Medscape Gastroenterology, February 15, 2013
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Hello. I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
Hepatitis C and treatment for hepatitis C have been an ongoing issue, and we have never been in a more exciting time for eradication of hepatitis C virus. Unfortunately, many patients with hepatitis C progress to develop cirrhosis. It is estimated that 25% of patients in the United States with hepatitis C have cirrhosis. An estimated backdrop is about 3.5 million patients. By 2040, it is estimated that this percentage will go up to 45% if left untreated. This is a real problem, not only because of the consequences in our medical care for these patients, but because of what we should do for them now. It has never been more exciting to treat these patients, but we are often held back by patients with cirrhosis or fibrosis, and we think that they may not tolerate the treatments as well or that they are too end-stage, that they don't really need to have these treatments.
An exciting article was just published this past month in JAMA.[1] It is a study that looked at patients with cirrhosis or bad fibrosis. All patients had hepatitis C and liver biopsies, which were classified by an Ishak score. The Ishak scores ranged from 4 to 6. What that means is that these patients had significant scarring of their liver and, in fact, most of the patients had cirrhosis; 27% of patients had an Ishak fibrosis score of 4, 19% had a score of 5, and 54% were very cirrhotic with a score of 6, which is the end of the fibrosis score.
All patients had hepatitis C and were entered into an evaluation. From 1990 to 2003, 530 patients were treated at 5 centers around Europe and Canada. They were followed for the endpoint of all-cause mortality. Secondary outcomes were liver-related mortality, liver-related failure, hepatocellular carcinoma, and need for transplant or decompensation. These endpoints were fairly significant. They looked at sustained virologic response (SVR), which was defined as the absence of a virus for 24 weeks after treatment. It would be a sustained treatment effect, and clearance of the virus would be expected to be maintained. The SVR at 24 weeks would be no virus.
The timeline for this study is 1990 to 2003, so many of these people were receiving monotherapy, pegylated interferon treatments, or consensus interferon treatments. A smaller percentage of patients received combination therapy with ribavirin. Only 34% of these people actually had an SVR. Of the patients who had an SVR, the all-cause mortality was 8.9% at 10 years. Of the non-SVR patients, the all-cause mortality was about 27%. The mean follow-up was 8.6 years, so the 10-year mortalities were calculated if they were available and there was a reasonable endpoint. If you put the numbers for mortality together and look at 8.9% vs 27%, the number needed to treat to prevent 1 all-cause mortality is 6.
In my 36 years of being in medicine, I have never seen such a number needed to treat for an endpoint that is as strong as mortality. With pharma trials, we get excited when we have a number needed to treat that is 10-20, a medium range of good news for pharma trials. Here, we are talking about mortality. A number needed to treat of 6 is unheard of. If you look at hepatocellular carcinoma, the number needed to treat here was 5. The number needed to treat for decompensation and liver transplantation was 4. Cause of death, liver failure, was 4. We have never seen this type of number before for the endpoint of mortality.
Interestingly, they also found a cofactor that was a subset risk, which was genotype 3. If you are genotype 3 and not treated, then you are 2 times more likely to have all of these consequences. We do know that genotype 3 tends to be a much more rapidly progressive disease, although genotypes 2 and 3 are easier to treat. If you don't treat them, they tend to more rapidly progress to fibrosis and cirrhosis. They also tend to be more associated with hepatic steatosis, an independent risk factor for hepatocellular carcinoma. For patients who are subset genotype 3, we need to be very germane in pushing this into a new paradigm shift of prevention of death and much less decompensation and all the consequences of cirrhosis. The endpoints here are so strong for all-comers and even more so for genotype 3, that we need to be treating these people.
Very interestingly, there is a parallel story related to coinfected patients. A paper was published earlier in 2012 regarding HIV and coinfection with hepatitis C.[2] The study had 19 patients who had fibrosis or advanced fibrosis. The numbers were not quite as implicit as the study we just talked about, in which all the patients had fibrosis or advanced cirrhosis. These patients had coinfection, and the number needed to treat was very much in parallel with what we talked about for hepatitis C infection alone. In fact, no HIV/HCV patients who had fibrosis on their biopsies had any related mortality once they had an SVR.
Where are we headed with this?
I think we are headed to a discussion with patients with hepatitis C and fibrosis or cirrhosis. If you have ever been hesitant to treat these people, get over it. These patients need to be aware of an endpoint that is so strong with mortality, that they need to be treated. I am not talking about waiting for new therapies. They need to be treated now. With an endpoint of mortality and a number needed to treat that is 4-6 for mortality, liver mortality, and hepatocellular carcinoma -- if you can't convince them at that point, it's never going to happen. Don't sit back on these patients. We have never seen a number needed to treat with an endpoint of mortality that is this low. Oncologic interventionalists would be ecstatic if they could have a cancer regimen that would prevent cancer or treat cancer with this type of number needed to treat.
Get off the dime. Look hard at your cirrhotic and fibrotic patients. Don't wait for new therapies. In the era of triple therapy with boceprevir, telaprevir, and some of the new protease inhibitors on the short-term horizon, we have an absolute indication and an obligation to treat our hepatitis C patients with fibrosis and cirrhosis, in particular the hepatitis C patients who are genotype 3.
Look at this article. Think about it. Don't forget the HIV-coinfected patients as well. It gives you an interesting discussion next time you have one of these patients in the clinic. It is an exciting time for hepatitis C. Let's make a real difference. I look forward to our next dialogue in the prevention of cancer. It's your opportunity now to take this back to your patients and apply it. I'm Dr. David Johnson. Thanks for listening.
Hepatitis C and treatment for hepatitis C have been an ongoing issue, and we have never been in a more exciting time for eradication of hepatitis C virus. Unfortunately, many patients with hepatitis C progress to develop cirrhosis. It is estimated that 25% of patients in the United States with hepatitis C have cirrhosis. An estimated backdrop is about 3.5 million patients. By 2040, it is estimated that this percentage will go up to 45% if left untreated. This is a real problem, not only because of the consequences in our medical care for these patients, but because of what we should do for them now. It has never been more exciting to treat these patients, but we are often held back by patients with cirrhosis or fibrosis, and we think that they may not tolerate the treatments as well or that they are too end-stage, that they don't really need to have these treatments.
An exciting article was just published this past month in JAMA.[1] It is a study that looked at patients with cirrhosis or bad fibrosis. All patients had hepatitis C and liver biopsies, which were classified by an Ishak score. The Ishak scores ranged from 4 to 6. What that means is that these patients had significant scarring of their liver and, in fact, most of the patients had cirrhosis; 27% of patients had an Ishak fibrosis score of 4, 19% had a score of 5, and 54% were very cirrhotic with a score of 6, which is the end of the fibrosis score.
All patients had hepatitis C and were entered into an evaluation. From 1990 to 2003, 530 patients were treated at 5 centers around Europe and Canada. They were followed for the endpoint of all-cause mortality. Secondary outcomes were liver-related mortality, liver-related failure, hepatocellular carcinoma, and need for transplant or decompensation. These endpoints were fairly significant. They looked at sustained virologic response (SVR), which was defined as the absence of a virus for 24 weeks after treatment. It would be a sustained treatment effect, and clearance of the virus would be expected to be maintained. The SVR at 24 weeks would be no virus.
The timeline for this study is 1990 to 2003, so many of these people were receiving monotherapy, pegylated interferon treatments, or consensus interferon treatments. A smaller percentage of patients received combination therapy with ribavirin. Only 34% of these people actually had an SVR. Of the patients who had an SVR, the all-cause mortality was 8.9% at 10 years. Of the non-SVR patients, the all-cause mortality was about 27%. The mean follow-up was 8.6 years, so the 10-year mortalities were calculated if they were available and there was a reasonable endpoint. If you put the numbers for mortality together and look at 8.9% vs 27%, the number needed to treat to prevent 1 all-cause mortality is 6.
In my 36 years of being in medicine, I have never seen such a number needed to treat for an endpoint that is as strong as mortality. With pharma trials, we get excited when we have a number needed to treat that is 10-20, a medium range of good news for pharma trials. Here, we are talking about mortality. A number needed to treat of 6 is unheard of. If you look at hepatocellular carcinoma, the number needed to treat here was 5. The number needed to treat for decompensation and liver transplantation was 4. Cause of death, liver failure, was 4. We have never seen this type of number before for the endpoint of mortality.
Interestingly, they also found a cofactor that was a subset risk, which was genotype 3. If you are genotype 3 and not treated, then you are 2 times more likely to have all of these consequences. We do know that genotype 3 tends to be a much more rapidly progressive disease, although genotypes 2 and 3 are easier to treat. If you don't treat them, they tend to more rapidly progress to fibrosis and cirrhosis. They also tend to be more associated with hepatic steatosis, an independent risk factor for hepatocellular carcinoma. For patients who are subset genotype 3, we need to be very germane in pushing this into a new paradigm shift of prevention of death and much less decompensation and all the consequences of cirrhosis. The endpoints here are so strong for all-comers and even more so for genotype 3, that we need to be treating these people.
Very interestingly, there is a parallel story related to coinfected patients. A paper was published earlier in 2012 regarding HIV and coinfection with hepatitis C.[2] The study had 19 patients who had fibrosis or advanced fibrosis. The numbers were not quite as implicit as the study we just talked about, in which all the patients had fibrosis or advanced cirrhosis. These patients had coinfection, and the number needed to treat was very much in parallel with what we talked about for hepatitis C infection alone. In fact, no HIV/HCV patients who had fibrosis on their biopsies had any related mortality once they had an SVR.
Where are we headed with this?
I think we are headed to a discussion with patients with hepatitis C and fibrosis or cirrhosis. If you have ever been hesitant to treat these people, get over it. These patients need to be aware of an endpoint that is so strong with mortality, that they need to be treated. I am not talking about waiting for new therapies. They need to be treated now. With an endpoint of mortality and a number needed to treat that is 4-6 for mortality, liver mortality, and hepatocellular carcinoma -- if you can't convince them at that point, it's never going to happen. Don't sit back on these patients. We have never seen a number needed to treat with an endpoint of mortality that is this low. Oncologic interventionalists would be ecstatic if they could have a cancer regimen that would prevent cancer or treat cancer with this type of number needed to treat.
Get off the dime. Look hard at your cirrhotic and fibrotic patients. Don't wait for new therapies. In the era of triple therapy with boceprevir, telaprevir, and some of the new protease inhibitors on the short-term horizon, we have an absolute indication and an obligation to treat our hepatitis C patients with fibrosis and cirrhosis, in particular the hepatitis C patients who are genotype 3.
Look at this article. Think about it. Don't forget the HIV-coinfected patients as well. It gives you an interesting discussion next time you have one of these patients in the clinic. It is an exciting time for hepatitis C. Let's make a real difference. I look forward to our next dialogue in the prevention of cancer. It's your opportunity now to take this back to your patients and apply it. I'm Dr. David Johnson. Thanks for listening.
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