The Supplementation of Acetyl-L-Carnitine DecreasesFatigue and Increases Quality of Life in Patients

with Hepatitis C Treated with PegylatedInterferon-a 2b Plus Ribavirin

Michele Malaguarnera,1 Marco Vacante,1 Gaetano Bertino,2 Sergio Neri,2 Mariano Malaguarnera,1

Maria Pia Gargante,1 Massimo Motta,1 Lorenzo Lupo,3 Giuseppe Chisari,4

Cosimo Marcello Bruno,2 Giovanni Pennisi,5 and Rita Bella5

The aim of this study was to evaluate whether supplementation of acetyl-l-carnitine (ALC) to pegylated-inter-feron-a 2b (Peg-IFN-a 2b) and ribavirin (RBV) improves the health-related quality of life during the treatment forchronic hepatitis C, thereby decreasing the risk of treatment discontinuation. Sixty patients with chronic hepatitis Cunderwent treatment with Peg-IFN-a 2b + RBV (group A; n = 29) or Peg-IFN-a 2b + RBV + ALC (group B; n = 31)for 12 months. At the end of the study, the comparison between group A and group B showed significantdifferences in aspartate aminotransferase (AST) ( - 80.9 versus - 110.3; P < 0.001), alanine aminotransferase ( - 111.6versus - 134.7; P < 0.001), Viremia ( - 3.26 versus - 3.82; P < 0.05), mental health (0 versus 11; P < 0.001), physicalfunctioning ( - 1 versus 8; P < 0.001), role-physical (1 versus 13; P < 0.001), bodily pain (1 versus 12; P < 0.001),general health (3 versus 12; P < 0.001), vitality (3 versus 13; P < 0.001), social functioning (3 versus 10; P < 0.001),physical fatigue (2.1 versus - 5.4; P < 0.001), mental fatigue ( - 0.7 versus - 2.7; P < 0.001), and fatigue severity scale( - 3.4 versus - 12; P < 0.001). ALC supplementation reduced both mental and physical fatigue, improved health-related quality of life, and, therefore, has the potential to increase patient adherence to the combination regimen.This, in turn, may increase the percentage of patients achieving a sustained virological response.

Introduction

Hepatitis C (HCV) is the most prevalent viral liverdisease in Western countries. It has been estimated that

chronic HCV infection is responsible for *250,000–350,000deaths per year (Chevaliez and Pawlotsky 2007). Approxi-mately 100 million people worldwide are infected with HCV.Of these, nearly 70% have chronic hepatitis, and 15%–20%develop cirrhosis (Tripi and others 2003). The current stan-dard in HCV treatment consists of combination regimens ofpegylated interferon-a (Peg-INF-a) with ribavirin (RBV)(Montalto and others 1998a). Such treatment schemes arequite successful in patients with HCV genotypes 2 and 3infection achieving HCV eradication rates of 75%–80%.However, they are much less effective in patients with ge-notype 1 infection with eradication rates ranging between45% and 52% (Manns and others 2001; Hadziyannis andKoskinas 2004). Multiple studies have revealed that infectionwith HCV and IFN treatment significantly reduces quality oflife, even in the absence of cirrhosis (Malaguarnera and

others 1995; Bonkovsky and Woolley 1999; Foster 1999).Previous studies on HCV therapy have shown that suchdeclines in health-related quality of life (HRQL) increase therisk of treatment discontinuation (Malaguarnera and others2008b). In the patients treated with IFN plus RBV, variousstudies showed increased incidence and severity of fatigueand mood changes that interfere with physical and emo-tional well-being, work productivity, and activities of dailyliving (Bonkovsky and Woolley 1999; Foster 1999; Ware andothers 1999). These changes in HRQL might adversely affectadherence and result in discontinuation of treatment (DiFazio and others 2004). Therefore, the need for improvementof existing therapies and for development of new effective,safe, and tolerable drugs is a matter of great clinical rele-vance and importance (Malaguarnera and others 2001;Blonsky and Harrison 2008). Acetyl-l-carnitine (ALC) treat-ment has been reported to reduce physical and mental fatiguein the elderly and improves both the cognitive status andphysical functions (Malaguarnera and others 2008a). ALCis an endogenous molecule synthesized in mitochondria by

1Research Center ‘‘The Great Senescence,’’ 2Department of Internal Medicine and Systemic Diseases, 3Department of Microbiology,4Policlinico Universitario, and 5Department of Neurosciences, University of Catania, Catania, Italy.

JOURNAL OF INTERFERON & CYTOKINE RESEARCHVolume 31, Number 9, 2011ª Mary Ann Liebert, Inc.DOI: 10.1089/jir.2011.0010

653

the enzyme ALC-transferase and is the predominant acyl-carnitine in normal tissues. It is involved in the uptake oflong-chain fatty acids into mitochondria and their b-oxidation.ALC mobilizes acetyl groups, stimulates phospholipids syn-thesis, increases acetylcoenzyme A and choline uptake andacetylcholine release. Therefore, ALC enhances oxidative en-ergy metabolism and adenosine triphosphate production andcounteracts oxidative and nitrosative stresses and apoptosis(Di Marzio and others 1999). The aim of the present study wasto evaluate whether supplementation of ALC to Peg-IFN-aand RBV improves the quality of life during the treatment forchronic hepatitis C (CHC).

Materials and Methods

Study design

This 12 month, randomized, placebo-controlled trial wasperformed in accordance with the principles of the WorldMedical Association Declaration of Helsinki (1997) and wasapproved by the local Ethics Committee. It was conducted inthe Department of Internal Medicine of Cannizzaro Hospital,University of Catania, Catania, Italy. All the patients pro-vided written informed consent before participating in thestudy. Eligible patients were randomly assigned to 1 of the2 study treatments in equal proportions by means of acomputer-generated table of random numbers allocated inour central unit. They were divided into 2 groups (A and B),and they were stratified by HCV genotype (1 versus others)and viral load ( £ 600,000 versus > 600,000 IU/mL). Group Areceived Peg-IFN-a 2b at dose 1.5 mg/kg per week plus dailyoral RBV. The dose of RBV was adjusted to body weight:800 mg for body weight below 60 kg, 1,000 mg when it wasbetween 60 and 75 kg, and 1,200 mg when it was above75 kg. Group B received Peg-IFN-a 2b and RBV at the samedosage, way, and duration plus ALC supplied in vials with2 g ALC taken orally twice a day. Patients were evaluatedbefore treatment, 6 and 12 months after the initiation of thetherapy. A follow-up evaluation was performed 6 monthsafter the end of the planned treatment. A medical interviewand a physical examination were realized for all patientsincluded in the study before starting therapy.

Patients

Between January 2003 and August 2007, a total of 60 pa-tients with chronic hepatitis (29 women and 31 men) wereconsecutively enrolled in the study (Table 1). The patientsunderwent treatment with Peg-IFN-a 2b + RBV (group A;n = 29) or Peg-IFN-a 2b + RBV + ALC (group B; n = 31) for12 months. All patients had to fulfill the following inclusioncriteria: alanine aminotransferase (ALT) levels > 1.5-foldhigher than the upper limit of normal, the presence of anti-HCV antibodies in the serum, the HCV-RNA > 1,000 copies/mL, and histological modifications in the liver biopsy. Ex-clusion criteria were positivity tests for serum hepatitis Bsurface antigen, positive test for serum HIV antibodies,negativity for HCV antibodies, alcoholic liver disease (dailyalcohol consumptions > 20 g/day), and diabetes. The pres-ence of other causes of hepatopathy, decompensated cir-rhosis, pregnancy, and formally known contraindications forPeg-IFN-a or RBV therapy such as hemoglobinopathies,cardiopathy, hemocromatosis, diabetes mellitus, autoim-mune diseases, major depression or other severe psychiatric

pathological conditions, every active illicit treatment, andany drug that might influence serum lipid levels within thelast 12 months were considered causes for ruling out. Pa-tients undergoing treatment were prospectively asked tocomplete questionnaires before, during, and after treatmentand follow up. Patients were excluded from the question-naire protocol if they were not able to read or speak Italian.Patients were prospectively enrolled in the trial examininghealth status [quantified by the Short Form (SF)-36] before,during, and after Peg-IFN-a + RBV + ALC treatment orPeg-IFN-a + RBV treatment.

Laboratory

A complete routine chemistry including red cell count,hemoglobin, white cell count, platelets prothrombin time,fasting plasma glucose, insulin, C-reactive protein, bloodurea nitrogen, serum creatinine, bilirubin, ALT, aspartateaminotransferase, alkaline phosphatase, g-glutamil trans-peptidase, and creatin phosphokinase levels was performedat every medical visit.

Virological findings

Anti-HCV antibodies were evaluated by using second-generation enzyme-linked immunosorbent assay (Ortho-Diagnostic Systems, Raritan, NJ), and positive samples wereconfirmed by immunoblotting (recombinant immunoblotassay [RIBA]; Chiron Corporation, Emeryville, CA). Forhepatitis B virus serological markers, we used kits (AbbottLaboratories, Chicago, IL). The presence of antibodies (anti-nuclear, antimitochondrial, antismooth muscle, and anti-liver-kidney-microsome) was evaluated by indirect immu-nofluorescence. Serum HCV RNA levels have been measuredby standardized quantitative polymerase chain reaction (PCR)assay with a lower limit of detection of < 1,000 copies/mL,using the Amplicor quantitative PCR system (Roche Diag-nostic System Inc., Branchburg, NJ). Serum samples negative

Table 1. Characteristics of the Subjects Included

in the Study (Mean – Standard Deviation)

Group A Group BPeg-IFN-a +

RBVPeg-IFN-a +RBV + ALC

(n = 29) (n = 31)

Mean age (years) 44.6 – 5.1 46.2 – 5.2Sex (M/F) 15/14 16/15HCV exposure time (years) 6.22 – 3.8 6.46 – 3.6BMI (kg/m2) 26.2 – 3.4 26.5 – 3.2Route of transmission of HCV

Blood transfusion 9 13Intravenous drug

abuse7 6

Occupational 1 2Unknown 12 10

HCV genotype1a 1 11b 24 252a 1 13a 3 4

There were not significant differences between groups.ALC, acetyl-l-carnitine; BMI, body mass index; HCV, hepatitis C;

Peg-IFN-a, pegylated-interferon-a 2b; RBV, ribavirin.

654 MALAGUARNERA ET AL.

for HCV RNA were re-tested using a more sensitive stan-dardized qualitative PCR assay with a lower limit of detectionof about 100 copies/mL to confirm HCV-RNA disappearance.HCV genotypes and subtypes were identified through amodification of the specific line probe assay (Inno-LiPAsys-tem; Innogenetics NV, Zwijnaarde, Belgium) as described byStuyver and others (1996). Briefly, primers complementaryto the conserved sequences of the 5 untranslated region of thedifferent HCV genotypes were used in the reverse transcrip-tion-PCR. HCV RNA were extracted from patients’ sera andamplified by reverse transcription-PCR with the incorporationof biotinylated deoxyuridine triphosphate. Oligonucleotideprobes (16-mers) that were specific for the different HCV ge-notypes and subtypes were hybridized with the patient’samplified viral complementary DNA. Hybridization wasdetected with alkaline phosphatase-labeled streptavidin andnitroblue tetrazolium/5-bromo-4-chloro-3-indolyl phosphatechromagens. The HCV genotypes were designated accord-ing to the nomenclature proposed by Simmonds and others(1994).

Histology

Liver biopsy was realized 6 months before the initiation oftherapy and 6 months after the end of treatment. It was ob-tained using a modified Menghini technique. The specimenwas fixed in neutral formaldehyde 4% solution for routinehistological processing and evaluation. The Knodell and IshakHistological activity index (HAI) score was used to assess thehistological grading of the disease (Knodell and others 1981).

Short Form-36

The self-administered version of the SF-36 Health Surveywas included to comprehensively measure HRQL (Ware andothers 1993). The SF-36 is a generic health status measure thatconsists of 36 items and 8 domain scales. Domain scale scoresare linearly transformed into a 0 (worst health) to 100 (besthealth) scale. Mental component summary and physicalcomponent summary scores were also generated. The SF-36has demonstrated good reliability and validity in chronicdisease populations, including patients with CHC (Bonkovs-ky and Woolley 1999; Foster 1999; Bernstein and others 2002).

Fatigue assessment

Severity of fatigue. Severity of fatigue was measured bythe fatigue severity scale (FSS). The FSS is a self-assessed 9questions ranging from 1 (no signs of fatigue) to 7 (mostdisabling fatigue). Here, the total score ranges from 9 to 63and is directly related to the severity observed (Krupp andothers 1989).

Nature of fatigue. Wessely’s test and Powell’s test wereused to examine fatigue, both mental and physical. The Wes-sely and Powell score consists of 2 scales measuring physicalfatigue [8 items scored from 0 (no fatigue) to 2 (highest possiblefatigue); total score range: 0–16] and mental fatigue (5 items;total score range: 0–10) (Wessely and Powell 1989).

Efficacy and safety assessment

All enrolled patients were included in the intention-to-treat efficacy analysis, and patients who received at least onedose of IFN-a plus RBV were included in the safety analysis.

Data were analyzed by an ‘‘intention to treat’’ principle. Weconsidered patients as ‘‘sustained virological responders’’(SVR) when they showed a nondetectable HCV RNA( < 50 IU/mL) in serum at the end of the follow-up period.Relapse was defined as undetectable HCV-RNA levels at theend of treatment but detectable levels during the follow-upperiod. Adverse events were assessed by interviews, labo-ratory, and clinical examinations during treatment. Theywere graded as mild, moderate, and severe on the basis ofWorld Health Organization score. The treatment was defin-itively stopped in the case of severe events, such as hema-tological toxicity, hepatic failure, and no compliance. Inmoderate and mild cases of adverse effects, a dose reductionof 50% was performed, until the resolution of the event whena full dose was restarted.

Statistical analysis

Results are expressed as means – standard deviations.Comparisons of quantitative data were made using theStudent’s t-test or Mann–Whitney test. Qualitative data wereanalyzed using the chi-square test. A P value of < 0.05 wasconsidered as indicating a statistically significant difference.All data management and statistical calculations were per-formed using SPSS 15.0 statistical package (Chicago, IL).

Results

Baseline characteristics

Baseline demographics characteristics and histologicalfindings in liver biopsy were similar between the 2 treatmentgroups. The mean time since their CHC infection was com-parable. The most frequent viral genotype in patients was 1b.Baseline viremia was parallel in the 2 groups. No significantdifferences were assessed between the 2 groups for ALT,AST, body mass index, HRQL, and fatigue score (Table 1).

Laboratory parameters

Effects of Peg-IFN-a plus RBV. In the group treated withPeg-IFN-a plus RBV, we observed a significant decrease inAST (P < 0.001) and ALT (P < 0.001) after 6, 12 months, and atfollow up. Viremia was significantly reduced after 6 months(P < 0.05), 12 months (P < 0.001), and at follow up (P < 0.001)(Table 2).

Effects of Peg-IFN-a plus RBV plus ALC. After 6, 12months, and at follow up in the group treated with Peg-IFN-a plus RBV plus ALC, we observed a significant decreasein AST (P < 0.001), ALT (P < 0.001), and viremia (P < 0.001)(Table 2).

Comparison between treatments. The comparison betweengroup A (treated with Peg-IFN-a plus RBV) and group B(treated with Peg-IFN-a plus RBV plus ALC) showed asignificant difference after 12 months in AST ( - 80.9 versus- 110.3; P < 0.001), ALT ( - 111.6 versus - 134.7; P < 0.001),and viremia ( - 3.26 versus - 3.82; P < 0.05). At follow up,we observed a significant difference in AST ( - 69.8 versus- 89.3; P < 0.05) (Table 2).

Quality of life

Effects of Peg-IFN-a plus RBV. In the group treated withPeg-IFN-a plus RBV, there was a significant increase in

ALC IN PATIENTS WITH HCV TREATED WITH IFN-a 2B AND RBV 655

physical fatigue after 6 months (P < 0.05), 12 months(P < 0.001), and at follow up (P < 0.05) (Table 3).

Effects of Peg-IFN-a plus RBV plus ALC. After 6 months inthe group treated with Peg-IFN-a plus RBV plus ALC, weobserved a significant increase in physical functioning(P < 0.05) and general health (P < 0.05). After 12 months, therewas a significant increase in mental health (P < 0.001), role-emotional (P < 0.05), physical functioning (P < 0.001), role-physical (P < 0.001), bodily pain (P < 0.001), general health(P < 0.001), vitality (P < 0.001), and social functioning(P < 0.001). At follow up, we observed an increase in physicalfunctioning (P < 0.05), role-physical (P < 0.05), bodily pain(P < 0.05), general health (P < 0.05), and vitality (P < 0.05)(Table 3).

Comparison between treatments. In the comparison be-tween group A (treated with Peg-IFN-a plus RBV) and groupB (treated with Peg-IFN-a plus RBV plus ALC), we observeda significant difference after 6 months in physical functioning

(2 versus 3; P < 0.05) and general health (1 versus 7; P < 0.05).After 12 months, we observed a significant difference inmental health (0 versus 11; P < 0.001), physical functioning( - 1 versus 8; P < 0.001), role-physical (1 versus 13; P < 0.001),bodily pain (1 versus 12; P < 0.001), general health (3 versus12; P < 0.001), vitality (3 versus 13; P < 0.001), and socialfunctioning (3 versus 10; P < 0.001) (Table 3).

Fatigue

Effects of Peg-IFN-a plus RBV. In the Peg-IFN-a plus RBVgroup, we observed a significant increase in physical fatigueafter 6 months (P < 0.05), 12 months (P < 0.001), and at followup (P < 0.05) (Table 3).

Effects of Peg-IFN-a plus RBV plus ALC. After 6 and 12months in the group treated with Peg-IFN-a plus RBV plusALC, we observed a significant decrease in physical fatigue(P < 0.001), mental fatigue (P < 0.001), and FSS (P < 0.001). At

Table 2. Laboratory Parameters of Subjects Included in the Study (Mean – Standard Deviation)

Group APeg-IFN-a + RBV

(n = 29)

Group BPeg-IFN-a + RBV + ALC

(n = 31)

BaselineAfter

6 monthsAfter 12months Follow up Baseline

After 6months

After12 months Follow up

AST (IU/L) 131 – 40.2 78.1 – 35.4aA 50.1 – 15.2aB 61.2 – 14.2aC 141.2 – 41.8 67.2 – 30.1aA 30.8 – 14.2aB 51.8 – 14.2aC

ALT (IU/L) 168 – 41.8 81.2 – 39.2aA 56.4 – 13.7aB 51.4 – 19.7aA 178.2 – 44.2 77.2 – 37.1aA 43.4 – 13.7aB 55.1 – 19.2aA

Bilirubin (mM) 10.1 – 9.1 10.8 – 9.2bA 10.1 – 7.0bA 10.4 – 7.2bA 10.3 – 7.0 10.4 – 6.1bA 10.0 – 5.8bA 10.2 – 5.6bA

Albumin (g/dL) 4.3 – 0.8 4.1 – 0.9bA 4.0 – 0.8bA 4.2 – 0.9bA 4.2 – 0.7 4.0 – 1.6bA 4.1 – 0.6bA 4.2 – 0.9bA

Viremia(106 copies/mL)

5.44 – 3.6 3.62 – 2.1cA 2.18 – 1.2aC 2.08 – 1.7aA 5.43 – 3.08 2.44 – 2.7aA 1.6 – 1.0aC 1.9 – 1.2aA

HAI score 10.2 – 2.9 — 8.7 – 2.9cA — 10.4 – 3.1 — 7.9 – 2.6aA —

Comparison within group A and within group B according to the values before the treatment.aP < 0.001; bP = NS; cP < 0.05.Comparison between groups A and B after treatment.ANS; BP < 0.001; CP < 0.05.ALT, alanine aminotransferase; AST, aspartate aminotransferase; NS, not significant.

Table 3. Comparison of Evaluated Parameters Within Groups and Between Groups

(Mean – Standard Deviation)

Group APeg IFN-a + RBV

(n = 29)

Group BPeg IFN-a + RBV + ALC

(n = 31)

Baseline After 6 months After 12 months Follow up Baseline After 6 months After 12 months Follow up

Mental health 69 – 6 68 – 7aA 69 – 9aB 69 – 11aA 67 – 7 70 – 8aA 78 – 8bB 70 – 7aA

Role-emotional 70 – 5 69 – 6aA 70 – 6aA 70 – 7aA 69 – 6 71 – 7aA 73 – 7cA 70 – 6aA

Physical functioning 77 – 9 75 – 8aC 76 – 9aB 78 – 9aA 76 – 5 79 – 6cC 84 – 8bB 80 – 7cA

Role-physical 76 – 8 75 – 7aA 77 – 8aB 76 – 9aA 75 – 9 78 – 10aA 88 – 8bB 80 – 8cA

Bodily pain 58 – 7 57 – 8aA 59 – 5aB 58 – 6aA 56 – 8 60 – 9aA 68 – 7bB 61 – 7cA

General health 56 – 8 55 – 8aC 58 – 4aB 57 – 9aA 54 – 7 61 – 7cC 66 – 6bB 60 – 6cA

Vitality 55 – 9 56 – 10aA 58 – 6aB 56 – 9aA 53 – 8 55 – 8aA 66 – 9bB 58 – 9cA

Social functioning 75 – 7 76 – 8aA 78 – 9aB 77 – 7aA 76 – 6 77 – 9aA 86 – 9bB 78 – 7aA

Physical fatigue 11.0 – 1.9 12.2 – 2.1cC 13.1 – 1.9bB 12.4 – 2.6cC 11.4 – 2 9.6 – 2.1bB 6.0 – 2.7bB 10.8 – 2.4aC

Mental fatigue 6.4 – 1.5 5.9 – 1.6aA 5.7 – 1.8aB 6.0 – 1.6aA 6.8 – 1.7 5.0 – 1.9bA 4.1 – 1.6bB 5.4 – 1.8cA

Fatigue severity scale 47.6 – 7.2 46.4 – 7.8aC 44.2 – 7.1aB 45.9 – 7.4aC 48.2 – 6.9 41.8 – 6.2bC 36.2 – 6.1bB 40.2 – 6.4bC

Comparison within group A and within group B according to the values before the treatment.aP = NS; bP < 0.001; cP < 0.05.Comparison between groups A and B after treatment.ANS ; BP < 0.001; CP < 0.05.

656 MALAGUARNERA ET AL.

follow up, we observed significant differences in mental fa-tigue (P < 0.05) and FSS (P < 0.001) (Table 3).

Comparison between treatments. In the comparison be-tween group A (treated with Peg-IFN-a plus RBV) and groupB (treated with Peg-IFN-a plus RBV plus ALC), we observeda significant difference after 6 months in physical fatigue (1.2versus - 1.8; P < 0.001) and FSS ( - 1.2 versus - 6.4; P < 0.05).After 12 months, we observed a significant difference inphysical fatigue (2.1 versus - 5.4; P < 0.001), mental fatigue( - 0.7 versus - 2.7; P < 0.001), and FSS ( - 3.4 versus - 12;P < 0.001). At follow up, there were significant differences inphysical fatigue (1.4 versus - 0.6; P < 0.001) and FSS ( - 1.7versus - 8; P < 0.001) (Table 3).

Virological response

In the comparison between group A (treated with Peg-IFN-a plus RBV) and group B (treated with Peg-IFN-a plusRBV plus ALC) after 12 months, we observed a significantimprovement of SVR in 10 versus 15 patients (34% versus48%), whereas the relapsers were 4 versus 3 (13% versus 9%)(odds ratio 0.5; 95% confidence interval = 0.09–2.72). The re-sponders were 14 versus 18 (48% versus 58%), and thenonresponders were 15 versus 13 (51% versus 41%) (oddsratio 0.6; 95% confidence interval = 0.2–1.86) (Table 4).

Histological response

Effects of Peg-IFN-a plus RBV. In the Peg-IFN-a plus RBVgroup, we observed a significant decrease in HAI score after12 months (P < 0.05) (Table 2).

Effects of Peg-IFN-a plus RBV plus ALC. After 6 and 12months in the group treated with Peg-IFN-a plus RBV plusALC, we observed a significant decrease in HAI score(P < 0.001) (Table 2).

Adverse events. No serious adverse events (World HealthOrganization grade 3 or 4) have been reported in the 2groups. Six patients of the Peg-IFN plus RBV-treated groupand 2 of the group treated with ALC supplementationshowed mild psychological disorders such as anxiety, irri-tability, and depression. Median hemoglobin concentrationsignificantly fell during the first 3 months of treatment inboth groups, remaining stable for 3 months, and returning tovalues similar to the baseline within 3 months after the endof the treatment. Noteworthy, a higher decrease of hemo-globin values was observed in the Peg-IFN plus RBV alonetreatment. The patients treated with Peg-IFN plus RBV ex-perienced a fall in median hemoglobin concentration from12.1 g/dL (range 10.7–13.0 g/dL) to 11.0 (range 10.4–13.0 g/dL) at the end of therapy. The patients treated with Peg-IFN

plus RBV plus ALC experienced a fall in median hemoglobinconcentration from 13.0 g/dL (range 11.4–15.1) to 11.4 g/dL(range 10.6–13.8 g/dL) at the end of therapy. The Peg-IFNplus RBV showed a significant decrease in the white cellblood count. The platelet counts did not significantly changein both groups. Further, other side effects registered in bothgroups were anorexia (12% in IFN plus RBV plus patientswith ALC and 16% in IFN group plus RBV), nausea (20%and 24%, respectively), weight loss (5% versus 12%), head-ache (40% versus 48%), myalgia (30% versus 55%), muscu-loskeletal pain (27% versus 42%), irritability (18% versus22%), hypertriglyceridemia (16% versus 34%), hypercholes-terolemia (8% and 24%), and hyperglycemia (3% and 13%).Ten patients of Peg-IFN plus RBV-treated group dis-continued treatment (2 patients after 8 months, 1 patientafter 9 months, and 1 patient after 10 months for fatigue; 2patients after 8 months, 4 patients after 9 months, and 2patients after 10 months for decreased HRQL). Two patientsof the group treated with ALC supplementation dis-continued treatment (1 patient after 9 months for fatigue and1 patient after 10 months for decreased HRQL).

Discussion

The effective management of chronic HCV infection isvery important. The goal of treatment for chronic HCV in-fection is sustained virological response (SVR) accompaniedby improvement of liver damages (Montalto and others1998b). The results of our study indicated that patients withsustained response have an improvement in HRQL and areduction in severity of mental and physical fatigue. Potentialbenefits of SVR would be decreased infectivity, prevention ofliver damage, and improvement of the necro-inflammatoryprocess. In the long run, SVR may decrease the risk ofdeveloping cirrhosis, decompensation, and HCC, alongwith prolonged survival and improved quality of life(Malaguarnera and others 1998; Neri and others 2003).However, the treatment with IFN-a, in all its formulations,provokes adverse effects including depression, anxiety, irri-tability, muscle aches, fatigue, and sleep disturbances(Dieperink and others 2000). Bonaccorso and others (2002)reported that IFN-a therapy in patients with HCV led to adecrease of plasma tryptophan and serotonin, increase ofkynurenine, and also of depressive symptoms. Previousstudies showed that ALC decreases the severity of physicaland mental fatigue and improves the quality of life (Neriand others 2003; Pistone and others 2003; Malaguarnera andothers 2006). ALC mobilizes acetyl groups, stimulatesphospholipid synthesis, and increases acetyl-coenzyme Aand choline uptake and acetylcholine release (Imperato andothers 1989). It is also involved in the synthesis of glutamate;in fact, the acetyl moiety of ALC is metabolized mainlyto glutamate, but also, glutamine, aspartate, and gamma-aminobutyric acid by way of the tricarboxylic acid cycle.Studies about the role of ALC in the aged rats’ brain dem-onstrated that in the brain regions with lower amino acidlevels, the release of neurotransmitter amino acids is belownormal and ALC produces an increase in the extracellularlevel of neurotransmitter glutamate. On the other hand, ALCdecreases glutamate dehydrogenase activity in the in-trasynaptic mitochondria of the rat brain, suggesting thatALC interferes with glutamate metabolism. The increase ofglutamate, caused by the elevated plasma ALC levels, also

Table 4. Virological Response of the Subjects

Included in the Study

Group A Group BPeg-IFN-a + RBV Peg-IFN-a + RBV + ALC

(n = 29) (n = 31)

SVR 10 15ETR 14 18NR 15 13

SVR, sustained virological response; ETR, end of treatmentresponse; NR, nonresponders.

ALC IN PATIENTS WITH HCV TREATED WITH IFN-a 2B AND RBV 657

determines a protection against excitotoxic cell death. This ispossible through the direct antagonism of glutamate recep-tors and the activation of gamma-aminobutyric acid recep-tors that cause neuronal hyperpolarization and, therefore,resistance to NMDA receptor activation, or to inhibition ofsecondary events. These secondary events could include ac-tivation of the mitochondrial permeability transition that cancause release of mitochondrial cytochrome c and stimulationreactive oxygen species production. The improvement ofenergetic metabolism in myocardial tissue and in muscular-skeletal tissue is probably the factor that reduces the pres-ence and the severity of physical fatigue in subjects treatedwith ALC (Tomassini and others 2004). When ALC wasadministered to the elderly with lean body mass reduction,an increase of muscular mass up to 3-fold was observed,with resulting amelioration of muscular power and activity(Pistone and others 2003). Previous studies have shown thatboth fatigue and decreased HRQL are reasons often cited bypatients for the discontinuation of combination therapy(Bernstein and others 2002; Fried and others 2002; Gaeta andothers 2002). In this study, ALC supplementation reducedboth mental and physical fatigue, improved HRQL and,therefore, has the potential to increase patient adherence tothe combination regimen. This, in turn, may increase thepercentage of patients achieving a SVR. Adherence to RBVtherapy, in particular, has been shown to significantly impactSVR. Recent data suggest that the reduction of RBV dosealone during the first 12–20 weeks of treatment results in asignificant decrease in SVR rates in a retreated population(Shiffman 2004). Although the results of this study do notindicate that ALC improves SVR, they clearly provide supportfor additional studies with adequate sample size to determinewhether adjuvant ALC therapy is associated with a statisti-cally significant improvement in SVR. This study demon-strated the significant beneficial effect of oral ALC added toIFN-a and RBV in lipid metabolism, in inflammation markers,and in steatosis and fibrosis The results keep them up after 12months and at the follow-up visit; indeed, patients with HCVquite well tolerated ALC therapy. The limitation of our studyincludes the relatively small sample size and its open labeldesign. A further weakness of the study is that no subanalysishas been performed for different HCV genotypes but it wasbecause of the prevalence of genotype 1. This study showsthat the supplementation with ALC is associated with sig-nificant improvements in patient energy levels, physicalfunction, and mental status, as reported on HRQL instru-ments. Confirmation of these findings is important, becausethey imply that the decreased quality of life associated withHCV treatment can be improved with successful therapy.

Acknowledgment

This clinical trial was supported by a grant from Ministerodell’Universita e Ricerca Scientifica e Tecnologica.

Author Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Prof. Mariano Malaguarnera

Research Center ‘‘The Great Senescence’’University of Catania

Ospedale Cannizzaro, Viale MessinaCatania 829-95125

Italy

E-mail: malaguar@unict.it

Received 31 January 2011/Accepted 17 March 2011

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