EASL released its previous hepatitis C treatment guidelines update at last year's International Liver Congress in Vienna. This year
the EASL panel members discussed the guidelines and announced that the next
revision will be released at a special meeting, New Perspectives in Hepatitis C Virus Infection – The Roadmap for Cure, to be held September 23-24 in Paris.
The panel decided to delay the release to wait
for European approval of newer DAAs, said guidelines co-ordinator Jean-Michel
Pawlotsky of Henri Mondor University Hospital. The grazoprevir/elbasvir (Zepatier)
co-formulation, approved in the US this past January, is expected to receive
European Union approval this summer.
Massimo Puoti of Ospedale
Niguarda Ca' Granda in Milan emphasised that all hepatitis C patients should be
treated, except those with a short life expectancy due to other causes, in
consideration of both individual health and
the public health benefit of preventing HCV transmission.
"Every hepatitis C patient has a right to
be treated," Prof Pawlotsky concurred. "People misunderstand
prioritization. A good reason is that we cannot treat everyone at once so we
treat those with advanced disease first. A bad reason is not to treat because
it's too expensive."
With regard to repeat treatment of people who
become reinfected with HCV, panel members agreed that this should not be limited.
"In medicine we don't punish people for their behaviour," stressed Christoph
Sarrazin of JW Goethe University Hospital in Frankfurt. Geoffrey Dusheiko of the Royal Free Hospital in London suggested
that people who are reinfected should in fact be prioritised
for re-treatment because they're likely to also be HCV transmitters.
Duration of treatment remains subject to
debate. Prof Pawlotsky asked if everyone starting therapy for the first time
should be treated for 12 weeks to make it simple and to be safe, even if it
meant some people would be 'over-treated'.
Shorter treatment is more convenient, less
expensive and encourages adherence, but shortening it too much raises the risk
of relapse. HIV/HCV co-infected people, for example, will need longer than six
weeks, Prof Pawlotsky suggested.
When treating people with HCV genotype 3, Alessio Aghemo of
of Milan also argued for more intensive treatment to be safe. Sofosbuvir/daclatasvir plus ribavirin has
been shown to be effective, and he suggested that 24 weeks is an optimal
duration and ribavirin should not be omitted for patients with cirrhosis. "We
can manage the side effects," he said.
Noting that patients with cirrhosis with genotype 3
are especially difficult to treat, Prof Dusheiko argued that this group should
be prioritised for treatment before they develop advanced liver disease.
Turning to patients with decompensated liver
disease, Xavier Forns of the Hospital Clinic of Barcelona noted that about 15% of patients on transplant waiting lists can be
delisted after being cured of hepatitis C. It is unclear why some patients improve and others don't, but "there's a point of no return," he warned.
Looking at resistance, Prof Pawlotsky argued
for changing terminology: a resistance-associated variant or RAV is a type of
virus, while a resistance-associated substitution or RAS is a specific genetic
change – and the latter is what is generally meant when discussing DAA
Prof Sarrazin argued that baseline resistance testing is not necessary for first-line treatment. Prof
Pawlotsky added that while resistance tests are not recommended, they are also
not forbidden if they are available and affordable. "If you have access
they can help you, but without them you can still treat patients
successfully," he said.
Finally, the panel members discussed some of
the remaining medical challenges of hepatitis C treatment, including dealing
with the adverse effects of ribavirin, the risk of using HCV protease
inhibitors for patients with a history of decompensated cirrhosis and the unexpectedly high recurrence of liver cancer after DAA therapy compared to patients treated with interferon.