Man With Hepatitis C Infection: Making Treatment Decisions

By ANDRÉ N. SOFAIR, MD, MPH | April 1, 2006

Yale University

Dr Sofair is assistant professor of medicine at Yale University School of Medicine, New Haven, Conn, and a principal investigator in the Connecticut Emerging Infections Program, a collaborative effort of the Connecticut Department of Public Health and the Centers for Disease Control and Prevention.

PATIENT PROFILE
Infection with hepatitis C virus (HCV) was recently diagnosed in a 45-year-old man when a positive enzyme-linked immunosorbent assay was followed by a polymerase chain reaction assay that showed a viral load of 835,000 copies/mL. The patient probably acquired the infection when he was using intravenous heroin, a practice he quit 10 years ago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfection with HIV. Liver biopsy shows moderate cellular inflammation (grade 3) and bridging fibrosis (stage 3) but no evidence of cirrhosis. Iron staining shows no abnormal iron deposition in the liver. The HCV genotype is 1A. WHAT WOULD YOU DO NOW?
A. Observe patient; check liver function tests (LFTs) regularly; repeat biopsy in 3 to 5 years.
B. Recommend therapy with interferon and ribavirin(Drug information on ribavirin).
C. Initiate standard therapy for HCV infection and screen periodically for hepatocellular carcinoma.
D. Offer alternative therapy with silymarin(Drug information on silymarin) and vitamin E(Drug information on vitamin e).

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CLINICAL PEARLS

Unless contraindicated, treatment with interferon and ribavirin is recommended for patients with HCV infection in whom liver biopsy reveals at least grade 2 inflammation and stage 1 fibrosis. Although patients with subclinical cirrhosis may benefit from treatment, those with decompensated cirrhosis should not be treated.
Genotype is the most important predictor of response to therapy. Patients infected with genotype 1 (the most common type in the United States) have a sustained response rate approximately one half that of patients infected with other genotypes.
Genotype also affects the length of therapy. Patients infected with genotype 2 or 3 can be treated successfully in 24 weeks. In those with genotype 1 infection, extending the duration of therapy from 24 to 48 weeks doubles sustained response.
Psychiatric side effects, including irritability, emotional lability, depression, and even suicidal ideation, occur in at least 20% of patients treated with interferon. Consider a pretreatment psychiatric consultation for any patient with a history of psychiatric illness or substance abuse, a family history of psychiatric disease, or other risk factors for depression (such as multiple comorbidities or use of medications that predispose to depression). Regular screening for depression is mandatory throughout treatment.
Pegylated interferon offers better bioavailability, a longer half-life, and better response rates than conventional interferon.
Ribavirin often causes hemolysis, with decreases in hemoglobin levels of 2 g/dL to 4 g/dL. Erythropoietin can limit ribavirin-associated anemia and make it possible for some anemic patients to continue with the standard dosage. Permanent discontinuation of ribavirin therapy may be necessary in patients with cardiovascular disease whose hemoglobin level is persistently below 12 g/dL or in anyone whose hemoglobin level is consistently below 8.5 g/dL.
Ribavirin can cause fetal abnormalities and should not be used by either men or women who cannot use reliable birth control during treatment and for at least 6 months thereafter.

From June 10-12, 2002, the National Institutes of Health will convene a consensus development conference to update its 1997 recommendations on the management of hepatitis C. A draft of these recommendations will be posted at http://consensus.nih.gov on June 12.

Man With Hepatitis C Infection: Making Treatment Decisions

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