This issue of Hot Topics in Viral Hepatitis deals with 3 subgroups of patients with chronic hepatitis C for whom recommendations regarding antiviral therapy remain unclear.
The first contribution by Villa and Bernabucci points to a condition that has been unjustly neglected in HCV clinical research, that is, the impact of menopause on HCV-related liver disease. Villa reminds us how menopause is associated with a gamut of clinical consequences on many different organs and tissues, including the liver. The proinflammatory state induced by hormonal changes contributes to liver fibrosis progression. Moreover, menopause is the strongest negative predictor of treatment failure in women, especially when infected with genotype 1. The consequences of this important and original observation are difficult to ignore: women with chronic hepatitis C should be treated early, that is, during their fertile age, in order to maximize the chances of eradicating HCV.
The second chapter, contributed by Bortoletto and Alberti, relates to the management of patients with persistently normal alanine aminotransferase levels. Although usually asymptomatic and presenting with milder forms of liver disease, at least when compared to patients with abnormal liver enzymes, these patients may occasionally develop advanced fibrosis and even cirrhosis. The use of validated, noninvasive algorithms for assessing the fibrosis stage (the Padua group being a leader in this field) has considerably facilitated the identification of individuals at risk of clinically significant liver disease, who may benefit from combined therapy with pegylated interferon (PEG-IFN)α and ribavirin.
In the third chapter, Wirth gives an update on the antiviral therapy of children and adolescents infected with hepatitis C virus (HCV). Despite the scarcity of studies, the available data are convincingly showing that the same regimens currently applied to adults can be effectively used in patients <18 years of age. However, since spontaneous eradication of HCV may occur within the first years of life, Wirth suggests a watchful attitude up to 5 years of age, followed by a careful evaluation of all factors that may facilitate treatment uptake and success, including the collaboration of the family. Children and adolescents tolerate rather well the combined administration of PEG-IFNα and ribavirin, which can therefore be recommended as standard of care in children.
The authors present treatment options for these 3 subgroups. It would be beneficial for both clinicians and patients to have clear guidelines with which to follow for treating special patient populations.