The decision to treat a patient with chronic hepatitis C virus (HCV) infection is based upon several factors, including the natural history and stage of the disease, the efficacy of therapy, and potential side effects. In general, patients being considered for treatment should have histologic and virologic evidence of chronic HCV infection. When identifying patients who are candidates for treatment, factors that are associated with a favorable response (eg, HCV genotype 2) should be weighed against factors associated with a lower likelihood of response (eg, older age).
GUIDELINES
The 2009 guidelines from the American Association for the Study of Liver Diseases (AASLD) are commonly used in making decisions about which patients to treat. The discussion that follows is consistent with those guidelines, which can be accessed at www.aasld.org/practiceguidelines/Pages/default.aspx
PATIENTS FOR WHOM THERAPY IS WIDELY ACCEPTED
Therapy is generally accepted for patients with all of the following characteristics:
- At least 18 years of age.
- HCV RNA detectable in the serum.
- Liver biopsy with chronic hepatitis and significant fibrosis (bridging fibrosis or higher).
- Compensated liver disease.
- Total serum bilirubin <1.5 g/dL (25.7 micromol/L). INR <1.5. Albumin >3.4 g/dL (34 g/L).
- Platelet count >75,000 cells/mm3 (75,000 x 10(6)/L).
- No evidence of hepatic encephalopathy or ascites.
- Acceptable hematological and biochemical indices
- Hemoglobin >13 g/dL for men and >12 g/dL for women.
- Neutrophil count >1500 cells/mm3 (1500 x 10(6)/L).
- Creatinine <1.5 mg/dL (133 micromol/L).
- Willing to be treated and to conform to treatment requirementsNo contraindications to treatment
PATIENTS WHO MAY BE CANDIDATES FOR THERAPY
Therapy can be considered in the following settings:
- Patients who failed prior treatment (nonresponders and relapsers) with standard interferon (with or without ribavirin) or peginterferon .
- Current users of illicit drugs or alcohol who are willing to participate in a substance abuse program (such as a methadone program) or alcohol support program .
- Liver biopsy without fibrosis or with only mild.
- Acute hepatitis C.
- Coinfection with HIV.
- Less than 18 years of age.
- Chronic kidney disease either requiring or not requiring.
- Decompensated cirrhosis.
- Recipient of a liver transplant.
PATIENTS IN WHOM THERAPY IS CONTRAINDICATED
Antiviral therapy with peginterferon and ribavirin for chronic HCV infection is contraindicated in patients who have one or more of the following:
- Major, uncontrolled depressive illness.
- A kidney, heart, or lung transplant.
- Autoimmune hepatitis or other conditions known to be exacerbated by interferon or ribavirin.
- Untreated thyroid disease.
- Severe concurrent disease such as severe hypertension, heart failure, significant coronary artery disease, poorly controlled diabetes, obstructive pulmonary disease.
- Known hypersensitivity to drugs used to treat HCV
Therapy is also contraindicated in patients who are:
- Less than two years of age.
- Pregnant, contemplating pregnancy (including men), or unwilling to assure contraception.
References:UTD