The Importance of Hepatitis C Care After a Cure

Although virologic cure is achieved in most patients infected with hepatitis C virus (HCV) treated with direct-acting antivirals (DAAs), a noted hepatologist recently emphasized the importance of post-cure care to reduce risk of liver disease progression in those with advanced fibrosis and in those with ongoing risk factors for liver injury, as well as to reduce risk of reinfection and to monitor and manage related complications.

"The achievement of HCV cure substantially reduces the risk of liver disease progression, but some patients remain at risk," explained Norah Terrault, MD, MPH, a professor of Medicine and director of the Viral Hepatitis Center, University of California San Francisco. "Moreover, liver injury can occur from other causes before and after cure, specifically related to alcohol use or superimposed metabolic fatty liver."

In an editorial accompanying Terrault's assessment and recommendations, Gary Lichtenstein, MD succinctly posed the challenge of providing follow-up to an ostensible cure.

"As physicians, our goal is to treat patients as best we can, which hopefully results in curing them whenever possible,” he wrote. “But once they are cured, then what?"

Terrault addressed that question by considering when continued HCV RNA testing is advised and how fibrosis regression and progression should be assessed, describing roles of both specialists and primary care practitioners in providing appropriate monitoring and intervention after successful DAA treatment, and identifying the strong counseling messages which could be essential for effective aftercare of this population.

The rate of late relapse, beyond the sustained virologic response to treatment at 12 weeks (SVR12), is rare (0.2%), and "exceedingly rare" beyond 24 weeks posttreatment, Terrault noted. Studies with phylogenetic sequencing have indicated that 7 of 12 relapses are new infections rather than true relapses. Despite the relatively low rate of relapse, however, Terrault indicated that the possibility warrants testing beyond 12 weeks post-treatment.

"I recommend obtaining both SVR12 and SVR 48," Terrault wrote. "If HCV RNA is undetectable at the later time point, the patient can be confidently informed that he or she is cured, and no further testing is indicated unless the patient is at risk for reinfection."

While acknowledging the roles of primary care practitioners in following and counseling patients on maintaining good liver health after treatment for HCV infection, Terrault suggested collaboration with a gastroenterologist or hepatologist for patients at risk for liver-related complications. She noted that patients with advanced fibrosis (F3 or F4) on staging tests prior to HCV treatment are at risk for hepatocellular carcinoma (HCC) and decompensation even after SVR12 is achieved.

"These patients should undergo surveillance with ultrasound and α-fetoprotein every 6 months," Terrault indicated. "Also, for patients with cirrhosis, screening endoscopy is indicated, with the subsequent frequency of endoscopies dictated by the initial findings."

Although most patients, particularly those without cirrhosis at baseline, will evidence fibrosis regression following SVR12, Terrault noted that some patients can progress. This can be attributed in some cases to concurrent alcohol use or presence of nonalcoholic fatty liver disease, or from genetic or immunologic factors, and warrants periodic assessment of fibrosis severity with elastography.

"Specialists pay a key role in educating non-specialists regarding appropriate follow-up post-cure and in caring for patients with advanced fibrosis and liver-related complications," Terrault concluded.

The paper, "Care of Patients Following Cure of Hepatitis C Virus Infection," was published in Gastroenterology & Hepatology.

This article was originally published by MD Magazine.

Stay up to date on the latest news in specialty pharmacy by getting Specialty Pharmacy Times in your mailbox or inbox for free!

Click here to sign up for free for the bi-monthly Specialty Pharmacy Times print journal delivered to your address.

Click here to sign up for our email newsletters delivered every Monday, Wednesday, and Friday, in addition to breaking news alerts.

Click here to follow us on Facebook. 

Click here to follow us on Twitter. 

Click here to join our LinkedIn group. 

Most Popular

Related Articles

Kaiser Family Foundation analysis examines Medicaid outpatient prescription drug utilization and spending before rebates.
The study was the first to compare patients with hepatitis C treated with direct-acting antiviral drugs and those untreated for long-term risks.
Because pregnancy is one of the few times individuals are in contact with the health system and covered by health insurance, there is a cost-effective opportunity to screen for hepatitis C virus.
Company Profile >
Industry Guide >
Market News >
Peer Exchange >
Conferences >
Subscribe >
Specialty Times Resources
About Us
Contact Us
Terms & Conditions
MJH Associates >
Pharmacy Times
American Journal of Managed Care
MD Magazine
Targeted Oncology
Physicians' Education Resource
Pharmacy & Healthcare Communications, LLC
2 Clarke Drive
Suite 100
Cranbury, NJ 08512
P: 609-716-7777
F: 609-716-4747

Copyright Specialty Pharmacy Times 2006-2018
Pharmacy & Healthcare Communications, LLC. All Rights Reserved.