How is the landscape of hepatitis C virus (HCV) management changing since the advent of direct-acting antivirals?
Richard K. Sterling, MD, creator of the FIB-4 Index for Liver Fibrosis : “The development of DAA and non-invasive assessments of liver disease severity have dramatically changed how we approach and manage chronic HCV. The overall safety and tolerability of DAA also have expanded the patient population we can treat. Those with compensated cirrhosis or MELD <15 have similar high sustained virologic response (SVR) compared to those without cirrhosis, although they may require longer treatment or addition of ribavirin to the DAA. Data also suggests that those with mild decompensation (MELD 15-20) can be treated successfully although a percentage may worsen. In this group, we often evaluate for liver transplant first. In those with more severe decompensation (MELD >20), treatment should be done in liver transplant centers with expertise in managing these patients… with increased use of DAA, NASH is becoming the most common indication for liver transplantation.”
Douglas T. Dieterich, MD, professor of medicine, Mount Sinai: “It’s evolved quite a bit. There was no treatment [for HCV] until 1991, and that treatment was horrible. Horrible side effects, and low success rates. Then, for the next 20 years or so, there was no treatment available until the late ‘90s. The disease was only even first named in 1992. It was very hard to isolate it... in 2001, the combination of pegylated interferon and ribavirin was approved, and there was no progress at all between 2001 and 2011, with about a 25% cure rate with 48 weeks of terrible side effects. In 2011, the 2 new protease inhibitors telaprevir and boceprevir were approved, but they were add-ons to PEG and ribavirin. And they not only added but exponentially increased side effects. The real-world results went from about 25%-40% cure rates, and the side effects were unbelievably difficult...in November 2011, we saw the presentation of just one drug, sofosbuvir and ribavirin, cure 100% of hep C patients, genotypes 2 and 3, which sort of shook the world. And 2 years later, sofosbuvir was on the market, and basically, the days of interferon were over.”
Paul Y. Kwo, MD, ACG guideline author: “The advent of direct-acting antiviral agents for hepatitis C has revolutionized the treatment of this infection. There are few other chronic diseases that can be cured with a short course of therapy that is well-tolerated. We are seeing fewer patients listed for transplant for hepatitis C, and increasing awareness among many of the patients who were hesitant to take interferon-based therapies are coming in to be treated with our new direct-acting antiviral agents.“