Treatment


Pharmacological treatment is recommended for patients with chronic HCV infection, advanced fibrosis, compensated cirrhosis, liver transplant, severe extrahepatic manifestations, HIV co-infection, or mixed cryoglobulinemia with end-organ manifestations.13 The key to successful treatment is achieving a sustained virological response (SVR). 


An SVR is an undetectable HCV-RNA level 24 weeks after the completion of therapy, although the time varies per study. An SVR correlates with decreases in liver fibrosis, necrosis, and cirrhosis and a 70% reduction in the risk for liver cancer.13 In patients who achieved an SVR, the risk for death was 62% to 84% lower, the risk for hepatocellular carcinoma was 68% to 79% lower, and the risk for requiring a liver transplant was 90% lower than in patients who did not achieve an SVR.14 These studies were primarily of treatment with peginterferon alfa-2a and ribavirin, and the analyses will require repetition for the study of directly acting antivirals. 


Treatment recommendations and length of treatment are guided by HCV genotype, viral load, patient comorbidities, the presence of cirrhosis, and previous treatment (i.e., treatment-naïve or experienced). Current FDA-approved medications are listed in Table 5. The guidelines for HCV treatment in adults are rapidly changing with the advent of new therapies and other developments. Updated guidelines are published through the Infectious Diseases Society of America (IDSA), the American Association for the Study of Liver Diseases, and the European Association for the Study of the Liver. A full medication history must be elicited before treatment, as many of these drugs interact with P-glycoprotein inducers (i.e., rifampin, St. John’s wort), anticonvulsants, and antiretrovirals. Patients should be counseled to avoid alcohol and other toxic substances to prevent disease progression and to consult their clinician before taking any prescriptions or over-the-counter medications, supplements, or vitamins. A healthful diet, weight loss in case of obesity, and control of diabetes and other comorbidities are linked to improved liver health.


Click to enlarge.

Click to enlarge.

During treatment, the quantitative HCV viral load, CBC, creatinine level, GFR, and liver function test values should be monitored monthly. At 12 weeks, the TSH should be measured.13 The quantitative HCV viral load is analyzed at the completion of treatment and at variable intervals after treatment. It is well-documented that host factors (age, gender, ethnicity, genetic polymorphisms) may influence the outcome of treatment. 


Conclusion


HCV infection is the leading cause of liver cirrhosis and the most common reason for liver transplant in the United States. No vaccination is yet available; as such, it is crucial to screen patients at high risk for this disease. It is also important to provide patient education about ways to prevent HCV transmission. 


Several treatment options that can lead to an SVR are helping to improve patients’ quality and duration of life. In just the last year, several advances in medications and treatment guidelines for HCV have been reported. It is particularly important for clinicians to stay current with guidelines and to follow the results of clinical trials. More advances are on the horizon.

Rebecca Wong is a student in the Physician Assistant, Bachelor of Science program at St. John’s University College of Pharmacy and Health Sciences in Queens, NY. Cynthia Russell, PA-C, is a physician assistant with the Arya Gastroenterology Associates, P.C., in Brooklyn, NY. Danielle Kruger, PA-C, MSEd, is an associate professor in the Physician Assistant, Bachelor of Science program at St. John’s University College of Pharmacy and Health Sciences, and a physician assistant practicing emergency medicine, and Director of Physician Assistant Development at Coney Island Hospital in Brooklyn, NY. 

References


  1. Stockman LJ, Guilfoye SM, Benoit AL, et al; Centers for Disease Control and Prevention (CDC). Rapid hepatitis C testing among persons at increased risk for infection-Wisconsin, 2012-2013. MMWR Morb Mortal Wkly Rep. 2014;63(14):309-311. 

  2. Dhawan VK. Hepatitis C. Medscape. http://emedicine.medscape.com/article/177792-overview. Updated August 3, 2015. Accessed January 5, 2016. 

  3. Hepatitis C. New York State Department of Health Web site. https://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_c. Updated November 2015. Accessed January 5, 2016. 

  4. HC Hepatitis Central. http://www.hepatitiscentral.com. Accessed January 5, 2016.

  5. Rutherford A, Dienstag JL. Viral hepatitis. In: Greenberger NJ, Blumberg RS, Burakoff R. Current Diagnosis and Treatment: Gastroenterology, Hepatology and Endoscopy. 3rd ed. New York, NY: McGraw-Hill; 2009:434-443. 

  6. Hoofnagle JH. Chronic hepatitis. In: Goldman L, Ausiello D, Arend WP, et al, eds. Cecil Medicine. 23rd ed. Philadelphia, PA: Saunders Elsevier; 2008:1108-1116.

  7. Spach DH. Core concepts. HCV epidemiology in the United States. Hepatitis C Online. http://www.hepatitisc.uw.edu/go/screening-diagnosis/epidemiology-us/core-concept/all. Updated June 16, 2014. Accessed January 5, 2016.

  8. Boyer N, Marcellin P. Pathogenesis, diagnosis, and management of hepatitis C. J Hepatol. 2000;32(suppl 1):98-112.

  9. Fox RK. Core concepts. Extrahepatic conditions related to hepatitis C. Hepatitis C Online. http://www.hepatitisc.uw.edu/go/evaluation-staging-monitoring/extrahepatic-conditions/core-concept/all. Updated July 22, 2013. Accessed January 5, 2016.

  10. Sim M, Cheng W, Dore G, Beers K. Signs and symptoms of chronic viral hepatitis. In: HIV, Viral Hepatitis and STIs: A Guide for Primary Care. Surry Hills, Australia: Australasian Society for HIV, Viral Hepatitis, and Sexual Health Medicine; 2008:71-79. http://testingportal.ashm.org.au/resources/HCV/HIV_viral_hep_Chapter_7.pdf. Accessed January 5, 2016.

  11. Galossi A, Guarisco R, Bellis L, Puoti C. Extrahepatic manifestations of chronic HCV infection. J Gastrointestin Liver Dis. 2007;16(1):65-73. 

  12. Freeman AJ, Marinos G, French RA, Lloyd AR. Immunopathogenesis of hepatitis C virus infection. Immunol Cell Biol. 2001;79:515-536. 

  13. American Association for the Study of Liver Disease/Infectious Diseases Society of America. Recommendations for testing, managing, and treating hepatitis C. http://www.hcvguidelines.org. Accessed January 5, 2016.

  14. Boschert S. Achieving sustained response key to successful HCV treatment. Clinician Reviews. www.clinicianreviews.com/?id=26596&tx_ttnews[tt_news]=311185&cHash=3d8313f051b71602264694d3fb24239d. 

  15. Gilead Sciences. Highlights of prescribing information. Harvoni. https://www.gilead.com/~/media/Files/pdfs/medicines/liver-disease/harvoni/harvoni_pi.pdf. Updated November 2015. Accessed January 4, 2016. 

  16. American Association for the Study of Liver Disease/Infectious Diseases Society of America. Initial treatment box. Summary of recommendations for patients who are initiating therapy for HCV infection by HCV genotype. http://www.hcvguidelines.org/full-report/initial-treatment-box-summary-recommendations-patients-who-are-initiating-therapy-hcv. Updated August 7, 2015. Accessed January 4, 2016.


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