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Issue 3, 2006
HOT TOPICS IN VIRAL HEPATITIS
Difficult-to-treat patients with chronic hepatitis C (Part Two)
Abstract
This issue focuses on additional types of so-called difficult-to-treat patients with chronic hepatitis C, such as patients of African-American ethnicity, patients with cirrhosis, and those in whom prior antiviral therapy has failed. A concluding chapter analyzes the overall management of chronic hepatitis C from a critical standpoint.
African Americans have a higher prevalence of hepatitis C virus (HCV) infection, notably genotype 1. The rate of chronicity is higher, and sustained virological response after therapy lower than it is among Caucasians. Whether the latter is due to altered immune response or increased levels of insulin resistance or to other factors is presently unclear. Further research is warranted to identify factors influencing such a poor response among African Americans.
Many patients present with advanced fibrosis or cirrhosis at the time of diagnosis. Compensated cirrhosis should be treated with pegylated interferon alpha plus ribavirin. Even though the main goal of therapy is viral clearance, this is achieved only by 40 to 50% of those with cirrhosis. Thus, maintenance therapy schedules to halt disease progression are currently under investigation in large clinical trials. Patients with decompensated cirrhosis, in contrast, may be eligible for low-accelerating dose regimens. Suppression or clearance of HCV may halt disease progression and might either avoid the need for transplantation or improve graft and patient survival by preventing viral recurrence in the liver graft.
More than one half of patients initially treated for HCV infection are unable to achieve viral eradication. Contributing factors to poor treatment response, such as African-American ethnicity, genotype 1, high-serum HCV ribonucleic acid levels, cirrhosis, coinfection with human immunodeficiency virus, poor compliance, adverse effects, and dose reductions have to be carefully evaluated in order to select suitable candidates for a new course of treatment. In nonresponders, high doses of pegylated interferon could be considered, whereas relapsers could benefit from retreatment with interferon plus ribavirin at a higher dose or for longer periods.
Table of contents
Foreword
Dear Colleagues,
As a complement to the first two issues, the third number of Hot Topics in Viral Hepatitis is focused on additional types of so-called difficult-to-treat patients with chronic hepatitis C. In this case, we address the importance of racial and ethnic background in the response to interferon-based regimens, the treatment of cirrhosis, and the best approach to patients in whom a prior antiviral therapy has failed (such as responders experiencing a relapse of hepatitis after the end of treatment and primary nonresponders). A final article discusses the current management of the difficult-to-treat patient from a more general and critical standpoint.
It is the common experience of hepatologists that, paradoxically, patients who are the most difficult to treat tend to be those who need treatment the most. This is exemplified by patients with advanced cirrhosis, dealt with in this number, or those with the metabolic syndrome, who have been described in a previous issue. At the other extreme, patients who respond very easily to therapy tend to be those who have a less aggressive liver disease. This reductio ad absurdum represents the current dilemma of interferon-based regimens for treating chronic hepatitis C. Antivirals such as nucleoside and nucleotide analogues have partially addressed this issue for patients with chronic hepatitis B. New antivirals are badly needed for treating hepatitis C. Recent developments allow us to hope for the better, although it may take one or two more years before our difficult-to-treat patients may benefit from anti-serine protease, anti-replicase, or other similar molecules.
ARTICLES
Ethnic differences in response to antiviral treatment
K. Rajender Reddy, Elliott D. Kozin
Treatment of chronic hepatitis C in patients with cirrhosis
Gregory T. Everson
Responders-relapsers and nonresponders to previous antiviral therapy
Mitchell L. Shiffman, Nevin Yilmaz
Antiviral therapy in chronic hepatitis C: a critical approach to evidence
Calogero Cammà, Antonio Craxì
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Editors-in-chief
Francesco Negro - DO, MPH
Over the last 20 years, there have been great strides in the treatment of viral hepatitis. Both the discovery of the hepatitis C and E viruses, with the characterization of their genomes, and the avai...
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