BARRIERS TO THERAPY
Patient-related
Barriers to treatment include lack of acceptance of treatment due to the absence of symptoms; lengthy duration of treatment; adverse effects of HCV drugs; and treatment costs.10 Potential strategies to overcome such obstacles include patient education; simplified dosing; better-tolerated treatments; and collaboration with pharmaceutical companies that offer patient assistance programs.
Drugs for HCV treatment can cause unpleasant adverse effects. Clinicians should encourage adherence for the entire duration of treatment and provide practical advice for coping with adverse effects such as fatigue, headache and other flulike symptoms, injection site reactions, cough, bad taste in mouth, oral ulcers, dry mouth, anorexia, nausea or vomiting, skin reactions, hair thinning or hair loss, and insomnia.10,32
Strategies that may help alleviate these undesirable effects include regular low-impact exercise; drinking plenty of fluids; eating a well-balanced diet; maintaining good sleep hygiene; taking acetaminophen or ibuprofen for myalgias or headaches; and rotating PEG-IFN a injection sites.
Substance abuse and psychiatric disorders are common in patients with HCV infection. These patients should be referred to mental health or substance abuse services.10
Clinician-related
Obstacles to successfully treating patients with chronic HCV infection include patient-related barriers; lack of expertise in HCV management; practitioner bias against or resistance to treating patients who use illicit drugs or abuse alcohol; and concerns about the costs of treatment.
Potential strategies to overcome clinician barriers include collaboration with specialists (eg, hepatologists), utilizing telemedicine if necessary; availability of accessible, clear HCV treatment guidelines; and use of computer-based clinical decision support tools (eg, pop-up reminders and standing orders).10
PATIENT COUNSELING
Patients undergoing treatment for chronic HCV infection should be counseled on the following topics33
• Risk for transmission to sex partners
• Not sharing personal items that might have blood on them, such as toothbrushes or razors, and covering any bleeding wounds to keep from spreading infectious blood or secretions
• Need for vaccinations against HAV and HBV if not immune
• Not donating blood, organs, tissue, or semen
• Stop using illicit drugs
• If continuing to inject drugs, avoid reusing or sharing syringes, needles, water, or drug preparation equipment
• Clean the injection site with a new swab prior to injection
• Safely dispose of syringes after one use
• Consider the benefits of joining a support group
• Avoid alcohol because it can accelerate cirrhosis and end-stage liver disease
• Not to start any new medicines, including OTC and herbal medicines, without checking with their health care professional.
FUTURE TREATMENTS
Treatments for HCV infection are evolving rapidly, and IFN-free options with excellent SVRs are emerging. Below are brief summaries of some of the current research that is focused on the study of IFN-free options. Other new regimens are awaiting approval by the FDA. These include
• The combination of sofosbuvir plus ledipasvir (an NS5A inhibitor) with and without RBV, for HCV genotype 1 infection for 8 or 12 weeks. The SVR in both groups was 93% to 95%. RBV had no effect on SVR.33
• An all-oral combination therapy of daclatasvir (an HCV NS5A replication complex inhibitor) plus sofosbuvir, with or without RBV, for HCV genotypes 1, 2, and 3 for 24 weeks. The SVR varied from 98% with genotype 1, 92% with genotype 2, and 89% for genotype 3. Patients who received RBV had an SVR of 94%; those who did not achieved an SVR of 98%.34
• The combination of ABT-450 (a protease inhibitor boosted with ritonavir), ombitasvir (NS5A inhibitor), and dasabuvir (a nonnucleoside inhibitor) with RBV in patients with HCV genotype 1 and no cirrhosis. At 12 weeks, an SVR of 96% was achieved.35
Despite years of research, a vaccine to prevent HCV infection has not yet been developed, although research continues. The major challenge is the number of genotypes and subtypes of HCV. A vaccine to prevent HCV infection will need to induce immunity to all genotypes and subtypes.36
CONCLUSION
Patients with chronic HCV infection are frequently unaware of this fact, even though the majority of them acquired the liver disease decades ago. Because of the potentially serious consequences of untreated chronic HCV, it is critical that primary care clinicians identify and screen patients who are at risk for having or acquiring the disease. Identification of infected patients enables treatment initiation and, in most cases, cure of the infection. All patients at risk for infection should be counseled about risk reduction and screened periodically.
Thanks to newer, more effective treatment options, patients with HCV have an excellent chance today of clearing the virus and ultimately being cured. This could lead to a dramatic reduction in future HCV-associated morbidity and mortality. Since most of those infected today have never been treated, screening of at-risk patients is essential.
* Editor's note: At press time, the FDA had announced approval of a combination pill (ledipasvir/sofosbuvir) for the treatment of patients with chronic HCV.