Review: In chronic hepatitis C virus infection, oral direct-acting antivirals have high sustained virologic response

A commentary in ACP Journal Club noted that while screening and treating all patients with chronic hepatitis C virus (HCV) would be cost-effective and probably cost-saving, some payers are still resistant.

A systematic review and meta-analysis of 42 clinical trials found that FDA-approved direct-acting antiviral (DAA) for hepatitis C virus (HCV) yield high cure rates. The study included trials that involved patients with chronic HCV and evaluated at least eight weeks of therapy with an HCV regimen that was interferon-free and included two or more FDA-approved DAAs. Drugs studied included ribavirin along with the following DAAs: grazoprevir, paritaprevir, and simeprevir; daclatasvir, elbasvir, ledipasvir, ombitasvir, and velpatasvir; and sofosbuvir and dasabuvir.

The study was published online March 21 by Annals of Internal Medicine and was summarized in the March 24 ACP Gastroenterology Monthly. The following commentary, by Henry S. Sacks, PhD, MD, FACP, appeared in the ACP Journal Club section of the July 18 Annals of Internal Medicine.

Of the estimated 3.5 million people in the USA infected with chronic HCV, roughly half have been diagnosed and <10% have been successfully treated. The review by Falade-Nwulia and colleagues shows that we now have oral treatments of shorter duration that are simple, effective, and well-tolerated, including the combination of velpatasvir plus sofosbuvir ± ribavirin, which is effective for all 6 genotypes. There will likely be even better drugs in the near future, and vaccines are being developed, but it is now easier for primary care providers to play a major role in diagnosis and treatment of HCV. Barriers to care include access to treatment, cost, and practitioner expertise. Guidance on HCV from the American Association for the Study of Liver Diseases/Infectious Diseases Society of America is frequently updated and addresses testing and linkage to care (crucial first steps in improving health outcomes) and optimal treatment regimens in various situations.

Because concurrent hepatitis B infection is possible and may reactivate during HCV therapy, it is important for patients to be screened with HBsAg, HBsAb, and core Ab.

Even at today's outrageous prices, screening and treating all patients with chronic HCV would be cost-effective—and likely cost-saving—because cirrhosis, hepatocellular carcinoma, and mortality in infected persons, as well as transmission to others, can be reduced. However, some payers remain resistant and providers will need to be strong and vocal advocates for their patients.