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World J Hepatol. Jul 28, 2015; 7(15): 1953-1963
Published online Jul 28, 2015. doi: 10.4254/wjh.v7.i15.1953
Hepatitis C: Treatment of difficult to treat patients
Eric G Hilgenfeldt, Alex Schlachterman, Roberto J Firpi
Eric G Hilgenfeldt, Department of Internal Medicine, University of Florida College of Medicine, Gainesville, FL 32610, United States
Alex Schlachterman, Roberto J Firpi, Department of Gastroenterology, Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, FL 32610, United States
Roberto J Firpi, Section of Hepatobiliary Diseases and Transplantation, University of Florida, Gainesville, FL 32610, United States
Author contributions: Hilgenfeldt EG authored this review with assistance from Schlachterman A; Firpi RJ edited this review and provided guidance as to the content.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Roberto J Firpi, MD, MS, AGAF, Director of Hepatology and Liver Transplant, Section of Hepatobiliary Diseases and Transplantation, University of Florida, 1600 SW Archer Rd, MSB Rm M440, Gainesville, FL 32610, United States. roberto.firpi@medicine.ufl.edu
Telephone: +1-352-2739466 Fax: +1-352-3927393
Received: August 23, 2014
Peer-review started: August 26, 2014
First decision: December 17, 2014
Revised: May 29, 2015
Accepted: July 16, 2015
Article in press: July 17, 2015
Published online: July 28, 2015
Processing time: 350 Days and 4.2 Hours
Abstract

Over the past several years, more so recently, treatment options for hepatitis C virus (HCV) have seemed to exponentially grow. Up until recently, the regimen of pegylated interferon (peg-IFN) and ribavirin (RBV) stood as the standard of care. Direct acting antivirals, which target nonstructural proteins involved in replication and infection of HCV were first approved in 2011 as an addition to the peg-IFN and RBV regimen and with them have come increased sustained virological response rates (SVR). The previously reported 50%-70% SVR rates using the combination of peg-IFN and RBV are no longer the standard of care with direct acting antiviral (DAA) based regimens now achieving SVR of 70%-90%. Peg-IFN free as well as “all oral” regimens are also available. The current randomized controlled trials available show favorable SVRs in patients who are naive to treatment, non-cirrhotic, and not human immunodeficiency virus (HIV)-co-infected. What about patients who do not fit into these categories? In this review, we aim to discuss the currently approved and soon to be approved DAAs while focusing on their roles in patients that are treatment experienced, cirrhotic, or co-infected with HIV. In this discussion, review of the clinical trials leading to recent consensus guidelines as well as discussion of barriers to treatment will occur. A case will attempt will be made that social services, including financial support and drug/alcohol treatment, should be provided to all HCV infected patients to improve chances of cure and thus prevention of late stage sequela.

Keywords: Hepatitis C virus; Direct acting antiviral; Human immunodeficiency virus; Cirrhosis; Treatment experienced

Core tip: The current randomized controlled trials available show favorable sustained virologic responses in patients who are naive to treatment, non-cirrhotic, and not human immunodeficiency virus (HIV)-co-infected. What about patients who do not fit into these categories? In this review, we aim to discuss the currently approved and soon to be approved direct acting antivirals while focusing on their roles in patients that are treatment experienced, cirrhotic, or co-infected with HIV.