Hepatitis C Virus Treatment on an Individual Basis

The best way to treat chronic hepatitis C virus (HCV) infection is to acknowledge morbidity and mortality associated with the infection and to move forward from there, according to an editorial published in JAMA Internal Medicine.

Marc G. Ghany, MD, MHSc of the Liver Diseases Branch at the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health wrote the editorial in response to an article published in JAMA Internal Medicine. This suggested that after HCV infection, patients may experience a more rapid progression of liver fibrosis and accelerated time to develop cirrhosis than previously thought.

The study examined 1,840 persons who were HCV positive and an equal number of non HCV controls, and discovered, on average, HCV positive patients were generally younger, had a lower mean body mass index, a higher prevalence of alcohol and drug abuse and dependence diagnoses, and higher serum aminotransferase levels, but also had a lower prevalence of diabetes and hypertension.

Fibrosis progression began early after HCV infection in positive patients and tapered off after about 5 years. After a 10 year follow up period, HCV positive patients were more likely to have a cirrhosis diagnosis compared to negative controls (18.4% compared to 6.1%, respectively). After an additional 9 years of follow up post cirrhosis diagnosis, hepatic decompensation events were uncommon, although they had a higher rate in the HCV positive group (1.79% compared to 0.33%, respectively).

“Does this mean that we should change our approach to treatment and recommend therapy for patients earlier in the course of their disease?” asked Ghany. “Before addressing this question, we need to revisit the current state of therapy. Therapy of chronic HCV infection is at a watershed moment. Multiple oral agents have been developed that specifically target key viral proteins necessary for the viral lifecycle and tested in different combinations for variable durations ranging from 12 to 24 weeks,” Ghany continued, and added that the regimens are highly effective, increasing the response rate from about 50 to 90%. The new regimens, Ghany stressed, have become simpler to administer, safer, and more tolerable with minimal adverse effects.

Physicians are faced with the challenge of identifying which patients will benefit from therapy — but Ghany commented that patients with the greatest risk for disease progression, patients coinfected with human immunodeficiency virus (HIV) or hepatitis B virus, and patients who have received a liver transplant and are at risk for recurrent cirrhosis or a graft failure should be given top priority.

Additionally, Ghany said men who have sex with men, active injection drug users, incarcerated persons, and persons on long term hemodialysis are at a higher risk of transmitting the disease and are controversial for receiving treatment.

“The decision to treat other patients should be individualized,” Ghany concluded. “Patients who are not treated should be closely monitored for disease progression using liver biopsy, noninvasive testing, or a combination of the two. However, this is not an exact science.”