Overview of the management of chronic hepatitis C virus infection
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology; Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
- Paul J Pockros, MD
Paul J Pockros, MD
- Director, Liver Disease Center, Scripps Clinic
- Clinical Director of Research, Scripps Translational Science Institute
Hepatitis C virus (HCV) can cause both acute and chronic hepatitis. The acute process is self-limited, rarely causes hepatic failure, and usually leads to chronic infection. Chronic HCV infection often follows a progressive course over many years and can ultimately result in cirrhosis, hepatocellular carcinoma, and the need for liver transplantation. (See "Clinical manifestations and natural history of chronic hepatitis C virus infection".)
This topic addresses the general management of patients with chronic HCV infection. Patient selection for treatment and specific treatment regimens are discussed in detail elsewhere. (See "Patient evaluation and selection for antiviral therapy for chronic hepatitis C virus infection" and "Treatment regimens for chronic hepatitis C virus genotype 1 infection in adults" and "Treatment regimens for chronic hepatitis C virus genotypes 2 and 3 infection in adults" and "Treatment regimens for chronic hepatitis C virus genotypes 4, 5, and 6 infection in adults" and "Direct-acting antivirals for the treatment of hepatitis C virus infection".)
Guidelines for the diagnosis and management of hepatitis C virus (HCV) infection were released jointly by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) in 2014, are continuously updated, and can be accessed at www.hcvguidelines.org . The discussion in this topic is generally consistent with those guidelines.
Other guidelines include treatment recommendations from the European Association for the Study of the Liver (EASL), which was updated in 2015 , and United Kingdom consensus guidelines, which were updated in 2014 . World Health Organization (WHO) also released guidelines in 2014 on screening and treatment of HCV, intended primarily for clinicians and policy-makers in low- and middle-income countries .
The objectives of the evaluation of patients diagnosed with chronic hepatitis C virus (HCV) include the following:
- Recommendations for Testing, Managing, and Treating Hepatitis C. Joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America. http://www.hcvguidelines.org/ (Accessed on July 08, 2016).
- European Association for the Study of the Liver Recommendations on Treatment of Hepatitis C 2015. http://www.easl.eu/medias/cpg/HEPC-2015/Full-report.pdf (Accessed on July 17, 2015).
- Miller MH, Agarwal K, Austin A, et al. Review article: 2014 UK consensus guidelines - hepatitis C management and direct-acting anti-viral therapy. Aliment Pharmacol Ther 2014; 39:1363.
- World Health Organization. Guidelines for the screening, care, adn treatment of persons with hepatitis C infection. April 2014. http://apps.who.int/iris/bitstream/10665/111747/1/9789241548755_eng.pdf?ua=1 (Accessed on April 14, 2014).
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- Simmons B, Saleem J, Hill A, et al. Risk of Late Relapse or Reinfection With Hepatitis C Virus After Achieving a Sustained Virological Response: A Systematic Review and Meta-analysis. Clin Infect Dis 2016; 62:683.
- Ng V, Saab S. Effects of a sustained virologic response on outcomes of patients with chronic hepatitis C. Clin Gastroenterol Hepatol 2011; 9:923.
- Backus L, Boothroyd DB, Phillips BR, et al. Impact of sustained virologic response to pegylated interferon/ribavirin on all-cause mortality by HCV genotype in a large real-world cohort: The US Department of Veterans Affairs' experience. Hepatology 2010; 52:428A.
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- Cardoso AC, Moucari R, Figueiredo-Mendes C, et al. Impact of peginterferon and ribavirin therapy on hepatocellular carcinoma: incidence and survival in hepatitis C patients with advanced fibrosis. J Hepatol 2010; 52:652.
- Veldt BJ, Heathcote EJ, Wedemeyer H, et al. Sustained virologic response and clinical outcomes in patients with chronic hepatitis C and advanced fibrosis. Ann Intern Med 2007; 147:677.
- van der Meer AJ, Veldt BJ, Feld JJ, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA 2012; 308:2584.
- Morgan RL, Baack B, Smith BD, et al. Eradication of hepatitis C virus infection and the development of hepatocellular carcinoma: a meta-analysis of observational studies. Ann Intern Med 2013; 158:329.
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- Singal AG, Dharia TD, Malet PF, et al. Long-term benefit of hepatitis C therapy in a safety net hospital system: a cross-sectional study with median 5-year follow-up. BMJ Open 2013; 3:e003231.
- Chhatwal J, Kanwal F, Roberts MS, Dunn MA. Cost-effectiveness and budget impact of hepatitis C virus treatment with sofosbuvir and ledipasvir in the United States. Ann Intern Med 2015; 162:397.
- Najafzadeh M, Andersson K, Shrank WH, et al. Cost-effectiveness of novel regimens for the treatment of hepatitis C virus. Ann Intern Med 2015; 162:407.
- Saag MS. Editorial commentary: getting smart in how we pay for HCV drugs: KAOS vs CONTROL. Clin Infect Dis 2015; 61:169.
- Rein DB, Wittenborn JS, Smith BD, et al. The cost-effectiveness, health benefits, and financial costs of new antiviral treatments for hepatitis C virus. Clin Infect Dis 2015; 61:157.
- Linas BP, Barter DM, Morgan JR, et al. The cost-effectiveness of sofosbuvir-based regimens for treatment of hepatitis C virus genotype 2 or 3 infection. Ann Intern Med 2015; 162:619.
- Wyles D, Nelson D, Swain M, et al. On-treatment HCV RNA as a predictor of virologic response in sofosbuvir-containing regimens for genotype 2/3 HCV infection: Analysis of the FISSION, POSITRON, and FUSION studies. Presented at the 64th annual meeting of the American Association for the Study of Liver Diseases, Washington, DC, November 1-5, 2013.
- Kowdley KV, Nelson DR, Lalezari JP, et al. On-treatment HCV RNA as a predictor of sustained virological response in HCV genotype 3-infected patients treated with daclatasvir and sofosbuvir. Liver Int 2016; 36:1611.
- Recommendations for Testing, Managing, and Treating Hepatitis C. Joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America. http://www.hcvguidelines.org/ (Accessed on August 01, 2016).
- Sidharthan S, Kohli A, Sims Z, et al. Utility of hepatitis C viral load monitoring on direct-acting antiviral therapy. Clin Infect Dis 2015; 60:1743.
- Harrington R, Deming D, Komatsu TE, et al.. Hepatitis C virus RNA levels during interferon-free combination direct-acting antiviral treatment in registrational trials. Clin Infect Dis 2015.
- FDA Drug Safety Communication: FDA warns about the risk of hepatitis B reactivating in some patients treated with direct-acting antivirals for hepatitis C http://www.fda.gov/Drugs/DrugSafety/ucm522932.htm (Accessed on October 05, 2016).
- QuaterWatch: Monitoring FDA MedWatch Reports. Institute For Safe Medication Practices. January 25, 2017. http://www.ismp.org/quarterwatch/pdfs/2016Q2.pdf.
- Yoshida EM, Sulkowski MS, Gane EJ, et al. Concordance of sustained virological response 4, 12, and 24 weeks post-treatment with sofosbuvir-containing regimens for hepatitis C virus. Hepatology 2015; 61:41.
- Poordad F, Agarwal K, Younes Z, et al. Low relapse rate leads to high concordance of sustained virologic response (SVR) at 12 weeks with SVR at 24 weeks after treatment with ABT-450/ritonavir, ombitasvir, and dasabuvir plus ribavirin in subjects with chronic hepatitis C virus genotype 1 infection in the AVIATOR study. Clin Infect Dis 2015; 60:608.
- Sarrazin C, Isakov V, Svarovskaia ES, et al. Late Relapse Versus Hepatitis C Virus Reinfection in Patients With Sustained Virologic Response After Sofosbuvir-Based Therapies. Clin Infect Dis 2017; 64:44.
- PATIENT EVALUATION
- Psychosocial issues
- Transmission risk
- Diet and behaviors
- GENERAL MANAGEMENT
- Dose adjustments of medications
- Patients with advanced liver fibrosis or cirrhosis
- ANTIVIRAL THERAPY
- Goals of therapy
- Regimen selection
- MONITORING DURING ANTIVIRAL THERAPY
- Interferon-free regimens
- - Viral monitoring
- - Other monitoring
- - Adherence counseling
- Interferon-containing regimens
- FOLLOW-UP AFTER ANTIVIRAL THERAPY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS