Originally Published July 15, 2015
C treatment in the elderly: New possibilities and controversies
towards interferon-free regimens—Vespasiani-Gentilucci U, et al.
Source: World Journal of Gastroenterology, 07/06/2015
Results and Conclusions: In
this article the authors discuss some important issues regarding the
treatment of elderly patients with interferon-free therapies. Elderly
patients have additional health concerns that affect treatment
A generally faster disease progression to cirrhosis and liver cancer than those who are younger
More extrahepatic conditions such as fatigue, cognitive issues
A potential decrease in quality of life
Possible drug-drug interactions with medications taken by the elderly (diabetes, heart, blood-pressure medications)
The authors recommend that the
best case scenario is to treat every elderly patient because of the
risk of accelerated disease progression. If this is not realistic, we
should be treating those who need treatment first who are in danger of
disease progression. The patients who are not in immediate need of
treatment should be monitored on a regular basis. As with current
recommendations, those who have only a short-term survival are excluded
from HCV antiviral treatment.
The Bottom Line:
In general, the elderly population faces many health complications.
The elderly also face discrimination from healthcare professionals. It
is important that everyone with hepatitis C have an advocate—a family
member or friend to help them through the intricacies of monitoring HCV
and accessing HCV treatment.
We now have medications that have fewer side effects and have been
found to be safe in people with mild to moderate kidney impairment.
It is important that the newly approved drugs and the investigational
drugs be tested with the many medications that are commonly prescribed
to the elderly.
Everyone deserves the right to
be cured of hepatitis C including the elderly with hepatitis C. More
importantly, don’t we have an obligation to make sure that our elderly
population with hepatitis C be treated and cured? This way they can
live their lives in relative health and know that they no longer have
to deal with the potential physical and emotional consequences of
living with hepatitis C.
Hepatitis B Virus Reactivation During Successful Treatment of
Hepatitis C Virus with Sofosbuvir and Simeprevir—J. M. Collins et. Al
Source: Clinical Infectious Diseases Advance Access
Results and Conclusions: This was a case report of two individuals with hepatitis C.
The first case was a 55 yo man
who was coinfected with hepatitis B and hepatitis C genotype 1a. He had
been previously treated with pegylated interferon plus ribavirin but
did not achieve a cure. He was started on sofosbuvir and simeprevir.
After week 4 he was HCV undetectable, but at week 7 he started to have
severe liver symptoms (AST of 1792 IU/L, ALT of 1495 IU/L, total
bilirubin of 12.2 mg/dl and INR of 1.96) and his hepatitis B viral load
rose to 22 million. His other tests (antinuclear antibody, ferritin,
a-fetoprotein, etc.) were also abnormal.
The HCV treatment was
discontinued, and hepatitis B treatment (tenofovir/emtricitabine) was
started and the hepatitis B viral load subsequently decreased to less
than 20 IU/mL. The hepatitis B treatment was continued for ongoing
hepatitis B suppression.
The second case was a 57 yo man
with HCV genotype 1a. He had been treated for HCV with pegylated
interferon plus ribavirin but had not been cured. He was positive for
the hepatitis B virus, but the hepatitis B viral load was below the
level of detection (20 IU/mL). He was started on HCV
treatment—sofosbuvir and simeprevir and his HCV and hepatitis B viral
loads were monitored every two weeks. After two weeks, his HCV viral
load was undetectable and his hepatitis B viral load increased to 353
IU/mL. After four weeks of HCV treatment, HCV was still undetectable,
but the hepatitis B viral load increased to 11,255 IU/mL. The liver
function tests were normal, and there were no other signs of liver
disease. The patient remained on sofosbuvir/simeprevir treatment.
Tenofovir was added to the HCV treatment regime to treat hepatitis B.
The Bottom Line:
The reactivation of HBV in people who were coinfected with HBV and HCV
was rare in the days of pegylated interferon based therapies. This
was most likely because PEG works against HBV whereas the new HCV
direct acting antivirals do not have antiviral properties that will
suppress hepatitis B while treating HCV.
Editorial Comment: A couple of important points:
Everyone with hepatitis C should be tested for hepatitis B (and A), and if not previously infected should be vaccinated.
People who are chronically
infected with HBV and HCV who are being treated with the direct-acting
antiviral medications (Harvoni or Viekira Pak) should be monitored very
closely—every two weeks as listed in the second study—for HBV flares
and treated for HBV as needed.
Labels: elderly, HBV reactivation, snapshots