the present invention provides an advantageous treatment of chronic hepatitis b by administering a combination of a pharmacologically effective amount of a peg - ifn - α conjugate and a pharmacologically effective amount of ribavirin . preferably , said chronic hepatitis b is a hbeag - negative or hbeag - positive chronic hepatitis b . more particularly , the combination therapy of the present invention should provide an improved efficacy against a chronic hepatitis b which is a hbeag - negative chronic hepatitis b . the patients are either previously untreated patients , previously treated with ifn - α and / or ribavirin or any other drug but have subsequently relapsed , or nonresponders to previous treatment with ifn - α and / or ribavirin or any other drug . preferably , the patients are previous nonresponders to interferon monotherapy . hepatitis b e antigen ( hbeag ) is used to differentiate between hbeag - positive chronic hepatitis , which is due to wild type hbv , and hbeag - negative chronic hepatitis b , which is due to a naturally occurring hbv variant with mutations in the precore or / and basic core promoter regions of the genome . hbeag - negative chronic hepatitis has been recognized as increasing in many countries within the last decade and it represents the majority of cases in many countries . this form of hepatitis b is generally associated with more severe liver disease with a very low rate of spontaneous disease remission and a low sustained response rate to antiviral therapy . the term “ peg - ifn - α conjugate ” as used herein includes ifn - αs derived from any natural material ( e . g ., leukocytes , fibroblasts , lymphocytes ) or material derived therefrom ( e . g . cell lines ), or those prepared with recombinant dna technology . details of the cloning of ifnα and the direct expression thereof , especially in e . coli , have been the subject of many publications . the preparation of recombinant ifnαs is known , for example from goeddel et al . ( 1980 ) nature 284 , 316 - 320 and ( 1981 ), nature 290 , 20 - 26 , and european patents nos . 32134 , 43980 and 211148 . there are many types of ifnα such as ifnαi , ifnα2 ; and further their subtypes including but not limited to ifnα2a , ifnα2b , ifnα2c and ifnαii ( also designated ifnαii or α - ifn ). the term “ ifnα ” also includes consensus ifnα available from amgen or mixtures of natural and / or recombinant ifnαs or ifnα variants disclosed in wo01 / 25438 or wo2004 / 046356 . the use of ifnα2a is preferred . the manufacture of ifnα2a is described in european patents nos . 43980 and 211148 . the ifnα is conjugated to a polymer such as a polyalkylene glycol ( substituted or unsubstituted ), for example , polyethylene glycol , to form peg - ifn - α conjugate . conjugation may be accomplished by means of various linkers known in the art , in particularly by linkers such as those disclosed in european patent applications , publication nos . 0510356 , 593868 and 809996 . the molecular weight of the polymer , which is preferably polyethylene glycol , may range from 300 to 70 . 000 daltons , and one or more , preferably one to three , polymers may be conjugated to the ifn - α . a preferred peg - ifn - α conjugate has the formula : where r and r ′ are methyl , x is nh , and n and n ′ are individually or both either 420 or 520 . ribavirin , 1 - α - d - ribofuranosyl - 1h - 1 , 2 , 4 - triazole - 3 - carboxamide , is described in the merck index , compound no . 8199 , eleventh edition . its manufacture and formulation are described in u . s . pat . no . 4 , 211 , 771 . the dosage of peg - ifn - α conjugate for practicing the combination therapy of this invention is about 33 to 540 microgram ( mcg ) per week , more preferably 180 micrograms , in one or two weekly administrations the dosage of ribavirin for practicing this invention is about 400 to 1200 mg per day at least five days per week , preferably seven days per week . based on the assumption of a patient weighing between 40 and 150 kg , the range of dosing is therefore between 10 and 30 mg per kg body weight per day . in a more specific embodiment the daily dosage of ribavirin is 800 - 1200 mg , more preferably 1000 to 1200 mg . this daily dosage may be administered once per day in a single dose or in divided doses twice or thrice per day . preferably the daily dosage of ribavirin is administered in divided doses twice per day . in accordance with this invention , the ribavirin is administered to the patient in association with peg - ifn - α conjugate , that is , the peg - ifn - α conjugate dose is administered during the same or different periods of time that the patient receives doses of ribavirin . in an embodiment of this invention , at least one daily dose of ribavirin is administered within the same week as at least one dose of peg - ifn - α . in a more specific embodiment a majority of the ribavirin administrations occur within the same week as one or more peg - ifn - α administrations . in another specific embodiment , all or substantially all of the ribavirin administrations occur within the same week as one or more peg - ifn - α administrations . at present peg - ifn - α conjugate formulations are not effective when administered orally , so the preferred method of administering the peg - ifn - α conjugate is parenterally , preferably by subcutaneous ( sc ) or intramuscular ( im ) injection . the ribavirin may be administered orally in capsule or tablet form in association with the parenteral administration of peg - ifn - α conjugate . of course other types of administration of both medicaments , as they become available are contemplated , such as by nasal spray , transdermally , by suppository , by sustained release dosage form , etc . any form of administration will work so long as the proper dosages are delivered without destroying the active ingredient . the effectiveness of treatment can be determined by controlled clinical trials of the combination therapy versus monotherapy and / or combination therapy of ifn - α and ribavirin . the efficacy of the combination therapy in alleviating the signs and symptoms of chronic hepatitis b , preferably hbeag - negative or hbeag - positive chronic hepatitis b infection , more preferably hbeag - negative chronic hepatitis b infection , and the frequency and severity of the side effects will be compared with previous ifn - α monotherapy and / or combination therapy of ifn - α and ribavirin . three populations suffering from chronic hepatitis b infection , preferably hbeag - negative or hbeag - positive , more preferably hbeag negative chronic hepatitis b , are of relevance for evaluation . either only one or all three patient populations will be studied with the combination : 1 . patients previously untreated . 2 . patients previously treated with ifn - α and / or ribavirin or any other drug and who had subsequently relapsed . 3 . patients who were non - responsive to previous treatment with ifn - α and / or ribavirin or any other drug . the effectiveness of the combination therapy will be determined by the extent to which the previously described signs and symptoms of chronic hepatitis b , preferably hbeag - negative or hbeag - positive , more preferably hbeag - negative chronic hepatitis b , are alleviated . the primary purpose of this study is to compare the efficacy and safety of the combination of peg - ifn - α2a and ribavirin with peg - ifn - α2a in the treatment of hbeag - negative chronic hepatitis b . equal numbers of patients ( 61 patients per treatment group ) are receiving either the combination of peg - ifn - α2a and ribavirin or peg - ifn - α2a for 48 weeks . a third group of patients ( 165 patients ) is receiving peg - ifn - α2a plus placebo for 48 weeks . the monotherapy arm provides a safety and efficacy comparator for the peg - ifn - α2a combination arm . the dose of peg - ifn - α2a is 180 μg , administered sc once per week , in combination with ribavirin or placebo for 48 weeks . the dose of ribavirin is 1000 mg or 1200 mg based upon body weight , per day in split doses . patients weighing & lt ; 75 kg ( 165 lbs ) receive 1000 mg per day ( 400 mg in the morning and 600 mg in the evening ), whereas patients weighing ≧ 75 kg receive 1200 mg per day ( 600 mg in the morning and 600 mg in the evening ). the primary efficacy parameters are the combined sustained virological [ i . e ., hbv - dna level & lt ; 10 4 copies / ml as measured by the amplicor ® pcr assay ( sensitivity ≧ 100 copies / ml )] and biochemical ( normalization of serum alt concentration ) responses at the conclusion of the untreated follow - up period . to be considered a responder , patients must have a normal serum alanine aminotransferase ( alt ) activity at both weeks 68 and 72 and no detectable virus at week 72 . safety assessments are performed during screening , at baseline , at weeks 1 , 2 , 4 , 6 and 8 and then every 4 weeks thereafter throughout the 48 week treatment period . safety assessment continues during the subsequent 24 - week follow - up period . measures of safety include adverse events , vital signs , and laboratory tests as well as tabulations of dose adjustments and premature withdrawals from treatment for safety or tolerability reasons . male and female patients aged 18 years or older with hbeag - negative chronic hepatitis b who have not been treated against hbv within the previous 6 months who were not treated with any investigational drug within 30 days of entry into the present trial constitute the patient population . patients must have quantifiable hbv - dna , abnormal alt on two occasions within 2 months prior to randomization ( normal alt values in between are allowed ) and liver biopsy within 12 months consistent with hbeag - negative chronic hepatitis b . patients with other forms of liver disease , co - infection with hcv , hepatitiss d or human immunodeficiency virus ( hiv ), hepatocellular carcinoma , pre - existing severe depression or other psychiatric disease , cardiac disease , renal disease , seizure disorders , or severe retinopathy etc . are excluded . a screening period ( time from the first screening assessment to the first administration of test drug ) of up to 4 weeks precedes treatment portion of the trial ( 48 weeks ). patients meeting all eligibility criteria are randomized to one of the two treatment regimens . the primary outcome at the end of follow - up is taken as the basis for the following power analysis ( appendix c ). the estimated response rate is 30 % for peg - ifn monotherapy and 55 % for the combination therapy . the major study question will be addressed by a pair - wise comparison between the response rates at end of follow - up . the pair - wise significance level will be set at a = 0 . 05 ( two sided testing ). power is set to 80 %. drop - outs will be calculated as non - responders at the end of follow up . bringing the total number to be randomized to : response sample size final 1 : 1 peg - ifn monotherapy 30 % 61 combination therapy 55 % 61 total : 122
the present invention provides the use of peg - ifn - α conjugates in association with ribavirin for the treatment of chronic hepatitis b infections . the present invention also provides a method for treating chronic hepatitis b infections in patients in need of such treating comprising administering an amount of peg - ifn - α conjugate in association with an amount of ribavirin effective to treat chronic hepatitis b .