August 5, 2015
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Hepatitis C (cont.)

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What are the goals of therapy for hepatitis C infection?

The ultimate goals of antiviral therapy are to:

  • eliminate hepatitis C,
  • prevent transmission of HCV,
  • improve or normalize the liver tests,
  • improve histology (microscopic appearance of inflammation and scarring),
  • prevent progression to cirrhosis and liver cancer,
  • prolong survival, and
  • improve the quality of life of people with hepatitis C.

As previously mentioned, only a sustained virologic response provides the possibility of achieving all of these goals since most patients who have a sustained response will remain in remission indefinitely. The rest of the patients (non-responders, partial responders, and relapsers) may show improvement in blood tests with or without relief of symptoms.

What are the therapy options for previously untreated patients with chronic hepatitis C infection?

For many years the optimal approach for people with previously untreated hepatitis (and were candidates for therapy) was combined treatment with pegylated interferon and ribavirin (Rebetol, Copegus), and for some patients this still is an option. With the development of the direct acting antiviral drugs, however, there are now alternative treatments for patients that have fewer side effects and are safer and more effective. Details of each treatment has been described previously in the treatment section.

  • Peglated interferons
  • Ribavirin
  • Combined peglated interferon and ribavirin
  • Boceprevir (Victrelis) is given along with pegylated interferon and ribavirin. Administration along with interferon and ribavirin is known as triple therapy (three medications). Adding a protease inhibitor can shorten the overall duration of treatment for some patients and leads to a sustained response more frequently.
  • Sofosbuvir (Sovaldi) and simeprevir (Olysio) are oral medications used in combination with ribavirin and interferon, but with simeprevir, it is possible to eliminate the interferon. These drugs have fewer side effects and a shorter duration of treatment and thus more patients are able to successfully complete treatment and achieve a sustained response.
  • Ledipasvir and sofosbuvir (Harvoni), a combination pill, which is available as a once daily pill.

How are relapses and nonresponders treated?

In past, the optimal treatment for nonresponders and relapsers was not well established. A minority of non-responders was treated with a second course of pegylated interferon and ribavirin which was also not very effective (6% to 12% response).

Addition of newer, oral, highly effective, direct acting antiviral medications has greatly changed the treatment of non-responders. Various combination regimens are now available and approved for the treatment of these patients. These include combination pills of ledipasvir and sofosbuvir (Harvoni, approved in October 2014), ombitasvir, paritaprevir and ritonavir tablets co-packaged with dasabuvir tablets (Viekira Pak) and various combinations of sofosbuvir (Sovaldi) and simeprevir (Olysio) with ribavirin (see the section on untreated patients). These combinations are safe with fewer side effects than traditional therapy with interferon, are highly effective with a cure rate above 90% and require a shorter duration of treatment ranging from 12 to 24 weeks.

What is the treatment for patients with cirrhosis?

Treatment of hepatitis C infection in patient with cirrhosis is particularly challenging due to the presence of permanent damage to the liver. But again, as with other treatment categories, the treatment of patients with cirrhosis has significantly changed with the new oral medications. Many treatment options are available as well as approved for patients with cirrhosis and are similar to options for patents without cirrhosis (as above) although they differ due to longer durations of therapy and, at times, addition of ribavirin to the combination regimen. The treatments differ depending on the genotype of virus and whether patients have previously received or not received treatment for hepatitis C. These options need to be discussed with physicians specifically dealing with advanced liver disease and liver transplantation. Even after completion of hepatitis C treatment in patients with cirrhosis, it is important to continue follow up with the physician to determine if there is progression of the cirrhosis as assessed with blood cell counts, blood tests of liver injury, and blood coagulation studies along with twice-yearly ultrasound examination to identify liver cancer hepatocellular carcinoma).

What is the treatment for patients with kidney disease and co-infection with HIV?

Co-infection with HIV and the presence of kidney disease make the choice of treatment more complex due to the potential interaction among multiple medications and the fact that the kidneys play an important role in the elimination of medications from the body. Many medications are still available for treatment of hepatitis C, but the presence of HIV or kidney disease might require changes in dosage, adjustment of the types of medications and even discontinuation of therapy. Treatment needs to be done in consultation with the corresponding experts in infectious and kidney diseases.

What is the treatment for people with acute hepatitis C infection?

When people first acquire hepatitis C, the infection is said to be 'acute'. There is no standard approach to treatment for acute hepatitis C. Most patients with acute hepatitis C do not have symptoms, so they are not recognized as being infected. However, some have low-grade fever, fatigue or other symptoms that lead to an early diagnosis. Others who become infected have a known exposure to an infected source, such as a needlestick injury, and are monitored closely. Treatment decisions should be made on a case-by-case basis. Response to treatment is higher in acute hepatitis infection than chronic infection. However, many experts prefer to hold off treatment for 8-12 weeks to see whether the patient naturally eliminates the virus without treatment.

Medically Reviewed by a Doctor on 5/26/2015

Source: MedicineNet.com
http://www.medicinenet.com/hepatitis_c/article.htm

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