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Consider Eradication Therapy for Chronic Viral Hepatitis

There are new treatments currently available for eradication of chronic Hepatitis C infection. Patients who failed the curative strategies offered several years ago may now be pleasantly surprised to find that the most recent eradication regimen for chronic viral hepatitis is as simple as oral medication, and that this may be another opportunity for cure.

There are six main genotypes for Hepatitis C and until recently, the Pharmaceutical Benefits Scheme (PBS) subsidised combination peginterferon alfa and ribavirin were the main eradication therapy for all genotypes except 1, which required the addition of a viral protease inhibitor. Cure rates using these regimens are approximately 70%, but many patients are unable to tolerate peginterferon due to toxicity and some are ineligible for this medication. The commonest side effects from peginterferon include systemic symptoms (fevers, lethargy, malaise, fatigue), bone marrow suppression, depression, insomnia and hair loss.

In 2015, the Therapeutic Goods Administration approved peginterferon-free treatments which are shorter, less toxic and (some of which) have higher cure rates. The new treatment regimens depend also on the genotypes. Priority is given to patients with cirrhosis, but at this stage, if the patient is stable enough to wait, continuing six-monthly screening, it is their best interest to delay treatment until the PBS subsidy comes through. The side-effects of peginterferon-free treatments (sofosbuvir and ledipasvir)  include headache, mild fatigue, insomnia and nausea. Other peginterferon-free treatments (paritaprevir/ritonavir, ombitasvir and dasabuvir) may be indicated for certain other genotypes and side-effects include liver function abnormalities. Oral oestrogen should be ceased during therapy and decompensated liver disease is a contraindication to the other peginterferon-free treatments.

All patients with chronic Hepatitis C should be referred to a hepatologist for consideration of viral eradication therapy. It should be noted that a person who has had successful hepatitis C viral eradication will no longer have the virus in the liver cells (and undetectable hepatitis C viral RNA in plasma twenty-four weeks after treatment ends). They will have a reduced risk of progressive cirrhosis and hepatocellular carcinoma. Patients who only have minimal fibrosis and successful eradication do not need long-term follow-up for complications. However, they will remain hepatitis C antibody positive for life; because this antibody is not protective it is possible for these individuals to be reinfected in the future. Patients with cirrhosis still require follow-up (with six-monthly ultrasounds of the liver and alpha fetoprotein levels) in case of the development of portal hypertension and hepatocellular carcinoma.

 

1. Thompson, A., Holmes, J. Treating hepatitis C – what’s new? Aust Prescr 2015;38:191-7 | 18 September 2015
http://www.australianprescriber.com/magazine/38/6/191/7