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.