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. 1999 Aug 14;319(7207):450. doi: 10.1136/bmj.319.7207.450a

Treatment of hepatitis C infection

Review underplayed important public health issues

Kosh Agarwal 1, David D E Jones 1
PMCID: PMC1127052  PMID: 10445936

Editor—We were disappointed that McCarthy and Wilkinson’s review of recent advances in hepatology underplayed important public health issues and treatment options surrounding hepatitis C virus.1 In Western Europe about 5 million people are chronic carriers of hepatitis C virus, and in industrialised countries the virus accounts for 40% of cases of end stage cirrhosis and 30% of liver transplants.2 Hepatitis C is thus an important health problem.

Recent data confirm that combination antiviral treatment with ribavirin and interferon is better than interferon alone, with a 38-43% sustained response rate (polymerase chain reaction negative) with 12 months of combination treatment compared with 13-19% with interferon alone.3,4 Although ribavirin has been supplied for use only in trials in the United Kingdom, it is imminently to be licensed for patients who relapse after interferon alone and is already licensed for this indication in the United States and other European countries.

Moreover, a recent international consensus conference on hepatitis C recommended that interferon and ribavirin be first line treatment for previously untreated (naive) patients without contraindication to ribavirin. Duration of treatment should be tailored to viral load and viral genotype. It was suggested that patients with viral genotype 1 should have a six month course of combination treatment before viral response to treatment is assessed compared with three months for those infected with other viral genotypes. These recommendations (drawn from a panel of experts) have important public health and economic implications.

Lastly, we are not aware of any large trials using ribavirin alone in patients with recurrent hepatitis C infection after transplantation as it has little in vitro activity against the virus. Preliminary data on 122 patients with chronic recurrent infection after transplantation from Italy suggest that sustained response rates of up to 50% (similar to that in chronic non-immunocompromised hepatitis C infection) can be obtained safely in selected groups without precipitating graft rejection.5 Patients with coexistent HIV infection should be considered for antiviral treatment of hepatitis C if HIV disease activity is stable. We must be aware of improvements in treatment options for hepatitis C and the public health issues surrounding these advances, particularly in an environment where health resources are finite.

Footnotes

Competing interests: None declared.

References

  • 1.McCarthy M, Wilkinson MI. Recent advances in hepatology. BMJ. 1999;318:1256–1259. doi: 10.1136/bmj.318.7193.1256. . (8 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
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BMJ. 1999 Aug 14;319(7207):450.

Authors’ reply

M McCarthy 1, M Wilkinson 1

Editor—Although we agree with Agarwal and Jones’s comments regarding the importance of public health issues and treatment options for hepatitis C infection, we would like to point out that our article was aimed at providing an overall review of recent changes in hepatology for non-specialised readers. This meant addressing several topics, and although hepatitis C infection is one of the more important issues, we were obliged to limit the discussion to a concise and less detailed one.

Since our article was submitted, consensus statements have made clear recommendations on the treatment of naive hepatitis C infection with a first line combination therapy of interferon alfa and ribavirin, which was previously still being evaluated in controlled trials.1-1

Such guidelines now advocate the use of combination therapy with interferon alfa and ribavirin in naive patients without contraindication. Treatment for six months is advised for patients with genotype 2 or 3, irrespective of levels of viraemia. However, for those with genotype 1, treatment should be for six months if viraemia is low (<2 million copies/ml) but for 12 months if viraemia exceeds this level. If ribavirin is contraindicated, interferon should be offered alone for 12 months (3 MU three times a week), with continuation of therapy after three months only in those whose hepatitis C viral RNA has disappeared. Patients who have relapsed after treatment with interferon, can be given either six months of combination therapy or a higher dose of interferon alfa for 12 months.

Treatment of recurrent hepatitis C infection after transplantation has recently been comprehensively reviewed by Berenguer et al.1-2 Results of preliminary open label studies of ribavirin monotherapy have been disappointing with respect to viral clearance,1-3,1-4 and more recent studies have concentrated on combination therapy with interferon alfa and ribavirin with promising initial results.1-5

Footnotes

Competing interests: None declared.

References

  • 1-1.EASL international consensus conference on hepatitis C. J Hepatol. 1999;30:956–961. [PubMed] [Google Scholar]
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