Hepatitis C medical therapy

Treatment

Treatment during the acute infection phase has much higher success rates (greater than 90%) with a shorter duration of treatment (but balance this against the 80% chance of spontaneous clearance without treatment).

Those with low initial viral loads respond much better to treatment than those with higher viral loads (greater than 2 million virons/ml). Current combination therapy is usually supervised by physicians in the fields of gastroenterology, hepatology or infectious disease.

The treatment may be physically demanding, particularly those with a prior history of drug or alcohol abuse. It can qualify for temporary disability in some cases. A substantial proportion of patients will experience a panoply of side effects ranging from a 'flu-like' syndrome (the most common, experienced for a few days after the weekly injection of interferon) to severe adverse events including anemia, cardiovascular events and psychiatric problems such as suicide or suicidal ideation. The latter are exacerbated by the general physiological stress experienced by the patient.

In addition to the standard treatment with interferon and ribavirin, some studies have shown a higher success rates when the antiviral drug amantadine (Symmetrel) is added to the regimen. Sometimes called "triple therapy", it involves the addition of 100mg of amantadine twice a day. Studies indicate that this may be especially helpful for "nonresponders" - patients who have not been successful in previous treatments using interferon and ribavirin only. Currently, amantadine is not approved for treatment of Hepatitis C, and studies are ongoing to determine when it is most likely to benefit the patient. Followup studies have shown no benefit to adding this drug and currently it is not commonly used by experienced hepatologists.

Current guidelines strongly recommend that hepatitis C patients be vaccinated for hepatitis A and B if they have not yet been exposed to these viruses, as this would radically worsen their liver disease.

Alcoholic beverage consumption accelerates HCV associated fibrosis and cirrhosis, and makes liver cancer more likely; insulin resistance and metabolic syndrome may similarly worsen the hepatic prognosis. There is also evidence that smoking increases the fibrosis (scarring) rate.

Treatment Indications

• Clearly Indicated

  • Detectable HCV RNA and persistently elevated alanine aminotransferase (ALT)
  • Liver biopsy with fibrosis or moderate necrosis/inflammation

    • High risk disease progression

• Possibly Beneficial

  • Detectable HCV RNA and elevated ALT
  • Liver biopsy with minimal or mild inflammatory changes

    • Lower risk disease progression
    • Alternative = follow ALT and re-biopsy at 3-5 years

• Not Indicated

  • Detectable HCV RNA with persistently normal ALT
  • Liver biopsy with minimal or no inflammatory changes

    • Excellent prognosis without therapy
    • May consider therapy if extrahepatic hepatic manifestations

• Contraindicated

  • IFN-alfa

    • Severe depression, psychosis
    • Decompensated cirrhosis
    • Neutropenia or thrombocytopenia
    • Uncontrolled seizures
    • Organ transplant (other than liver)
    • Symptomatic heart disease

  • Ribavirin

    • Pregnancy or inadequate contraception
    • Anemia, hemoglobinopathy
    • Severe cardiac disease or end-stage renal disease (ESRD)

Chronic Pharmacotherapies

• Interferon alfa monoRx

  • Sustained response 16%
  • Genotype 1a or 1b--lowest response rate

• IFN-alfa + ribavirin

  • Sustained response 40%
  • Genotype 1 or high HCV RNA--max response at 48 weeks
  • Genotype 2 or 3--maximal response at 24 weeks
  • Doses = IFN 3 mU sc tiw + ribavirin 600 mg po bid
  • If HCV RNA+ at 24 weeks, discontinue therapy (no response)

• Pegylated Interferon

  • Higher response rate than conventional IFN monoRx
  • Weight-based dose given every week
  • Combination with ribavirin currently in clinical trials

During pregnancy and breastfeeding

If a pregnant woman has risk factors for hepatitis C, she should be tested for antibodies against HCV. About four out of every hundred infants born to HCV infected women become infected. The virus is spread to the baby at the time of birth. There is no treatment that can prevent this from happening.

In a mother that also has HIV, the rate of transmission can be as high as 19%. There is currently no data to determine whether antiviral therapy reduces perinatal transmission. Ribavirin and interferons are contraindicated during pregnancy. However, avoiding fetal scalp monitoring and prolonged labor after rupture of membranes may reduce the risk of transmission to the infant.

HCV antibodies from the mother may persist in infants until 15 months of age. If an early diagnosis is desired, testing for HCV RNA can be performed between the ages of 2 and 6 months, with a repeat test done independent of the first test result. If a later diagnosis is preferred, an anti-HCV test can performed after 15 months of age. Most infants infected with HCV at the time of birth have no symptoms and do well during childhood. There is no evidence that breast-feeding spreads HCV. To be cautious, an infected mother should avoid breastfeeding if her nipples are cracked and bleeding.

Adverse Effects

Interferon therapy

Most persons have flu-like symptoms (fever, chills, headache, muscle and joint aches, fast heart rate) early in treatment, but these lessen with continued treatment. Later side effects may include tiredness, hair loss, low blood count, trouble with thinking, moodiness, and depression. Severe side effects are rare (seen in less than 2 out of 100 persons). These include thyroid disease, depression with suicidal thoughts, seizures, acute heart or kidney failure, eye and lung problems, hearing loss, and blood infection. Although rare, deaths have occurred due to liver failure or blood infection, mostly in persons with cirrhosis. An important side effect of interferon is worsening of liver disease with treatment, which can be severe and even fatal. Interferon dosage must be reduced in up to 40 out of 100 persons because of severity of side effects, and treatment must be stopped in up to 15 out of 100 persons. Pregnant women should not be treated with interferon.

Combination (ribavirin + interferon) treatment

In addition to the side effects due to interferon described above, ribavirin can cause serious anemia (low red blood cell count) and can be a serious problem for persons with conditions that cause anemia, such as kidney failure. In these persons, combination therapy should be avoided or attempts should be made to correct the anemia. Anemia caused by ribavirin can be life-threatening for persons with certain types of heart or blood vessel disease. Ribavirin causes birth defects and pregnancy should be avoided during treatment. Patients and their healthcare providers should carefully review the product manufacturer information prior to treatment.

Treatment for symptoms or side effects due to antiviral treatment

You should report what you are feeling to your doctor. Some side effects may be reduced by giving interferon at night or lowering the dosage of the drug. In addition, flu-like symptoms can be reduced by taking acetaminophen before treatment.

The Food and Drug Administration has approved the use of the combination anti-viral therapy for the treatment of hepatitis C in children 3 to 17 years old.

Recommendations for Assessment Prior to Treatment and Monitoring During and After Therapy: AASLD Practice Guidelines 2009

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1. Treatment decisions should be individualized based on the severity of liver disease, the potential for serious side effects, the likelihood of treatment response, the presence of comorbid conditions, and the patient’s readiness for treatment (Class IIa, Level C). 2. For patients in whom liver histology is available, treatment is indicated in those with bridging fibrosis or compensated cirrhosis provided they do not have contraindications to therapy (Class I, Level B). 3. The optimal therapy for chronic HCV infection is the combination of peginterferon alfa and ribavirin (Class I, Level A). 4. HCV RNA should be tested by a highly sensitive quantitative assay at the initiation of or shortly before treatment and at week 12 of therapy, (Class I, Level A). Genotypes 1 and 4 HCV infection 1. Treatment with peginterferon plus ribavirin should be planned for 48 weeks; the dose for peginterferon alfa-2a is 180 µg subcutaneously per week together with ribavirin using doses of 1,000 mg for those <75 kg in weight and 1,200 mg for those >75 kg; the dose for peginterferon alfa-2b is 1.5 µg/kg subcutaneously per week together with ribavirin using doses of 800 mg for those weighing <65 kg; 1,000 mg for those weighing >65 kg to 85 kg, 1,200 mg for >85 kg to 105 kg, and 1,400 mg for >105 kg (Class I, Level A). 2. Treatment may be discontinued in patients who do not achieve an early virological response (EVR; >2 log reduction in HCV RNA at week 12 of treatment) (Class I, Level A). 3. Patients who do not achieve a complete EVR (undetectable HCV RNA at week 12 of treatment) should be re-tested at week 24, and if HCV RNA remains positive, treatment should be discontinued (Class I, Level A). 4. For patients with genotype 1 infection who have delayed virus clearance (HCV RNA test becomes negative between weeks 12 and 24), consideration should be given to extending therapy to 72 weeks (Class IIa, Level B). 5. Patients with genotype 1 infection whose treatment continues through 48 to 72 weeks and whose measurement of HCV RNA with a highly sensitive assay is negative at the end of treatment should be retested for HCV RNA 24 weeks later to evaluate for a sustained virological response (SVR; HCV RNA negative 24 weeks after cessation of treatment) (Class I, Level A) Genotype 2 or Genotype 3 HCV Infection 1. Treatment with peginterferon plus ribavirin should be administered for 24 weeks, using a ribavirin dose of 800 mg (Class I, Level A). 2. Patients whose treatment continues through 24 weeks and whose measurement of HCV RNA with a highly sensitive assay is negative should be retested for HCV RNA 24 weeks later to evaluate for an SVR (Class I, Level A). 3. Patients with HCV-related cirrhosis who achieve an SVR, regardless of the genotype, should continue to be monitored at 6 to 12 month intervals for the development of HCC (Class IBold textIa, Level C).

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Recommendations for Retreatment of Persons Who Failed to Respond to Previous Treatment : AASLD Practice Guidelines 2009

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1. Retreatment with peginterferon plus ribavirin in patients who did not achieve an SVR after a prior full course of peginterferon plus ribavirin is not recommended, even if a different type of peginterferon is administered (for relapsers, Class III, Level C; for non-responders, Class III, Level B). 2. Retreatment with peginterferon plus ribavirin can be considered for non-responders or relapsers who have previously been treated with non-pegylated interferon with or without ribavirin, or with peginterferon monotherapy, particularly if they have bridging fibrosis or cirrhosis (Class IIa, Level B). 3. Maintenance therapy is not recommended for patients with bridging fibrosis or cirrhosis who have failed a prior course of peginterferon and ribavirin (Class III, Level B)

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Recommendations for Treatment of Persons with Normal Serum Aminotransferase Values: AASLD Practice Guidelines 2009

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1. Regardless of the serum alanine aminotransferase level, the decision to initiate therapy with pegylated interferon and ribavirin should be individualized based on the severity of liver disease by liver biopsy, the potential for serious side effects, the likelihood of response, and the presence of comorbid conditions (Class I, Level B). 2. The treatment regimen for HCV-infected persons with normal aminotransferase levels should be the same as that used for persons with elevated serum aminotransferase levels (Class I, Level B).

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Recommendations for Treatment of Persons with Acute Hepatitis C: AASLD Practice Guidelines 2009

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1. Patients with acute HCV infection should be considered for interferon-based anti-viral therapy (Class I, Level B). 2. Treatment can be delayed for 8 to 12 weeks after acute onset of hepatitis to allow for spontaneous resolution (Class IIa, Level B). 3. Although excellent results were achieved using standard interferon monotherapy, it is appropriate to consider the use of peginterferon because of its greater ease of administration (Class I, Level B). 4. Until more information becomes available, no definitive recommendation can be made about the optimal duration needed for treatment of acute hepatitis C; however, it is reasonable to treat for at least 12 weeks, and 24 weeks may be considered (Class IIa, Level B). 5. No recommendation can be made for or against the addition of ribavirin and the decision will therefore need to be considered on a case-by-case basis (Class IIa, Level C)

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References