Special populations: treating hepatitis C in patients with decompensated cirrhosis and/or advanced renal impairment

Abstract

Direct-acting antivirals have revolutionized the treatment of hepatitis C. Sustained virological response rates of at least 95% have become common in the general population. However, along with the ageing of the HCV population, physicians face a growing group of HCV-infected patients with advanced liver and/or renal impairment. The safety and efficacy of treatment remains a clinical challenge in these patients. This review focuses on the current state of knowledge and treatment regimens in patients with decompensated cirrhosis and severe renal impairment. It shows that distinct interferon-free treatments can achieve favourable sustained virological response rates in these difficult-to-treat patients. Moreover, pitfalls and special considerations as well as new emerging challenges in an era of interferon-free regimens will be presented in this article.

Position Paper on Treatment of Hepatitis C in Romania 2017. Part Two

“…So far, no consensus has been established because there are no prospectively compared and appropriately powered randomized trials (RCTs) in this regard and it is unlikely that such trials will be performed [2]. Thus, the recommendations are based on the results of clinical trials assessing each approach, data coming from the real world and the experts' experience.…”

“…In daily clinical practice in our country, a case by case judgement is recommended, as this cut-off of MELD score was arbitrarily set [2]. Patients with HCV decompensated cirrhosis should be referred to a gastroenterologist with expertise in anti-HCV therapy and taking care of patients with end-stage liver disease (ESLD), ideally in a transplant center.…”

“…-Patients with GT-1 and F0-F3 fibrosis or compensated Child A cirrhosis can be treated with the combination of ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir plus RBV (1000mg or 1200mg/day in patients <75kg or ≥75 kg, respectively) for 24 weeks [2,27,35] [B1]. Due to drugdrug interactions (DDIs) of Ritonavir and Paritaprevir with tacrolimus and cyclosporine, dose reduction (cyclosporine at 20% of previous stable daily dose and tacrolimus 0.5 mg at 7-14 days interval) and frequent monitoring of immunosuppressive drugs is recommended.…”

“…-GT-1b patients should be treated with the combination ritonavir-boosted Paritaprevir, Ombitasvir and Dasabuvir [1,2,42] …”

“…A benefit of SVR may be a significant improvement of liver function, leading to temporary inactivation or even delisting of selected cases [5,6] [B1]; -Treatment regimens including an NS3/4A protease inhibitor, such as Simeprevir, ritonavir-boosted Paritaprevir or Grazoprevir, are contraindicated in patients with ChildPugh B and C decompensated cirrhosis and in compensated cirrhosis with previous episodes of decompensation, because of the substantially higher protease inhibitor exposure in these patients [A1]; -Only Sofosbuvir-based regimens are recommended: 1) Sofosbuvir plus Ledipasvir, 2) Sofosbuvir plus Daclatasvir, or 3) Sofosbuvir plus Velpatasvir with daily weight-based ribavirin (RBV) (1000 or 1200 mg if body weight is <75 kg or >75 kg, respectively). RBV should be initiated at a low dose of 600 mg per day, increased subsequently depending on patient's tolerability Patients with a MELD score >18-20 in LT programs where the waiting time to transplant exceeds 6 months can be treated cautiously before LT [B1] [2,3].…”