Hepatologist Urges Appropriate Hepatitis C Post-Cure Care

Norah Terrault, MD, MPH

Although virologic cure is achieved in most patients infected with hepatitis C virus (HCV) treated with direct-acting antivirals (DAAs), a noted hepatologist recently emphasized the importance of post-cure care to reduce risk of liver disease progression in those with advanced fibrosis and in those with ongoing risk factors for liver injury, as well as to reduce risk of reinfection and to monitor and manage related complications.

"The achievement of HCV cure substantially reduces the risk of liver disease progression, but some patients remain at risk," explained Norah Terrault, MD, MPH, a professor of Medicine and director of the Viral Hepatitis Center, University of California San Francisco. "Moreover, liver injury can occur from other causes before and after cure, specifically related to alcohol use or superimposed metabolic fatty liver."

In an editorial accompanying Terrault's assessment and recommendations, Gary Lichtenstein, MD succinctly posed the challenge of providing follow-up to an ostensible cure.

"As physicians, our goal is to treat patients as best we can, which hopefully results in curing them whenever possible,” he wrote. “But once they are cured, then what?"

Terrault addressed that question by considering when continued HCV RNA testing is advised and how fibrosis regression and progression should be assessed, describing roles of both specialists and primary care practitioners in providing appropriate monitoring and intervention after successful DAA treatment, and identifying the strong counseling messages which could be essential for effective aftercare of this population.

The rate of late relapse, beyond the sustained virologic response to treatment at 12 weeks (SVR12), is rare (0.2%), and "exceedingly rare" beyond 24 weeks posttreatment, Terrault noted. Studies with phylogenetic sequencing have indicated that 7 of 12 relapses are new infections rather than true relapses. Despite the relatively low rate of relapse, however, Terrault indicated that the possibility warrants testing beyond 12 weeks post-treatment.

"I recommend obtaining both SVR12 and SVR 48," Terrault wrote. "If HCV RNA is undetectable at the later time point, the patient can be confidently informed that he or she is cured, and no further testing is indicated unless the patient is at risk for reinfection."

While acknowledging the roles of primary care practitioners in following and counseling patients on maintaining good liver health after treatment for HCV infection, Terrault suggested collaboration with a gastroenterologist or hepatologist for patients at risk for liver-related complications. She noted that patients with advanced fibrosis (F3 or F4) on staging tests prior to HCV treatment are at risk for hepatocellular carcinoma (HCC) and decompensation even after SVR12 is achieved.

"These patients should undergo surveillance with ultrasound and α-fetoprotein every 6 months," Terrault indicated. "Also, for patients with cirrhosis, screening endoscopy is indicated, with the subsequent frequency of endoscopies dictated by the initial findings."

Although most patients, particularly those without cirrhosis at baseline, will evidence fibrosis regression following SVR12, Terrault noted that some patients can progress. This can be attributed in some cases to concurrent alcohol use or presence of nonalcoholic fatty liver disease, or from genetic or immunologic factors, and warrants periodic assessment of fibrosis severity with elastography.

"Specialists pay a key role in educating non-specialists regarding appropriate follow-up post-cure and in caring for patients with advanced fibrosis and liver-related complications," Terrault concluded.

The paper, "Care of Patients Following Cure of Hepatitis C Virus Infection," was published in Gastroenterology & Hepatology.