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Meeting highlights from 2017: HCV elimination, treating injection drug users

The introduction of direct-acting antivirals was a significant step toward hepatitis C. Physicians, researchers and medical associations have continued to focus on developing methods and programs to treat as many patients with HCV as possible, especially injection drug users who have a high prevalence for transmission.

In 2017, experts from around the world discussed the path to HCV elimination and aftercare for successfully treated patients at The Liver Meeting, Digestive Disease Week, the World Congress of Gastroenterology and the International Liver Congress.

Below are several reports from this year’s meetings focused on specialized care and outreach for injection drug users with HCV, preemptive DAA therapy in HCV-positive liver transplantation, and results that show increased hepatocellular carcinoma risks after DAA therapy correlate with preexisting risk factors rather than treatment.

Surgeon General: We will conquer HCV, opioids ‘one bite at a time’

WASHINGTON — During a session focused on the connection between the hepatitis and opioid epidemics at The Liver Meeting 2017, Jerome M. Adams, MD, MPH, Surgeon General of the U.S., advised physicians in attendance that hepatitis C elimination will require nontraditional partnerships and innovative strategies for education, prevention and screening.

“I want to ask you all a question that I hope all of you know the answer to,” Adams said to the audience. “How do you eat an elephant? One bite at a time. If you take one bite at a time, if you help all of our partners see which part of that elephant they can take a bite of, we will be able to consume that elephant that is the opioid epidemic.” Read more

Fewer HCC cases from HCV clearance improves quality of life, cost savings

WASHINGTON — Through treatment of hepatitis C genotype 1 with direct-acting antivirals, significant direct and indirect cost savings may arise due to fewer cases of hepatocellular carcinoma and decompensated cirrhosis, according to results of a simulated model presented at The Liver Meeting 2017.

“As you know, chronic hepatitis C is a systemic infection that’s associated with adverse clinical outcomes, both hepatic as well as extrahepatic,” Zobair M. Younossi, MD, MPH, chairman of the department of medicine at Inova Fairfax Hospital and vice president for research at Inova Health System in Falls Church, Virginia, said in his presentation. “There is a significant burden associated hepatic infection and there’s also a number of, as studies have shown, that hepatitis C impairs patient-reported outcome such as health-related quality of life. Read more

VIDEO: Reduce HCV reinfection in drug users with strategic care

WASHINGTON — In this exclusive video from The Liver Meeting 2017, Gregory J. Dore, MBBS, PhD, FRACP, MPH, from the Kirby Institute at the University of New South Wales, Sydney, provides a perspective on reinfection of hepatitis C among injection drug users.

“It’s important to approach reinfection as a clinical scenario that needs to be addressed in terms of clinical management, to offer that person advice in terms of improving their harm reduction strategy, to reduce their risk of further reinfection, but to offer them retreatment discrimination,” he told Healio Gastroenterology and Liver Disease. Watch here

Genetic marker predicts SVR failure in patients with HCV, cirrhosis

CHICAGO — A research team identified genetic markers that predict which patients with hepatitis C and cirrhosis will most likely improve with direct-acting antiviral agent and those who will fail to improve or possibly worsen, according to a presentation at Digestive Disease Week.

“The current generation of direct-acting antiviral agents provides virological cure for 90% to 95% of patients with hepatitis C cirrhosis. Unfortunately, about 5% of hepatitis C patients with ... cirrhosis, failed to clinically improve or even worsened after achieving virological response SVR,” Winston Dunn, MD, associate professor of gastroenterology at the University of Kansas Medical Center, said during a pre-conference press program. “It is important that we figure out a way to identify, in advance, the people with decompensated cirrhosis who may respond best to treatment and those who may not. The information will help us minimize the need for liver transplantations.” Read more

VIDEO: Pharmacy-delivered HCV therapy reached more injection drugs users

AMSTERDAM — In this exclusive video from International Liver Congress, John Dillon, MD, from the University of Dundee, Scotland, discusses new pathways of care for patients with hepatitis C, particularly those who inject drugs.

“If we really want to get into the treatment as prevention agenda with hepatitis C, we have to move toward elimination of this disease, we have to prevent infections. And the big groups that are driving infection in most countries are now people who inject drugs,” Dillon said. “Opportunities for interacting with those patients are within needle exchanges or within pharmacies, particularly with patients who are on opioid substitution therapy if they were previously injecting heroin or are still injecting heroin and interacting with the pharmacies.” Watch here

Most opioid users alter substance-use behavior after positive HCV tests

WASHINGTON — Most opioid users who screened positive for hepatitis C altered their substance-use behavior within 1 year, according to a presentation at The Liver Meeting 2017.

“Evidence shows that reduced injection drug use has important health benefits, most on the individual level in terms of reducing the direct health consequences for the individual but also on a societal level in terms of decreasing the rate of HCV and infection transmission,” Hooman Farhang Zangneh, from the Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, said in his presentation. Read more

Primary care pharmacists successfully manage uncomplicated HCV cases

WASHINGTON — existing primary care pharmacists allowed for an increased number of patients treated with comparable results to liver specialists, according to a presenter at The Liver Meeting 2017.

“Primary care pharmacists can effectively manage patients with uncomplicated HCV infection after treatment evaluation and initiation by a liver pharmacist,” Macy Ho, PharmD, from the VA Long Beach Healthcare System, said in her presentation. “There was no difference in patient outcomes.” Read more

VIDEO: Liver disease topics discussed at DDW include HCV, NAFLD, statins

CHICAGO — In this exclusive video from Digestive Disease Week, Norah Terrault, MD, MPH, discusses the topics reviewed during a press conference involving several experts attending the meeting. Some of the key features of the meeting included new developments for treating hepatitis C, new data emerging on difficult to treat groups such as persons who inject drugs, and the industry’s focus on fatty liver disease.

“While we have many very effective treatments that are currently available [for HCV], there remain some more difficult to cure groups and also a need to try to come up with a simpler, shorter treatment duration,” Terrault said. Watch here

No increased HCC risk after HCV SVR seen with DAAs vs. interferon

AMSTERDAM — When adjusted for age and severity of liver disease, occurrence and recurrence of hepatocellular carcinoma after curing hepatitis C virus showed no difference between treatment with interferon or direct-acting antivirals, according to an expert at the International Liver Congress.

“Our meta-analysis has found that there is no evidence for differential HCC occurrence or recurrence following a cure from DAA or interferon-based regimens. Higher incidence after DAA therapy can be explained by a shorter duration or the so-called ‘cohort effect’ and older age of those at baseline as a higher baseline risk,” Gregory Dore, MD, of the Kirby Institute in Sydney, Australia, said during a press conference. Read more

Age, comorbidities greater impact on HCC rates than DAA therapy

Researchers found no evidence of increased rates of de novo or recurrent hepatocellular carcinoma following treatment with direct-acting antivirals compared with patients treated with interferon therapy, according to a presentation at the World Congress of Gastroenterology at ACG 2017.

Stephanie Rutledge, MBBCh, BAO, MRCPI, presented results of a systematic review and meta-analysis designed to compare rates of HCC after hepatitis C treatment. According to Rutledge and colleagues, recent studies have revealed unexpectedly high rates of HCC after DAA therapy. Read more

Expert weighs risks and benefits of HCV-positive liver donation

AMSTERDAM — While hepatitis C virus-positive liver donation into HCV-positive recipients solves public health problems, donation into HCV-negative recipients remains controversial, according to a presenter at the International Liver Congress.

Didier Samuel, MD, PhD, professor of hepatology and gastroenterology at Université Paris-Sud, Villejuif, said that the most convincing argument for using positive livers is the organ shortage. “Also, seroprevalence of HCV is higher in donors than in the overall population,” he said. Read more

VIDEO: Telemedicine aids treatment of patients with HCV, substance use disorders

AMSTERDAM — In this exclusive video from International Liver Congress, Andrew Talal, MD, MPH, from the University of Buffalo, New York, discusses alternative paths to ensure patients with substance use disorders with hepatitis C can receive appropriate care.

“One of the models that has been particularly successful for engaging persons with substance use disorders into treatment has been the concept of integrated health or integrating hepatitis C care with that of substance use treatment,” Talal said. “This can be done either one of two ways: either physical integration in which both services are delivered by specialists physically located in the same local or via telehealth.” Read more

Timing of DAA therapy and HCC response may impact recurrence rate

AMSTERDAM — Unexpectedly high hepatocellular carcinoma recurrence rates were reported among patients who achieved sustained virologic response after receiving direct-acting antiviral therapy, according to data presented at the International Liver Congress.

“This update further supports our findings about an unexpected high recurrence rate associated in time with DAA, but also exposes a more aggressive pattern of recurrence and faster tumor evolution,” Maria Reig, MD, of the Barcelona Clinic Liver Cancer Group, Liver Unit, Hospital Clinic Barcelona, at the University of Barcelona, said in her presentation. Read more

Preemptive DAA therapy viable for HCV-positive liver transplantation

WASHINGTON — Results of a virtual trial showed that transplantation with hepatitis C-positive livers with preemptive direct-active antiviral therapy may be a viable option for improving patient survival on the liver transplant waitlist, according to an expert at The Liver Meeting 2017.

“The fact is that donor liver availability continues to be limiting factor in increasing the number of liver transplants. Therefore, it becomes very important that we utilize all organs for a maximum potential,” Jagpreet Chhatwal, PhD, from the Massachusetts General Hospital and Harvard Medical School, said in his presentation. “However, under current guidelines, hep C-positive livers are not transplanted into hep C-negative recipients because of adverse post-transplant outcomes previously demonstrated in the interferon-based therapy [era]. But several things have changed in the last few years that prompt us to revisit this question. In particular, the availability of hep C-positive liver donors has increased substantially because of the ongoing opioid epidemic.” Read more