A Randomized Controlled Study of the Effect of AT1 antagonist on Fibrosis Markers in HCV Egyptian Patients

Alaa E El-sisi, Asem A Elfert, Magda El-sayad, Sherin Zakaria

Alaa E El-sisi, Tanta University, Faculty of Pharmacy, Department of Pharmacology and Toxicology, Tanta, Egypt
Asem A Elfert, Tanta University Faculty of Medicine, Department of Tropical Medicine and Infectious diseases, Tanta, Egypt
Magda El-sayad, Tanta University, Faculty of Pharmacy, Department of Pharmacology and Toxicology, Tanta, Egypt
Sherin Zakaria, Kafr El−Sheikh Liver and Cardiac Research Centre, Pharmacy department, Kafr El−Sheikh, Egypt

Correspondence to: Alaa E El-sisi, Tanta University, pharmacy collage, Department of pharmacology and toxicology, Tanta, Egypt.
Telephone: + 0020403336007
Received: May 16, 2012
Revised: August 8, 2012
Accepted: August 9, 2012
Published online: October 21, 2012


AIM: The aim of this study was to evaluate the effect of telmisartan and losartan on liver functions and fibrosis markers in patients with chronic hepatitis C.

METHODS: Sixty patients were randomized into 3 groups. All groups received pegylated interferon α-2a and ribavirin. Telmisartan has been added to the first group and losartan has been added to the second group for the first 12 weeks of therapy. Blood samples have been collected before starting the treatment and after 12 weeks for counting of blood cells and measurement of alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyl transferase (GGT), α-2macroglobulin, and transforming growth factor beta (TGF-β1). Urinary hydroxyproline has been estimated.

RESULTS: Early virological response showed no significant difference between groups (p>0.05). All groups had a significant decrease in serum ALT and α2-macroglubulin compared to pretreatment values. Telmisartan group showed a significant reduction in serum AST, GGT, TGF-β, and urinary hydroxyproline compared to control. Patients treated with telmisartan and losartan suffered significantly less leucopenia and thrombocytopenia than control patients (p<0.05).

CONCLUSION: Addition of telmisartan to pegylated interferon and ribavirin may have a hepatoprotective, anti-fibrotic, and bone marrow stimulating effects in patients with chronic hepatitis C.

Key words: Telmisartan; Losartan; HCV; Liver fibrosis

© 2012 The Authors. Published by Thomson research Group Ltd.

El-sisi AE, Elfert AA, El-sayad M, Zakaria S. A Randomized Controlled Study of the Effect of Telmisartan and Losartan on Liver Functions, Fibrosis Markers and Blood Counts in Egyptian Patients with Chronic Hepatitis C Treated with Pegylated Interferon Alpha 2a and Ribavirin. Journal of Gastroenterology and Hepatology Research 2012; 1(9): 217-222 Available from: URL: http://www.ghrnet.org/index./joghr/


HCV infection is a worldwide health problem[1]. Liver fibrosis is the main determinant of HCV- related morbidity and mortality[2]. Apart from the anti-viral effect, several evidences suggested that interferon (IFN) could improve liver fibrosis. However, the histological improvement could be observed only in patients who accomplish sustained virological response (SVR)[3]. Combination of interferon with anti-fibrotic agents may provide synergistic effects[4].

It has been reported that inhibition of rennin angiotensin system (RAS) significantly attenuated liver fibrosis development in several experimental models[5]. Telmisartan is an angiotensin II receptors type 1 (AT1) antagonist which can activate peroxisome proliferator activated receptors gamma (PPARγ)[6]. Telmisartan markedly attenuated hepatic fibrosis in a rat model of non alcoholic steatohepatitis (NASH)[7], and CCl4 induced hepatic fibrosis[8]. Also, telmisartan had expressed an anti-fibrotic effect in hypertensive patients with NASH[9]. The aim of this study was to evaluate the effect of telmisartan and losartan on liver functions and fibrosis markers in patients with chronic hepatitis C.


Study design

This study has been done at the outpatient clinics of Kafr El-Sheikh Liver Research Center and Tanta University Hospitals from May 2008 to December 2009. Patients were subjected to different investigation including clinical investigation, laboratory analysis and liver biopsy within 1 to 5 d. the eligibility of the patients to the study were determined based on the results of these investigation. Sixty eligible patients with chronic hepatitis C were randomized using a computer generated list into 3 groups. All patients were treated with pegylated interferon α-2a 180 µg subcutaneously weekly and ribavirin 15 mg/kg orally daily. Telmisartan (40 mg/d/orally) was added to the first group of patients (telmisartan group) and losartan (50 mg/d/orally) was added to the second group of patients ( losartan group ) for the first 12 weeks of therapy. The third group of patients have been treated with standard of care only (control group). All drugs pegylated interferon α-2a, ribavirin, telmisartan and losartan started at the 6th day of the study (Figure 1).

Informed consent has been signed and dated by every patient before the study. The study protocol has been approved by the institutional review board of the Faculty of Pharmacy, Tanta University, Tanta, Egypt. The study was conducted in conformity with ethical and human principles.

Selection of patients

Medical history was taken before starting any investigation with stress on schistosomiases, bleeding attacks, smoking, alcohol intake, hypertension and diabetes.

Patients were excluded if they were unable to take oral medications; were pregnant, breast-feeding females; had a history of alcoholism or alcohol consumption of more than 40 g ⁄d; had acute hepatitis A or were co-infected with HBV; had any alternative cause of liver disease; had a history of hypersensitivity or intolerance to losartan or telmisartan or were clinically unstable or had any concomitant condition that, in the opinion of the investigator, would preclude participation in this trial. Sexually active patients were informed to use birth control during and six month after last dose of interferon and ribavirin.

Patients enrolled in this study were adults of both sexes of age (20-60). All patients were infected with HCV genotype 4 with detectable serum HCV RNA in their blood. All patients were normotensive (Systolic pressure was in the range (110-140 mmHg) and diastolic pressure was in the range (70-100 mmHg).

Only Patients with Controlled diabetes defined as active treatment for diabetes with blood glucose values generally <120 mg ⁄ dL were accepted in this study. Diabetic patients enrolled in this study were treated with insulin.

Liver biopsies obtained from patients within 3 months of randomization showing findings compatible with chronic hepatitis C were accepted for this study. Two slides prepared form patients' liver biopsy were examined by one pathologist. Patients' liver biopsies showed fibrosis scores between 1 and 5 according to Ishak scores[9]. Cirrhotic patients were excluded from the study.

Fibrosis scores of patients liver biopsies was correlated to fibrotic markers [urinary excretion of hydroxyproline , serum level of α2-macroglubulin , transforming growth factor beta (TGF-β1) and serum gamma glutamyl transferase (GGT) before starting treatments.

Study schedule and surveillance parameters

After selection, the enrolled patients started treatment. They were asked to return to the clinic five times at the end of 1st, 2nd, 4th and 8th and 12nd weeks from starting treatment (Figure 1).

During each visits patients were clinically examined, blood pressure were measured, blood sample were collected for monitoring liver function [alanine aminotransferase (ALT), aspartate aminotransferase (AST), total and direct bilirubin], kidney function (serum creatinine) and counting of blood cells. In addition, patients were asked about any undesirable or irritable adverse event. At the end of the 12th week patients were asked to give urine sample in addition to blood sample and routine examination as previous visits.

In each visit patients were asked to give the remain of the provided drugs for compliance calculation. Patients whose compliance was less than 75% in any visit were excluded.

Laboratory analysis

Blood and urine samples were collected before treatment and after 12 weeks. Neutrophils, red blood cells, and platelets were counted automatically on a hematology analyzer (Sysmex KX-21, Japan).

ALT, AST, albumen, alkaline phosphatase (ALP) , bilirubin, blood sugar, serum creatinine, prothrombin time, alpha-fetoprotein and thyroid stimulating hormone (TSH) were done according to kit instructions.

HCV RNA was determined using RT-PCR technique using QIAamp® viral RNA kit (QIAGEN, Germany).

Liver biopsy

The percutaneous liver biopsy technique was performed in all cases according to Grant and Neuberger[10]. All biopsies were fixed, paraffin embedded and stained with hematoxylin and eosin. Grading of the necroinflammatory activity and staging of fibrosis was assessed according to modified histological activity index (Ishak et al, 1995)[11].

Assay of fibrotic markers

Urinary excretion of hydroxyproline: 1mL of urine was hydrolyzed in 1.5 mL of 10 N HCl (final concentration is 6 N HCl). Tubes were then well closed and left in an oven at 110 °C for 12 h. The hydroxyproline content in the hydrolysate was measured according to Battaler et al[12].

Human α2-macroglubulin: Human α2-macroglubulin was quantitively measured in fully automated turbidimetric system (Turbi-quick, Italy).

Transforming growth factor TGF-β1

TGF-β1 was assayed using Enzyme Linked-Immuno-Sorbent Assay (ELISA) according to the kit instructions (Biosourse, Belgium)[13].

Statistical analysis

Statistical analysis was performed using SPSS for windows version 15. The data were parametric by using Kolmogrov-smirnov test. Results were expressed as mean±standard error (SE). Baseline data were compared using one way analysis of variance (ANOVA). Paired t-test was used to assess the change in parameters before and after treatment. Proportions were compared using Fisher’s exact test (two-sided). F-test was used to compare between groups. Pearson correlation coefficient was used to study correlation between variable. Significance was considered when p value was less than 0.05.


IV-1 Patients Characteristics

All patients were matched as regards age and sex (Table 1). Baseline biochemical indices and blood cells count were not significantly different between all groups (Table 1). Measuring serum level of TSH and α-fetoprotein revealed that all patients had normal levels of both parameters (Table 1)

Patients showed non significant differences concerning hepatic fibrosis scores and fibrotic markers at baseline (Table 2). All patients enrolled in this study were normotensive. They were matched as regard to both systolic and diastolic pressure (Table 3). Baseline HCV–RNA revealed that all patients had moderate viremia with no significant difference between all groups (Table 4).

Effect of AT1 antagonists on blood pressure

Only telmisartan treated patients showed a significant decrease in systolic and diastolic blood pressure compared to baseline level (p<0.05) while losartan treated and control patients expressed a non significant changes (Table 5) with on significant differences between groups.

Effect of AT1 antagonists on virological response

Rapid virological response (RVR) was 52% in telmisartan and losartan groups while it was 55% in control group with no significant difference between groups. Early virological response (EVR) was 75% in telmisartan group , and 70% in the two other groups with no significant difference between groups (Figure 2).

Effect of AT1 antagonists on biochemical liver function

All patients included in the study showed significant decrease in ALT compared to baseline levels. Telmisartan treated patients had a significant decrease in AST compared to baseline levels and other groups (Figure 3). Telmisartan treated patients showed a significant decrease in bilirubin while losartan treated patients and control group patients showed non significant decreases compared to baseline levels with no significant difference between groups (Figure 3).

Effect of AT1 antagonists on blood cells count

Telmisartan and losartan treated patients showed less reduction in platelets, total leukocytic count (TLC) and absolute neutrophilic count (ANC) than patients in the control group. The difference was statistically significant (p<0.05) (Figure 4).

Effect of AT1 antagonists on fibrosis markers

Telmisartan treated patients showed a significant decrease in urinary excretion of hydroxyproline and serum GGT compared to control group (Figure 5).

All patients showed significant decreases in α2-Macroglobuline and TGF-β1 serum levels. Only telmisartan treated patients showed a significant decrease in TGF-β1serum level compared to control (Figure 5).

Correlation of fibrosis markers with Ishak fibrosis score of liver biopsy

Urinary excretion of hydroxyproline, α2-macroglubulin, TGF-β1 and serum GGT showed a significant correlation with Ishak fibrosis score of liver biopsies of patients enrolled in this study (Table 6).


RAS-inhibitory agents exerted anti-fibrotic effects in several types of chronic liver diseases, including hepatitis C[14,15]. Despite the large number of animal studies, there is a relative paucity of human data to support the use of these drugs in human liver disease[16]. This study investigated the effect of telmisartan and losartan on hepatic fibrosis in HCV patients treated with pegylated interferon and ribavirin .

In the current study, telmisartan augmented pegylated interferon α-2a hepatoprotective effect expressed as significant reduction in ALT and AST serum level. Our results were consistent with Yoshiji et al 2006[4], who reported that interferon monotherapy decreased ALT and that ACE inhibitors augmented this hepatoprotective effect in hepatitis C patients.

Liver fibrosis is the main determinant of HCV-related morbidity and mortality[2]. In this study hepatic fibrosis was assayed using four markers, urinary hydroxyproline, serum level of GGT, TGF-β1 and α2-macroglubulin. These parameter were significantly correlated with Ishak fibrosis score of liver biopsies of patients enrolled in this study.

α2-macroglobulin serum level showed a very good correlation with histological stages in patients with hepatitis C and B[17]. Moreover, It is the most useful single test predicting hepatic fibrosis among other markers included in the fibrotest[18].

TGF-β1 is considered as a pivotal inducer of liver fibrosis acting through activation of hepatic stellate cells (HSCs) and their transformation to myofibroblasts, which are the main source of extracellular matrix proteins[19]. Our results revealed that addition of telmisartan but not losartan to pegylated interferon and ribavirin significantly decreased serum level of GGT as well as urinary excretion of hydroxyproline. Also, telmisartan increased the inhibitory effect of pegylated interferon and ribavirin on TGF-β1 serum level.

In other studies, losartan has been found to have an antifibrotic effect in HCV patients whether given alone or combined with ursodeoxycholic acid[14,15]. However these studies had been conducted for longer period (at least six months) compared to our study 12 weeks. We have conducted a preliminary study for only 4 weeks, the preliminary data revealed that 4 weeks is too short time for both telmisartan and losartan to exert antifibrotic activity (Data are not shown).

Our study detect the early antifibrotic effect of AT1 blocker however longer studies may be useful to illustrate the effect of these agent on sustained viral response (SVR ) in hepatitis C patients. Longer studies may also demonstrate the tolerability of AT1 blocker for chronic use in normotensive hepatitis C patients.

In consistency with our results, Georgescu et al[9] reported that telmisartan but not valsartan improved fibrosis score in NASH patients via its PPAR-γ effect. PPAR-γ may represent potential therapeutic targets in HCV infection[20]. Jin [7] provided evidence that telmisartan was able to reverse activated HSCs into quiescent state through inhibition of AT1 receptors and activation of PPAR-γ in the liver.

The effect of telmisartan on TGF-β1 may be in part PPAR-γ dependent where the PPAR-γ antagonist GW9662 blocked the inhibitory effect of telmisartan on TGF-β1 induced accumulation of extracellular matrix on kidney[21].

The antifibrotic effect of interferon was supported by another study reported that pegylated interferon-α2b and ribavirin induce a significant decrease in TGF-β1, TIMP-1, and MMP-1 serum concentrations of HCV patients[19].

Interferon and ribavirin combination therapy is associated with hematologic abnormalities such as anemia, neutropenia, and thrombocytopenia[22]. An interesting finding of our study was that both telmisartan and losartan ameliorated hematopoietic abnormalities induced by pegylated interferon.

This was in accordance with Charrier et al[23] who demonstrated that perindopril and telmisartan accelerated hematopoietic recovery and led to a significant increase in platelet and red cell counts in irradiated mice. They have also found that pretreatment with perindopril increased bone marrow cellularity and the number of hematopoietic progenitor cells after irradiation.

Although AT1 antagonists may act as negative regulators of hematopoiesis those drugs may exert myeloprotective effects by mediating G0/G1 arrest[24]. In this way, they may prevent DNA breakage during the S phase and subsequent cell apoptosis[23].

According to our results, both losartan and telmisartan appear to be well tolerated with no significant side effect. No patient had a hypotensive shock. The reported side effect during the study period was headache and drowsiness with both telmisartan and losartan.

Different studies reported the safety and tolerability of same doses of losartan and telmisartan in normotensive patients[25,26].

In conclusion, telmisartan but not losartan improved the effect pegylated interferon and ribavirin on fibrosis markers. The partial PPAR-γ activity of telmisartan could illustrate its antifibrotic activity which could not be achieved by the AT1 antagonist losartan. AT1 antagonists appeared to be safe and well tolerated in normotensive HCV patients. Furthermore, combining either losartan or telmisartan with pegylated interferon and ribavirin has been found to decrease interferon induced myletoxicity may be via AT1 blocking dependent mechanism.


We are very grateful to the late professor Wageh Awara, who started this work, but passed away during final steps.


1 Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J Med 2001; 345: 41-52

2 Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C. The OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups. Lancet 1997; 349: 825-832

3 Shiratori Y, Imazeki F, Moriyama M, Yano M, Arakawa Y, Yokosuka O, Kuroki T, Nishiguchi S, Sata M, Yamada G, Fujiyama S, Yoshida H, Omata M. Histologic improvement of fibrosis in patients with hepatitis C who have sustained response to interferon therapy. Ann Intern Med 2000; 132: 517-524

4 Yoshiji H, Noguchi R, Kojima H, Ikenaka Y, Kitade M, Kaji K, Uemura M, Yamao J, Fujimoto M, Yamazaki M, Toyohara M, Mitoro A, Fukui H. Interferon augments the anti-fibrotic activity of an angiotensin-converting enzyme inhibitor in patients with refractory chronic hepatitis C. World J Gastroenterol 2006; 12: 6786-6791

5 Yoshiji H, Kuriyama S, Yoshii J, Ikenaka Y, Noguchi R, Nakatani T, Tsujinoue H, Fukui H. Angiotensin-II type 1 receptor interaction is a major regulator for liver fibrosis development in rats. Hepatology 2001; 34: 745-750

6 Benson SC, Pershadsingh HA, Ho CI, Chittiboyina A, Desai P, Pravenec M, Qi N, Wang J, Avery MA, Kurtz TW. Identification of telmisartan as a unique angiotensin II receptor antagonist with selective PPARgamma-modulating activity. Hypertension 2004; 43: 993-1002

7 Jin H, Yamamoto N, Uchida K, Terai S, Sakaida I. Telmisartan prevents hepatic fibrosis and enzyme-altered lesions in liver cirrhosis rat induced by a choline-deficient L-amino acid-defined diet. Biochem Biophys Res Commun 2007; 364: 801-807

8 Awara WM, El-sayed ME, Zakaria S, EL-desoky K , El-masry SA. Telmisartan prevents CCl4 induced hepatic fibrosis in rats. 2008; l29: 175-200.

9 Georgescu EF, Ionescu R, Niculescu M, Mogoanta L, Vancica L. Angiotensin-receptor blockers as therapy for mild-to-moderate hypertension-associated non-alcoholic steatohepatitis. World J Gastroenterol 2009; 15: 942-954

10 Grant A, Neuberger J. Guidelines on the use of liver biopsy in clinical practice. British Society of Gastroenterology. Gut 1999; 45 Suppl 4: IV1-IV11

11 Ishak K, Baptista A, Bianchi L, Callea F, De Groote J, Gudat F, Denk H, Desmet V, Korb G, MacSween RN. Histological grading and staging of chronic hepatitis. J Hepatol 1995; 22: 696-699

12 Bataller R, Gäbele E, Schoonhoven R, Morris T, Lehnert M, Yang L, Brenner DA, Rippe RA. Prolonged infusion of angiotensin II into normal rats induces stellate cell activation and proinflammatory events in liver. Am J Physiol Gastrointest Liver Physiol 2003; 285: G642-G651

13 Howat WJ, Holgate ST, Lackie PM. TGF-beta isoform release and activation during in vitro bronchial epithelial wound repair. Am J Physiol Lung Cell Mol Physiol 2002; 282: L115-L123

14 Terui Y, Saito T, Watanabe H, Togashi H, Kawata S, Kamada Y, Sakuta S. Effect of angiotensin receptor antagonist on liver fibrosis in early stages of chronic hepatitis C. Hepatology 2002; 36: 1022

15 Sookoian S, Fernández MA, Castaño G. Effects of six months losartan administration on liver fibrosis in chronic hepatitis C patients: a pilot study. World J Gastroenterol 2005; 11: 7560-7563

16 Lubel JS, Herath CB, Burrell LM, Angus PW. Liver disease and the renin-angiotensin system: recent discoveries and clinical implications. J Gastroenterol Hepatol 2008; 23: 1327-1338

17 Turecky L, kupcova V, Szantova M , Uhlikova E. α2-macroglobulin as a biochemical marker of hepatic fibrosis in patients with chronic viral hepatitis. Biomed papers 2003; 147: 48-49.

18 Imbert-Bismut F, Ratziu V, Pieroni L, Charlotte F, Benhamou Y, Poynard T. Biochemical markers of liver fibrosis in patients with hepatitis C virus infection: a prospective study. Lancet 2001; 357: 1069-1075

19 Flisiak R, Jaroszewicz J, Lapinski TW, Flisiak I, Prokopowiczi D. Effect of pegylated interferon alpha 2b plus ribavirin treatment on plasma transforming growth factor-beta1, metalloproteinase-1, and tissue metalloproteinase inhibitor-1 in patients with chronic hepatitis C. World J Gastroenterol 2005; 11: 6833-6838

20 Dharancy S, Lemoine M, Mathurin P, Serfaty L, Dubuquoy L. Peroxisome Proliferator-Activated Receptors in HCV-Related Infection. PPAR Res 2009; 2009: 357204

21 Yao Y, Zou R, Liu X, Jiang J, Huang Q, He Y, Li M, Wang S, Zhou J, Ma D, Xu G. Telmisartan but not valsartan inhibits TGF-beta-mediated accumulation of extracellular matrix via activation of PPARgamma. J Huazhong Univ Sci Technolog Med Sci 2008; 28: 543-548

22 Ong JP, Younossi ZM. Managing the hematologic side effects of antiviral therapy for chronic hepatitis C: anemia, neutropenia, and thrombocytopenia. Cleve Clin J Med 2004; 71 Suppl 3: S17-S21

23 Charrier S, Michaud A, Badaoui S, Giroux S, Ezan E, Sainteny F, Corvol P, Vainchenker W. Inhibition of angiotensin I-converting enzyme induces radioprotection by preserving murine hematopoietic short-term reconstituting cells. Blood 2004; 104: 978-985

24 Parker AN, Pragnell IB. Inhibitors of haemopoiesis and their potential clinical relevance. Blood Rev 1995; 9: 226-233

25 Zandbergen AA, Baggen MG, Lamberts SW, Bootsma AH, de Zeeuw D, Ouwendijk RJ. Effect of losartan on microalbuminuria in normotensive patients with type 2 diabetes mellitus. A randomized clinical trial. Ann Intern Med 2003; 139: 90-96

26 Makino H, Haneda M, Babazono T, Moriya T, Ito S, Iwamoto Y, Kawamori R, Takeuchi M, Katayama S. Microalbuminuria reduction with telmisartan in normotensive and hypertensive Japanese patients with type 2 diabetes: a post-hoc analysis of The Incipient to Overt: Angiotensin II Blocker, Telmisartan, Investigation on Type 2 Diabetic Nephropathy (INNOVATION) study. Hypertens Res 2008; 31: 657-664

Peer reviewers: Chang Gue Son, PhD, Professor, Liver & Immunology Research Center, Daejeon Oriental Hospital of Daejeon University, 22-5 Daeheung-dong, Jung-gu, Daejeon, South Korea; Milton Gordon Mutchnick, MD, Division of Gastroenterology, Harper University Hospital, 3990 John R., 6 Hudson, Detroit, MI., 48201, the United States; Eric R Kallwitz MD, Section of Hepatology, 840 S Wood Street MC 787, Chicago, Il 60612, the United States.


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