Introduction
There are about 70 million people infected with the hepatitis B virus (HBV) and 20 to 30 million chronic hepatitis B (CHB) patients in China. About ten percent of CHB patients develop cirrhosis or liver cancer.1,2 In order to reduce the incidence of cirrhosis and liver cancer and improve long-term prognosis, CHB patients who meet the criteria for antiviral therapy should start treatment promptly. Peginterferon-α, which can inhibit HBV replication and improve the long-term prognosis of CHB, is currently approved by many countries as a first-line drug for CHB treatment. However, the serological conversion rate of hepatitis B e antigen (HBeAg) and the negative conversion rate of HBV DNA are low in peginterferon-α treatment, while the adverse effects of myelosuppression are often severe enough to cause some patients to discontinue therapy. Traditional Chinese medicine (TCM) is effective at alleviating liver inflammation and fibrosis and improving immunity in CHB, which is worthy of further exploration and application.3 This study aimed to evaluate the clinical effect of TCM combined with peginterferon-α and its impact on myelosuppression adverse effects in the real world to provide more evidence to guide clinical treatment.
Materials and methods
Study subjects
This single-center, retrospective cohort study included HBeAg-positive CHB patients who initiated antiviral therapy at Xiamen Hospital of TCM between June 2018 and January 2023 and maintained long-term follow-up. All included patients met the diagnostic criteria4: (1) Serum hepatitis B surface antigen (HBsAg) positive for more than six months; (2) Serum HBV DNA positive; (3) Persistent abnormal alanine aminotransferase (ALT) (>upper limit of normal) excluding other causes, or liver biopsy showing significant liver inflammation (G ≥ 2) or significant liver fibrosis (S ≥ 2). This study was performed in accordance with the ethical guidelines of the 2024 Declaration of Helsinki. The study was approved by the ethics committee of Xiamen Hospital of TCM (Ethics approval number: 2023-K031-01). The requirement for written informed consent was waived due to the retrospective nature of the study.
Inclusion criteria
(1) Patients who met the above diagnostic criteria for CHB and were HBeAg positive; (2) Age between 18 and 65 years old; (3) Pegylated-interferon (PEG-IFN) α-2b monotherapy for more than 48 weeks; (4) Complete clinical records and follow-up data.
Exclusion criteria
Patients with (1) cirrhosis, liver failure, hepatocellular carcinoma, or autoimmune hepatitis; (2) Co-infection with other viruses such as hepatitis A virus, hepatitis C virus, hepatitis D virus, hepatitis E virus, Epstein-Barr virus, cytomegalovirus, or human immunodeficiency virus; (3) Serious primary cardiovascular, kidney, digestive, respiratory, or hematological diseases; (4) History of alcohol or drug abuse; (5) Pregnant,or lactating women, and women preparing to become pregnant; (6) Poorly controlled hypertension or diabetes.
Cohort grouping and treatments
(1) Control group: treated with PEG-IFN α-2b (Xiamen Tebao Biological Engineering Co., LTD.) 180 µg per dose, subcutaneous injection, once a week. (2) Observation group: treated with PEG-IFN α-2b combined with TCM for more than six months. The TCM included decoctions (Licorice 15 g, Angelica sinensis 20 g, Poria 20 g, Paeonia lactiflora 20 g, Rhizoma Atractylodis Macrocephalae 20 g, Radix Bupleurum Chinense 20 g, Mentha piperita 3 g, Ginger three slices) and granules, all from the TCM pharmacy of Xiamen Hospital of TCM. Both groups received a 48-week course of PEG-IFN α-2b antiviral treatment.
Data collection and follow-up
Collected data included family history, age, sex, drinking history, presence of fatty liver, blood routine, blood biochemistry, virology tests, and histological results before treatment. All data were obtained from the visit at which the patient was included. Patients were included either at the start date of antiviral treatment (for treatment-naïve patients starting during the study period) or at the first visit date for patients already on treatment at the beginning of the study period. All patients were routinely followed every 12 weeks.
Efficacy evaluation
Main efficacy indicators4: HBeAg seroconversion rate, HBV DNA negative rate (HBV DNA < 20 IU/mL), and ALT/aspartate aminotransferase (AST) normalization rate (ALT reference: 9–40 IU/L; AST reference: 15–40 IU/L). Secondary efficacy indicators: incidence of myelosuppression based on blood routine4: Criteria for PEG-IFN-α-2b dose reduction: neutrophil count ≤0.75 × 109/L and/or platelet count <50 × 109/L; Criteria for PEG-IFN-α-2b withdrawal: neutrophil count ≤0.5 × 109/L and/or platelet count <25 × 109/L. Mild myelosuppression was defined as neutrophil and/or platelet counts below the normal range but not reaching the reduction criteria. Moderate myelosuppression met the reduction criteria but not the withdrawal criteria. Severe myelosuppression met the withdrawal criteria (normal range: neutrophils 1.8–6.3 × 109/L; platelets 125–350 × 109/L).
Statistical processing and analysis
Continuous data were expressed as mean ± standard deviation, median (interquartile range), or number (percentage), as appropriate, based on the Kolmogorov-Smirnov test for normal distribution. Differences in continuous variables were assessed using Student’s t-test or the Mann-Whitney test, depending on distribution. Categorical variables were presented as n (%) and compared using the chi-square test or Fisher’s exact test, as appropriate. All analyses were performed using SPSS 27.0 (IBM, Chicago, IL, USA). All tests were two-sided with α = 0.05, and P-values < 0.05 were considered statistically significant.
Propensity score matching (PSM) was used to reduce bias and improve comparability between groups. PSM was based on age, sex, family history, drinking history, presence of fatty liver, histological results before treatment, baseline levels of HBV DNA, ALT, AST, and quantification of HBeAg and HBsAg. A 1:1 nearest neighbor matching method was applied with a caliper value of 0.02.
Results
After screening based on the inclusion and exclusion criteria, a total of 117 HBeAg-positive CHB patients were included in this study. There were 61 cases in the control group and 56 cases in the observation group. Using the PSM method, matched according to baseline conditions, 45 cases in the control group and 45 cases in the observation group were finally obtained (Fig. 1).
Baseline clinical parameters of the two groups before PSM and after PSM
Among the patients included in this study, there were no statistically significant differences in gender ratio, age, family history, alcohol consumption history, fatty liver status, HBV DNA, ALT, AST, HBsAg quantification, HBeAg quantification, or degree of liver inflammation and fibrosis (Table 1), indicating that the baseline characteristics of the two groups were similar.
Table 1Comparison of baseline characteristics between the two groups before PSM and after PSM
| Variable | Before PSM1,2
| After PSM3
|
|---|
| Control group (n = 61) | Observation group (n = 56) | Control group (n = 45) | Observation group (n = 45) |
|---|
| Male [n,%] | 34 (55.7) | 34 (60.7) | 26 (57.78) | 27 (60) |
| Age [y, m (P25,P75)] | 31 (28,35.5) | 31 (27,34) | 30.82 ± 5.28 | 31.84 ± 5.67 |
| Family history [n,%] | 8 (13.1) | 7 (12.5) | 5 (11.11) | 6 (13.33) |
| Drinking history [n,%] | 5 (8.20) | 6 (10.71) | 5 (11.11) | 6 (13.33) |
| Combined fatty liver [n,%] | 13 (21.31) | 16 (28.57) | 12 (26.67) | 11 (24.44) |
| ALT[IU/L, m (P25,P75)] | 99 (64.50,174.50) | 110 (70.25,230.00) | 99 (66,173) | 104 (69,224.50) |
| AST[IU/L, m (P25,P75)] | 54 (35.00,90.50) | 62 (38.25,111.75) | 54 (33.50,82.50) | 60 (36,106.50) |
| HBsAg [log10IU·mL−1,m (P25,P75)] | 4.32 (3.76,4.69) | 4.32 (3.56,4.69) | 4.35 (3.85,4.74) | 4.31 (3.63,4.65) |
| HBeAg [log10 IU·mL−1, m (P25,P75)] | 2.77 (2.03,2.93) | 2.85 (2.06,3.10) | 2.85 (2.30,2.99) | 2.85 (1.59,3.11) |
| HBV DNA [log10 IU·mL−1,m (P25,P75)] | 7.94 (7.00,8.23) | 7.75 (6.88,8.24) | 7.96 (7.36,8.23) | 7.90 (6.93,8.27) |
| Degree of inflammation [n,%] | | | | |
| G1 | 6 (9.84) | 3 (5.36) | 5 (11.11) | 3 (6.67) |
| G2 | 40 (65.67) | 25 (44.64) | 30 (66.67) | 29 (64.44) |
| G3 | 14 (22.95) | 18 (32.14) | 9 (20) | 13 (28.89) |
| G4 | 1 (1.64) | 0 | 1 (2.22) | 0 |
| Degree of fibrosis [n,%] | | | | |
| S0 | 1 (1.64) | 0 | 1 (2.22) | 0 |
| S1 | 43 (70.49) | 42 (75) | 32 (71.11) | 33 (73.33) |
| S2 | 12 (19.67) | 9 (16.07) | 10 (22.22) | 8 (17.78) |
| S3 | 5 (8.20) | 5 (8.93) | 2 (4.44) | 4 (8.89) |
To further balance the baseline characteristics and control for bias, PSM was performed. The propensity score nearest neighbor matching method was used for 1:1 matching with a caliper value of 0.02. After matching, 45 cases in each group were obtained. As shown in Table 1, the baseline indicators of the observation and control groups were balanced (P > 0.05) and comparable.
Antiviral efficacy between the two groups before treatment and at 12, 24, and 48 weeks of treatment
As shown in Table 2, there was no significant difference between the two groups at 12 weeks of treatment (P > 0.05). After 24 and 48 weeks of treatment, the reduction in HBsAg quantification in the observation group was more significant than in the control group (P < 0.05). The HBeAg serological conversion rate in the observation group was higher than that in the control group at each time point, with statistically significant differences at 12, 24, and 48 weeks of treatment (P < 0.05). There was no significant difference between the observation and control groups after 12 weeks of treatment (P > 0.05). After 24 and 48 weeks, the reduction in HBV DNA levels was significantly greater in the observation group compared to the control group (P < 0.05).
Table 2Comparison of HBsAg decline, HBeAg serological conversion rates, HBV DNA quantification and HBV DNA negative conversion rate between the two groups before treatment and at 12, 24, and 48 weeks of treatment
| Variable | Before treatment
| Treatment for 12W
| Treatment for 24W
| Treatment for 48W
|
|---|
| Control group (n = 45) | Observation group (n = 45) | Control group (n = 45) | Observation group (n = 45) | Control group (n = 45) | Observation group (n = 45) | Control group (n = 45) | Observation group (n = 45) |
|---|
| HBsAg decline [log10 IU/mL] | 4.35 (3.83,4.73) | 4.31 (3.61,4.66) | 3.64 (2.35,3.97) | 3.52 (2.55,3.84) | 3.58 (3.32,3.94) | 3.22* (2.63,3.58) | 3.03 (2.79,3.22) | 2.54* (1.64,2.99) |
| HBeAg serological conversion rates [Case (%)] | | | 2 (4.44) | 9 (20.00)△ | 6 (13.33) | 18 (40.00)△ | 17 (37.78) | 29 (64.44)△ |
| HBV DNA Quantification [log10 IU/mL] | 7.96 (7.36,8.23) | 7.90 (6.93,8.27) | 5.51 ± 1.73 | 4.8 ± 2.01 | 4.64 (2.88, 5.93) | 2.91 (1.80, 4.99)# | 1.88 (1.30, 3.48) | 1.51 (1.30, 2.15)# |
| HBV DNA negative conversion rate [Case (%)] | | | 1 (2.22) | 1 (2.22) | 4 (8.89) | 5 (11.11) | 12 (26.67) | 21 (46.67)※ |
There was no significant difference in the negative conversion rate of HBV DNA between the two groups at 12 and 24 weeks (P > 0.05). After 48 weeks, the negative conversion rate of HBV DNA in the observation group was 46.67%, significantly higher than 26.67% in the control group (P < 0.05).
Serum ALT and AST changes between the two groups before treatment and at 12, 24, and 48 weeks of treatment
As shown in Table 3, there were no statistically significant differences in ALT and AST normalization rates between the observation and control groups at 12, 24, and 48 weeks of treatment (P > 0.05).
Table 3Comparison of ALT and AST recovery rates between the two groups after 12, 24, and 48 weeks of treatment [Case (%)]
| Characteristic | Treatment for 12W
| Treatment for 24W
| Treatment for 48W
|
|---|
| Control group (n = 45) | Observation group (n = 45) | Control group (n = 45) | Observation group (n = 45) | Control group (n = 45) | Observation group (n = 45) |
|---|
| ALT | 7 (15.56) | 6 (13.33)* | 14 (31.11) | 13 (28.89)* | 23 (51.11) | 20 (44.44)* |
| AST | 12 (26.67) | 12 (26.67)* | 23 (51.11) | 18 (40)* | 29 (64.44) | 21 (46.67)* |
The incidence of myelosuppression between the two groups before treatment and at 12, 24, and 48 weeks of treatment
As shown in Table 4, there was no significant difference in the incidence of myelosuppression between the observation and control groups after 12 weeks of treatment (P > 0.05). After 24 and 48 weeks, the incidence of myelosuppression in the observation group was lower than in the control group, with statistically significant differences (P < 0.05).
Table 4Comparison of cases of myelosuppression occurring at 12, 24, and 48 weeks of treatment [Case (%)]
| Characteristic | Treatment for 12W
| Treatment for 24W
| Treatment for 48W
|
|---|
| Control group (n = 45) | Observation group (n = 45) | Control group (n = 45) | Observation group (n = 45) | Control group (n = 45) | Observation group (n = 45) |
|---|
| Mild | 27 (48.89) | 32 (71.11) | 26 (57.78) | 27 (60) | 25 (55.56) | 20 (44.44) |
| Moderate | 8 (17.78) | 3 (6.67) | 10 (22.22) | 3 (6.67) | 4 (8.89) | 0 |
| Severe | 1 (2.22) | 0 | 0 | 0 | 0 | 0 |
| Total cases of myelosuppression | 36 (80) | 35 (77.78) | 36 (80) | 30 (66.67)* | 29 (64.44) | 20 (44.44)* |
Discussion
HBV infection is a serious infectious disease that severely harms public health in our country, with 85–90% of liver cancer patients having HBV-related hepatocellular carcinoma. HBeAg-positive patients often present with a high baseline viral load, recurrent liver function abnormalities, and poor long-term prognosis. Serological conversion of HBeAg is a marker of HBV immune clearance and disease remission in vivo, and an essential indicator for evaluating the therapeutic endpoint of HBeAg-positive CHB patients.5,6 Meanwhile, studies have shown that serum HBV DNA level is an independent risk factor for the occurrence, recurrence, and prognosis of liver cancer, and long-term inhibition of HBV replication can significantly improve patient outcomes.7 Therefore, HBeAg serological conversion and HBV DNA decline and negative conversion are key indicators for evaluating antiviral efficacy in HBeAg-positive CHB.
The concentration of PEG-IFN α in the blood is stable, and its therapeutic effect is superior to that of conventional interferon-α in improving HBeAg seroconversion rate and HBV DNA negative conversion rate.8 However, only 30–43% of HBeAg-positive CHB patients receiving initial PEG-IFN α-2a therapy achieve HBeAg serological conversion; furthermore, severe myelosuppression induced by PEG-IFN α-2a often leads to treatment interruption. Several studies have shown that TCM decoctions combined with interferon α in treating CHB significantly enhance antiviral efficacy and reduce interferon α adverse reactions.9,10 Huang et al.3 treated CHB with Xiaoyao powder combined with interferon α and concluded that TCM combined with interferon α yielded higher negative conversion rates of HBeAg and HBV DNA than interferon α alone. This study showed that compared to the control group, the observation group achieved greater declines in HBsAg and HBV DNA quantification after 24 and 48 weeks of treatment (P < 0.05). After 48 weeks, the negative conversion rate of HBV DNA in the observation group was higher than that in the control group (P < 0.05). At 12, 24, and 48 weeks, the HBeAg serological conversion rate in the observation group was also higher than in the control group (P < 0.05).
HBsAg is a key marker for achieving a functional cure.11 The lower the HBsAg level, the milder the liver inflammation and fibrosis, and the better the long-term prognosis.12 This study demonstrated that TCM combined with PEG-IFN α-2b significantly reduced HBsAg quantitative levels at 24 and 48 weeks, with better therapeutic effects than the control group. This aligns with Wang Zhanglin’s research,13 which showed that compound Chinese medicine can effectively inhibit HBsAg secretion by cells, with increasing inhibition over time. The quantitative level of HBeAg reflects viral replication levels, and HBeAg seroconversion indicates immune control and is an important treatment efficacy marker for CHB.14 Studies have found that PEG-IFN α-2b not only enhances immune response but also inhibits HBV replication,15, reducing HBV DNA levels and achieving HBeAg seroconversion or HBsAg loss. This study showed greater reductions in HBsAg and HBV DNA in the observation group tcompared to the control group after 24 and 48 weeks. After 48 weeks, the HBV DNA negative conversion rate in the observation group was higher than in the control group (46.67% vs. 26.67%). These results suggest that TCM combined with PEG-IFN α-2b effectively reduces HBV DNA quantification and promotes HBV DNA negative conversion. Qi et al.16 found that TCM pharmacological action can reduce HBV DNA reverse transcriptase activity, block viral replication pathways, prevent liver tissue damage, and continuously inhibit HBV DNA replication. This study found that the combination of TCM and interferon α did not outperform the control group in liver function normalization rates. This may be because TCM promotes ALT elevation caused by cytotoxic T lymphocyte and natural killer cell activation after interferon α treatment, thereby facilitating decreases in HBV DNA, HBeAg, and HBsAg.17 Tang et al.18 also found that the proportion of patients with elevated ALT at 24 weeks in the 48-week HBsAg clearance group was significantly higher than in the non-clearance group.
Reversible myelosuppression induced by PEG-IFN α-2b is one of the most common adverse reactions in antiviral therapy. This study found that during PEG-IFN α-2b therapy,19 the incidence of myelosuppression in the observation group was lower than in the control group at 24 and 48 weeks of treatment. Modern pharmacological studies show that TCM can reduce apoptosis of bone marrow cells and peripheral blood lymphocytes induced by cyclophosphamide by improving antioxidant activity.20 No obvious adverse events were observed during this study, indicating that TCM decoctions are safe for clinical application.
This study was a retrospective single-center study without balanced enrollment conditions. Large-sample, multicenter, prospective randomized controlled trials are needed in the future to enhance result credibility. This study could not evaluate liver histology changes before and after treatment to assess the effect of TCM combined with PEG-IFN α-2b on liver histology improvement. One patient in each group achieved HBsAg clearance and HBsAb positivity at treatment end. However, due to the small sample size, statistical analysis between groups was not possible. Future studies should extend treatment duration and increase sample size to obtain more accurate results.
Conclusions
The real-world findings demonstrate that adjunctive TCM significantly enhances the antiviral efficacy of peginterferon α-2b in HBeAg-positive CHB patients, while concurrently mitigating treatment-limiting myelosuppression. This combination strategy may represent a clinically valuable approach to optimize interferon-based therapy for CHB.
Declarations
Acknowledgement
The authors thank all the clinical and research staff of the Liver Disease Center of Xiamen Hospital of Traditional Chinese Medicine.
Ethical statement
This study was performed in accordance with the ethical guidelines of the 2024 Declaration of Helsinki. This study was approved by the Ethics Committee of Xiamen Hospital of Traditional Chinese Medicine [2023-K31-01]. The requirement for written informed consent was waived due to the retrospective nature of the study.
Data sharing statement
The dataset used to support the findings of this study is included within the article.
Funding
This work was supported by the National Natural Science Foundation of China (No. 82174141, 82374353); the Support Project for Young Qihuang Scholars of the State Administration of Traditional Chinese Medicine [No. 256 (2022)]; the Natural Science Foundation of Fujian Province (No. 2023J011636); the Xiamen Science and Technology Planning Project (No. 3502Z20224018); the Xiamen Medical and Health Guidance Project (No. 3502Z20224ZD1166); and the Xiamen Traditional Chinese Medicine Support Project (No. XWZY-2023-0202).
Conflict of interest
The authors have no conflicts of interest to declare.
Authors’ contributions
Study concept and design (HQL, XTZ), acquisition of data (XWW, LYZ, YYL, YRZ, MYZ), analysis and interpretation of data (MH, MJ, YD, YZX), drafting of the manuscript (HQL, XTZ), critical revision of the manuscript for important intellectual content (HQL, SDC), administrative, technical support (SDC), and study supervision (HQL, SDC). All authors have made significant contributions to this study and have approved the final manuscript.