Antiviral therapy in hepatitis C virus cirrhotic patients in compensated and decompensated condition

Abstract

The main goals of treating cirrhotic patients with antiviral therapy are to attain sustained viral clearance (SVR), halt disease progression, and prevent reinfection of the liver graft. However, while the medical need is great, the use of interferon and ribavirin might expose these patients to severe treated-related side effects as a large proportion of them have pre-existing hematological cytopenias. We have reviewed potential benefits and risks associated with antiviral drugs in patients with liver cirrhosis, due to hepatitis C virus (HCV) infection. In cases presenting with bridging fibrosis or cirrhosis, current regimens of antiviral therapy have attained a 44%-48% rate of SVR. In cirrhotic patients with portal hypertension, the SVR rate was 22% overall, 12.5% in patients with genotype 1, and 66.7% in those with genotypes 2 and 3 following therapy with low doses of either Peg-IFN alpha2b and of ribavirin. In patients with decompensated cirrhosis, full dosages of Peg-IFN alpha-2b and of ribavirin produced a SVR rate of 35% overall, 16% in patients with genotype 1 and 4, and 59% in those with genotype 2 and 3. Use of hematological cytokines will either ensure full course of treatment to be accomplished with and prevent development of treatment-associated side effects. Major benefits after HCV eradication were partial recovery of liver metabolic activity, prevention of hepatitis C recurrence after transplantation, and removal of some patients from the waiting list for liver transplant. Several observations highlighted that therapy is inadvisable for individuals with poor hepatic reserve (Child-PughTurcotte score ≥ 10). Although SVR rates are low in decompensated cirrhotics due to hepatitis C, these patients have the most to gain as successful antiviral therapy is potentially lifesaving.

Boceprevir and telaprevir‐based triple therapy for chronic hepatitis C: virological efficacy and impact on kidney function and model for end‐stage liver disease score

“…Based on a large number of patients enrolled within routine clinical practice, this study reports an overall SVR rate of 52.5% varying from 48% in cirrhotic patients to 63% in non‐cirrhotics. These SVR rates are higher than those previously reported in patients receiving PEG‐IFN/RBV combination therapy (20% of SVR in cirrhotics ) and are slightly higher than those reported in the CUPIC study based on cirrhotic patients only (44% for telaprevir vs 38% for boceprevir‐treated patients) .…”

Systematic review: interferon‐free regimens for patients with HCV‐related Child C cirrhosis

“…The efficacy, safety and long‐term outcome of treatment with new direct acting antiviral agents of patients with Child C cirrhosis are unknown, as the low numbers of these patients enrolled in either registrative or post‐marketing clinical trials do not allow conclusions to be drawn. This lack of information reflects concerns and fears regarding the treatment of such patients with peg‐interferon and ribavirin: although such a therapy has been shown to be feasible, the associated severe events and worsening of hepatic decompensation have discouraged physicians from administering interferon‐based therapies to patients with Child C. These same concerns and fears also apply to the new interferon‐free regimens. While these new regimens have proved safe and effective in patients with Child A and B cirrhosis, data describing their use in Child C patients are limited.…”

“…A sustained virological response with a positive impact on outcome in patients with HCV‐related cirrhosis has been documented following therapy with peg‐interferon and ribavirin . Initial and fragmentary information concerning a similar favourable effect following treatment with the new direct acting antivirals has been also reported .…”

Basic answers to complicated questions for the course of chronic hepatitis C treatment

“…However, if Child-Pugh score is over 11 or MELD score is over 25, patients should not be treated. Although the response rate appears to be lower in cirrhotic patients, successful therapy may potentially improve survival and can be life saving [59].…”

“…Valla et al conducted a randomized controlled multicentric study to evaluate the effect of IFN-α2b (3 million units, three-times weekly for 48 weeks) in patients with compensated HCV-related cirrhosis [59]. The treatment group was compared with untreated patients as the control group in terms of SVR, improvement of histological activity and occurrence of HCC.…”