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Hepatitis C guidelines focus on eradication of virus before liver damage occurs

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Clinical practice guidelines on the management of hepatitis C infection, issued by the European Association for the Study of the Liver, underscore the goal of detecting and treating the condition before it leads to complications, such as cirrhosis and possibly liver cancer.

The author of the guidelines, Dr. Antonio Craxì at the University of Palermo, Italy, notes that up to 210 million people worldwide may be affected by HCV infection, and it has become the leading cause of liver cancers in Europe.

As outlined in the Journal of Hepatology online February 28, the diagnosis of acute or chronic HCV infection is based on detection of anti-HCV antibodies. However, acute hepatitis C is usually silent, so early identification is less likely. Nonetheless, the guidelines advise, “Patients with acute hepatitis C should be considered for antiviral therapy in order to prevent progression to chronic hepatitis C.”

The severity of liver disease should be determined before beginning therapy, according to the report. In particular, patients with cirrhosis have to be identified “as their prognosis and likelihood to respond to therapy are altered, and they require surveillance for HCC (hepatocellular carcinoma)”.

Furthermore, HCV should be genotyped, since that also influences treatment.

Currently, the first-line “standard-of-care” treatment for chronic hepatitis C is based on the use of either of the two pegylated alpha interferons available, administered weekly subcutaneously, and daily oral ribavirin. “All treatment-naive patients with compensated chronic liver disease related to HCV who are willing to be treated and have no contraindication to pegylated interferon-alpha or ribavirin should be considered for therapy, whatever their baseline ALT level,” according to the report.

Absolute contraindications to interferon-based treatment include uncontrolled depression, uncontrolled autoimmune diseases, pregnancy, and poorly controlled diabetes, among other conditions. Relative contraindications include hematologic abnormalities, significant CHD and untreated thyroid disease.

With treatment, a sustained viral response (SVR) with suppression to undetectable levels is achieved in 40%-54% of patients with HCV 1 and in 65%-82% of those with genotypes 2 or 3, Dr. Craxi notes.

The duration of treatment should be based on the virological response at weeks 4 and 12, and eventually week 24, the guidelines recommend. “The likelihood of SVR is directly proportional to the time of HCV RNA disappearance.”

Up to 53% of patients who relapse respond to re-treatment with pegylated interfereon-alpha and ribavirin.

The guidelines go on to address the management of HCV in patients coinfected with HIV or hepatitis B virus, patients on dialysis, and transplant patients.

Meanwhile, the author notes that progress is being made in the development of specific inhibitors and antiviral agents directly active against HCV, to be used in combination with interferon and ribavirin. “The present guidelines will be updated when these combinations are approved.”

J Hepatol 2011.