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Professor of Medicine
Chief, Section of Hepatology
Associate Director, Solid Organ Transplantation
Richard B. Capps Chair of Hepatology
Rush University Medical Center
Nancy Reau, MD: consultant/advisor: AbbVie, Antios, Arbutus, Gilead Sciences, Intercept, Salix; researcher: AbbVie, Gilead Sciences, Intercept.
I think that one of the biggest messages from AASLD 2022 was that we still have a lot of work to do. Between the pandemic and propagation of unhealthy behaviors—such as increases in alcohol use disorder and alcoholic hepatitis—there’s still an incredible burden of liver disease, and viral hepatitis continues to contribute to that.
Although many healthcare professionals (HCPs) may think that hepatitis C is no longer exciting because we have good drugs that are highly effective and easy to administer, it was refreshing to see the concentration on challenges like hepatitis C virus (HCV) microelimination and some of the alternative care models for patients with HCV.
One simple example is nonspecialist care of persons with HCV; you do not have to be an HCV expert or hepatologist to have very good cure rates for HCV. We also saw improved linkage to services like needle exchange programs and providing alternative ways of bringing HCV treatment to the places where these patients are (eg, addiction treatment centers), recognizing that people who use drugs are still driving a lot of the new hepatitis C cases. Each of these models was successful in linking patients with HCV to care.
There was an interesting program that attempted to re-engage individuals with known HCV in care. We have done a lot of screening to identify individuals with active disease, but these patients tend be lost to follow-up. Sometimes the solution can be as simple as finding a patient who is being followed in primary care but has not been linked to curative services for their HCV.
Location of HCV screening may make the individual harder to collocate or link to care. Patients screened for HCV in urgent care or emergency department programs are a little bit more difficult to engage in curative services because those patients may not be connected to an HCP at that facility. But there are ways of calling, reaching out, sending messages through the electronic medical records or sending letters, and all of these are able to capture a percentage of these screened patients. However, none of these methods was an overwhelmingly successful strategy, so HCPs really have to decide what will be best for their own healthcare system.
Hepatitis B and Delta
We all continue to hope that the therapeutic breakthroughs that we have seen for HCV will be mimicked in hepatitis delta virus (HDV) or hepatitis B virus (HBV), and although we do have very attractive drugs in development for these 2 viruses, the drugs don’t seem to be creating that short-term high cure rate that we have witnessed with HCV.
Screening is still a big limitation in identifying patients with chronic hepatitis B who have HDV; you can’t manage or cure a viral hepatitis that you don’t know exists. Risk-based screening for HDV is still the guideline-recommended approach in the United States and that is a big limitation because risk-based screening doesn’t work very well. It is easy for HCPs to forget what risk factors we need to ask about in our patients. Many risk factors are geographic in nature, and those are a little more difficult for an HCP to identify when they’re in the midst of a clinic visit with the patient.
Even when patients with HBV and/or HDV are identified, they still don’t always get linked to care. We have seen that previously, and there were also highlights at the AASLD conference of areas where our guidelines break down when it comes to screening and identifying patients with viral hepatitis.
There was a study that evaluated patients in the indeterminate treatment phase. Our guidelines are good at identifying patients with HBV who need treatment. But when the guidelines categorize patients who may not be eligible for treatment and fall into a so-called gray zone (eg, someone with viral replication who has a normal alanine aminotransferase level or does not have significant fibrosis, or someone with significant fibrosis but very minimal viral replication), these are all places where our guidelines are difficult to interpret. In this study, the authors looked carefully at patients like this, and they found that the risk of liver cancer in some of these patients in the “gray zone” was elevated. And there was a suggestion that treating these individuals in the “gray zone” decreased liver cancer rates. That’s an important practical consideration because treating someone in the indeterminate phase is a step toward advocating for more permissive treatment guidelines.
Fatty Liver Disease
Fatty liver disease always will be a significant burden on the healthcare system. We see this in patients with fatty liver disease with or without concurrent viral hepatitis. There was information presented at AASLD demonstrating that using noninvasive tests that were originally used for patients with HCV for identifying patients with fatty liver disease at high risk for complications really do perform similar to histology.
However, if you have a fatty liver disease treatment that’s meant to decrease early fibrosis or eliminate inflammation and steatosis, using a noninvasive test that’s designed to risk stratify an individual may not be the best tool to evaluate treatment efficacy. But if the tool is meant to triage individuals at high risk for liver complications toward longitudinal management, it does seem that these noninvasive tests may have a role.
The last key piece of practice-changing information from AASLD 2022 was the use of statins in patients with liver disease. We have long known that medications like aspirin, statins, and metformin seem to have signals in decreasing liver-related morbidity and mortality, even though we don’t typically use these to decrease morbidity and mortality in people with liver disease. There have been consistent signals across multiple big databases that statins may play a role in decreasing liver cancer rates or decreasing all-cause mortality in patients with liver disease.
Statins were again highlighted at AASLD 2022 as associated with decreasing the risk of death—or at least short-term mortality—in individuals with acute or chronic liver failure. To me, this is one more reminder that we should not be afraid of agents like statins just because we’re afraid of their potential liver-related complications. They may decrease cardiovascular disease, which is a common cause of morbidity and mortality in patients with liver disease. Statins, as a class, appear to have favorable liver effects, and we want to make sure that we use them appropriately in patients who are indicated.
What do you think were the most practice-changing viral hepatitis data presented at AASLD 2022? Join the conversation by leaving a comment below.