Curr Hepat Rep. 2011 March; 10(1): 33–40.
Published online 2010 December 24. doi: 10.1007/s11901-010-0078-7. PMCID: PMC3030745
Management of Hepatitis C Antiviral Therapy Adverse Effects
Hubert Sung,1 Michael Chang,2 and Sammy Saab1,2,3 -1Department of Surgery, University of California at Los Angeles, Los Angeles, CA USA ,2Department of Medicine, University of California at Los Angeles, Los Angeles, CA USA ,3Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095 USA
Hepatitis C is one of the leading causes of liver disease in the United States, affecting more than 4 million individuals. The current treatment regimen involves pegylated interferon in combination with ribavirin. Although antiviral treatment has been associated with a greater than 50% sustained viral response rate, the adverse effects have proven to be detrimental to quality of life and therapy adherence, and consequently lead to lower sustained viral response rates. This article identifies the most frequently described complications associated with pegylated interferon and ribavirin. The active management of these complications is discussed, including both preventive and empiric treatments.
Keywords: Hepatitis C virus, Pegylated interferon, Ribavirin, Side effects, Management
Hepatitis C is a major public health concern. With almost 4 million Americans with chronic infection, hepatitis C is the one of the leading causes of chronic liver disease and is the single most common indication for liver transplantation [1–3]. Antiviral therapy is effective in more than half of infected patients, but the actual rate of sustained viral response depends on viral, host, and adherence factors. Viral and host factors tend to be nonmodifiable, whereas interventions may increase adherence.
The current standard of care for hepatitis C therapy is the combination of pegylated interferon and ribavirin . Sustained viral response for antiviral therapy is about 55% [5•, 6•]. However, adverse effects from antiviral therapy directly affect treatment adherence and can decrease the likelihood of a sustained viral response. These complications can severely compromise quality of life . Both interferon and ribavirin are associated with signature effects that are predictable, manageable, and improve with dose modification or discontinuation [8••]. Rarely is an adverse effect from hepatitis C antiviral therapy permanent. Adverse effects can arise from both interferon and ribavirin, and may lead to treatment termination and dose modifications in 10% to 15% and 32% to 42% of patients, respectively [5•, 6•, 9]. When interferon and ribavirin doses are reduced by a certain threshold, the sustained viral response may also decrease . For instance, the results of a recent study by Reddy et al. [11••] demonstrated the sustained viral response is 34% when a patient’s cumulative ribavirin dose decreases below 60%.
An understanding of the antiviral adverse effects is essential to effectively deal with adverse effects in a timely manner. The goal during therapy is to maximize the likelihood of achieving a sustained viral response while improving tolerability and maintaining quality of life. Providers should discuss the potential issues with patients and with their social support. During clinic follow-up, patients should be queried about treatment adverse effects. Many times, the adverse effects can accumulate over time and lead to early treatment discontinuation. The current paper reviews the most frequent adverse effects associated with hepatitis C therapy, and proposes interventions to ameliorate complications. The adverse effects from pegylated interferon and ribavirin are considered separately.
The efficacy and therapeutic value of hepatitis C treatment is dependent on the degree of tolerability and adherence to the drugs, which in turn are related to the management of the side effects. The frequency and number of side effects related to interferon therapy are common, with most clinical trials reporting at least one interferon-related adverse effect in 95% of the patient group [5•, 10, 12]. The most frequently reported adverse effects from interferon include constitutional, hematologic, neuropsychiatric, and endocrinologic complications See; (Table 1). The onset of the adverse effects differ. The onset can be from minutes after the interferon injection, to months See; (Table 2).
The most common adverse effects from interferon are constitutional symptoms. The severity of these side effects is inversely related to the amount of time after the interferon injection. Fatigue, headache, and fever were each reported in about 50% to 60% of treated patients [6•, 9, 12].
Constitutional effects can manifest early during therapy, even after the first dose of interferon . However, several constitutional effects (e.g., fever) resolve or wane after the first several injections. Certain precautions can assist with the effects, such as maintaining adequate hydration and light to moderate exercise. The suggested intake of water in ounces is equivalent to half the patient’s body weight in pounds. To prevent interferon therapy from interfering with work, injections should occur on Fridays. As a result, most of the constitutional effects will occur on Saturday. By Monday, treated patients tend to feel better. The use of acetaminophen or ibuprofen before the injection can also ameliorate many of the constitutional adverse effects. Other adverse effects (e.g., arthralgia) can respond to acetaminophen or ibuprofen. However, ibuprofen should be avoided in patients with liver cirrhosis.
Hematologic side effects are the most recurrent abnormal laboratory values that can lead to dosage reductions and premature treatment termination . Because of its myelosuppressive effect, interferon can affect hemoglobin, white blood cell, and platelet values. However, the anemia seen during combination treatment is mostly associated with ribavirin-induced hemolytic anemia.
The definition of neutropenia varies between the two commercially available pegylated interferons. For instance, neutropenia is defined as an absolute neutrophil count less than 500 cells/mm3 when using pegylated interferon α-2a, and below 750 cells/mm3 when using pegylated interferon α-2b [13, 14]. Certain populations appear to be more likely affected by the neutropenic effects of interferon, such as the elderly and non-African Americans . Although African Americans are prone to constitutional neutropenia, initiation of interferon treatment usually only leads to minimal further decreases in neutrophil count. However, the clinical impact of neutropenia on significant infection is controversial. In a study of 119 subjects, 22 infections were documented and were dominated by sinusitis, pharyngitis, and urinary tract infections .
In most clinical trials, neutropenia is treated with dose modification. Interferon dose reduction occurs in about 17% to 20% of patients and treatment termination in 2% to 3% of patients [16••, 17, 18]. The rapid decline in neutrophils usually occurs within the first 2 weeks of treatment initiation, with stabilization occurring over the next 4–6 weeks . One study of 25 patients illustrated a median drop of 21% in neutrophils following the first dose of interferon .
Another option for patients who develop neutropenia from interferon therapy is the use of granulocyte colony-stimulating factor (GCSF) [20–22]. Few clinical studies have included the use of GCSF [20, 21]. These studies have indicated that the GCSF is able to raise neutrophil counts during interferon therapy. However, the results of a recent study failed to show a correlation between interferon-induced neutropenia and incidence or severity of infections . Thus, although GCSF can improve neutrophil counts, future studies are required to determine the utility of GCSF in clinical practice, particularly given its increased costs and its own associated adverse effects. Regardless of the intervention of neutropenia, affected patients need regular cell counts to monitor neutrophil levels.
Another interferon-induced hematologic adverse effect is thrombocytopenia. Several mechanisms exist for the development of thrombocytopenia. It has been shown that platelet count can fall up to 50% because of posttranscriptional suppression of megakaryopoiesis or platelet sequestration in capillaries . In addition, there have been rare cases of immune-mediated thrombocytopenia leading to significant decreases in platelet count, which can be rectified by termination of interferon treatment or corticosteroid therapy [24, 25]. Platelet reduction often occurs within the first 24 h of interferon administration, with nadir being reached within 8 weeks of therapy. Platelet levels will then stabilize at this low level during the length of therapy [23, 24]. However, it may compound the already present thrombocytopenia associated with cirrhosis and portal hypertension. With pegylated interferon α-2a, dose reduction is suggested when platelet counts fall below 50,000/mL and therapy termination when counts fall below 25,000/mL . The threshold is set a little higher with respect to pegylated interferon α-2b, with limits of 80,000/mL for dose reduction and 50,000/mL for discontinuation . Discontinuation of therapy is often followed by normalization of platelet counts within 4–8 weeks [23, 24]. Recent studies have shown eltrombopag, a thrombopoietin receptor agonist, to effectively increase platelet counts to greater than 250,000/mm3 in thrombocytopenic patients with hepatitis C virus . However, its safety and utility in patients with advanced liver disease remains to be determined, because it may increase the risk of thrombosis .
Not only is the prevalence of depression in patients with hepatitis C higher than the general population, antiviral therapy increases the likelihood of a variety of neuropsychiatric complications, including worsening depression, anxiety, and suicidal ideation . Thus, it is imperative to assess for underlying depression and other preexisting psychiatric illness before considering antiviral therapy. In fact, antiviral therapy is contraindicated in patients with uncontrolled neuropsychiatric disorders. With a treated patient’s approval, it is helpful for their social support to provide feedback on mood changes because patients themselves may not notice changes in their disposition.
About 20% to 30% of patients treated with interferons report depression during therapy or the exacerbation of a preexisting depressive state [6•, 29]. Depending on the type and severity of neuropsychiatric effects, patients may be monitored or may be treated with more frequent clinic visits or telephone calls, antidepressant medications, psychiatric referral, or dose modification or even discontinuation.
The selection of antidepressant medication requires tailoring, because depression may have nuances that improve or worsen with the choice of therapy . The greatest experience with antidepressant medications is with selective serotonin reuptake inhibitors (SSRIs) [31, 32]. Although the use of antidepressant medication may not necessarily significantly improve the likelihood of a sustained viral response, it does improve adherence and help maintain quality of life . In patients believed at increased risk of interferon-associated depression, preemptive treatment with SSRIs was associated with a significant reduction in the incidence of major depression .
Thyroid abnormalities are the most commonly associated interferon-induced endocrinologic adverse effect, occurring in 1% to 6% of interferon-treated patients [34, 35]. Both hypo- and hyperthyroidism can develop. Patients with hepatitis C may be predisposed to developing thyroid abnormalities because of an increased rate of thyroid autoantibodies prior to starting antiviral therapy . For instance, one study described the development of thyroid disorder in 60% of patients with antithyroid microsome antibodies present prior to the initiation of interferon therapy, compared to only 3.3% of patients without these antibodies . In a similar study, 38.5% of females with antithyroid peroxidase antibodies developed hypothyroidism versus only 7.8% of females lacking these antibodies .
Thyroid function tests should be obtained at baseline and every 12 weeks during antiviral treatment, and after treatment completion. If a patient develops symptomatic hypothyroidism, hormone replacement should be initiated while continuing antiviral therapy. Moreover, if the patient develops hyperthyroidism, the patient should be referred to an endocrinologist for further management with reevaluation of the antiviral regimen. Similar to the autoantibody destruction seen in the thyroid, antibodies to the adrenal cortex, pancreatic islet cells, and antiphospholipid antibodies have been reported with the use of interferon [38, 39]. Although rare, new-onset insulin-dependent diabetes mellitus with the presence of antibodies directed toward islet cells and insulin has been reported .
Many dermatologic adverse effects are associated with interferons, with an incidence ranging from 13% to 87% [5•, 41]. Besides nonspecific symptoms, reactions at the site of interferon injection are common, with 30% to 40% of patients complaining of erythema, pruritus, and tenderness [6•, 42]. Because the lesions may take weeks to resolve, it is recommended to rotate between unique injection sites. After injection, the sites are often warm and raised, expanding to a circumference of 5 cm or more. If the site continues to enlarge and remains warm and tender, the patient must be examined for possible abscess formation. Rarely, infection and skin necrosis are seen at the injection site. However, these symptoms do not necessarily warrant termination of treatment.
An additional major complaint from interferon therapy is skin dryness, which occurs in two of three treated patients . Skin dryness can be exacerbated in cold weather, and may be accompanied by intense pruritus. Topical steroids, emollients, and soothing baths may help to alleviate these symptoms, but studies have not shown a significant response . Another typical adverse effect seen with interferons is alopecia, occurring in about one third of patients, with a higher prevalence in females . To combat alopecia, the patient can cut his/her hair short prior to interferon initiation and avoid pulling, braiding, or vigorously combing the hair. In addition, patients should avoid the use of harsh hair-care products, harsh hair dyes, hair dryers, and other products that may be detrimental to hair growth.
Neurologic, pulmonary, and ophthalmologic adverse effects associated with interferon use have been reported. Sensory and autonomic neuropathies, as well as Bell’s palsy, have been documented with interferon use, most likely arising from an autoimmune phenomenon or neuronal injury caused by interferon stimulation of the immune system . Neuropathy usually resolves with the termination of interferon treatment, but additional steroids and/or cyclophosphamide may be beneficial . In addition to the neuropathies stated, there have been rare cases of myasthenia gravis. In such cases, interferon therapy is withdrawn and pyridostigmine therapy is initiated . During interferon treatment, multiple pulmonary adverse effects can occur, such as interstitial pneumonitis, alveolar disease, and sarcoidosis reactivation. If a patient complains of continual cough and dyspnea on exertion or rest, a chest radiograph should be obtained to exclude pneumonitis. Possible bacterial pneumonia should be treated with proper antibiotics in conjunction with halting antiviral therapy, which can be reinitiated when there is clinical improvement. Occasionally, pulmonary function tests may be indicated, including forced vital capacity, forced expiratory volume, and carbon monoxide diffusion capacity, as well as a thoracic CT scan. Interferon-induced interstitial pneumonitis can be life-threatening, although it usually resolves with withdrawal of interferon. However, the most common cause for cough and shortness of breath is likely ribavirin-induced .
In addition to the pulmonary and neurologic effects, interferons have been associated with retinopathy (e.g., retinal hemorrhages and cotton wool spots), particularly in patients with diabetes . In one study of 63 patients treated with antiviral therapy, 40% of patients developed retinal hemorrhages and 44% developed cotton wool spots . Diabetes and hypertension were risk factors for retinopathy [47, 49]. It is important for patients with pre-treatment risk factors for retinopathy to undergo retinal examination prior to treatment, and if any visual changes occur during treatment, to undergo ocular re-evaluation. Antiviral treatment must be halted if retinopathy worsens during therapy.
Ribavirin is used with interferon to treat hepatitis C. Like interferon, it is associated with several adverse effects. Although the adverse effects from ribavirin appear to be less severe than those from interferon, maintaining ribavirin dose appears more critical to the likelihood of achieving a sustained viral response than sustaining the interferon dose [6•]. Thus, it is still imperative to understand and be able to manage ribavirin-associated complications.
The signature adverse effect of ribavirin is anemia, occurring in up to 30% of treated individuals [5•, 6•]. Ribavirin-related anemia is one the most common reasons for dosage reduction or discontinuation of the drug, resulting in 9% to 22% of patients requiring dosage reduction [5•, 6•]. Anemia can result in persistent fatigue, shortness of breath, and lower quality-of-life scores . Treatment with ribavirin displays a drop in hemoglobin during the first 4 weeks of treatment, followed by stabilization, then normalization after treatment completion . The mechanism of ribavirin-associated hemolytic anemia is unclear, but is believed to be related to impaired antioxidant defenses and red blood cell oxidative damages through its metabolites . The degree of hemolytic anemia is directly related to ribavirin dose, renal function, and perhaps patient age [52, 53]. Recently, ITPA gene variants have been found to be protective of anemia in patients treated with ribavirin [54••].
The definition of anemia can vary. Although anemia may be suggested by the rate of hemoglobin drop, it is commonly defined by an absolute value of less than 10 g/dL . Intervention for ribavirin-induced anemia depends on the rate of hemoglobin decrease, absolute hemoglobin value, comorbidities, and symptoms. Therapeutic options include frequent monitoring, blood transfusion, erythropoietin grown factor, and ribavirin dose modification [6•, 8••, 50••]. The risk of significant anemia can be predicted by hemoglobin trends. For instance, a decrease in hemoglobin of at least of 1.5 g/dL after 2 weeks predicts significant decreases after 4 weeks of therapy . Recognition of impending anemia may prompt small reductions of ribavirin to avoid significant decline in hemoglobin.
There is a discrepancy between the intervention for anemia according to package inserts, and what is often done in clinical practice. The respective package inserts recommend decreasing the ribavirin dose by 200 mg/day when using peginterferon α-2b/ribavirin and by 600 mg/day when using peginterferon α-2a/ribavirin, if hemoglobin decreases to less than 10 g/dL in a patient without cardiac risk factors [13, 14, 55]. The package inserts also recommend termination of ribavirin if the hemoglobin levels decrease below 8.5 g/dL.
Studies have shown erythropoietin can improve hemoglobin values, maintain ribavirin dosage levels, and improve quality of life in patients with symptomatic ribavirin-induced anemia . Despite improved adherence with erythropoietin, no studies have shown that the use of erythropoietin translates to higher sustained viral response. This may be due to the large cohort of treated patients needed to show a beneficial effect. There have been reported cases of antibody-mediated pure red-cell aplasia induced by erythropoietin, which is potentially life-threatening, but resolves with termination of erythropoietin treatment and initiation of danazol . A recent study highlighted the correlation between the magnitude of hemoglobin decline and the likelihood of sustained viral response, and indicated an association between the magnitude of hemoglobin decline and ribavirin exposure . Erythropoietin use in early-onset anemia minimized treatment discontinuation and led to higher sustained viral response rates. However, erythropoietin for anemia after 8 weeks of therapy was not associated with higher sustained viral response rates. Moreover, erythropoietin has been linked to a greater incidence of mortality with its use in ischemic stroke patients . These recent concerns regarding raised risks of thromboembolic events and aplastic anemia with erythropoietin justify the judicious use of this agent.
Other ribavirin-associated complications include nausea and pulmonary, dermatologic, and teratogenic effects. Studies have shown that 25% to 40% of patients complain of nausea [5•, 6•, 12]. However, this symptom can be managed with alterations in the patient’s dietary regimen. More specifically, along with maintaining adequate hydration, patients should avoid acidic, spicy, sweet, or greasy foods. Instead, dietary intake should consist of clear beverages and dry foods (e.g., toast and crackers). If nausea persists after dietary changes, antiemetics may be prescribed.
Ribavirin therapy is often associated with a dry, nonproductive cough, which resolves only upon termination of treatment. Most patients can tolerate this adverse effect, and thus it is not a major cause of dose reductions or treatment termination. However, if the cough becomes productive or other clinical indications are present, a chest radiograph should be considered.
The addition of ribavirin in combination therapy increases the incidence of dermatologic adverse effects. More specifically, one study compared the incidence of skin rash in two groups, one receiving interferon monotherapy and one receiving interferon and ribavirin. Monotherapy resulted in an 8% incidence, whereas combination therapy resulted in 28% incidence . Dermatologic side effects with combination therapy are typified by generalized pruritus, skin xerosis, and eczematiform lesions, which are localized to the extremities. Although ribavirin is shown to increase the incidence of dermatologic conditions when added to interferon treatment, it should be noted that ribavirin alone may cause rash and pruritus. Ribavirin must be discontinued if an acute hypersensitivity reaction develops. However, transient rashes do not require ribavirin treatment interruption . Management entails topical corticosteroids, which may be tapered once signs of inflammation and irritation begin to recede. Preventive measures can be taken, with daily emollient therapy and skin moisturizers to commonly affected areas.
Ribavirin has been associated with significant teratogenic or embryocidal effects in nonhuman animal species exposed to it; therefore, patients must take proper precautions when beginning ribavirin treatment. Moreover, ribavirin therapy, which according to the Food and Drug Administration is pregnancy category X, is contraindicated in pregnant woman and in the male partners of women who are pregnant. It is imperative for patients to avoid pregnancy during ribavirin treatment and for 6 months after treatment completion. It is suggested that two reliable forms of effective contraception be used during this time. Upon cessation of treatment, recovery from ribavirin-induced testicular toxicity was apparent within one or two spermatogenesis cycles. Although human studies are lacking, there is a ribavirin pregnancy registry that enrolls pregnant women who have been directly or indirectly exposed to ribavirin . Although underpowered, the results of a recent registry questioned the association between ribavirin and human teratogenicity .
References ConclusionsThe current standard of care for the treatment of hepatitis C infection involves the use of pegylated interferon and ribavirin. This antiviral combination therapy is associated with several potentially serious adverse effects. Fortunately, pegylated interferon and ribavirin have been available for almost a decade, and most of the adverse effects regarding incidence and time of onset have been defined. The management of these antiviral complications has also been well described, including preventive and empiric strategies. Understanding the limitations of current treatment is essential to assure quality of life and adherence during therapy, and may provide insight to deal with the finer points of future treatment strategies.
AcknowledgmentsDisclosure Conflicts of interest: H. Sung—none; M. Chang—none; S. Saab—consultancy, grants, speakers’ honoraria, and travel reimbursement from Bristol-Myers Squibb, Gilead, Three Rivers, Genentech, Merck, Bayer, and Onyx, and stock/stock options in Gilead, Vertex, and Zymogenetics.
Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
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44. Lang AM, Norland AM, Schuneman RL. Localized interferon alfa-2b-induced alopecia. Arch Dermatol. 1999;135:1126–8. doi: 10.1001/archderm.135.9.1126. [PubMed] [Cross Ref]
45. Stubgen JP. Interferon alpha and neuromuscular disorders. K Neuroimmunol. 2009;207:3–17. doi: 10.1016/j.jneuroim.2008.12.008. [Cross Ref]
46. Weegink CJ, Chamuleau RA, Reesink HW, et al. Development of myasthenia gravis during treatment of chronic hepatitis C with interferon-alpha and ribavirin. J Gastroenterol. 2001;36:723–4. doi: 10.1007/s005350170038. [PubMed] [Cross Ref]
47. Jain K, Lam WC, Waheeb S, et al. Retinopathy in chronic hepatitis C patients during interferon treatment with ribavirin. Br J Ophthalmol. 2001;85:1171–1173. doi: 10.1136/bjo.85.10.1171. [PMC free article] [PubMed] [Cross Ref]
48. Kawano T, Shigehira M, Uto H, et al. Retinal complications during interferon therapy for chronic hepatitis C. Am J Gastroenterol. 1996;91:309–313. [PubMed]
49. Hayasaka S, Fujii M, Yamamoto Y, et al. Retinopathy and subconjunctival haemorrhage in patients with chronic viral hepatitis receiving interferon alfa. Br J Ophthalmol. 1995;79:150–152. doi: 10.1136/bjo.79.2.150. [PMC free article] [PubMed] [Cross Ref]
50. McHutchison JG, Manns MP, Brown RS, Jr, et al. Strategies for managing anemia in hepatitis C patients undergoing antiviral therapy. Am J Gastroenterol. 2007;102(4):880–9. doi: 10.1111/j.1572-0241.2007.01139.x. [PubMed] [Cross Ref]
51. DeFranceschi L, Fattovich G, Turrini F, et al. Hemolytic anemia induced by ribavirin therapy in patients with chronic hepatitic C virus infection: role of membrane oxidative damage. Hepatology. 2000;31:997–1004. doi: 10.1053/he.2000.5789. [PubMed] [Cross Ref]
52. Saab S, Oh MK, Ibrahim AB, et al. Anemia in liver transplant recipients undergoing antiviral treatment for recurrent hepatitis C. Liver Transpl. 2007;13(7):1032–8. doi: 10.1002/lt.21184. [PubMed] [Cross Ref]
53. Nomura H, Tanimoto H, Kajiwara E, et al. Factors contributing to ribavirin-induced anemia. J Gastroenterol Hepatol. 2004;19:1312–7. doi: 10.1111/j.1440-1746.2004.03459.x. [PubMed] [Cross Ref]
54. Fellay J, Thompson AJ, Ge D, et al. ITPA gene variants protect against anaemia in patients treated for chronic hepatitis C. Nature. 2010;464:405–8. doi: 10.1038/nature08825. [PubMed] [Cross Ref]
55. Ribavirin [package insert]. South San Francisco, CA: Hoffman-La Roche Inc. 2010.
56. Reau N, Hadziyannis SJ, Messinger D, et al. Early predictors of anemia in patients with hepatitis C genotype 1 treated with peginterferon alfa-2a (40KD) plus ribavirin. Am J Gastroenterol. 2008;103(8):1981–8. doi: 10.1111/j.1572-0241.2008.01957.x. [PMC free article] [PubMed] [Cross Ref]
57. Dieterich DT, Prockros P, Schiff ER, et al.: Interim results of a randomized, double-blind placebo-controlled study demonstrates that epoietin-alfa (PROCRIT) allows maintenance of ribavirin dosing. Hepatology 2002;493.
58. Stravitz RT, Chung H, Sterling RK, et al. Antibody-mediated pure red cell aplasia due to epoetin alfa during antiviral therapy of chronic hepatitis C. Am J Gastroenterol. 2005;100:1415–9. doi: 10.1111/j.1572-0241.2005.41910.x. [PubMed] [Cross Ref]
59. Sulkwski MS, Shiffman ML, Afdhal NH, et al. Hepatitis C virus treatment-related anemia is associated with higher sustained virologic response rate. Gastroenterology. 2010;139(5):1602–11. doi: 10.1053/j.gastro.2010.07.059. [PubMed] [Cross Ref]
60. Jia L, Chopp M, Zhang L, et al. Erythropoietin in combination of tissue plasminogenactivator exacerbates brain hemorrhage when treatment is initiated 6 h after stroke. Stroke. 2010;41(9):2071–6. doi: 10.1161/STROKEAHA.110.586198. [PubMed] [Cross Ref]
61. Ribavirin Pregnancy Registry. Available at http://ribavirinpregnancyregistry.com/. Accessed September 2010.
62. Roberts SS, Miller RK, Jones JK, et al. The Ribavirin Pregnancy Registry: Findings after 5 years of enrollment, 2003–2009. Birth Defects Res A Clin Mol Teratol. 2010;88:551–9. doi: 10.1002/bdra.20682. [PubMed] [Cross Ref]
Curr Hepat Rep. 2011 March; 10(1): 33–40.
HCV In The News
Check Out The Website
Hepatitis C New Drug Research And Liver Health
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DDW 2013 - May 18-21, 2013 - Orlando, FL
Digestive Disease Week - The conference will showcase the latest advances in GI research, medicine and technology in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery
View Media and DDW Updates
Hot Topics - May 2013
Gilead Announces U.S. FDA Priority Review Designation for Sofosbuvir for the Treatment of Hepatitis C
Hepatitis C: The Pace of Progress/Interferon-Free Treatment Still Searching
Interferon-free, treat-all approach cost effective, beneficial for chronic HCV
European Medicines Agency Validates Gilead's Marketing Application for Sofosbuvir for the Treatment of Hepatitis C
(On April 08) Gilead Submitted New Drug Application to U.S. FDA for Sofosbuvir (GS-7977) for the Treatment of Hepatitis C
Current and Future Therapies for Hepatitis C Virus Infection
If the past is a harbinger of the future, therapy for HCV infection will probably continue to advance at a brisk pace. Many additional potent agents are in the clinical pipeline, and interferon-free regimens are likely to dominate the HCV therapeutic landscape within the next 5 years.....
Summary EASL 2013 - New HCV DAAs on their way soon: what do the phase III studies tell us?
At this year's EASL in Amsterdam with over 9600 delegates the phase III study results for the two "second wave HCV protease inhibitors" faldaprevir and simeprevir each in combination with pegylated interferon (PEG-IFN) and ribavirin (RBV) for HCV genotype 1 patients were presented as well as the phase III findings for the polymerase inhibitor sofosbuvir again in combination with PEG-IFN/RBV for treatment of genotypes 1,4,5 and 6. In addition phase III results of the first interferon free combination of sofosbuvir with ribavirin for treatment of genotype 2 and 3 were presented....
HCV: Highlights from EASL 2013/Fred Poordad, MD
Best of the EASL 2013 on hepatitis C - webcast with Dr Andrew Muir
Hepatitis C in the United States Perspective
Care for hepatitis C is evolving rapidly, with increasingly effective and better-tolerated antiviral therapies being evaluated and approved for use. It's clear, however, that not everyone who would qualify for therapy has been tested and identified, referred for appropriate care, and offered or given the best therapy available. Furthermore, currently used antiviral drugs - pegylated interferon and ribavirin "base" plus either telaprevir or boceprevir - can cost more than $70,000 for a full course of therapy. It is expected that the new oral antiviral agents will be just as expensive, at least in the short term.
Hepatitis C Therapy Update 2013-What About Interferon-free Regimens?
U.S. FDA grants priority review to Simeprevir (TMC435) for combination treatment of genotype 1 chronic hepatitis C
AbbVie's ABT-450- Breakthrough Therapy Designation from the U.S. Food and Drug Administration Granted to Investigational HCV Regimen
Gilead Sofosbuvir and ledipasvir: Plans to initiate a third Phase 3 clinical trial with and without ribavirin
Cost will limit uptake of off-label Gilead/Bristol-Myers Squibb Hep C combo, despite best-in-class data
ViewPoints: New Hep C data validates Gilead's solo approach
Gilead Submits New Drug Application to U.S. FDA for Sofosbuvir (GS-7977) for the Treatment of Hepatitis C-- Sofosbuvir Would Form Basis of First All-Oral Regimen for HCV Genotype 2 and 3 Patients, and Interferon-Sparing Regimen for Genotype 1 Patients --
Anemia Top Side Effect of HCV Antivirals
Hepatitis C Virus Infection: Looking for Interferon Free Regimens
Review: NS5A Inhibitors in the Treatment of Hepatitis
VX-135/daclatasvir: Vertex signs agreement with Bristol-Myers for all-oral midstage studies for hepatitis C treatments
Simeprevir (TMC435) - Janssen Submits New Drug Application to U.S. FDA
Miravirsen- Hepatitis C drug goes after patients’ RNA
Update on Phase 3 Study of Oral Fixed-Dose Combination of Sofosbuvir and Ledipasvir for Genotype 1 Hepatitis C Patients
Hepatitis C - Presidio Collaboration with Boehringer Ingelheim for interferon-free Phase IIa clinical trial
Gilead hepatitis C drug sofosbuvir (GS-7977) meets goal of fourth late-stage study
EASL-Burden of Liver Disease in Europe: Looks at leading causes of cirrhosis and primary liver cancer in Europe
Gilead Announces SVR Rates from Two Phase 3 Studies of Sofosbuvir (GS-7977) for Hepatitis C
Potential IFN-Free Regimens For HCV
IDX184 and IDX19368 - Idenix drops development of hepatitis C drugs
Interferon free regimens for the “difficult to treat”: are we there?
Current Prospects for Interferon-free Treatment of Hepatitis C in 2012
Numerous other DAAs are in clinical development, and phases 2 and 3 trials are evaluating interferon-free combination DAA therapy. Interferon-free sustained virologic responses have now been achieved with combinations of asunaprevir and daclatasvir; sofosbuvir and ribavirin; sofosbuvir and daclatasvir; faldaprevir and BI207127; ABT-450, ritonovir and ABT-333; ABT-450, ritonovir and ABT-072; miracitabine, danoprevir and ritonavir; and alisporivir and ribavirin. Some drugs are genotype-specific in their activity, whereas others are pan-genotypic, and differential responses for the genotype 1 subtypes 1a and 1b have emerged with many DAA combinations. Viral breakthrough and resistance are important considerations for future trial design. The prospect of interferon-free combination DAA therapy for hepatitis C virus is now finally becoming a reality.
2013-Guide to Clinical Trials for People with Hepatitis C
Bristol-Myers to Hold Talks On Settling Claims of Hepatitis C Patients
Treat Now or Wait?
The debate rather to treat HCV now or wait is ongoing, in the journal "Liver International" factors which affect the decision to treat now or delay therapy are discussed. You can view the article here: Patients with HCV and F1 and F2 fibrosis: treat now or wait?
Lucinda K. Porter, RN Shares A Personal Experience: Starting 12 weeks of sofosbuvir, GS-5885, and ribavirin
Coming in September 2013
A second book authored by Lucinda K. Porter, RN: Hepatitis C Treatment One Step at a Time: Inspirational Readings and Practical Tips for Successful Hepatitis C Treatment
FREE FROM HEPATITIS C
Clinical Trial Updates
ClinicalTrials.gov: updated in the last 30 days
HCV PipelineHCV Advocate - News & Pipeline Blog
Chronic Hepatitis C Infection: Treat Now or Wait?
INCIVEK® (telaprevir)-Updates label after reports of a ‘small number of fatal skin reactions’
Vertex discloses Hep C drug deaths
HCV Transplant Studies GS-7977 Also Telaprevir & Boceprevir
Perspectives and challenges of interferon-free therapy for chronic hepatitis C
Hepatitis C–What Are Your Treatment Choices: New Webinar
Setbacks in HCV Drug Development Highlight Uncertainties in Treat or Wait Decisions
So You Think You’re a Hepatitis C Expert
Back in July Clinical Care Options released part one of a three part online quiz containing 35 questions on hepatitis C, answered by nine world-renowned hepatology experts. In October CCO released part two of the series which included case scenarios from 11 leading international experts on hepatitis C, and today part three was released!
Idenix: FDA Places IDX19368 Hepatitis C Treatment on Clinical Hold
IDX184-Idenix hepatitis C drug put on partial hold
BMS halts the development of BMS-986094 due to patient death
BMS-986094-Bristol-Myers Sued Over Heart Damage In Hepatitis C Drug Trial
The International Liver Congress 2013 of the European Association for the Study of the Liver (EASL), will take place April 24 to 28 in Amsterdam, The Netherlands.
EASL Website - Press Room
EASL Abstract Search
Click here for a downloadable PDF version of the Abstract Book.
Tips For Viewing Hepatitis C Abstracts
Download now the ILC 2013 congress app and have full access to the scientific programme, posters, abstracts, floorplans and more!
EASL: Direct-acting antivirals now ready for prime time with promising alternatives on the way
AbbVie is a new, independent biopharmaceutical company composed of Abbott’s former proprietary pharmaceutical business
ABT-267, ABT-333-non- nucleoside, ABT-450/r
r = ritonavir
Faldaprevir/ (BI 201335)
MK-5172 and Daclatasvir
MK-5172 and Daclatasvir-Merck Enters Agreement with Bristol-Myers Squibb to Conduct a Phase II Clinical Trial
CCO's independent conference coverage
An update on treatment of genotype 1 chronic hepatitis C virus infection: 2011 practice guideline by the American Association for the Study of Liver Diseases
Long-term management of the successful adult liver transplant: 2012 practice guideline by the -AASLD
VA guidelines for management and treatment of HCV, published in the American Journal of Gastroenterology
UK consensus guidelines for the use of the protease inhibitors boceprevir and telaprevir in genotype 1 chronic hepatitis C infected patients
Nonalcoholic Fatty Liver Disease (NAFLD)
New Clinical Practice Guideline Developed for Nonalcoholic Fatty Liver Disease
2012-New guidelines on the management of hepatocellular carcinoma (HCC).
These guidelines result from a joint collaboration between the European Association for the Study of the Liver (EASL) and the European Organization for Research and Treatment of Cancer (EORTC).
EASL-April 2012 Revised Clinical Practice Guidelines on the Management of Chronic Hepatitis B
HCV Information and Educational Resources
Clinical Liver Disease -Digital Liver Disease Journal
This journal is an official digital educational resource from the American Association for the Study of Liver Diseases.
Visitors are able to view videos, full data, and download files in either HTML or PDF formats
View all issues here.
Projects In Knowledge
Offered at the site is a program series of HCV Video Case Vignettes. In the videos individual patient case studies are discussed, topics include side effects, drug-drug interactions, treatment duration, and outcome.
AASLD - Liver Learning
If you haven't yet explored the "Liver Learning" section available @ the AASLD web site you're missing out on the November meeting webcasts, video podcasts, abstracts and more.
Other HCV Sites:
These links will take you to the premier Hepatitis C sites and keep you informed with breaking news, clinical studies, new drugs, podcasts, newsletters, support, personal experiences, chat rooms, forums and more.
2012 Articles Of Interest
2012-New Antiviral Agents for Hepatitis C
This article describes the direct acting antivirals and host-targeted agents that have recently been approved or have been tested in HCV-infected patients and discusses their two current paths of clinical development: with or without interferon-α.
Standardization of Terminology of Virological Response in the Treatment of Chronic Hepatitis C
Protease inhibitors: Silver bullets for chronic hepatitis C infection?
Recent trials evaluated the safety and efficacy of two protease inhibitors, boceprevir (Victrelis) and telaprevir (Incivek), added to standard care with pegylated interferon and ribavirin, in patients with chronic hepatitis C virus (HCV) infection. These drugs open the door for triple therapy and other new therapies involving combinations of other direct-acting antiviral agents to become the new standard of care for this population.
Treatment of chronic hepatitis C genotype 1 with triple therapy comprising telaprevir or boceprevir
A significant increase in the number of patients with CHC to be treated is expected for 2012, with triple therapy regimens that are more complex. These expected developments represent a significant challenge and will stretch current resources.
The present Swiss Association for the Study of the Liver (SASL) expert opinion statement is not intended as guideline but shall provide some guidance on the management of CHC genotype 1 and the use of TPV and BOC
If you have just been diagnosed with hepatitis C or considering HCV therapy click here for easy to understand information.
Patient Assistance Program
INCIVEK/Telaprevir and VICTRELIS (Boceprevir) Patient Assistance Programs
Prescribing Information for INCIVEK including the Medication Guide.
VICTRELIS™- Boceprevir: Prescribing Information and Medication Guide
Hepatitis C-New Protease Inhibitor (NS3/4A) Drug Resistance Test
LabCorp has begun offering nationwide its hepatitis C GenoSure NS3/4A assay, which is designed to identify NS3 and NS4A mutations and NS3-associated resistance to a pair of recently approved HCV protease inhibitors.
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After the exposure (especially if the blood exposure involved another person known to have the hepatitis C virus), it is recommended that testing for the hepatitis C antibody be performed at 4 to 6 months after the exposure OR that testing for the hepatitis C virus itself (a test often called an HCV PCR or hepatitis C viral load test) be performed 4 to 6 weeks after the potential exposure. These tests are done to determine whether or not hepatitis C infection has occurred as a result of the exposure.;
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- New HCV Drugs
- Keeping current on the potential arrival of new improved hepatitis C drugs. As once a hepatitis C patient myself (I successfully treated the virus with standard HCV therapy in 2000) I understand the difficult decisions and overwhelming fear that ensues after being diagnosed with this serious and life-changing disease. This blog serves as a starting point for information on the rapidly evolving number of new agents in development to treat hepatitis C. Tina