly synthesized HDV genomes, virus assembly and
release [13].
Epidemiology
It is estimated that HDV's worldwide prevalence is 15e20
million people, with an overall average of ~5% of the HBV popu-
lation harboring HDV, but the percentage of HBV patients co-
infected with HDV is variable in different geographic regions
[14]. Some areas have been identified as endemic for HDV infec-
tion, including regions in Africa, South America, Turkey, Southern
Italy and countries from the former Soviet Union [14]. In the
United States and Northern Europe HDV prevalence has settled at
around 8% in HBsAg positive patients with higher prevalence in
populations of intravenous drug users (IVDU) and hemophiliacs
[15]. This represents a balance between declines from the origi-
nally reported prevalences when HDV was first discovered, and
the influx of immigrants into western European countries from
areas of high endemicity, such as Turkey, Eastern Europe and Af-
rica [14e18]. Higher prevalence of HDV infection is observed in the
eastern Mediterranean basin, Middle East, central and northern
Asia and central western Africa [14]. For example, in Brazil, while
the prevalence in the general population is around 8%, the prev-
alence in the Amazonian Basin is 65% in HBsAg positive out-
patients, with similar observations in other South American
countries [19]. In Africa, HDV affects mostly Western and Central
Africa with prevalence ranging from 33% in Mauritania [20] to up
to 66% in Gabon [21,22]. In Asia, a mixed picture emerges with
some areas demonstrating low HDV prevalence such as Malaysia,
Thailand, Philippines and Japan, while a higher prevalence is
observed in India and Pakistan [23]. In Taiwan while prevalence in
the general population is around 6%, in IVDU patients, the prev-
alence has been reported to be 67% [24]. In Mongolia, some studies
have reported populations with extremely high rates of HDV co-
infection (>88%). A recent large nationwide survey using vali-
dated assays documented ~60% HDV co-infection among HBsAg
subjectsdan extraordinarily high prevalence that may help
explain the world's highest rate of hepatocellular carcinoma being
observed in that country [25,26]. It is noteworthy that diagnostics
for anti-HDV infection are not standardized, and although there is
an international standard for HDV RNA detection to enable con-
version to International Units (IU), commercial pangenotypic as-
says for HDV RNA are not readily available in many countries. In
addition, many HBsAg-positive patients are simply not screened
for HDV. Together these factors combine to potentially underes-
timate HDV prevalence in many countries.
Pathogenesis
From its discovery, it was noted that HDV infection worsens the
liver disease of HBV infected patients when compared to in-
dividuals with HBV infection alone [1], however clinically there is
no difference between HBV and HDV induced hepatitis [27]. Indeed,
HDV induces the worst form of hepatitis in humans and is associ-
ated with higher risk of liver decompensation and death compared
to HBV infection alone [3].
HDV infection can occur in one of two ways: coinfection, by
which HBV and HDV infection happens simultaneously, or super-
infection, where HDV infects an individual already chronically
infected with HBV [28]. As for acute HBV infection, coinfection in
adults is less likely to induce chronic hepatitis (>5%) [29], however
development of severe acute hepatitis with a potential to result in
acute liver failure (2e20%) is the major risk [27]. Superinfection on
the other hand, results in 70e90% of infected individuals devel-
oping chronic hepatitis [30]. Chronically infected HDV patients are
at high risk of developing cirrhosis [31], with an estimated 80% of
infected individuals developing cirrhosis within 30 years after
infection [30]. Additionally, 10e15% of chronically infected patients
may develop cirrhosis within two years of infection [30]. These
observations on the pathogenesis of HDV-infected patients clearly
demonstrate the high health burden of this infection and the need
for the development of better diagnostic tools as well as more
effective antivirals.
HDV infection is associated with HCC, although the precise risk
estimate is somewhat controversial. In one study, Fattovich et al.
[31] reported a 3-fold increased risk of developing HCC with a 2-fold
increased risk for death. A similar result was obtained in a US study
conducted among veteran patients demonstrating that HDV was an
independent predictor with 3-fold increased risk for HCC develop-
ment [32]. In a Swedish study, the Standard Incidence Ratio (SIR) to
develop HCC in chronic HDV patients was higher compared to HBV
infection alone [33]. In contrast, Romeo et al. [34] showed that 15% of
 M. Elazar et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 321e327
patients with chronic HDV develop cancer with a relatively low
annual rate of 2.8%, and that there was no clear correlation with HDV
RNA levels [35]. Niro et al. [36] reported 9% of patients with chronic
HDV advanced to HCC, and Buti et al. [37] found that only 3% of
patients developed HCC. These authors attributed the low rate to the
young age of patients in their study, but all of these studies suggest
that liver decompensation and death are a major risk factors in
chronic HDV infected patients [34,36,37].
Treatment
Currently, no efficient anti-HDV therapy is available nor is there
an FDA-approved therapy for HDV infection. The wide spectrum of
antiviral activity of interferon (IFN) alpha (a) initially prompted a
plethora of studies to examine its effect on HDV infection [38e40].
One early study reported a beneficial effect of IFNa with 48 weeks of
treatment, where 71% of patients treated with a high dose (9 million
units) had undetectable virus in serum at the end of treatment
(EOT). However, at the end of 6 months post-therapy follow-up, only
43% of subjects maintained RNA negativity and a longer follow-up
extending to 39 months post-therapy, demonstrated virologic
relapse in all responders [38]. Although the interpretation of these
results may reflect in part an early HDV RNA assay with suboptimal
sensitivity, long-term follow-up of the patients in this study (out to
12 years) demonstrated an increased survival rate in the patients
treated with high dose IFN and overall a better clinical outcome in
terms of liver disease progression. Additionally, significantly better
clinical outcomes were associated with achieving a 2 log drop in
HDV RNA [41]. Gunser et al. (2004) conducted a similar study but
extended treatment duration out to two years. In this study, similar
trends were observed with 50% of patients achieving undetectable
HDV RNA levels at EOT, however only 20% of patients remained
negative at end of the follow-up period of 6 months [39]. Similar
outcomes with pegylated interferon a (PEG-IFNa) treatment were
observed when tested in HDV infected subjects. One year PEG-IFNa
treatment resulted in 57 % of patients achieving HDV RNA negativity,
which dropped to 43% at end of follow-up (up to 42 months, median
16 months) [42], while up to 5 years of treatment resulted in only
42% of patients becoming HDV RNA negative with only 25%
remaining negative by the end of 5 years [43]. The subsequent
addition of ribavirin (RBV) to PEG-IFNa did not improve response
rates and does not appear to have a role in the therapy of HDV
infected patients [44]. Thus far, the most comprehensive evaluation
of PEG-IFNa treatment with long-term outcome reporting has been
conducted by the Hep-Net-International Delta Hepatitis Interven-
tion Trial (HIDIT) study group. This consortium's first study, the
HIDIT-1 study, enrolled 90 subjects into one of three arms
comparing PEG-IFNa with adefovir (nucleotide analog) versus
PEG-IFNa versus adefovir alone, and had a primary end point of ALT
normalization and clearance of HDV RNA at the end of 48 weeks of
therapy. Unfortunately, only 7% of subjects achieved the primary
end-point in both PEG-IFNa treated study arms while none of those
treated with adefovir alone did [45]. It is noteworthy that in both
PEG-IFNa treated groups, 28% of patients cleared the virus within 24
weeks after completing the treatment while none of the adefovir
alone treated patients achieved viral clearance [45]. A long-term
follow-up of patients from this study (range of 0.5e5.5 years of
follow-up) showed that 70% of patients that were treated with
either of the PEG-IFNa arms, and who were HDV negative at end of
treatment, were positive at least once during follow-up, with 44%
being HDV RNA positive at end of follow-up. This highlights the need
for a close follow-up of patients even when HDV RNA negativity is
achieved [46]. The consortium's second study, the HIDIT-2 study,
aimed at determining the benefit of longer treatment (96 week)
with PEG-IFNa and tenofovir in chronically infected HDV subjects.
323
However, this study did not demonstrate any improvement in
response rates [47], thereby underscoring the need for more effi-
cient therapies. Despite the poor response rates of IFNa therapy in
HDV patients, the potential for long-term clinical benefits in re-
sponders supports a recommendation for treatment in chronically
HDV infected patients for 48 weeks with once weekly dosing of
180 mg PEG-IFNa. However, careful selection of patients for treat-
ment taking into consideration ALT levels, the degree of histologic
fibrosis, and side effects, is recommended. Fig. 1 offer a suggested
algorithm for HDV management.
Potential antiviral targets
The unique HDV life cycle and dependence on HBV for its entry
and egress presents several steps that have the potential for anti-
viral intervention, including entry, replication, viral egress and RNA
interference (RNAi).
Replication
Targeting the RNA dependent RNA replication, the genomic or
the antigenomic ribozymes, or the ligation step that produces the
final circular genomic/antigenomic molecules are all valid sites for
antiviral intervention in the HDV life cycle. Inhibition of the host
polymerase has not been reported, presumably as it may be too
toxic to interfere with an essential host functions. However, SHDAg
is an essential cofactor of Pol-II in the HDV replication cycle thus,
inhibition of the interaction between these two proteins may
inhibit viral replication.
Aminoglycosides have been shown to inhibit the ribozyme ac-
tivity, however this was not translated to inhibition of HDV in cell
culture [48,49]. One possible explanation is that all the replication
steps occur in the nucleus, thus every candidate molecule will have
to reach the nucleus in order to exert an inhibitory effect on HDV
replication, which might prove challenging.
HBV inhibition
The dependence of HDV on HBV for completing its life cycle
suggests that HBV inhibition will result in inhibition of HDV viral
load. However, several attempts to utilize various anti-HBV nucle-
os(t)ide analog therapies to treat HDV have demonstrated little to
no response in chronically infected HDV subjects [50e53]. This is
not surprising as inhibition of the HBV polymerase does not result
in HBsAg inhibition, which is the sole required HBV element for
HDV. Attempts to use HBV nucleos(t)ide analog therapy alone or in
combination with IFN and PEG-IFN has been attempted with no
success (see Treatment above).
RNA interference
RNA interference (RNAi) is a collective name for small RNA
molecules used to inhibit gene expression in a sequence specific
manner.
Since its discovery, RNAi approaches have been evaluated as
potential therapeutic modalities for various conditions including
infectious diseases and more specifically viral infections. A similar
approach for HDV treatment may be feasible [54].
Promising clinical trials
Several agents have advanced beyond the preclinical stage and
are being actively investigated in a variety of clinical trials. The
most advanced of these will be briefly reviewed next. Like other
viral diseases, combination therapy may ultimately result in the
324 M. Elazar et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 321e327

Fig. 1. Suggested algorithm for management of HDV infection.

highest response rates as these experimental therapies progress
through the pipeline.
HBV entry inhibitor e Myrcludex-B
The HBV entry receptor, human sodium-taurocholate cotrans-
porting polypeptide (hNTCP) has been identified as a potential
target against HBV and HDV [55]. The 48 amino-acids of the preS1
N-terminal of the L-HBsAg are the essential determinant for re-
ceptor binding [56], and it has recently been demonstrated that a
myristoylated peptide corresponding to this sequence inhibits HBV
and HDV entry in vitro and in vivo [57,58], through competitive
inhibition of the particle binding to hNTPC [59]. This peptide, called
Myrcludex-B (Myr), is undergoing evaluation in clinical trials in
subjects with chronic HBV monoinfection and chronic HDV/HBV co-
infection. In an early phase clinical study, 24 patients with serum
 M. Elazar et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 321e327
HDV RNA levels ranging from 1e3 to 1e5 copies/ml were treated
with Myr (2 mg SQ QD) alone or in combination with PEG-IFNa and
compared to PEG-IFNa alone for 24 weeks. A reported interim
analysis at the end of 24 weeks of treatment revealed no significant
changes in HBsAg, the study's primary end-point. However, HDV
RNA declined 1.67 (Myr arm), 2.6 (Myr þ PEG-IFNa arm), and 2.2 log
(PEG-IFNa arm), with 2, 5, and 2 subjects in the respective groups
achieving serum HDV RNA levels below the level of quantitation
[60]. HBV DNA was inhibited to near or below detectable levels in all
the patients in the Myr-PEG-IFNa arm while no changes were
observed in the patients from the Myr or PEG-IFNa arms of the study
[60]. Subjects were then continued on PEG-IFNa monotherapy for a
total of 48 weeks, which did not appear to provide a significant
benefit, with end of treatment responses comparable to what has
been seen historically for PEG-IFNa, and patients generally
rebounding following cessation of therapy (Hepatitis Delta Inter-
national Network (HDIN) at AASLD 2016 and [61]. This pilot study
demonstrated that Myr-mediated inhibition of viral entry can have
inhibitory activity against HDV, however higher doses, longer
treatment or combination with another drug will be required to
eradicate the virus. Additionally, all the participants in this study
demonstrated relatively low viremia at baseline and further evalu-
ation is needed to determine if similar results can be achieved in
patients with higher levels of serum HDV RNA.
HBsAg secretion inhibitors e REP2055 and REP2139-Ca
Polymers demonstrating inhibitory activity against a variety of
viruses have been described for many years where their activity
appears to be dependent on polymer length and hydrophobicity (see
review [62]). One such polymer class is the phosphorothioate nucleic
acid polymers (PS-ON or NAP) which possesses a broad spectrum
antiviral activity due to its length and amphipathic nature [62].
In vitro, NAPs have been shown to inhibit HIV-1 entry via interaction
with an exposed amphipathic helix in the viral fusion protein gp41
[63]. Additionally, NAPs have demonstrated inhibitory activity
against herpes simplex virus (HSV) [64,65], Arenaviruses [66] and
hepatitis C virus (HCV) [67] through interaction of the NAP's hydro-
phobic side with amphipathic stretches within proteins from these
pathogens. Preclinical testing of the NAP molecule REP2055 against
duck HBV (DHBV) demonstrated inhibition of HBV infection in
addition to post-entry inhibition [68]. This post-entry mechanism
involves the inhibition of DHBsAg secretion and its accumulation in
liver cells [69], a result that may have a clinical utility in HDV infected
patients. REP2139 was developed to address tolerability issues with
REP2055 in initial early clinical studies in HBV patients. 3 of 12 sub-
jects had HBsAg levels decline below the limit of quantitation after
being treated with weekly IV infusions of REP2139 for 20e35 weeks,
which was accompanied by 4e6 log reductions in HBV DNA [70].
These promising results in HBV moninfected patients have resulted
in a small cohort study testing REP2139 in HBV/HDV coinfected pa-
tients. REP2139 was administered once weekly at a dose of 500 mg
IV for 15 weeks followed by an additional 15 weeks of weekly
REP2139 250 mg IV combined with PEG-IFNa, and then transitioning
to PEG-IFNa monotherapy for another 33 weeks (REP301-
ClinicalTrials.gov # NCT02233075). 4/12 patients exhibited large
drops in HBsAg (up to 5 logs) at week 15, which were accompanied by
HDV RNA going below the limit of detection [71], and several addi-
tional patients were reported below the limit of quantitation after
addition of PEG-IFNa [72]. Upon withdrawal of therapy, however, 5/
12 patients became HDV RNA positive again (A. Valiant et al. the 12th
HDIN at AASLD Boston, USA 2016 and [73]). A long-term follow-up
study of these patients is underway to assess for maintenance of
response. While these early results are promising, evidence is still
lacking for the safety of NAPs for long term administration. Given the
325
mechanism of action of NAPs in HBV, with inhibition of HBsAg
secretion in animal models, this raises the question of whether long
term administration may increase the risk of HCC [69,74].
Viral assembly and release inhibitors e lonafarnib
HDV requires HBsAg for completing its life cycle successfully,
but this is not sufficient. Prenylation, in particular the covalent
addition of a farnesyl prenyl lipid group to the C-terminus of HDV
large antigen (HDLAg) is essential for successful interaction of
HDLAg with HBsAg and formation of secreted particles, with HBsAg
[75]. Inhibition of farnesyltransferase was shown to inhibit HDV
virion secretion and inhibit infection in vitro [7] and in vivo [76].
This requirement prompted the investigation of farnesyltransferase
inhibitors (FTIs) for HDV treatment. The FTI lonafarnib (Sarasar®)
was extensively studied for use as a cancer therapy. Its develop-
ment as an oncology product was terminated due to insufficient
anti-tumor efficacy, but these studies provided an extensive safety
data base in over 2000 patients, where the side effects were pre-
dominantly gastrointestinal. This presented an ideal repurposing
opportunity as a potential anti-HDV agent. Lonafarnib (LNF) has
now been tested in multiple trials comprising over 100 HDV pa-
tients. In a placebo-controlled proof-of-concept study, 14 patients
were treated with either 100 mg BID or 200 mg BID lonafarnib
administered orally for 4 weeks, and followed up for 6 months post
therapy. Both dosing groups had a drop in serum HDV RNA (0.73 log
and 1.54 log in the low and high dose treatment arms, respectively),
and the changes in HDV RNA were highly correlated with the drug
concentration measured in patients' sera [77], demonstrating the
potential utility of this drug for HDV management. Importantly,
there was no evidence of virus resistance, as had been predicted for
such a host targeting antiviral therapy. Following this study, a series
of studies aiming to optimize drug dose and treatment duration
were conducted. The LOWR HDVd1 (LOnafarnib With and without
Ritonavir in HDV e 1) study explored higher doses and longer
duration of treatment, as well as combination with ritonavir (an
inhibitor of LNF's metabolism). 300 mg LNF PO BID achieved a 2-log
reduction at 4 weeks, but had increased GI side effects. Adminis-
tering a lower 100 mg dose PO BID, but with ritonavir (RTV) to
maximize post-absorbed levels of LNF, resulted in less GI side ef-
fects with better antiviral response e 2.4 log drop at 4 weeks and
3.2 log at 8 weeks [78]. Similar antiviral responses were seen with
100 mg LNF PO BID combined with standard PEG-IFNa. In both
cases, the onset of viral inhibition in these combination treatments
was more rapid and profound than previously observed with
PEG-IFNa alone in the context of the HIDIT-2 study. The LOWR-2
study aimed to identify the optimal combinations of LNF and
RTV, with or without PEG-IFNa, to maximize efficacy and tolera-
bility. Although still ongoing, interim results have identified regi-
mens (e.g. 50 mg PO BID þ 100 mg RTV PO BID, and 25 mg PO
BID þ 100 mg RTV PO BID þ PEG-IFNa) that appear to show good
antiviral activity in a significant number of patients, and are suffi-
ciently well tolerated to enable treatment for as long as needed to
achieve HDV RNA negativity. Regimens bracketing those explored
in LOWR HDV-2 were explored in LOWR HDV-3 and LOWR HDV-4.
LOWR HDV-3 explored single daily doses of LNF (50 mg vs. 75 mg
vs. 100 mg) þ RTV (100 mg) for 12 vs. 24 weeks, and LOWR HDV-4
sought to determine the efficacy of rapid step-wise dose escalation
to 100 mg LNF þ 100 mg RTV, each PO BID [79]. The final results of
both will soon be available. In addition to a progressive decline of
HDV RNA on LNF therapy, another mechanism has emerged
whereby LNF treated patients can achieve HDV RNA negativity. In
particular, when LOWR-1 and LOWR-2 patients were monitored
post treatment, approximately 20% of patients who did not clear
HDV RNA on 3e6 months of LNF treatment experienced
326 M. Elazar et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 321e327
THerapeutic Alt Normalizing ChangeS (THANCS) accompanied by
serum HDV RNA negativity. After as little as 6 months of achieving
such normalized ALT and HDV RNA negativity, regression in fibrosis
was observed on liver biopsy [80].
Type III interferon
Although shown to have anti-HDV efficacy, PEG-IFNa has sig-
nificant side effects, attributed in part to the fact that its receptors
are widely expressed throughout the body. In contrast, the re-
ceptors for Type-III IFNs (such as IFNl) have a more restricted
localization on specific cell types that include the liver [81]. It was
therefore (successfully) hypothesized that PEG-IFNl could be active
against a human hepatitis virus, such as HCV, yet with less side
effects than PEG-IFNa. Similarly, PEG-IFNl may also be able to
inhibit HDV with less side effects than PEG-IFNa, and a clinical trial
is under way to examine this possibility (ClinicalTrials.gov
NCT02765802). If successful as a monotherapy, IFNl can also be
considered as an attractive combination therapeutic with the above
mentioned investigational drugs.
Concluding remarks
HDV infections pose a major health problem world-wide. The
fast disease progression and lack of appropriate treatment results
in an increased risk of end stage liver complications. It is clear that
PEG-IFNa treatment is not sufficient to alleviate this problem, and
that new approaches for HDV management are in need. The recent
developments of new candidate therapeutics to treat HDV are very
promising, suggesting that we may have new therapeutic ap-
proaches in coming years.
Practice points
 Hepatitis delta is the worst form of human viral hepatitis.
 Patients with hepatitis B should be screened for hepatitis
delta virus (HDV).
 HDV-infected patients should be considered for treatment
with interferon alpha or experimental therapies.
Research agenda
 Updated prevalences of HDV co-infection should be
determined in most countries.
 Promising new therapies in development need to be
proven safe and effective and are likely to change man-
agement for this serious unmet medical need.
 Detailed studies focusing on the natural long-term history
outcomes for HDV-infected patients can help highlight the
danger of not treating patients.
Conflict of interest
Elazar: Equity interest in Eiger BioPharmaceuticals, Inc.; Koh:
none; Glenn: Equity interest in Eiger BioPharmaceuticals, Inc.
Acknowledgement
None.
References
[1] Rizzetto M, Canese MG, Arico S, Crivelli O, Trepo C, Bonino F, et al. Immu-
nofluorescence detection of new antigen-antibody system (delta/anti-delta)
associated to hepatitis B virus in liver and in serum of HBsAg carriers. Gut
1977;18:997e1003.
[2] Rizzetto M, Hoyer B, Canese MG, Shih JW, Purcell RH, Gerin JL. Delta Agent:
association of delta antigen with hepatitis B surface antigen and RNA in serum
of delta-infected chimpanzees. Proc Natl Acad Sci USA 1980;77:6124e8.
[3] Rizzetto M. Hepatitis D virus: introduction and epidemiology. Cold Spring
Harb Perspect Med 2015;5, a021576.
[4] Griffin BL, Chasovskikh S, Dritschilo A, Casey JL. Hepatitis delta antigen re-
quires a flexible quasi-double-stranded RNA structure to bind and condense
hepatitis delta virus RNA in a ribonucleoprotein complex. J Virol 2014;88:
7402e11.
[5] Casey JL. Control of ADAR1 editing of hepatitis delta virus RNAs. Curr Top
Microbiol Immunol 2012;353:123e43.
[6] Glenn JS, Watson JA, Havel CM, White JM. Identification of a prenylation site in
delta virus large antigen. Science 1992;256:1331e3.
[7] Bordier BB, Marion PL, Ohashi K, Kay MA, Greenberg HB, Casey JL, et al. A
prenylation inhibitor prevents production of infectious hepatitis delta virus
particles. J Virol 2002;76:10465e72.
[8] Bonino F, Heermann KH, Rizzetto M, Gerlich WH. Hepatitis delta virus: protein
composition of delta antigen and its hepatitis B virus-derived envelope. J Virol
1986;58:945e50.
[9] Sureau C, Negro F. The hepatitis delta virus: replication and pathogenesis. J
Hepatol 2016;64:S102e16.
[10] Chang J, Nie X, Chang HE, Han Z, Taylor J. Transcription of hepatitis delta virus
RNA by RNA polymerase II. J Virol 2008;82:1118e27.
[11] Luo GX, Chao M, Hsieh SY, Sureau C, Nishikura K, Taylor J. A specific base
transition occurs on replicating hepatitis delta virus RNA. J Virol 1990;64:
1021e7.
[12] Glenn JS, White JM. trans-dominant inhibition of human hepatitis delta virus
genome replication. J Virol 1991;65:2357e61.
[13] Chao M, Hsieh SY, Taylor J. Role of two forms of hepatitis delta virus antigen:
evidence for a mechanism of self-limiting genome replication. J Virol 1990;64:
5066e9.
[14] Noureddin M, Gish R. Hepatitis delta: epidemiology, diagnosis and manage-
ment 36 years after discovery. Curr Gastroenterol Rep 2014;16:365.
[15] Ciancio A, Rizzetto M. Chronic hepatitis D at a standstill: where do we go from
here? Nat Rev Gastroenterol Hepatol 2014;11:68e71.
[16] Reinheimer C, Doerr HW, Berger A. Hepatitis delta: on soft paws across
Germany. Infection 2012;40:621e5.
[17] Servant-Delmas A, Le Gal F, Gallian P, Gordien E, Laperche S. Increasing
prevalence of HDV/HBV infection over 15 years in France. J Clin Virol 2014;59:
126e8.
[18] William Tong CY, Asher R, Toby M, Ngui SL, Tettmar K, Ijaz S, et al.
A re-assessment of the epidemiology and patient characteristics of
hepatitis D virus infection in inner city London. J Infect 2013;66:521e7.
[19] Crispim MA, Fraiji NA, Campello SC, Schriefer NA, Stefani MM, Kiesslich D.
Molecular epidemiology of hepatitis B and hepatitis delta viruses circulating
in the Western Amazon region, North Brazil. BMC Infect Dis 2014;14:94.
[20] Lunel-Fabiani F, Mansour W, Amar AO, Aye M, Le Gal F, Malick FZ, et al. Impact
of hepatitis B and delta virus co-infection on liver disease in Mauritania: a
cross sectional study. J Infect 2013;67:448e57.
[21] Andernach IE, Leiss LV, Tarnagda ZS, Tahita MC, Otegbayo JA, Forbi JC, et al.
Characterization of hepatitis delta virus in sub-Saharan Africa. J Clin Microbiol.
2014;52:1629e36.
[22] Makuwa M, Mintsa-Ndong A, Souquiere S, Nkoghe D, Leroy EM, Kazanji M.
Prevalence and molecular diversity of hepatitis B virus and hepatitis delta
virus in urban and rural populations in northern Gabon in central Africa. J Clin
Microbiol. 2009;47:2265e8.
[23] Rizzetto M, Ciancio A. Epidemiology of hepatitis D. Semin Liver Dis 2012;32:
211e9.
[24] Chang SY, Yang CL, Ko WS, Liu WC, Lin CY, Wu CH, et al. Molecular epide-
miology of hepatitis D virus infection among injecting drug users with and
without human immunodeficiency virus infection in Taiwan. J Clin Microbiol
2011;49:1083e9.
[25] Takahashi M, Nishizawa T, Gotanda Y, Tsuda F, Komatsu F, Kawabata T, et al.
High prevalence of antibodies to hepatitis A and E viruses and viremia of
hepatitis B, C, and D viruses among apparently healthy populations in
Mongolia. Clin Diagn Lab Immunol 2004;11:392e8.
[26] Oyunsuren T, Kurbanov F, Tanaka Y, Elkady A, Sanduijav R, Khajidsuren O,
et al. High frequency of hepatocellular carcinoma in Mongolia; association
with mono-, or co-infection with hepatitis C, B, and delta viruses. J Med Virol
2006;78:1688e95.
[27] Caredda F, Rossi E, d'Arminio Monforte A, Zampini L, Re T, Meroni B, et al.
Hepatitis B virus-associated coinfection and superinfection with delta agent:
indistinguishable disease with different outcome. J Infect Dis 1985;151:
925e8.
[28] Negro F. Hepatitis D virus coinfection and superinfection. Cold Spring Harb
Perspect Med 2014;4, a021550.
[29] Rizzetto M. Hepatitis D: virology, clinical and epidemiological aspects. Acta
Gastroenterol Belg 2000;63:221e4.
 M. Elazar et al. / Best Practice & Research Clinical Gastroenterology 31 (2017) 321e327
[30] Yurdaydin C, Idilman R, Bozkaya H, Bozdayi AM. Natural history and treat-
ment of chronic delta hepatitis. J Viral Hepat 2010;17:749e56.
[31] Fattovich G, Giustina G, Christensen E, Pantalena M, Zagni I, Realdi G, et al.
Influence of hepatitis delta virus infection on morbidity and mortality in
compensated cirrhosis type B. The European Concerted Action on Viral Hep-
atitis (Eurohep). Gut 2000;46:420e6.
[32] Kushner T, Serper M, Kaplan DE. Delta hepatitis within the Veterans Affairs
medical system in the United States: prevalence, risk factors, and outcomes. J
Hepatol 2015;63:586e92.
[33] Ji J, Sundquist K, Sundquist J. A population-based study of hepatitis D virus as
potential risk factor for hepatocellular carcinoma. J Natl Cancer Inst 2012;104:
790e2.
[34] Romeo R, Del Ninno E, Rumi M, Russo A, Sangiovanni A, de Franchis R, et al. A
28-year study of the course of hepatitis Delta infection: a risk factor for
cirrhosis and hepatocellular carcinoma. Gastroenterology 2009;136:1629e38.
[35] Romeo R, Foglieni B, Casazza G, Spreafico M, Colombo M, Prati D. High serum
levels of HDV RNA are predictors of cirrhosis and liver cancer in patients with
chronic hepatitis delta. PLoS One 2014;9, e92062.
[36] Niro GA, Smedile A, Ippolito AM, Ciancio A, Fontana R, Olivero A, et al.
Outcome of chronic delta hepatitis in Italy: a long-term cohort study. J Hep-
atol 2010;53:834e40.
[37] Buti M, Homs M, Rodriguez-Frias F, Funalleras G, Jardi R, Sauleda S, et al.
Clinical outcome of acute and chronic hepatitis delta over time: a long-term
follow-up study. J Viral Hepat 2011;18:434e42.
[38] Farci P, Mandas A, Coiana A, Lai ME, Desmet V, Vaneyken P, et al. Treatment of
chronic hepatitis-D with interferon-alfa-2a. New Engl J Med 1994;330:88e94.
[39] Gunsar F, Akarca US, Ersoz G, Kobak AC, Karasu Z, Yuce G, et al. Two-year
interferon therapy with or without ribavirin in chronic delta hepatitis. Antivir
Ther 2005;10:721e6.
[40] Yurdaydin C, Bozkaya H, Karaaslan H, Onder FO, Erkan OE, Yalcin K, et al. A
pilot study of 2 years of interferon treatment in patients with chronic delta
hepatitis. J Viral Hepat 2007;14:812e6.
[41] Farci P, Roskams T, Chessa L, Peddis G, Mazzoleni AP, Scioscia R, et al. Long-
term benefit of interferon alpha therapy of chronic hepatitis D: regression of
advanced hepatic fibrosis. Gastroenterology 2004;126:1740e9.
[42] Castelnau C, Le Gal F, Ripault MP, Gordien E, Martinot-Peignoux M, Boyer N,
et al. Efficacy of peginterferon alpha-2b in chronic hepatitis delta: relevance of
quantitative RT-PCR for follow-up. Hepatology 2006;44:728e35.
[43] Heller T, Rotman Y, Koh C, Clark S, Haynes-Williams V, Chang R, et al.
Long-term therapy of chronic delta hepatitis with peginterferon alfa. Aliment
Pharmacol Ther 2014;40:93e104.
[44] Niro GA, Ciancio A, Gaeta GB, Smedile A, Marrone A, Olivero A, et al. Pegylated
interferon alpha-2b as monotherapy or in combination with ribavirin in
chronic hepatitis delta. Hepatology 2006;44:713e20.
[45] Wedemeyer H, Yurdaydin C, Dalekos GN, Erhardt A, Cakaloglu Y,
Degertekin H, et al. Peginterferon plus adefovir versus either drug alone for
hepatitis delta. N Engl J Med 2011;364:322e31.
[46] Heidrich B, Yurdaydin C, Kabacam G, Ratsch BA, Zachou K, Bremer B, et al. Late
HDV RNA relapse after peginterferon alpha-based therapy of chronic hepatitis
delta. Hepatology 2014;60:87e97.
[47] Wedemeyer H, Yurdaydin C, Ernst S, Caruntu FA, Curescu MG, Yalcin K, et al.
Prolonged therapy of Hepatitis Delta for 96 weeks with pegylated-interferon-
a-2a plus tenofovir of placebo does not prevent HDV RNA relapse after
treatment: the Hidit-2 study group. J Hepatol 2014;60:S2e3.
[48] Chia JS, Wu HL, Wang HW, Chen DS, Chen PJ. Inhibition of hepatitis delta virus
genomic ribozyme self-cleavage by aminoglycosides. J Biomed Sci 1997;4:
208e16.
[49] Rogers J, Chang AH, von Ahsen U, Schroeder R, Davies J. Inhibition of the self-
cleavage reaction of the human hepatitis delta virus ribozyme by antibiotics. J
Mol Biol 1996;259:916e25.
[50] Kabacam G, Onder FO, Yakut M, Seven G, Karatayli SC, Karatayli E, et al.
Entecavir treatment of chronic hepatitis D. Clin Infect Dis 2012;55:645e50.
[51] Yurdaydin C, Bozkaya H, Onder FO, Senturk H, Karaaslan H, Akdogan M, et al.
Treatment of chronic delta hepatitis with lamivudine vs lamivudine +
interferon vs interferon. J Viral Hepat 2008;15:314e21.
[52] Lau DT, Doo E, Park Y, Kleiner DE, Schmid P, Kuhns MC, et al. Lamivudine for
chronic delta hepatitis. Hepatology 1999;30:546e9.
[53] Niro GA, Ciancio A, Tillman HL, Lagget M, Olivero A, Perri F, et al. Lamivudine
therapy in chronic delta hepatitis: a multicentre randomized-controlled pilot
study. Aliment Pharmacol Ther 2005;22:227e32.
[54] Chang J, Taylor JM. Susceptibility of human hepatitis delta virus RNAs to small
interfering RNA action. J Virol 2003;77:9728e31.
[55] Yan H, Zhong G, Xu G, He W, Jing Z, Gao Z, et al. Sodium taurocholate
cotransporting polypeptide is a functional receptor for human hepatitis B and
D virus. Elife 2012;1, e00049.
[56] Engelke M, Mills K, Seitz S, Simon P, Gripon P, Schnolzer M, et al. Charac-
terization of a hepatitis B and hepatitis delta virus receptor binding site.
Hepatology 2006;43:750e60.
[57] Lutgehetmann M, Mancke LV, Volz T, Helbig M, Allweiss L, Bornscheuer T,
et al. Humanized chimeric uPA mouse model for the study of hepatitis B and D
virus interactions and preclinical drug evaluation. Hepatology 2012;55:
685e94.
327
[58] Gripon P, Cannie I, Urban S. Efficient inhibition of hepatitis B virus infection by
acylated peptides derived from the large viral surface protein. J Virol 2005;79:
1613e22.
[59] Barrera A, Guerra B, Notvall L, Lanford RE. Mapping of the hepatitis B virus
pre-S1 domain involved in receptor recognition. J Virol 2005;79:9786e98.
[60] Bogomolov P, Alexandrov A, Voronkova N, Macievich M, Kokina K,
Petrachenkova M, et al. Treatment of chronic hepatitis D with the entry in-
hibitor myrcludex B: first results of a phase Ib/IIa study. J Hepatol 2016;65:
490e8.
[61] Bogomolov P, Voronkova N, Schoeneweis K, Schwab M, Lempp FA, Haag M,
et al. A proof-of-concept Phase IIa clinical trial to treat chronic HBV/HDV with
the entry inhibitor myrcludex B. The Liver Meeting. Boston, USA: Hepatology;
2016. p. 121A.
[62] Vaillant A. Nucleic acid polymers: broad spectrum antiviral activity, antiviral
mechanisms and optimization for the treatment of hepatitis B and hepatitis D
infection. Antiviral Res 2016;133:32e40.
[63] Vaillant A, Juteau JM, Lu H, Liu S, Lackman-Smith C, Ptak R, et al. Phosphor-
othioate oligonucleotides inhibit human immunodeficiency virus type 1
fusion by blocking gp41 core formation. Antimicrob Agents Chemother
2006;50:1393e401.
[64] Bernstein DI, Goyette N, Cardin R, Kern ER, Boivin G, Ireland J, et al. Amphi-
pathic DNA polymers exhibit antiherpetic activity in vitro and in vivo. Anti-
microb Agents Chemother 2008;52:2727e33.
[65] Guzman EM, Cheshenko N, Shende V, Keller MJ, Goyette N, Juteau JM, et al.
Amphipathic DNA polymers are candidate vaginal microbicides and block
herpes simplex virus binding, entry and viral gene expression. Antivir Ther
2007;12:1147e56.
[66] Lee AM, Rojek JM, Gundersen A, Stroher U, Juteau JM, Vaillant A, et al. Inhi-
bition of cellular entry of lymphocytic choriomeningitis virus by amphipathic
DNA polymers. Virology 2008;372:107e17.
[67] Matsumura T, Hu Z, Kato T, Dreux M, Zhang YY, Imamura M, et al. Amphi-
pathic DNA polymers inhibit hepatitis C virus infection by blocking viral entry.
Gastroenterology 2009;137:673e81.
[68] Noordeen F, Vaillant A, Jilbert AR. Nucleic acid polymers inhibit duck hepatitis
B virus infection in vitro. Antimicrob Agents Chemother 2013;57:5291e8.
[69] Noordeen F, Scougall CA, Grosse A, Qiao Q, Ajilian BB, Reaiche-Miller G, et al.
Therapeutic antiviral effect of the nucleic acid polymer REP 2055 against
persistent duck hepatitis B virus infection. PLoS One 2015;10, e0140909.
[70] Al-Mahtab M, Bazinet M, Vaillant A. Safety and efficacy of nucleic acid poly-
mers in monotherapy and combined with immunotherapy in treatment-
Naive Bangladeshi patients with HBeAg+ chronic hepatitis B infection. PLoS
One 2016;11, e0156667.
[71] Bazinet M, Pantea V, Cebotarescu V, Cojuhari L, Jimbei P, Vaillant A. Significant
reduction of HBsAg and HDV RNA by the nucleic acid polymer REP 2139 in
caucasian patients with chronic HBV/HDV co-infection. EASL. Vienna, Austria:
J Hepatol 2015:S257e8.
[72] Vaillant A, Pantea V, Cebotarescu V, Cojuhari L, Jimbei P, Albrecht J, et al.
HBsAg and HDV RNA reduction with REP 2139-Ca and peg-INF alpha 2a in
chronic HBV/HDV infection. APASAL. Tokyo, Japan: Hepatol Int 2016. p. S54.
[73] Bazinet M, Pantea V, Cebotarescu V, Cojuhari L, Jimbei P, Albrecht J, et al.
Initial follow up results from the REP 301 trial: safety and efficacy of REP
2139-Ca and pegylated interferon alpha-2a in caucasian patients with chronic
HBV/HDV co-infection. AASLD. Boston, USA: Hepatology 2016. p. 912A.
[74] Wang Y, Cui F, Lv Y, Li C, Xu X, Deng C, et al. HBsAg and HBx knocked into the
p21 locus causes hepatocellular carcinoma in mice. Hepatology 2004;39:
318e24.
[75] Einav S, Glenn JS. Prenylation inhibitors: a novel class of antiviral agents. J
Antimicrob Chemother 2003;52:883e6.
[76] Bordier BB, Ohkanda J, Liu P, Lee SY, Salazar FH, Marion PL, et al. In vivo
antiviral efficacy of prenylation inhibitors against hepatitis delta virus. J Clin
Invest 2003;112:407e14.
[77] Koh C, Canini L, Dahari H, Zhao X, Uprichard SL, Haynes-Williams V, et al. Oral
prenylation inhibition with lonafarnib in chronic hepatitis D infection: a
proof-of-concept randomised, double-blind, placebo-controlled phase 2A
trial. Lancet Infect Dis 2015;15:1167e74.
[78] Yurdaydin C, Idilman R, Choong I, Kalkan C, Keskin O, Karakaya MF, et al.
Optimizing the prenylation inhibitor lonafarnib using ritonavir boosting in
patients with chronic delta hepatitis. The International Liver Congress. Vienna,
Austria: J Hepatol 2015. p. S252.
[79] Wedemeyer H, Port K, Deterding K, Wranke A, Kirschner J, Martins EB, et al. A
phase 2 study of titrating-dose lonafarnib plus ritonavir in patients with
chronic hepatitis D: interim results from the lonafarnib with ritonavir in
HDV-4 (LOWR HDV-4) study. The Liver Meeting. Boston, MA: Hepatology;
2016. p. 121A.
[80] Yurdaydin C, Idilman R, Kalkan R, Karakaya F, Kartal AC, Keskin O, et al. The
prenylation inhibitor lonafarnib can induce post-treatment Alt Flares with
viral clearance in patients with chronic delta hepatitis. The Liver Meeting.
Boston, MA: Hepatology; 2016. p. 927A.
[81] Lasfar A, Abushahba W, Balan M, Cohen-Solal KA. Interferon lambda: a new
sword in cancer immunotherapy. Clin Dev Immunol 2011;2011:349575.