Efficacy of standardized extract of Phyllanthus niruri , EPN 797 in inducing HBeAg clearance and seroconversion of HBV infection: three case reports

K.T. Singam

B.sc. MBBS [S’PORE], MCGP., DIP. STD./AIDS

K Singam And Associate Clinic, Sg. Pelek, Sepang, Selangor.

K. A. Ong

B. Pharm.[USM], Rph.

²Nova Laboratories Sdn. Bhd., Sg. Pelek, Sepang, Selangor.

ABSTRACT:

Active viral replication in hepatocytes is indicated by the presence of hepatitis B e antigen (HBeAg) in serum. HBeAg is thus a surrogate marker for the presence of hepatitis B virus DNA. There are recent data that show the relationship between the risk of developing hepatocellular carcinoma (HCC) with the activity of the virus. There is a markedly increased risk of developing HCC in those individuals with chronic hepatitis B who are also e-antigen positive. We describe three cases where patients with positivity of HBeAg treated with the combination therapy of lamivudine 100mg and EPN 797 1500mg daily or monotherapy with EPN 797 1500 mg daily alone for a duration of treatment ranged from 3 to 7 months, had achieved HBeAg clearance in all three cases and seroconversion in 2 cases. Throughout the treatment period, these three patients had normal ALT level. These three cases suggested that the use EPN 797 alone or combination with lamivudine might be useful in inducing HBeAg clearance and seroconversion that could possibly reduce the risk of developing HCC.

Correspondent to:

Email : kuiannong@nova.com.my(K.A.Ong)

Tel : 03-3141 3181

Fax : 03-3141 1661

1. INTRODUCTION

· Hepatitis B virus (HBV) infection is a serious global health problem.

· Recent data has shown there is a markedly increased risk of developing HCC in those individuals with chronic hepatitis B who are also e-antigen positive.¹

· EPN 797, is the standardized extract from Phyllanthus niruri, commercially available as Hepar-P^TM capsule (250 mg of EPN 797), contains 4% of corilagin (a strong antiviral compound) and 18% of total Phyllanthus flavonoids (potent inhibitor for hepatocyte lipid membrane peroxidation)

· Dr. Baruch Blumberg, the 1976 Nobel Prize winner for his discovery of the HBV antigen, has found that Phyllanthus niruri could clear up the chronic carrier state of Hepatitis B.²

· We describe three cases in which patients with positivity of HBeAg was treated with the combination therapy of lamivudine 100mg and EPN 797 1500mg daily or monotherapy with EPN 797 1500 mg daily alone for a duration of treatment ranged from 3 to 7 months, had achieved HBeAg clearance in all three cases and seroconversion in 2 cases.

2.0 CASE REPORT

Case 1:

Patient’s name : SLM Gender : Female Ethnic group : Chinese Age : 50

History of present illness :

• Known chronic HBV carrier for more than 15 years

• Two of her children are also known carriers

Test	Time of testing			Reference range
	November 99	August 02 (Treatment Initiation)^a	May 03
Liver Function Test
Total protein	77	-	80	66-87 g/L
Albumin	41	-	42	38-50 g/L
Globulin	36	-	38	18-42 g/L
A/G Ratio	1.1	-	1.1	1.0-2-2
Total bilirubin	11.0	-	9	< 20.0 umol/L
ALT (SGPT)	51	-	54	8 – 54
AST (SGOT)	35	-	38	16 – 40
ALP	92	-	76	36-110 IU/L
GGT	37	-	47	8-35 IU/L
AFP	2.5	-	-	< 12 kU/L
Hepatitis B Serology
HBsAg	Reactive	Reactive	Reactive
HBsAb	Negative	Negative	Negative
HBeAg	Reactive	Reactive	Non-reactive
HBeAb	Negative	Negative	-

^a Lamivudine 100 mg daily + EPN 797 500 mg three times daily

Case 2:

Patient’s name : SPC Gender : Female Ethnic group : Chinese Age : 38

History of present illness :

• Known chronic HBV carrier for more than 5 years

Test	Time of testing			Reference range
	June 03	April 03 (Treatment Initiation)^b	July 03
Liver Function Test
Total protein	84	-	82	66-87 g/L
Albumin	48	-	50	38-50 g/L
Globulin	36	-	32	18-42 g/L
A/G Ratio	1.3	-	1.6	1.0-2-2
Total bilirubin	10	-	16	< 20.0 umol/L
ALT (SGPT)	43	-	22	8 – 54
AST (SGOT)	36	-	22	16 – 40
ALP	19	-	42	36-110 IU/L
GGT	19	-	14	8-35 IU/L
AFP	1.0	-	0.7	< 12 kU/L
Hepatitis B Serology
HBsAg	Reactive	Reactive	Reactive
HBsAb	Negative	Negative	Negative
HBeAg	Reactive	Reactive	Non-reactive
HBeAb	Negative	Negative	Reactive

^b EPN 797 500 mg three times daily

Case 3:

Patient’s name : LCH Gender : Female Ethnic group : Chinese Age : 74

History of present illness :

• Known chronic HBV carrier for more than 5 years
• Husband died of HCC

Test	Time of testing				Reference range
	February 02		March 02 (Treatment Initiation)^c	July 02
Liver Function Test
Total protein	71		-	-	66-87 g/L
Albumin	42		-	-	38-50 g/L
Globulin	29		-	-	18-42 g/L
A/G Ratio	1.4		-	-	1.0-2-2
Total bilirubin	20		-	-	< 20.0 umol/L
ALT (SGPT)	21		-	13	8 – 54
AST (SGOT)	25		-	22	16 – 40
ALP	81		-	-	36-110 IU/L
GGT	14		-	-	8-35 IU/L
AFP	1.3		-	1.2	< 12 kU/L
Hepatitis B Serology
HBsAg	Reactive	Reactive		Reactive
HBsAb	Negative	Negative		Negative
HBeAg	Reactive	Reactive		Non-reactive
HBeAb	Negative	Negative		Reactive

^c EPN 797 500 mg three times daily

4.0 DISCUSSION

4.1 Phytopharmaceutical used:

· Phyllanthus niruri (local name: dukung anak) is a small plant from the family of Euphorbiaceae which is indigenous to Malaysia.

· EPN 797 is standardized extract of Phyllanthus niruri which contains the following compounds:

a) a bioactive polyphenol fraction consists of corilagin, geraniin and brevifolincarboxylic acid (antiviral compounds)

b) a bioactive Phyllanthus flavonoids fraction containing rutin and other plant flavonoids (strong liver protection by acting as an inhibitor of hepatocyte lipid membrane peroxidation).

4.2 Relationship of HBeAg seropositivity and HCC

· The cumulative HCC risk from age 30 to 70 years has been estimated to be 87% for those with persistently seropositive on HBsAg and HBeAg, 12% for those with persistently seropositivity of HBsAg only, and 1% for those who were seronegative on HBsAg and HBeAg³.

4.3 Definition of treatment end points

· Important in the treatment of chronic HBV infection and the evaluation of the efficacy of therapeutic agent.

· The treatment end points in hepatitis B are as follows⁴:

i) to normalize the ALT

ii) to decreased the HBV DNA to very low or undetectable levels by polymerase chained reaction (PCR)

iii) to induce loss of e-antigen

iv) to develop e-antibody if possible

v) to achieve histopathological improvement

4.4 Phases of Chronic HBV infection^*.

Phases		HBsAg	HBeAg	HBV DNA (copies/ml)	ALT levels (IU/L)
Immunotolerant		+	+	10^5 - 10^10	Persistently normal
Immuno- active	Variation 1 (wild type)	+	+	10^4 – 10^8	Persistenly or intermittently elevated
	Variation 2 (mutants)	+	-
Non-replicative		+ (may become negative over long-term)	-	10^2 – 10^5	Persistently normal

*This is a framework used by us and it may not be perfect.

4.6 Patients’s Response

· The above patients are normally classified to be in the immunotolerant phase of HBV infection with very low rate of spontaneous HBeAg clearance.

· In Case 1, initial response was shown by the clearance of HBeAg after 7 months of therapy.

· The remaining two cases, response as shown by HBeAg seroconvertion was noted as early as 3 months in Case 2 and 4 months in Case 3 respectively.

4.7 Limitations of the above case reports.

· Patients were not tested for HBV DNA, this had caused the incomplete evaluation of patients’ response.

· Liver enzyme levels tested were at a single time point, this may cause misclassification of patients into different phases of HBV infection. This may lead to the inappropriate interpretation of patient’s response.

5.0 Conclusion

· The effect of EPN 797 in inducing HBeAg clearance in the immunotolerant phase may offer a new treatment option for this category of patients.

· However, a number of better designed trials are underway to evaluate its therapeutic potential.

6.0 Reference

1. You SL et al. Ann Med.2004; 36(3):215-24.

2. Thyagarajan SP, B.S Blumberg et al., Lancet, 1988. 2(8614): 764-6

3. Yang HI. et al. NEJM. 2002(Jul); 347: 168-74.

4. Conjeevaram HS. J Hepatol. 2003; 38: S30-S103