Despite virologic cures of hepatitis C with direct-acting antivirals, post-cure care is necessary to prevent liver disease progression and manage complications.
Although virologic cure is achieved in most patients infected with hepatitis C virus (HCV) treated with direct-acting antivirals (DAAs), a noted hepatologist recently emphasized the importance of post-cure care to reduce risk of liver disease progression in those with advanced fibrosis and in those with ongoing risk factors for liver injury, as well as to reduce risk of reinfection and to monitor and manage related complications.
“The achievement of HCV cure substantially reduces the risk of liver disease progression, but some patients remain at risk,” explained Norah Terrault, MD, MPH, a professor of Medicine and director of the Viral Hepatitis Center, University of California San Francisco. “Moreover, liver injury can occur from other causes before and after cure, specifically related to alcohol use or superimposed metabolic fatty liver.”
In an editorial accompanying Terrault’s assessment and recommendations, Gary Lichtenstein, MD succinctly posed the challenge of providing follow-up to an ostensible cure.
“As physicians, our goal is to treat patients as best we can, which hopefully results in curing them whenever possible,” he wrote. “But once they are cured, then what?”
Terrault addressed that question by considering when continued HCV RNA testing is advised and how fibrosis regression and progression should be assessed, describing roles of both specialists and primary care practitioners in providing appropriate monitoring and intervention after successful DAA treatment, and identifying the strong counseling messages which could be essential for effective aftercare of this population.
The rate of late relapse, beyond the sustained virologic response to treatment at 12 weeks (SVR12), is rare (0.2%), and “exceedingly rare” beyond 24 weeks posttreatment, Terrault noted. Studies with phylogenetic sequencing have indicated that 7 of 12 relapses are new infections rather than true relapses. Despite the relatively low rate of relapse, however, Terrault indicated that the possibility warrants testing beyond 12 weeks post-treatment.
“I recommend obtaining both SVR12 and SVR 48,” Terrault wrote. “If HCV RNA is undetectable at the later time point, the patient can be confidently informed that he or she is cured, and no further testing is indicated unless the patient is at risk for reinfection.”
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