Therapy For Hepatitis C

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Therapy For Hepatitis C
Therapy For Hepatitis C
Video: Therapy For Hepatitis C
Video: How to treat hepatitis C 2023, February
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Hepatitis C: Therapy

Therapy is generally recommended for HCV-RNA-positive patients if the hepatitis C virus has been detectable in the blood for more than six months. In recent years, drugs with completely new modes of action have been developed. They intervene directly at different points in the replication cycle of the hepatitis C virus and are therefore referred to as direct antiviral substances (DAAs).

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  • How is hepatitis C treated?
  • Modern therapy concepts for chronic hepatitis C.
  • Goals of Therapy
  • Whom can I ask?
  • How are the costs going to be covered?

How is hepatitis C treated?

In the past, the dual combination therapy of pegylated interferon alfa plus ribavirin was the standard therapy for chronic hepatitis C for many years. However, this therapy had three serious disadvantages:

  • The cure rates (SVR rates, SVR = sustained virological response = sustained virological response) were only around 40–50 percent in genotype 1, despite a long treatment period of six to 18 months. The SVR rate for genotypes 2, 3, 5 and 6 was significantly higher at 70–90 percent; the SVR rates for genotype 4 were in between.
  • As part of the therapy, side effects - some of them serious - occurred very frequently.
  • Numerous contraindications had to be observed, so that a considerable proportion of all patients were unsuitable for the therapy. In addition, interferon is contraindicated in decompensated cirrhosis of the liver, so that precisely those patients who most urgently needed therapy could not be treated.

Modern therapy concepts for chronic hepatitis C

In recent years, drugs with completely new modes of action have been developed. They intervene directly at different points in the replication cycle of the hepatitis C virus and are therefore referred to as substances with a direct antiviral effect (DAAs = Direct Acting Antivirals). Depending on the approach, a distinction is made between protease inhibitors, polymerase inhibitors and NS5A inhibitors as subgroups.

Eight modern DAAs are currently approved for the treatment of chronic hepatitis C across Europe. The DAAs contain one or more active substances (elbasvir / grazoprevir, daclatasvir, dasabuvir, ombitasvir / paritaprevir / ritonavir, simeprevir, sofosbuvir, sofosbuvir / ledipasvir, sofosbuvir / velpatasvir) and are administered individually or in combination. In addition, administration of ribavirin or, in some patients, administration of pegylated interferon alfa may be necessary. All DAAs are taken orally and are characterized by a favorable side effect profile.

Numerous studies have shown that by combining two or three of these new DAAs from different classes, a successful therapy for chronic hepatitis C is possible even without interferon. The choice of therapy depends on the genotype and stage of liver disease. The duration of therapy is usually twelve weeks. In some cases it makes sense to shorten the therapy to eight weeks or to extend it to up to 24 weeks. All of the new DAAs mentioned are extremely effective against genotype 1. The cure rates are slightly lower for the other genotypes. Overall, cure rates of around 90 to 95 percent can usually be achieved, even with genotype 3, which is difficult to treat.

New therapy regimen for genotype 1

As the modern DAAs mentioned are highly effective against genotype 1, there are currently four therapy regimes to choose from for treating this genotype:

  • Sofosbuvir + simeprevir
  • Sofosbuvir + daclatasvir
  • Sofosbuvir + ledipasvir
  • Paritaprevir / ritonavir + ombitasvir + dasabuvir

Numerous studies have shown that in patients in whom the liver still functions well, healing rates of over 95 percent can be achieved with all four therapy regimens with virtually no side effects. The combinations sofosbuvir + simeprevir or sofosbuvir + daclatasvir are, however, significantly more expensive than the other two schemes, so that they are currently not reimbursed by health insurers for genotype 1 therapy in Austria. Therefore, only the other two therapy regimes are described below.

  • Sofosbuvir + Ledipasvir: The two active ingredients are combined in one tablet that must be taken once a day. For patients without liver cirrhosis who have never had treatment for chronic hepatitis C, an eight-week therapy is sufficient. All other patients should be treated for twelve weeks.
  • Paritaprevir / Ritonavir + Ombitasvir + Dasabuvir: Here three modern DAAs are combined with one another. The twelve-week administration of this so-called “3D regime” enabled cure rates of well over 90 percent to be achieved in patients with good liver function. In some patient groups (especially with genotype 1a) the additional administration of ribavirin is recommended.
  • Patients with decompensated cirrhosis of the liver: One speaks of decompensated cirrhosis of the liver when the organ can no longer compensate for the decline in function and can thus perform its tasks. If this is the case, not all modern DAAs can be unreservedly recommended: The two protease inhibitors simeprevir and paritaprevir are broken down in the liver, so that if the liver function is severely impaired, there is a risk of relevant side effects. In contrast, the NS5A inhibitors daclatasvir and ledipasvir and the polymerase inhibitor sofosbuvir do not cause any problems in this regard. In patients with decompensated cirrhosis of the liver, the combinations sofosbuvir + ledipasvir or sofosbuvir + daclatasvir have been studied best.

New therapy regimes for genotype 2

In patients with genotype 2, a twelve-week therapy with sofosbuvir + ribavirin can achieve virological cure rates of over 90 percent. In patients with liver cirrhosis, an extension of the therapy to 16 to 20 weeks should be considered. A very good, but more expensive alternative is the combination of sofosbuvir + daclatasvir for twelve weeks.

New therapy regimes for genotype 3

With the new DAA regimens, genotype 3 is the most difficult to treat genotype. The best therapy regimen currently is the combination of sofosbuvir + daclatasvir: With a twelve-week therapy, virological cure rates of over 95 percent were achieved in patients without liver cirrhosis. For patients with liver cirrhosis, however, a longer duration of therapy and / or the additional administration of ribavirin seems to be necessary. As an alternative to the combination of sofosbuvir + daclatasvir, a 24-week therapy with sofosbuvir + ribavirin or a twelve-week therapy with sofosbuvir + ledipasvir + ribavirin can be considered.

New therapy regimen for genotype 4

Essentially the same therapy regimens are available for genotype 4 as for genotype 1. The most important difference is that dasabuvir (due to insufficient effectiveness against genotype 4) is omitted in the “3D regime” and paritaprevir / ritonavir + ombitasvir with ribavirin instead be combined.

Goals of Therapy

The aim of therapy is a cure, i.e. to remove the hepatitis C virus from the body. One speaks of a cure if no virus is detectable in the blood three months after the end of therapy. This is usually accompanied by a normalization of the liver values ​​in the blood and can also lead to an improvement in the liver structure and tissue.

Note Successful hepatitis C therapy and a previous infection do not leave any immunity! This means that a new infection with the same genotype or with a different genotype is possible at any time.

Patients who have HCV in their blood again during the first three months after the end of therapy are referred to as relapsers. If patients do not respond at all or only very slightly during therapy and cannot be virus-free at all, they are referred to as non-responders. Studies confirm the ability of the liver to regenerate under therapy; this was shown by tissue samples from patients (liver biopsy).

Note If you also take medication or natural remedies, you should discuss this with your doctor beforehand, as the new medications for the treatment of chronic hepatitis C are not compatible with all medications. During the therapy, laboratory checks are carried out at regular intervals (usually once a month).

Whom can I ask?

The therapy can be prescribed by one of the hepatitis C centers in Austria, which are listed on the website of the umbrella organization of Austrian social insurance.

How are the costs going to be covered?

The costs are covered by the respective health insurance company if defined medical criteria are present and after approval from the chief physician.

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