INFO: Who Should Be Targeted for Treatment?

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From Medscape Gastroenterology Hepatitis C Expert Column Posted 03/06/2007 Reau, MD; F. Fred Poordad, MD Who Should Be Targeted

for Treatment? It seems logical that young patients with minimal injury should be targeted for therapy. However, treatment in this subset is controversial because not all patients with chronic active hepatitis C develop progressive liver disease. The rate of fibrosis can be slow, moderate, or rapid, and is not necessarily linear over time.[25] Although negative contributing factors have been identified, there is still no way to determine with certainty which track a patient with minimal injury will follow. This has led some experts to recommend therapy only for patients who have "declared" their risk for progressive disease.[13] However, this approach needs to be reexamined as well. Accurate monitoring of disease progression will require serial liver biopsies, which has a risk for complications, a component of sampling error, and is both inconvenient and painful. Patients would need continued biochemical evaluation. Indeed, it has

been demonstrated that among patients with normal alanine aminotransferase (ALT) levels, nearly one fourth develop abnormal serum ALT over 5 years of observation.[26] Moreover, when told that a disease does not require immediate therapy, many patients fail to return for follow-up. With time, patients are likely to develop other health problems that may have an impact on treatment outcomes (such as obesity or diabetes) or even preclude initiation of therapy (such as coronary artery disease, malignancy, or severe depression). As it has also been established that younger patients are more likely to obtain SVR,[11,12] treatment for patients with minimal disease should be considered in those with good prognostic indicators for response. If RVR or EVR is not achieved, treatment can then be discontinued, electing for observation until disease progression is documented. Hepatitis C treatment has evolved to a more sophisticated

and patient-specific approach. Patient and viral characteristics that predict treatment response and failure, allowing implementation of strategies to improve viral response, such as age, race, fibrosis score, immune status, genotype, baseline viral load, RVR, and EVR, are increasingly linked to outcome and will likely lead to "a la carte" therapy or individualized treatment regimens in both dosing and duration. As disease burden is expected to exponentially increase over the coming years, all patients should continue to be evaluated with eradication of infection as the primary goal. http://www.medscape.com/viewarticle/552614_5