The AGA Institute issued a clinical practice update for managing hepatitis C virus–infected patients who achieve a sustained virologic response after antiviral therapy, who still require ongoing care for their liver disease. The expert review appears in the May issue of Gastroenterology (doi: 10.1053/j.gastro.2017.03.018).
Even though direct-acting antiviral regimens have produced remarkably high sustained virologic response (SVR) rates and it appears that fewer than 1% of patients relapse, and even though liver fibrosis and cirrhosis may regress with this therapy, continued surveillance and even intervention may be needed “to reduce complications arising from liver damage that has already accrued by the time SVR was attained,” said Ira M. Jacobson, MD, AGAF, chair of the department of medicine, Mount Sinai Beth Israel Medical Center, New York, and his associates.
Dr. Ira M. Jacobson
Dr. Jacobson and his associates at the AGA Institute reviewed the current literature and expert opinion to formulate 11 best-practice recommendations for managing this patient population. Among their recommendations:
SVR should be confirmed by hepatitis C virus RNA testing at 12 weeks after completion of an all-oral direct-acting antiviral regimen, and routine confirmation after 48 weeks is also “prudent.” Further testing for later virologic relapse is not supported by the available evidence. However, further periodic testing is advised for patients at risk for reinfection, such as those who continue to use IV drugs.
All patients with stage 3 or higher liver fibrosis or cirrhosis before achieving SVR should continue to be monitored by liver imaging (with or without serum alpha fetoprotein testing) twice a year “for an indefinite duration.” At present, there is no evidence of a finite point beyond which the risk of hepatocellular carcinoma is reduced to the level of people who don’t have a history of liver disease. And there have been documented cases of hepatocellular carcinoma developing more than 5 years after attaining SVR.
Regardless of SVR status, all patients with liver cirrhosis should undergo endoscopic screening for esophagogastric varices. If no varices or only small varices are detected, repeat endoscopy should be done 2-3 years after achieving SVR. If no varices are identified then, “cessation of further endoscopic screening may be considered on an individual patient basis if there are no risk factors for progressive cirrhosis.”
Noninvasive assessment of fibrosis, such as liver elastography, may be considered on an individual basis after SVR is attained, to assess whether fibrosis has progressed or regressed or to guide clinical management.
All patients who achieve SVR must be counseled regarding factors that could further injure the liver and contribute to the progression of fibrosis, hepatic decompensation, or the development of hepatocellular carcinoma. These include alcohol consumption, fatty liver, diabetes, and potential toxins. If serum liver enzyme levels rise, all patients should be evaluated for possible liver injury.