Shorter HCV Treatment? Yes, for some…
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Because genotypes 2 and 3 respond so well to interferon therapy, researchers are studying how little they can give and still have a positive effect.
This is great for 30% of North Americans who have chronic Hepatitis c. But the rest of us are still looking at a year of treatment and maybe a 50% chance of success (at best).
Actually, I look at articles like this as much for secondary information as primary. For instance, I hadn’t realized that only 5% of Americans have type 2. Wow! This means the best response to interferon can only be achieved by 5% of us.
Shorter Hepatitis C Treatment Works for Some
For Those With Hepatitis Type 2 or 3, 3-Month Treatment May Suffice
By Daniel DeNoon
WebMD Medical News
Reviewed By Michael Smith, MD
on Wednesday, June 22, 2005
June 22, 2005 — Some people with hepatitis C may get by with only three months of treatment, an Italian study shows.
The findings apply only to people infected with type 2 or type 3 hepatitis C virus. They do not apply to people infected with the more common type 1 virus. In the U.S., about 70% of hepatitis C infections are type 1, about 5% are type 2, and about 20% are type 3.
Treatment for hepatitis C isn’t easy. The drugs of choice are a once-a-week form of interferon alpha (peg-interferon) plus ribavirin, an antiviral drug. The side effects — including flu-like symptoms, fatigue, and depression — can be very hard to handle.
Current guidelines call for six months of treatment for hepatitis C type 2 and type 3 infections. A year of treatment is needed for type 1 infections.
But Alessandra Mangia, MD, of Casa Sollielo della Sofferenza Hospital, in San Giovanni Rotondo, Italy, and colleagues report that some patients with hepatitis C type 2 or type 3 infections may be able to cut their treatment time in half.
Fast Response, Shorter Treatment?
The goal of hepatitis C treatment is what doctors call a sustained virologic response. That’s when the hepatitis C virus can no longer be detected in the blood. Many experts call this a cure; others are more cautious. Whatever it’s called, patients with sustained virologic responses to treatment almost never see their hepatitis C infection come back to dangerous levels.
Side effects force some patients to quit treatment early. Usually, that means treatment failure; usually — but not always.
“We saw that a few patients, who withdrew from therapy before the standard six-month period, had sustained virologic responses anyway despite their short course of treatment,” Mangia tells WebMD. “And we saw that some patients show a very fast reduction of hepatitis C virus levels after their first interferon treatment.”
Did early response to treatment predict who would do well with short-term therapy? The researchers designed an experiment. They enrolled 283 people with hepatitis type 2 or type 3 infection. Seventy of the patients got the full six months of peg-interferon plus ribavirin. The other 213 patients started with the same treatment. If, after four weeks, their blood levels of hepatitis C virus became undetectable, these “fast responders” got only three months of treatment — called variable-length treatment.
Mangia and colleagues report their findings in the June 23 issue of The New England Journal of Medicine.
What happened?
The researchers had good news for patients with hepatitis C type 2 or 3 that had no evidence of the virus after four weeks of treatment. “Patients treated for 12 weeks were spared the expense and inconvenience of extended treatment and still had a high response rate.”
Too Good to Be True?
The response rates were similar between those treated for three months and those treated for six months. Overall, 76% of patients getting standard treatment and 77% of patients getting the variable-length treatment had a sustained virologic response.
But there were some differences.
At first, early responders — those who had undetectable levels of hepatitis C virus after four weeks of treatment — looked the same in both the standard and variable treatment groups. Ninety-three percent of early responders treated for six months and 95% of those treated for three months still had no detectable virus at the end of treatment. Six months later, that percentage dropped from 93% to 91% in those treated for six months. But it dropped from 95% to 85% in those treated for three months.
Although it sounds like the variable-length group have more viral “rebound,” Mangia notes that the results were very similar between the two groups. And of the 13 patients who rebounded after three months of treatment, 10 agreed to 24 more weeks of treatment. This second course of treatment was successful for nine of these 10 rebounders.
“Only this small number of persons rebounded, without any major side effects, and without any reduction in the response rate for [further] treatment,” Mangia says.
But these numbers worry hepatitis C expert Robert Fontana, MD, associate professor of medicine and medical director for liver transplant at the University of Michigan in Ann Arbor.
“Is this really an efficient way to manage patients? If you are going to go through this therapy, you would rather get rid of the virus,” Fontana tells WebMD. “Yes, you have less of the side effects with 12 vs. 24 weeks of treatment. But if someone is tolerating it well, why risk the relapse? Plus there is the whole psychological letdown from learning you’ve had a rebound. … If you can get by with less treatment, great. But when you start to have a trend toward rebound, I don’t think it’s worth the risk.”
Mangia says her hospital already is using the variable-treatment strategy for all patients with type 2 or type 3 hepatitis C infection.
Based on the study findings, Fontana doesn’t think this is a good idea. He praises the Mangia study. Though he notes that it was carefully done and that it addresses crucial issues in hepatitis C treatment, he says doctors and patients would do better to focus on managing side effects than by trying to shorten treatment.
“During the first 12 weeks, the most severe side effects are flu-like symptoms,” Fontana says. “Beyond 12 weeks, the depression, the weakness, and the sort of mental aspect becomes more prominent. That is where a lot of patients going out to 48 weeks just can’t hack it. By reducing the dose, by seeing patients more often, by introducing antidepressants, and by helping with sleep, you can get a lot of those patients through.”
SOURCES: Mangia, A. The New England Journal of Medicine, June 23, 2005; vol 352: pp 2609-2617. Alessandra Mangia, MD, Casa Sollielo della Sofferenza Hospital, San Giovanni Rotondo, Italy. Robert Fontana, MD, associate professor of medicine and medical director for liver transplant, University of Michigan, Ann Arbor. Zeuzem, S. Annals of Internal Medicine, March 2, 2004; vol 140: pp 370-381. AASLD Practice Guideline: “Diagnosis, Management, and Treatment of Hepatitis C,” Strader, D. B. Hepatology, April 2004; vol 39: pp 1147-1171.
