Many patients with interleukin 28B genotypes associated with response to therapy are ineligible for treatment because of comorbidities

Impact of DAA-Based Regimens on HCV-Related Extra-Hepatic Damage: A Narrative Review

Two-third of patients with chronic hepatitis C show extrahepatic manifestations due to HCV infection of B lymphocytes, such as mixed cryoglobulinemia and non-Hodgkin B-cell lymphoma, or develop a chronic inflammatory status that may favor the development of adverse cardiovascular events, kidney diseases or metabolic abnormalities.DAAs treatments induce HCV eradication in 95% of treated patients, which also improves the clinical course of extrahepatic manifestations, but with some limitations. After HCV eradication a good compensation of T2DM has been observed, but doubts persist about the possibility of obtaining a stable reduction in fasting glucose and HbA1c levels.Chronic HCV infection is associated with low total and LDL cholesterol serum levels, which however increase significantly after HCV elimination, possibly due to the disruption of HCV/lipid metabolism interaction. Despite this adverse effect, HCV eradication exerts a favorable action on cardiovascular system, possibly by eliminating numerous other harmful effects exerted by HCV on this system.DAA treatment is also indicated for the treatment of patients with mixed cryoglobulinemia syndrome, since HCV eradication results in symptom reduction and, in particular, is effective in cryoglobulinemic vasculitis. Furthermore, HCV eradication exerts a favorable action on HCV-related lymphoproliferative disorders, with frequent remission or reduction of clinical manifestations.There is also evidence that HCV clearance may improve impaired renal functions, but same conflicting data persist on the effect of some DAAs on eGFR.

Integrating Care for Patients With Chronic Liver Disease and Mental Health and Substance Use Disorders

Mental health disorders are common among patients with chronic liver disease, and current literature supports the use of better screening and providing integrated or multidisciplinary care where possible.

Efficacy of sofosbuvir plus ribavirin in treatment-naive patients with genotype-1 and -3 HCV infection: results from a Russian Phase IIIb study

BACKGROUND

In this Phase IIIb study, we evaluated the efficacy and safety of the oral nucleotide analogue inhibitor sofosbuvir plus ribavirin, with special attention given to viral resistance, in Russian patients with HCV genotype-1 or -3.

METHODS

Treatment-naive patients with and without compensated cirrhosis were randomized (1:1) to receive 16 or 24 weeks of once-daily sofosbuvir 400 mg plus twice-daily oral ribavirin 1,000 or 1,200 mg/day. The primary efficacy end point was the proportion of patients with sustained viral response 12 weeks after the end of treatment (SVR12). Viral resistance testing was performed by deep sequencing on all baseline samples and for patients who experienced virological failure.

RESULTS

SVR12 rates for patients with genotype-1 HCV were 50% and 76% for those in the 16-week and 24-week groups, respectively, and for patients with genotype-3 HCV, SVR12 rates were 87% and 90% for patients in the 16-week and 24-weeks groups, respectively. Genotype-1 patients with the L159F resistance-associated variant who received 16 weeks of treatment had lower SVR12 rates than those without, but in patients who received 24 weeks of treatment, response rates were similar in those with and without L159F (80% versus 74%). Sofosbuvir plus ribavirin was well tolerated with no deaths, adverse event-related study drug discontinuations, or grade 3 or 4 adverse events, and few grade 3 or 4 laboratory abnormalities.

CONCLUSIONS

Sofosbuvir plus ribavirin for 16 or 24 weeks was associated with a high SVR rate in patients with HCV genotype-3. Among HCV genotype-1b patients, the presence of the L159F variant at baseline was associated with a lower SVR rate in those treated for 16 weeks but not in those treated for 24 weeks. Sofosbuvir plus ribavirin was safe and well tolerated regardless of treatment duration. Clinicaltrials.gov number NCT01896193.

Epidemiology and outcomes of hepatitis C infection in elderly US Veterans

The chronic hepatitis C (CHC) cohort in the United States is getting older. Elderly patients with CHC may be at a high risk of cirrhosis and hepatocellular carcinoma (HCC), but also other nonhepatic comorbidities that negatively impact their likelihood of receiving or responding to antiviral treatment. There is little information on the clinical epidemiology or outcomes of CHC and its treatment in the elderly. We conducted a retrospective cohort study of 1 61 744 patients with a positive Hepatitis C virus RNA in the Veterans Health Administration Hepatitis C Clinical Case Registry to examine the association between age subgroups (20-49, 50-64, 65-85 years) and risk of cirrhosis, HCC or death using Cox proportional hazards models. We also examined the effect of treatment with a sustained viral response (SVR) on these outcomes in each age subgroup. The age distribution was 36.8% 20- to 49-year-olds, 57.6% 50- to 64-year-olds and 5.6% 65- to 85-year-olds (i.e. elderly). Risk of cirrhosis, HCC and death was significantly elevated in elderly patients [HR cirrhosis = 1.14 (1.00-1.29), HR HCC = 2.44 (1.99-2.99); HR death 2.09 (1.98-2.22)] compared with younger patients. The incidence of HCC was than 8.4 per 1000 PY in the elderly compared with 2.6 per 1000 PY and 5.7 per 1000 PY, among the 20-49 and 50-64 age groups, respectively. Elderly patients were significantly less likely to receive antiviral treatment (3.8% vs 14.8% and 19.1%, P < 0.0001), but among those who received treatment SVR was not different among the age groups (33.5% vs 33.2% and 32.1%). In an analysis limited to those who received treatment, SVR compared to treatment receipt with no SVR was associated with a reduction in risk of developing cirrhosis (HR = 0.34; 0.18-0.66) and HCC (HR = 0.60; 0.22-1.61) and all-cause mortality risk (HR = 0.52, 0.33-0.82). Elderly patients with CHC are more likely to develop HCC than younger patients but have traditionally received less antiviral treatment than younger patients. However, receipt of curative treatment is associated with a benefit in reducing cirrhosis, HCC and overall mortality, irrespective of age.

Extrahepatic morbidity and mortality of chronic hepatitis C

Chronic hepatitis C virus (HCV) infection is associated with several extrahepatic manifestations. Patients with HCV may develop mixed cryoglobulinemia and its sequelae, ranging from cutaneous and visceral vasculitis to glomerulonephritis and B-cell non-Hodgkin lymphoma. HCV-infected patients have increased rates of insulin resistance, diabetes, and atherosclerosis, which may lead to increased cardiovascular morbidity and mortality. Neurological manifestations of HCV infection include fatigue and cognitive impairment. The mechanisms causing the extrahepatic effects of HCV infection are likely multifactorial and may include endocrine effects, HCV replication in extrahepatic cells, or a heightened immune reaction with systemic effects. Successful eradication of HCV with interferon alfa and ribavirin was shown to improve some of these extrahepatic effects; sustained virological response is associated with resolution of complications of cryoglobulinemia, reduced levels of insulin resistance, reduced incidence of diabetes and stroke, and improved fatigue and cognitive functioning. The availability of new interferon-free, well-tolerated anti-HCV treatment regimens is broadening the spectrum of patients available for therapy, including those in whom interferon was contraindicated, and will likely result in greater improvements in the extrahepatic manifestations of HCV. If these regimens are shown to confer significant benefit in the metabolic, cardiovascular, or neuropsychiatric conditions associated with HCV infection, extrahepatic manifestations of HCV may become a major indication for treatment even in the absence of liver disease.

Coffee and Caffeine Are Associated With Decreased Risk of Advanced Hepatic Fibrosis Among Patients With Hepatitis C

BACKGROUND & AIMS

Coffee or caffeine has been proposed to protect against hepatic fibrosis, but few data are available on their effects in patients with chronic hepatitis C virus (HCV) infection.

METHODS

We conducted a cross-sectional study of veterans with chronic HCV infection to evaluate the association between daily intake of caffeinated and decaffeinated coffee, tea, and soda, and level of hepatic fibrosis, based on the FibroSURE test (BioPredictive, Paris, France) (F0-F3, mild [controls] vs. F3/F4-F4, advanced). Models were adjusted for multiple potential confounders including age, alcohol abuse, and obesity.

RESULTS

Among 910 patients with chronic HCV infection, 98% were male and 38% had advanced hepatic fibrosis. Daily intake of caffeinated coffee was higher among controls than patients with advanced fibrosis (1.37 vs. 1.05 cups/d; P = .038). In contrast, daily intake of caffeinated tea (0.61 vs. 0.56 cups/d; P = .651) or soda (1.14 vs. 0.95 cans/d; P = .106) did not differ between the groups. A higher percentage of controls (66.0%) than patients with advanced fibrosis (57.9%) consumed 100 mg or more of caffeine daily from all sources (P = .014); controls also received a larger proportion of their caffeine from coffee (50.2% vs. 43.0%; P = .035). Hepatoprotective effects of an average daily intake of 100 mg or more of caffeine (adjusted odds ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .020) and 1 cup or more of caffeinated tea by non-coffee drinkers (adjusted odds ratio, 0.56; 95% confidence interval, 0.34-0.94; P = .028) persisted after adjustment for confounders, including insulin resistance.

CONCLUSIONS

A modest daily caffeine intake (as little as 100 mg) may protect against advanced hepatic fibrosis in men with chronic HCV infection. Additional research is needed to confirm these findings in women and in people with other chronic liver diseases.

Utility of evaluating HCV in an uninsured population

OBJECTIVES

Although effective HCV treatment is available, it can be difficult to access for uninsured, urban patients. Our aim was to assess the utility of evaluation and outcomes in the uninsured with HCV when access to health care and treatment with triple therapy is provided.

METHODS

We performed a retrospective review of consecutive patients referred for HCV from 2011 to June 2013 to an indigent HCV clinic. The primary outcomes were assessment of disease severity by noninvasive means and initiation of therapy.

RESULTS

We identified 350 patients: mean age 50.6, 84 % with no insurance, 62 % men, 58 % black, 91 % HCV treatment naïve. Of these, 148 underwent liver biopsy and 68 % had F0-F1 and 10 % had F3-F4 fibrosis. FIB-4 and APRI were highly correlated (r = 0.9; p < .0001) and correctly classified patients by fibrosis strata (F0-F1, F2, and F3-F4; p = .0004). When combined, a FIB-4 ≤1.5 and APRI ≤0.5 correctly classified the absence of advanced disease in 97 % (p < .0001). Of those evaluated, 39 (11 %) went on to HCV treatment. Of those not in a clinical trial, 51 % completed treatment with SVR in 61 % with genotype 1 and 75 % in genotypenon-1. Of those not treated (n = 309), the most common reasons were mild disease (16 %), lost to follow-up (23 %), ongoing alcohol or substance abuse (24 %), and uncontrolled depression (10 %).

CONCLUSION

Noninvasive assessment can accurately exclude advanced fibrosis. Despite access to care, the utility of evaluating to initiate HCV treatment is low suggesting that eliminating the barrier to health care may not increase HCV treatment.

The hepatitis C cascade of care: identifying priorities to improve clinical outcomes

BACKGROUND

As highly effective hepatitis C virus (HCV) therapies emerge, data are needed to inform the development of interventions to improve HCV treatment rates. We used simulation modeling to estimate the impact of loss to follow-up on HCV treatment outcomes and to identify intervention strategies likely to provide good value for the resources invested in them.

METHODS

We used a Monte Carlo state-transition model to simulate a hypothetical cohort of chronically HCV-infected individuals recently screened positive for serum HCV antibody. We simulated four hypothetical intervention strategies (linkage to care; treatment initiation; integrated case management; peer navigator) to improve HCV treatment rates, varying efficacies and costs, and identified strategies that would most likely result in the best value for the resources required for implementation.

MAIN MEASURES

Sustained virologic responses (SVRs), life expectancy, quality-adjusted life expectancy (QALE), costs from health system and program implementation perspectives, and incremental cost-effectiveness ratios (ICERs).

RESULTS

We estimate that imperfect follow-up reduces the real-world effectiveness of HCV therapies by approximately 75%. In the base case, a modestly effective hypothetical peer navigator program maximized the number of SVRs and QALE, with an ICER compared to the next best intervention of $48,700/quality-adjusted life year. Hypothetical interventions that simultaneously addressed multiple points along the cascade provided better outcomes and more value for money than less costly interventions targeting single steps. The 5-year program cost of the hypothetical peer navigator intervention was $14.5 million per 10,000 newly diagnosed individuals.

CONCLUSIONS

We estimate that imperfect follow-up during the HCV cascade of care greatly reduces the real-world effectiveness of HCV therapy. Our mathematical model shows that modestly effective interventions to improve follow-up would likely be cost-effective. Priority should be given to developing and evaluating interventions addressing multiple points along the cascade rather than options focusing solely on single points.