3. Treatment of chronic hepatitis C
The goal of therapy is to prevent complications and death from
HCV infection.
The currently recommended therapy of chronic hepatitis C
infection is the combination of a Peg-IFN and Ribavirin.14-16
Treatment should be considered in all adults with confirmed chronic hepatitis C and particularly in those who are at increased risk of developing cirrhosis. For patients in whom liver histology is available, treatment is indicated if advanced fibrosis (F2 or F3 according to the METAVIR scoring system) is present. As with all decisions in medicine, a balance must be struck between the benefit and risk of therapy and fibrosis is not a prerequisite for treatment.
Symptomatic cryoglobulinaemia is an indication for anti- viral therapy regardless of the stage of liver disease.
Additional factors that may influence the decision to treat are age, occupations in which there is a risk of transmission to others, quality of life, co-morbidities, the potential for serious side effects and the likelihood of treatment success.
Treatment may worsen psychiatric disorders and, in such patients, a pre-treatment psychiatric evaluation and close follow-up are mandatory.
Treatment is currently contraindicated in
- Age less than 2 years.
- Untreated thyroid disease.
- Autoimmune hepatitis or other autoimmune condition known to be exacerbated by Peg-IFN or Ribavirin.
- Decompensated liver disease.
- Severe concurrent medical disease such as severe hypertension, significant coronary artery disease, heart failure, chronic obstructive pulmonary disease, poorly controlled diabetes mellitus.
- Pregnancy or an unwillingness to use adequate contraception.
- Major uncontrolled depressive illness.
- Known hypersensitivity to drugs used to treat HCVinfection.
- Solid organ transplantation (heart, lung or kidney).
Obesity is believed to play a role in the progression of fibrosis in HCV-infected individuals and may adversely affect treatment outcome. Patients with a BMI > 25.0 kg/m2 should therefore be advised to lose weight.
Excessive alcohol consumption results in rapid progression of fibrosis, enhances viral replication and may interfere with treatment. Although no consensus exists, it seems reasonable to recommend either the complete cessation of alcohol intake or restricting its use whilst on treatment. Alcoholics should be abstinent for at least 1 year before commencing anti-viral treatment.
All patients with chronic hepatitis C should be screened for hepatitis A and B and, if not immune, offered vaccination.
Venesection is recommended in patients in whom a liver biopsy reveals significant iron overload.
There is no evidence that herbal products have a role in the treatment of patients with acute or chronic hepatitis C.
Because of the slow evolution of chronic hepatitis C, treatment responses are defined by surrogate virologic parameters rather than clinical endpoints.
The major predictors of a SVR are viral genotype and pre- treatment viral load.14-16 SVR rates are higher in genotypenon-1 infections (predominantly genotypes 2 and 3) and in those with a viral load of < 600,000 IU/mL. Other less consistently reported baseline characteristics associated with a favourable response are female gender, age < 40 years, lower body weight (< 75 kg), the absence of insulin resistance, ALT levels > 3 times the upper limit of normal and the absence of bridging fibrosis or cirrhosis.
Patients with HCV-related cirrhosis, who achieve an SVR regardless of genotype, should continue to be monitored at 6 to 12 month intervals for the development of HCC.17
A RVR is highly predictive of achieving a SVR independent of genotype and regardless of treatment regimen.18,19
Failure to achieve at least a pEVR is the most robust means of identifying non-responders in patients with genotype 1 infection.15,20-22 As less than 3 % of such individuals achieve an SVR, this is an indication to stop treatment. The clinical utility of an EVR is less helpful in patients with genotypes 2 and 3 infection since a majority of such individuals clear the virus by
12 weeks and respond to therapy.