To Treat or not to Treat
Weighing the Options with Current Hepatitis C Treatment
Michelle T Martin, PharmD, BCPS, BCACP
Walgreens
Costica Aloman, MD
Charmaine Stewart, MD, FACP
University of Illinois at Chicago
The authors report no financial conflicts with any products discussed in this paper.
Introduction
The recent approval of two new direct acting
antiviral (DAA) agents for the treatment of hepatitis
C virus (HCV) offers improved sustained virologic
response (SVR) rates over previous HCV treatment.
A thorough evaluation of the social and medical
factors that influence therapy is necessary in order
to individualize treatment and increase favorable
outcomes. Despite the availability of additional DAAs,
some patients are still not appropriate candidates
for current HCV treatment options. Both new DAAs
(the NS3/4A protease inhibitor, simeprevir; and the
NS5B polymerase inhibitor, sofosbuvir) are effective
in genotype 1 and 4, yet only sofosbuvir has efficacy
in treating genotypes 2 and 3. Current guidelines
only recommend use of sofosbuvir, and simeprevir,
in lieu of the older protease inhibitors, boceprevir
and telaprevir.1 The recent HCV guidelines, published
in 2014 by the American Association for the Study
of Liver Diseases (AASLD), International Antiviral
Society (IAS), and Infectious Diseases Society of
America (IDSA), will soon add a section entitled
“When to Treat.”1 Until then, our urban, academic
medical center’s multidisciplinary hepatology team
offers insight on patients for whom they would opt
to delay treatment. It is currently recommended to
treat patients waiting for liver transplantation and
those with progressive fibrosis post liver transplant,
patients with HIV/HCV co-infection, and all patients
with advanced fibrosis, in order to reduce the risk of
liver decompensation and hepatocellular carcinoma.
The following categories describe patients who would
benefit from waiting for future treatment options.
Renally-Impaired Patients
Available DAA treatments are not FDA-approved in
dialysis patients or patients with creatinine clearance
less than 30mL/minute. Gilead has an ongoing
clinical trial evaluating the currently-approved
sofosbuvir 400mg daily dose, and a 200mg daily
dose in combination with ribavirin for 24 weeks in
renally-impaired and dialysis patients with genotypes
1 and 3. ȁ!