Saturday, April 29, 2017

Practice update for managing patients cured of HCV infection

AGA Institute releases practice update for managing patients cured of HCV infection
Direct-acting antiviral (DAA) regimens for chronic HCV infection achieve high rates of SVR and have replaced interferon (IFN) in many countries. The current definition of SVR is undetectability of HCV RNA at 12 weeks after treatment (SVR12). Patients who achieve an SVR have a less than 1% risk of relapse and are considered cured.

Patients cured of HCV may experience reductions in the risk for death and hepatocellular carcinoma (HCC), as well as regression of liver changes including fibrosis or cirrhosis, but may still have higher rates of HCV-related complications than the general population. Patients who have already developed liver damage at the time of achieving SVR may be particularly at risk for future complications.
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Full Text
May 2017 Volume 152, Issue 6, Pages 1578–1587
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American Gastroenterological Association Institute Clinical Practice Update—Expert Review: Care of Patients Who Have Achieved a Sustained Virologic Response After Antiviral Therapy for Chronic Hepatitis C Infection
Chronic hepatitis C virus infection is well-recognized as a common blood-borne infection with global public health impact affecting 3 to 5 million persons in the United States and more than 170 million persons worldwide. Chronic hepatitis C virus infection is associated with significant morbidity and mortality due to complications of liver cirrhosis and hepatocellular carcinoma. Current therapies with all-oral direct-acting antiviral agents are associated with high rates of sustained virologic response (SVR), generally exceeding 90%. SVR is associated with a reduced risk of liver cirrhosis, hepatic decompensation, need for liver transplantation, and both liver-related and all-cause mortality.

However, a subset of patients who achieve SVR will remain at long-term risk for progression to cirrhosis, liver failure, hepatocellular carcinoma, and liver-related mortality. Limited evidence is available to guide clinicians on which post-SVR patients should be monitored vs discharged, how to monitor and with which tests, how frequently should monitoring occur, and for how long. In this clinical practice update, available evidence and expert opinion are used to generate best practice recommendations on the care of patients with chronic hepatitis C virus who have achieved SVR.

The battle against hepatitis C virus (HCV) has culminated in remarkably high rates of sustained virologic response (SVR) conferred by 6 currently approved interferon (IFN)-free direct-acting antiviral (DAA) regimens against genotypes 1−6 HCV.1, 2, 3, 4, 5, 6 In the many countries where these regimens are available, the use of IFN has essentially ceased. Follow-up studies and cumulative experience have affirmed that, as with earlier IFN-based therapy, SVR is tantamount to virologic cure. Fewer than 1% of patients relapse after SVR, defined during the years of IFN therapy as HCV RNA undetectability 24 weeks, and more recently as 12 weeks, after completion of treatment (SVR12).7, 8, 9, 10, 11, 12, 13

With the increasingly frequent opportunity to celebrate virologic cure with patients comes the corresponding need to advise them about whether, when, and for how long ongoing care for liver disease is needed. Therefore, it is critical to identify the ongoing risks for the individual patient and the measures needed to mitigate those risks. Numerous studies in patients cured of HCV by IFN-based therapy have demonstrated reductions in all-cause mortality, liver-related mortality, need for liver transplantation, variceal bleeding, and hepatocellular carcinoma (HCC),14, 15, 16 as well as a reduction in mortality from extrahepatic complications.17 Regression of fibrosis and even cirrhosis has been documented, as has been demonstrated in other liver diseases when the underlying cause has been controlled.18, 19, 20, 21 Nevertheless, reduction in risk is still potentially relative rather than absolute, and ongoing surveillance and intervention may be required in some patients to reduce complications arising from liver damage that has already accrued by the time SVR has been attained. Of greatest concern is the ongoing risk of HCC in patients with pre-existing advanced fibrosis or cirrhosis. In this article, the considerations surrounding the care of patients who have achieved SVR will be discussed, and proposed recommendations will be presented
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