SAN FRANCISCO — In patients coinfected with HIV and hepatitis C, the presence of HIV disease complicates the treatment of hepatitis C, and, likewise, the presence of hepatitis C complicates the treatment of HIV, Teresa L. Wright, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.
Based on recently published studies and current U.S. and Canadian guidelines, Dr. Wright of UCSF listed some key principles in the management of patients coinfected with HIV and hepatitis C virus (HCV):
▸ If the patient is in an early stage of HIV disease, consider HCV therapy prior to HIV treatment.
▸ If the patient's HIV disease is progressing, optimize HIV control first. Then, once the patient is on a stable HIV regimen, consider HCV therapy.
▸ Treat psychiatric disease and substance abuse, which can lead to reinfection.
▸ When treating HCV, peginterferon alfa-2a should be administered subcutaneously at a fixed dosage of 180 mcg once a week. Peginterferon alfa-2b should be administered subcutaneously at a dosage of 1.5 mcg/kg once per week. Two recently published studies indicate that total HCV viral suppression is more likely with either of the pegylated interferons plus ribavirin than with standard interferon plus ribavirin. Neither of the studies compared pegylated interferon alfa-2a (Pegasys) directly with pegylated interferon alfa-2b (Peg-Intron).
▸ Start patients on a reduced dosage of ribavirin. The guidelines recommend that the dosage of combination ribavirin should reach 400 mg b.i.d. But Dr. Wright said, “we know from a lot of experience with hepatitis C monoinfected patients that this dose of ribavirin is going to be inadequate and suboptimal, particularly in patients with genotype 1 infections. So I think most of us now are increasingly trying to get patients up at higher doses of ribavirin if tolerated.” She mentioned a daily dosage of 1,000-1,200 mg.
▸ Especially with the higher dosages of ribavirin, patients are likely to require growth hormone support with epoetin alfa and/or granulocyte colony-stimulating factor.
▸ When treating HCV, avoid HIV regimens containing didanosine (Videx) because of ribavirin-associated increases in drug levels and mitochondrial toxicity.
▸ Monitor patients closely for side effects and drug-drug interactions.
Dr. Wright said she had no financial relationships relevant to her presentation.