Registration
This multi-center, double-blind, randomized placebo-controlled trial was registered before recruitment on the Chinese Clinical Trial Registry (No. ChiCTR1900021232) and conducted in accordance with the principles of the Declaration of Helsinki (2004 version). The study protocol was approved by Ethics Committee of Dongzhimen Hospital, affiliated to Beijing University of Chinese Medicine, before recruiting participants (Ethical approval No.DZMEC-KY-2018-61).
Recruitment
A total of 490 patients will be recruited by eighteen clinical trial centers in China listed as follows: Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine, Shenzhen Traditional Chinese Medicine Hospital, Guangdong Hospital of Traditional Chinese Medicine, Liaoning Hospital of Traditional Chinese Medicine, the First Affiliated Hospital of Guangxi University of Chinese Medicine, Shaanxi Hospital of Traditional Chinese Medicine, Mengchao Hepatobiliary Hospital of Fujian Medical University, Beijing Chinese Medicine Hospital, Beijing Ditan Hospital, Chongqing Traditional Chinese Medicine Hospital, Affiliated traditional Chinese medicine hospital of Southwest Medical University, Shanghai Shuguang Hospital, the Sixth People's Hospital of Shenyang, 302 Military Hospital of China, Shandong Hospital of Traditional Chinese Medicine, the Second People's Hospital of Tianjin, Public Health Clinical Center of Chengdu, the Third People's Hospital of Shenzhen. The case inclusion obeyed the principle of geographical balance nationwide. Volunteers were mainly recruited from outpatient clinics. The principal investigator will introduce the protocol as well as the benefits and risks of the study to the participants. An informed consent form is mandatory for enrollment.
The case inclusion obeyed the principle of geographical balance nationwide. Volunteers were mainly recruited from outpatient clinics. The inclusion and exclusion criteria were listed below. The criteria for premature withdrawal from the study included protocol deviation, pregnancy, or investigator discretion. Participants were also entitled to halt the study any time.
Inclusion Criteria
(1) Diagnosed CHB with positive HBeAg, who has been achieved HBeAg loss and/or seroconversion; (2) Aged between 18 and 65; (3) TBIL < 3×ULN; (4) HBsAg < 5000 IU/ml; (5) TCM symptoms are classified as Stagnation of liver and deficiency of Spleen Qi, Damp-Heat in the liver and gallbladder; (6) Voluntarily sign informed consent.
Exclusion Criteria
Any of the following cases will be excluded: (1) Diagnosed with chronic hepatitis caused by non-viral causes, overlapped virus infections, or cryptogenic hepatitis; (2) Accompanied by liver failure, hepatocirrhosis (including stage 4 fibrosis), hepatic encephalopathy, electrolyte disorders, gastrointestinal bleeding, fatal infections or any other severe complications; (3) Diagnosed with malignant tumors or with a progressive elevation of serum tumor markers; (4) Diagnosed with primary or secondary cardiovascular, cerebrovascular, pulmonary, renal, endocrine, nerve and hematology diseases; (5) Participating or participated in other clinical trials within one month; (6) Diagnosed mental disorders; (7) Confirmed Hepatitis B virus Pre C/C or P gene variants; (8) Pregnant or lactating women, individuals that are scheduled to conceive or fertilize; (9) With other unfavorable situations.
Sample Size Estimation
We calculated the samples size by the equation: N = (Uα + Uβ)2 × 2P × (1 - P) / (P1 - P0) 2. We referred to a study published in 2016, in which the recurrence rate was 32% CHB patients after withdrawal NAs at 24weeks. In this study, we assumed to reduce the recurrence rate by 10% to 22%. The certainty was set at 80%, considering 20% of sample lose. The sample size was set to 245 for each group, 490 in total.
Study Drugs
The trial ingested TCM granules named Tiaogan-Buxu-Jiedu Granule(调肝补虚解毒颗粒 TGBXJD ) and corresponding placebos. All patients were randomized to treatment with Tiaogan-Buxu-Jiedu Granule or placebos combined with entecavir (ETV). TGBXJD Granules (including placebos, 30g per dose) were provided by PuraPharm Co. Ltd, China (lot No. A190069710). The manufacturing procedure was as follows: every herb, including Bupleurum, atractylodes rhizome, scutellaria root, was dynamic extracted of hanging basket method with 97±2°C water. The extract was then filtered through 200 mesh filter cloth, and the filtrate was concentrated under vacuum to relative density 1.10 ~ 1.20 (temperature 60 ± 5 ° C), a suitable amount of dextrin and water was added, the concentrate was mixed after stirring for 30 minutes, the dried extract powder was obtained after spray drying, the calculated amount of dextrin was added to mix uniformly, so the herbal granulates were obtained by dry granulation method. ETV tablet (0.5 mg per tablet) were provided by CHIATAI TIANQING company, China (lotNo.181214101,181203201,181024101). The major ingredients of TGBXJD are scutellaria, Bupleurum and atractylodes.
Therapeutic Regimen
Patients who meet the inclusion criteria will be allocated in a 1:1 ratio to either the experimental group or the control group. Patients in the experimental group will receive TGBXJD Granule along with ETV. Patients in the control group will receive placebo along with ETV. The treatment duration is 96 weeks. All patients will accept drug withdrawal and observe for 24 weeks after treatment course. Once clinical recurrence occurs, antiviral treatment is suggested.(Figure 1)
Randomization and Blind
Stratified block randomization is conducted by the third party (Chinese Academy of Chinese Medicine Sciences, CACMS) with their online central randomization system. Clinical physicians in sub-centers oversaw recruitment. They would apply for an ID through a web interface provided by CACMS for each patient, by which the patients would be randomly allocated to each group at a ratio of 1:1 via a central randomization system. Each trial drug was assigned to a patient with a unique number, which would be dispatched by the online system. All experimental drugs and corresponding placebo were consistent in appearance and taste. The grouping information of each participant was concealed to all research personnel and data analyzers until the trial ended.
Interviews
From 1st day to the observation point of week 96, patients would be interviewed once every 24 weeks (± 3 days). Corresponding drugs were dispatched each visit. From week 96 to week 120, interviews were conducted every 4 weeks (± 3 days). Medications will be reintroduced in patients who had a relapse during the period of observation.
Assessments
To ensure safety and reveal the curative effects of trail drugs, assessments were adopted regularly throughout the whole trial. (Table 1)
Primary Outcomes
The primary outcome measurement will be the recurrence rate after drug withdrawal.
Secondary Outcomes
Secondary outcome measurements include the virus serological indicator, HBV DNA, liver function, liver biopsy, cccDNA, HBcrAg, HBV-pgRNA, L-HBsAg, symptomatic score of TCM, SF-36 and the CLDQ, which will be measured at the intervention.
Safety Monitoring
Primary vital signs, physical examinations, and some laboratory tests will be performed for safety assessment daily. Primary vital signs include body temperature, blood pressure, heart rate, and respiratory rate. Laboratory tests include routine blood, urine, and stool tests, along with fecal occult blood tests, ECG, abdominal B ultrasound scan. In particular, the relapse after drug discontinuation was defined HBV DNA levels > 2,000 IU/mL as while serum ALT > 2-fold of the upper limit of the normal.
Adverse events
All unexpected AEs occurring during the intervention period will be reported, and the causality related to the TGBXJD will be analyzed. If any adverse event occurs, the study managers will ensure that the participant receives adequate treatment. The AEs will be immediately reported to the principal investigator and to the ethics committee to decide whether the participant should withdraw from the trial. If any symptoms aggravate, the patient will be withdrawn from the study and will be referred for further treatment.
Statistics Analysis
The statistical report is made by an independent statistical analysis team using the proposed blind method in the statistical analysis plan and then submitted to the personnel responsible for summarizing clinical research data for comprehensive analysis. The statistical analysis plan covers objectives, indicators, analysis types, hypothesis testing, significance level, statistical software, analysis, and result expression methods, curative effect analysis, safety evaluation, and analysts, etc. The statistical analysis team conducts intention-to-treat (ITT) analysis of the main effect indicators.
Data description: The enumeration data is described by the constituent ratio, the measurement data is represented by mean ± standard deviation, and non-normal distribution is described by median and interquartile range.
Comparison of baseline data: Pearson chi-square test or Fisher test is used for comparison of enumeration data, group variance test is used for the comparison of normal distribution measurement data, and non-parametric analysis and test is used for the comparison of non-normal distribution measurement data.
Comparison of curative effect: The total effect of the scale scores is tested by Wilcoxon rank-sum test. Variance test is adopted for the baseline comparison of symptom score and rate, the comparison after treatment and the difference comparison among groups before and after treatment, and paired t-test is used for the comparison before and after treatment within groups.
Safety evaluation: The comparison of quantitative data in the laboratory is made using the variance test. Meanwhile, all the laboratory data is classified according to whether they are normal or not. The number of normal and abnormal cases before and after treatment is respectively described according to different intervention groups. The adverse events are described using incidence, and the specific performance and degree of all the adverse events in each group and their relationship with drugs are described in detail.