Hepatitis C Medications: The Good, The Bad And The Unexpected

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The past three years have seen a revolution in the treatments of hepatitis C. No other infectious disease has gone from initial identification to cure in such a short period of time. Multiple oral regimens have been approved which treat all types of hepatitis C and all patients with the disease. It is always good to take a step back and look at the ramifications of such an advance.

The Good

Hepatitis C, the leading cause of liver transplantation and the most common chronic blood-borne infectious disease in the United States, is now curable in greater than 95 percent of all patient groups. These cure rates apply to all genotypes. These cure rates also apply to those patients who failed previous interferon and ribavirin therapies, who have compensated and decompensated cirrhosis, who have advanced kidney disease including dialysis and those co-infected with the human immunodeficiency virus.

The pill burdens are low with most regimens being a single tablet once a day for either eight, 12 or 24 weeks. The side effects of these therapies are minimal. Most people state that they have no side effects or that they feel better on treatment than they did before starting the medications. The high cure rates have led to a decrease in disease progression, a decrease in the development of cirrhosis and liver cancer and an overall improvement in what the liver looks like with many patients improving to a point that they no longer have cirrhosis. Curing hepatitis C has been associated with overall increased survival from non-liver diseases like stroke and heart disease.

The Bad

Treatment of hepatitis C still has some subtleties that need to be addressed. The various new therapies represent different classes of medications that act differently on the virus and these different classes are used together. Each class of medications has its own safety profile. It is very important not to give a protease inhibitor to someone with decompensated liver disease as that can cause the liver to fail. It is also very important to review medications patients are taking to ensure there are no drug-drug interactions which can lead to either medication toxicity or decreased potency.

The real problem with these therapies is access. While the therapies are costly, they have been shown to be cost effective and their price has come down considerably over the past three years. In late 2015, access to these therapies improved significantly and appropriate therapies were easily obtainable for deserving patients. In November 2016, something changed that we cannot explain but all of a sudden access to treatments has decreased and not only are patients not able to get these therapies but many doctors are being told that they cannot prescribe these therapies because they are not skilled enough. This is a real problem. We have curative therapies that patients cannot get for any reason other than insurance companies do not want to pay for them.

The Unexpected

Curing hepatitis C seems to reinvigorate dormant viruses in the patient. For example, there have been more than 25 patients with inactive hepatitis B whose disease flared after being cured of hepatitis C. This is concerning and has led to the recommendation that all patients being considered for hepatitis C treatment be evaluated for hepatitis B and either monitored for disease flares on treatment with periodic blood tests or simply treated for hepatitis B when appropriate. This should not be a reason to withhold hepatitis C treatments. In addition, more than 10 patients have reported a flare of herpes infection after hepatitis C cure. These viral flares were certainly unexpected and we will need to follow our cured patients closely to observe for any other unexpected consequences of curing hepatitis C.

David Bernstein, MD, is chief of gastroenterology, hepatology and nutrition at Northwell Health.

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