In my last blog, I discussed the latest hepatitis C treatment guidelines (Recommendations for Testing, Managing, and Treating Hepatitis C) released by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA). These recommendations send a clear message: If there is a doctor-shortage, or if your state Medicaid program, insurance plan, or healthcare organization limits access to hepatitis C treatment, then certain patients may be given priority for hepatitis C treatment. Those with the most advanced liver damage should be treated first, followed by those who have complicated medical problems, lots of symptoms, or who have a high risk of infecting others. Healthy patients who have low transmission risks and minimal fibrosis (liver damage), and not obviously symptomatic may be treated if “resources allow.”
Although I am appalled by these recommendations (I believe in equal access to healthcare), I take some consolation in the fact that the AASLD and IDSA didn’t leave patients high and dry. They made clear recommendations about how to handle those who might be on the bottom of the list. They recommend monitoring hepatitis C patients for progression of fibrosis to determine the urgency to treatment.
A Few Facts about Fibrosis
AASLD/IDSA mentioned the following points about fibrosis progression:
- "Fibrosis progression varies markedly between individuals based on host, environmental, and viral factors.
- Fibrosis may not progress linearly. Some individuals (often those who are aged 50 years or older) may progress slowly for many years followed by an acceleration of fibrosis progression.
- Others may never develop substantial liver fibrosis despite longstanding infection.
- The presence of existing fibrosis is a strong risk factor for future fibrosis progression... a higher activity grade on liver biopsy and higher liver enzyme are associated with more rapid fibrosis progression.
- Even patients with normal ALT levels may develop substantial liver fibrosis over time."
What are these host factors that may cause more rapid fibrosis progression?
- male sex
- longer duration of infection
- older age at the time of infection
- nonalcoholic fatty liver disease, elevated body mass index, insulin resistance
- iron overload
- alcohol consumption (especially chronic use - a safe amount of alcohol consumption has not been established)
- cigarette smoking
In short, if you are an overweight man who smokes and drinks and acquired hepatitis C at age 50, you have a high risk of progressive liver disease.
Now for the Good News
The dark ages of liver biopsies may be ending, or at least tapering down. Based on the evidence, the AASLD/IDSA declared, “The most efficient approach to fibrosis assessment is to combine direct biomarkers and vibration-controlled transient liver elastography (Fibroscan).” This means labs and ultrasound.
In the absence of the availability of these tests, the aspartate aminotransferase (AST)-to-platelet ratio index (APRI) or fibrosis-4 index (FIB-4) can help identify those most likely to have F3 or F4 fibrosis stage. An APRI above 2.0 or FIB-4 above 3.25 is highly predictive for advanced fibrosis or cirrhosis.
However, liver biopsies aren’t going to vanish. Sometimes Fibroscan and lab tests yield different results. In that case, biopsy may yield better information, and help you and your doctor make treatment-related decisions.
How Often Should I See the Doctor About My Hepatitis C and Liver Disease?
AASLD/IDSA recommended that all individuals with advanced fibrosis be considered for antiviral therapy, and screened for liver cancer, esophageal varices, and liver function at least every 6 months. Everyone else needs to be checked annually.