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Management of Hepatitis C Infection

Stefan Zeuzem, MD
Program Director
Jordan J. Feld, MD, MPH
Hemant Shah, MD, MScCH HPTE
Released: June 17, 2019

Treatment Candidacy

According to the latest American Association for the Study of Liver Diseases (AASLD)/Infectious Diseases Society of America (IDSA) guidance, treatment is recommended for all patients who have chronic HCV infection, except pregnant patients and those with a short life expectancy that cannot be improved by HCV therapy, transplantation, or other direct therapy.[54] Patients whose short life expectancy is the result of liver disease should be managed in consultation with physicians who have experience in HCV treatment in conjunction with a liver transplantation center. However, the AASLD/IDSA guidance panel suggests that patients with a life expectancy of less than 12 months that is due to nonliver-related comorbid conditions are unlikely to benefit from HCV treatment and suggests pursuing palliative care. HCV treatment is also not recommended for pregnant women because safety and efficacy have not yet been established.

The AASLD/IDSA guidance emphasizes the benefits, to the liver and extrahepatic, of treating HCV infection—including decreased all-cause morbidity and mortality, reduced HCV transmission to others, and improved quality of life—and points out that initiating treatment in patients with early stages of fibrosis (below Metavir stage F2) enhances these benefits. The current guidance states that deferring treatment based on fibrosis stage may diminish the benefits of virologic cure. If treatment is deferred, the AASLD/IDSA guidance panel recommends ongoing assessment of liver disease.[54]

Although the most recent AASLD/IDSA guidance no longer specifies populations for high prioritization of HCV treatment, certain groups possess unique risks that can be emphasized by clinicians as needed when justifying insurance coverage of treatment.[54] These populations include patients with advanced liver disease; those who have undergone liver transplantation; groups at risk of rapid progression to fibrosis and cirrhosis such as patients coinfected with HIV or HBV and patients who have other chronic liver diseases such as nonalcoholic steatohepatitis; and patients with extrahepatic manifestations of chronic HCV infection such as cryoglobulinemia, diabetes, debilitating fatigue, porphyria cutanea tarda, or lichen planus. Table 24 lists the conditions that define these high-risk groups along with the available evidence on the risks associated with each condition and the benefits of effective, timely HCV therapy.

Table 24. Specific Populations With Unique Risks Ameliorated by HCV Treatment[54]

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The AASLD/IDSA recommendations also emphasize the public health benefits of treating patients who are at elevated risk of transmitting HCV infection to others, which is based on the expectation that achieving virologic cure in this group may decrease the overall prevalence of HCV disease by reducing further HCV transmission.[87] HCV-infected individuals at high risk for transmission include[54]: HIV-coinfected men who have sex with men and engage in high-risk sexual practices, people who inject drugs, incarcerated persons, patients receiving long-term hemodialysis, and HCV-infected healthcare personnel who perform exposure-prone procedures. Eradicating HCV infection among families and between couples also removes the perception that an individual may be contagious, whereas eradication in women planning to become pregnant eliminates mother-to-child transmission of HCV. The AASLD/IDSA guidance panel also notes that people who inject drugs should be treated in a multidisciplinary setting that offers risk reduction counseling to prevent reinfection as well as social and psychiatric services to address common comorbidities associated with injection drug use. Likewise, continued education on safer sex strategies and other reinfection risk reduction approaches should be provided in conjunction with HCV treatment for HIV-infected men who have sex with men.[54]

The 2018 European Association for the Study of the Liver (EASL) recommendations indicate that all patients with HCV infection must be considered for therapy, including both treatment-naive patients and those who experienced previous treatment failure.[88] Treatment without delay should be given to patients with significant fibrosis or cirrhosis (Metavir score F2-F4, including compensated and decompensated cirrhosis), patients at risk of faster liver disease progression because of concurrent comorbidities (organ or stem cell transplantation, diabetes), patients with recurrent HCV after liver transplantation, patients with clinically significant extrahepatic manifestations, and all patients at risk of transmitting HCV (eg, injection drug users, men who have sex with men with high-risk practices, women with potential to get pregnant, hemodialysis patients, incarcerated individuals). In patients indicated for liver transplantation with Model for End-Stage Liver Disease (MELD) ≥ 18-20, HCV treatment should occur after transplantation unless the wait time for transplantation is longer than 6 months, in which case, patients can be treated for HCV infection before transplantation. These guidelines also note that treatment is not recommended in patients with limited life time expectancy from comorbidities that are not liver related.

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