Hepatitis C (cont.)

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Who should receive antiviral therapy for hepatitis C virus infection?

Patients with hepatitis C infection should discuss treatment options with a physician who is experienced in treating the disease.

In the past, frequent side effects and ineffectiveness of treatment made decisions to treat or not to treat more difficult. Decisions to treat or not to treat focused on identifying patients who would be most likely to respond to therapy, and who were most likely to suffer liver-related damage without successful treatment. With the newer treatments that are safer and more effective, the decision making has become less complicated. Treatment is recommended in patients at increased risk for cirrhosis unless there are reasons that would make treatment unsafe. According to the American Association for the Study of Liver Disease (AASLD) and Infectious Disease Society of America (IDSA) these include patients with:

  • Persistent elevation of ALT (alanine aminotransferase, a liver enzyme in the blood)
  • High levels of HCV RNA in the blood
  • Evidence of early fibrosis (scarring) on imaging or moderate inflammation and injury of liver cells on liver biopsy
  • Liver transplant recipients
  • Coexisting liver disease or advanced kidney disease
  • Coexisting HIV and/or diabetes
  • Symptomatic hepatitis C infection (for example, with debilitating fatigue or other less severe extra hepatic manifestations)

Potential for transmission of hepatitis C is an additional consideration that might prioritize treatment for a given patient, including:

  • Men who have sex with men (MSM) with high-risk sexual practices
  • Active injection drug users
  • Incarcerated persons
  • Persons on long-term hemodialysis
  • Hepatitis C-infected women of child-bearing potential wishing to get pregnant

These are general guidelines. Patients and health-care professionals may decide that treatment is needed for other reasons. For example, hepatitis C infection may cause ryoglobulinemia. (See above.) Persistent cryoglobulinemia may be a reason for treating hepatitis C. Availability of newer therapies with direct acting antivirals; highly effective, all-oral regimens have allowed more and more patients to be able to receive treatments.

Who should not receive treatment with antiviral therapy?

Individuals who should not be treated with antiviral therapy include those who:

  • Are unable to comply with the treatment schedule
  • Have reasons that may make treatment unsafe (for example, allergy to the medications)
  • Have received a solid organ transplant
  • Are pregnant or unwilling to practice adequate birth control (contraception) during treatment
  • Have reversible serious untreated conditions such as unstable heart disease, uncontrolled high blood pressure, or untreated major depression.

Patients with unstable (decompensated) cirrhosis are at higher risk for complications with treatment and in the past usually have not received treatment except in research settings. This is changing, however, since studies are beginning to show that even these patients can be treated safely and successfully. Fundamentally, the decision regarding antiviral therapy in chronic hepatitis C infection should be tailored to the individual patient with careful consideration of the risks and benefits.

All patients with hepatitis C should be:

  • Vaccinated against hepatitis B and hepatitis A
  • Counseled regarding abstinence from alcohol use.
  • Counseled on measures to prevent the spread of hepatitis C
  • Tested for HIV (The behaviors for people with hepatitis C overlap with those of people with HIV, and all patients with hepatitis C should be tested for HIV.)

Ongoing and continuing evaluation for advanced fibrosis using liver biopsy, imaging, or noninvasive blood tests and liver stiffness is also very important for all persons with hepatitis C infection to help make appropriate decisions regarding treatment. Development of new complications might change the course of disease; the need for more frequent monitoring or the decision to treat or not treat.

Medically Reviewed by a Doctor on 5/26/2015

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