Thursday, February 13, 2014

Current HCV therapies may not benefit older patients

Current HCV therapies may not benefit older patients

Innes H. J. Hepatol. 2014;doi:10.1016/j.jhep.2014.01.020.

A sustained virologic response to existing hepatitis C treatments — namely, pegylated interferon and ribavirin combined with a protease inhibitor — is less likely to benefit older patients with less advanced liver fibrosis, according to recent data. In light of these findings, older patients may opt to wait for future regimens with fewer adverse effects.

“The question of what value a [sustained virologic response], in itself, imparts on the patient is often left unstated,” researchers wrote in the Journal of Hepatology.” Given that many treatment candidates are without symptoms of their infection, patients must be well-informed regarding what, by way of prognosis improvement, [sustained virologic response] can offer. Yet, to date, this issue has received little attention despite being critical to informed consent.”

The researchers created the HCV Individualized Treatment-decision model to simulate the lifetime course of HCV-related liver disease according to two scenarios: the patient who achieves sustained virologic response (SVR) as a result of antiviral therapy and the patient who does not either because he or she does not accept therapy or fails to respond to treatment and the infection persists. The course of liver disease was compared for each model subject. The benefit of SVR was defined in the study as the likelihood of gaining additional life-years and “healthy” life-years spent avoiding liver failure.

Results indicated that the benefit of SVR varied widely. For example, the probability that a patient aged 60 years with mild liver fibrosis would gain life-years as a result of achieving SVR was just 1.6% (95% CI, 0.8-2.7) and 2.9% (95% CI, 1.5-4.7) for gaining healthy life-years. In comparison, the likelihood of a patient aged 30 years with compensated cirrhosis gaining life-years was 57.9% (95% CI, 46-69) and 67.1% (95% CI, 54.1-78.2) for healthy life-years.

“This benefit-disparity is equivalent to a clinician needing to clear infection in, on average, ~35 times as many persons of the former description, than persons of the latter, in order to avert the same number of HCV-related deaths,” the researchers wrote.

Severe liver disease is not necessarily an inevitable outcome in the absence of treatment, and because existing HCV therapies have well-documented adverse effects, clinicians and older patients face a difficult decision as to whether they should wait for future regimens that are more tolerable.

“In the short term, this work will inform the contemporary patient dilemma of immediate treatment with existing interferon-centered therapies, versus holding out for future regimens that promise higher SVR rates and improved tolerability,” the researchers concluded. “Longer term, it urges that broadened access to therapy be twinned with efforts to more objectively communicate, to the individual patient, the benefits of therapy.”

Disclosure: See the study for a full list of financial disclosures.

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