4 Good Reasons to Worry about Hep C

Even though hepatitis C cure rates are high, here are 4 issues that should still concern all healthcare providers.

The challenge of successfully treating infection with the hepatitis C virus (HCV) has been significantly reduced in this era of highly effective direct-acting antiviral (DAA) agents; however, there are still important issues for clinicians to be aware of, according to liver disease expert Mitchell L. Shiffman, MD.

“They're not challenges. You just need to be concerned about them,” Dr. Shiffman said in a presentation at the recent American College of Gastroenterology (ACG) meeting in Philadelphia.

While first- and second-line therapy for HCV is very effective, there are still a small number of DAA treatment failures that can be very challenging to manage, said Dr. Shiffman, liver disease expert at Bon Secours Liver Institute of Richmond, Va.

Other issues that should be on the radar: 

• Monitoring for chronic hepatitis B reactivation
• Ttreatment of active drug users
• Managing patients with end-stage renal disease

Read on to learn more about these key issues and comments on each Dr. Shiffman made at ACG.

DAA treatment failure

DAA treatment failure

Practice Point: Patients who fail first- and second-line therapy will have limited treatment options, though this scenario is not common with DAA therapy.

“If you treat enough patients, you're going to eventually see some failures,” Dr. Shiffman said.

Regimens available for retreatment of patients who failed first-line therapy include sofosbuvir-velpatasvir-voxilaprevir or glecaprevir-pibrentasvir. Patients who fail second-line therapy-often HCV genotype 3 patients with cirrhosis, in Dr. Shiffman’s experience-can be retreated yet again by adding ribavirin to either regimen.

After that, there isn’t much else that can be done beyond continuing to monitor and screen for liver cancer if cirrhosis is present, consider liver transplant when indicated, and ensure that the HCV infection is not a reinfection in a patient injecting drugs (see “Active Drug Users,” next page). Fortunately, the scenario is uncommon: “The number of patients that are not cured by a DAA combination either in first or second line now is only two out of a thousand patients,” Dr. Shiffman told attendees at ACG. “So most of you will never encounter this scenario in your practice.”

Next: Chronic hepatitis B reactivation

Chronic hepatitis B reactivation

Practice Point: Check for hepatitis B virus (HBV) before initiating treatment.

“Watch out for hepatitis B, screen for it, and be careful because reactivation can occur, either during the course of [DAA] therapy or after therapy has been completed,” Dr. Shiffman said at the ACG meeting.

A solid understanding of HBV and HCV co-infection is important, Dr. Shiffman and a colleague concluded in a recent review article on the topic that they authored for Current Hepatology Reports.

They note that up to 60% of patients with chronic HCV have previous HBV exposure, although only 1% to 6% have serologic evidence of co-infection. Some coinfected may have HBV surface antigen and HBV DNA suppressed to undetectable levels by HCV. Patients with antibody to hepatitis B core antigen (anti-HBc) should be monitored more closely for reactivation, Dr. Shiffman added.

Next: Active drug users

Active drug users

Practice Point: Make a decision on what to do about HCV infection in people who inject drugs. Try to encourage them to stop using drugs before you treat them.

To treat or not to treat HCV is often the question in persons who inject drugs. On one hand, DAA therapy works: “Even if they’re still actively injecting drugs, they still have a great cure rate,” Dr. Shiffman said, citing studies showing that inection drug users with HCV have rates of sustained viral response similar to HCV patients in the general population.

On the other hand, drug use will likely continue in those whose addiction is not addressed, and HCV can recur in those patients, he added. Recurrence in some will be within the same genotype, while in others recurrence will develop with different genotypes.

There is some evidence to suggest that treating HCV can decrease substance abuse. In results of the ACTIVATE study, which looked at peg-interferon/ribavirin treatment in participants with HCV genotype 2 or 3 infection, there was a decrease in recent injecting drug use and hazardous alcohol use following treatment, which investigators said supported further expansion of HCV care among people who inject drugs.

Next: End stage renal disease

End stage renal disease

Practice Point: For patients with end-stage renal disease (ESRD) and HCV, consider renal transplant prior to HCV treatment.

For patients who are candidates for renal transplant and a hepatitis C-infected organ is available, Dr. Shiffman said he would recommend holding off on HCV treatment until after the transplant takes place. “You can easily go ahead and then treat the patient once they have their kidney transplant,” he said.

He also pointed to studies that show in patients with chronic kidney disease (CKD) and ESRD, HCV treatment produces rates of sustained viral response similar to individuals with normal renal function.

The evidence includes a study of once-daily grazoprevir and elbasvir, given for 12 weeks, that was effective in HCV genotype 1 patients with stage 4-5 CKD, and another study showing glecaprevir and pibrentasvir produced a high rate of sustained virologic response in HCV patients with severe renal impairment.