Wednesday, August 30, 2017

Editorial: Health-Related Quality of Life in Chronic Hepatitis C

View Original Journal Article - Health-Related Quality of Life in Portuguese Patients with Chronic Hepatitis C, editorial provided below.

GE Port J Gastroenterol 2017;24:55-57

Health-Related Quality of Life in Chronic Hepatitis C
Cardoso H. · Silva M.                       

Hepatitis C virus (HCV) infection is one of the main causes of liver disease and has a great impact on patient outcomes. The estimate of chronically infected persons is about 160 million worldwide, but most of them are unaware of the disease. The clinical impact of HCV infection is highly variable, from minimal changes to cirrhosis and hepatocellular carcinoma, with or without extrahepatic manifestations. Nevertheless, the outcome of HCV infection is not restricted to the clinical endpoints, as it can affect multiple health and psychosocial dimensions.

In recent years, HCV infection has become increasingly noticeable for different reasons. On the one hand, the development of highly effective antiviral therapy has enabled the actual treatment and cure of most diagnosed patients, but on the other hand, the burden from the most severe complications, such as hepatocellular carcinoma, keeps increasing [1,2].

A comprehensive assessment of overall outcomes would include, besides clinical hepatic and extrahepatic manifestations, patient-reported outcomes (PRO) and economic consequences. A PRO is any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else. It reflects patient experience using surrogate markers such as health-related quality of life (HRQoL), functional status, perceived stigma, and work productivity [3,4]. In this context, the study by Rei et al. [5] addresses an important topic and contributes to improve the scarce available Portuguese data. The main self-administered instruments used were the SF-12 (generic) and CLDQ (disease-specific) HRQoL questionnaires.

The first studies on the effects of HCV infection on patients' quality of life, using the short form SF-36 Health Survey, revealed that patients were polysymptomatic and had diminished quality of life with significant reductions in all domains. The reduction in quality of life could not be attributed to the degree of liver inflammation or to the mode of acquisition of the infection. Hence, the authors conclude that chronic HCV infection gives rise to physical symptoms that reduce the quality of life of infected patients [6]. Also, studies with matched controls demonstrated that work productivity is significantly impaired [7]. Regarding cognitive performance, a meta-analysis of studies in HIV-infected patients demonstrated a higher level of cognitive impairment associated with HCV infection [8].

One of the most frequent extrahepatic manifestations is depression. A review of neuropsychiatric symptoms commonly associated with HCV infection showed that major depression was related to illness perception, functional disability, impaired quality of life, fatigue severity, and the presence of psychiatric comorbidity [9]. Likewise, in the study of Rei et al. [5], there was a high prevalence of mood disorders (namely depression) with a negative impact on HRQoL, and the authors therefore recommend screening and suitable psychosocial interventions in a multidisciplinary setting.

Regarding the impact of antiviral therapy on PRO, there were several concerns regarding interferon-based regimens, which negatively affected quality of life during treatment [4,10,11]. Recent studies with antiviral regimens without interferon or ribavirin demonstrated an improvement of quality of life during treatment coinciding with viral suppression within the first month of therapy [12]. Also, Rei et al. [5] reported that oral antiviral treatment could be correlated with HRQoL increases in some domains, which provides growing evidence for the multiple benefits of appropriate HCV treatment.

The achievement of a sustained virological response is associated with an improvement of clinical outcomes, namely a reduction of all-cause mortality [13]. The impact on PRO following successful HCV therapy is also significant; several studies with paired HRQoL assessments demonstrated an overall improvement of all domains of SF-36. Viral eradication leads to HRQoL improvement, regardless of fibrosis stage. HCV patients with early fibrosis experience similar improvement of PRO as those with advanced fibrosis [12,14,15]. Curiously, the HRQoL improvement was progressive over time after the end of treatment, with scores after 24 weeks greater than at 12 weeks [15]. It might be interesting to study what will be the time frame for an extensive recovery of HRQoL after sustained virological response, in relation to healthy controls. Another issue that would benefit from research is the extent of recovery of other PRO, such as perceived stigma and work productivity.

In this era of widespread HCV antiviral therapy, it is important to recognize the comprehensive burden of this disease as well as the value of achieving HCV cure, which translates into benefits at different levels for the patient and society.

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