When should treatment be started?

Figuring out if you should begin treatment for hepatitis C and determining when you should start it are complicated issues. Because HCV treatment can cause side effects, along with the fact that there is no guarantee that treatment will be completely effective, people with hepatitis C must weigh the risks of therapy against the benefits in deciding if and when to start treatment.

As a rule of thumb, the American Academy for the Study of Liver Diseases (AASLD) recommends that treatment be started before cirrhosis occurs (this can be determined through a liver biopsy), but only for those who are considered to be at a “high risk” of developing cirrhosis in the future. These include people—18 years of age or older who are willing to be treated and to adhere to treatment requirements—with:

1. HCV that is detectable by PCR; and
2. A liver biopsy showing severe signs of “fibrosis”; and
3. Compensated liver disease (laboratory signs and symptoms suggesting that the liver is still working normally); and
4. Blood tests indicating that certain blood cell counts and organ enzymes are still within healthy ranges.

If these criteria are met, a patient should be offered treatment, regardless of the presence or absence of symptoms, the route of HCV infection, the genotype of HCV, or the HCV viral load.

Treatment should not be offered in certain situations. These include:

1. Major uncontrolled depression (which can be exacerbated further by HCV treatment)
2. Solid organ transplant (e.g., kidney, heart or lung)
3. Autoimmune hepatitis or other autoimmune condition (which can be exacerbated further by HCV treatment)
4. Untreated thyroid disease
5. Pregnant or unwilling to practice effective birth control
6. Severe accompanying diseases, such as very high blood pressure, heart failure, significant coronary disease, poorly controlled diabetes and chronic obstructive disease/emphysema
7. A parent of children younger than 2 years old
8. Known allergies to the drugs used to treat HCV

AASLD also notes that treatment should be individualized—timed and tailored based on the risks and benefits of therapy in each patient—in the following circumstances:

1. Failed earlier treatment
2. Current users of alcohol and illicit drugs, but willing to participate in a substance abuse program
3. Liver biopsy evidence of either no or mild fibrosis
4. Acute hepatitis C
5. Younger than 18 years old
6. Chronic kidney disease 
7. Decompensated cirrhosis, or severe liver disease
8. Liver transplant recipients

Above all, deciding if and when to start treatment should be individualized. Meaning that, regardless of what “official” guidelines do or don’t say, it is up to you and your health care provider to figure out what’s best for you, based on your own thoughts, concerns and capabilities.

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