Risks of Waiting to Treat HCV in HIV/HCV-Coinfected Patients

October 21, 2013

Rajesh T. Gandhi, MD reviewing Macías J et al. Clin Infect Dis 2013 Oct 4.

In a retrospective study, patients with advanced fibrosis, particularly those with cirrhosis, had a significant risk for hepatic decompensation within a relatively short period.

As the pace of drug development for hepatitis C virus (HCV) infection accelerates, physicians and their patients are faced with the question of whether to treat with current regimens or wait until better agents become available. To assess the risk of waiting, investigators in Spain examined the likelihood of liver decompensation among HIV/HCV-coinfected patients with advanced fibrosis.

In a retrospective analysis involving 892 HIV/HCV-coinfected patients, liver biopsy or liver stiffness measurement (LSM) by hepatic transient elastography was used to diagnose advanced fibrosis (stage 3 or 4 on biopsy; pre-cirrhosis or cirrhosis on LSM). Liver decompensation was defined as development of spontaneous bacterial peritonitis, portal hypertensive gastrointestinal bleeding, ascites, hepatorenal syndrome, encephalopathy, nonobstructive jaundice, or hepatocellular carcinoma.

Among the 317 individuals with advanced fibrosis diagnosed by biopsy, 12.6% had liver decompensation during a median follow-up of 5.4 years; among the 575 with advanced fibrosis diagnosed by LSM, 9.2% developed liver decompensation during a median follow-up of 2.1 years. In both groups, more-advanced fibrosis (stage 4 or cirrhosis, vs. stage 3 or pre-cirrhosis) was associated with greater risk for hepatic decompensation; in those diagnosed by LSM, a platelet count ≤100,000 was independently associated with higher risk. Overall, 97% to 98% of patients with pre-cirrhosis or stage-3 fibrosis remained free of hepatic decompensation at 3 years of follow-up, compared with only 83% to 87% of those with cirrhosis or stage-4 fibrosis.

Comment

This study suggests that HIV/hepatitis C virus–coinfected patients with advanced fibrosis — particularly those with stage-4 fibrosis or cirrhosis — should receive expeditious HCV treatment. In those with advanced fibrosis who do not yet have cirrhosis, especially if the platelet count is declining, close monitoring for worsening liver disease is essential, perhaps with hepatic transient elastography (a test that received FDA approval earlier this year but is not yet widely available in the U.S.). Fortunately, new and more-effective drugs will soon be here: Sofosbuvir, an HCV polymerase inhibitor, and simeprevir, an HCV protease inhibitor, are scheduled for FDA review this year, and all-oral interferon-sparing regimens are in advanced phases of testing.

Citation(s):

Macías J et al. Risk of liver decompensation among HIV/hepatitis C virus–coinfected individuals with advanced fibrosis: Implications for the timing of therapy. Clin Infect Dis 2013 Oct 4; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/cit537)

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