Curing your Patients from Hepatitis C: Addressing Complex Needs with Simplified Treatment Approaches - Episode 5

Candidates for HCV Treatment

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Expert hepatologist Mark Sulkowski, MD discusses which patients are candidates for HCV treatment.


Anthony Martinez, MD: OK, so we’ve diagnosed our patient we’ve done our baseline workup. That’s been pretty easy. Mark, who are you treating, who needs to be treated? And the second part of the question is, are you still differentiating between acute hepatitis C and chronic hepatitis C?

Mark Sulkowski, MD: Well, it’s a really great question with a pretty simple answer. We’re treating patients with active hepatitis C infection. If they are [for] positive hepatitis C RNA, and people have talked about giving the antibody reflexing to RNA testing, if that’s positive, it’s telling you that there is an active infection. That person has replicating virus in the liver. Then we can look at other tests things like their liver enzymes, but that’s not really important [as] they’ve already met the definition for needing treatment. The guidelines from the liver society and the [Infectious Disease Society of America] adopted this stance several years ago that said everybody is a candidate for treatment. Now, they have some caveats to that; they say if your life expectancy is short, perhaps you don’t treat, although I’ll tell you, I’ve been challenged in my own practice. I’ve had patients being treated [for] malignancy where there is concern about liver toxicity of chemotherapeutic agents, and by treating the hepatitis C with a safe and effective therapy, we can enable them to take treatment. So I don’t like to draw a line in the sand and say someone who’s 80 years old shouldn’t be treated. I think you have to evaluate the patient who may have a short life expectancy and decide whether that makes sense. But otherwise our guidelines say treat everyone. And to your second point, Tony, they actually recently said don’t distinguish the chronicity. And we get into this discussion about acute hepatitis C vs chronic hepatitis C, and why is that important? Well, because the human immune system actually can clear acute hepatitis C, and it happens anywhere from 25% to 50% of people. So in the old days, back when we used interferon therapy, something that many of us are trying to forget, [in] those days, treatment was ineffective and caused a lot of [adverse] effects. So you would say to that person with acute hepatitis C, “Let’s wait and see what happens. Maybe you’ll clear, and if you don’t clear by 6 months, we’ll treat with interferon.” But in the current era, we know the oral therapies work highly effectively with standard dosing. They can prevent chronicity in nearly 100% of people. But we also, getting back to our discussion of elimination and transmission, really start to think about what’s happening while we’re waiting. And the people I’m seeing in my clinic with acute hepatitis C are people at risk to transmit the virus to other people, perhaps through sharing needles or equipment or among men having sex with men who are HIV co-infected. And while you’re waiting to see if they clear, they may be spreading the infection to 2, 3, or more people. So from a perspective of that patient, let’s get rid of the hepatitis C. From a perspective of treatment as prevention, if we do that, we protect society and their networks as well. So I think that’s really evolved to say, [if you] see a virus, treat a virus.

Anthony Martinez, MD: Essentially, I think what we’re hearing is if they’re [in a] viremic period, they need to be treated. Especially, as you said, if we’re waiting in this higher-risk population, there’s data that suggests that 1 person who’s actively using drugs, left untreated, will potentially infect up to 20 other individuals. So this is a concept of treatment as prevention. We’re not going to be able to eliminate unless we get people initiated, diagnosed quickly, and started on treatment rapidly.

Mark Sulkowski, MD: I’ll add to that. I think one of the biggest barriers…[is], we still see health care provider attitudes and stereotypes about who is a treatment candidate being one of the biggest barriers. Even [in] our group, I’ve reviewed charts, and it says patient actively injecting, will treat when they’re more stable or waiting for some milestone, or a patient actively drinking alcohol, will refer to a program and wait. And that’s not the right attitude. We know that we can successfully treat people with active substance use disorder. We can concurrently treat their substance use disorder and leave them hopefully cured of hepatitis C and in a treatment program. So I think that attitude of a clinician deciding when someone’s ready is [where] we need to break that mold.

Anthony Martinez, MD: I think it’s important to point out too that the guidelines have changed around all of this. There’s no more recommended period of sobriety. We saw a few states that have some language around substance use and treatment and the need for treatment, but overall the guidelines right now do not support or recommend any period of abstinence prior to initiating hepatitis C therapy. And if you equate it with other disease states, you think about things like diabetes. We don’t mandate that patients lose X amount of weight before we initiate treatment with insulin, for example. So if we kind of wrap our head around that same concept and sort of equate it to the same type of thing.

Mark Sulkowski, MD: I’ll pause to talk just a little more about alcohol because it’s one of those things that really kind of drives me crazy. Whereas alcohol worsens hepatitis C liver disease and so 1 plus 1 equals 3, they’re synergistic. If we can cure the hepatitis C, which is easy to do, we can leave them with 1 cause of liver disease and focus on that. Yet for some reason I think it’s carved into stone. [Going all the way] back to the very first hepatitis C guidelines in the late 1990s, they were adamant about not treating hepatitis C if someone was [actively] drinking. I think they were still suffering from some of these residual guidelines from decades ago.

Anthony Martinez, MD: Sure, the medications and therapeutics evolved, but maybe the guidelines didn’t necessarily evolve as quickly.

Nancy Reau, MD: And if I could add, some of that is how we capture data. So there were studies that looked at inpatients with alcoholic hepatitis and they decided that treating their hepatitis C didn’t improve their mortality. Well, that’s because these were people who were dying of acute alcoholic hepatitis that had nothing to do with someone who had alcohol use disorder and hepatitis C. So I think that was a self-fulfilling prophecy. We chose to look specifically at patients who were going to do poorly and then concluded, like Mark said, if you have a short life expectancy and hepatitis C isn’t driving that life expectancy, that you may not need treatment. Well, we’ve super selected a group that that told us we didn’t have to treat these patients or that the alcohol was going to hurt them. And now we know that, at least in my clinic, the vast majority of individuals have both metabolic syndrome and alcohol use disorder and hepatitis C, and of those 3 injuries that are all wildfire in their liver, 1 of them can be cured.

Transcript was AI-generated and edited for clarity.