Transcript Evaluation of Combination Regimens in GT1 Treatment

Hepatitis C in the Elderly
Todd Wills, MD
ETAC Infectious Disease Specialist
HEPATITIS C TREATMENT EXPANSION INITIATIVE
MULTISITE CONFERENCE CALL
MAY 15, 2013
Epidemiology
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• National Health and Nutrition Examination Survey III
(NHANES III) 21,241 participants
• HCV Ab +
– 0.9% 60-69 yrs
– 1.0% > 70 yrs
• Non-Hispanic Blacks/HCV Ab+
– 2.5% 60-69 yrs
– 2.8% > 70 yrs
• NHANES 1999-2002
– Largest prevalence group 40-49 (4.3%)
– 60% of those >60 years old infected via blood transfusion
M.J. Alter D. Kruszon-Moran O.V. Nainan The prevalence of hepatitis C virus infection in the United States, 1988 through
1994. N Engl J Med. 1999;341:556-562
G.L. Armstrong A. Wasley E.P. Simard The prevalence of hepatitis C virus infection in
the United States, 1999 through 2002. Ann Intern Med. 2006;144:705-714
Natural History
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Transfusion acquired HCV and time to
development of cirrhosis
• Minola et al.
– Acquired age 21-30yrs, 33 years to cirrhosis
– Acquires after 40 yrs, 16 years to cirrhosis
• Tong et al.
– Acquired before 50 yrs, 23.6 years to cirrhosis
– Acquired after 50 yrs, 9.8 years to cirrhosis
E. Minola D. Prati F. Suter Age at infection affects the long-term outcome of
transfusion-associated chronic hepatitis C. Blood. 2002;99:4588-4591
M.J. Tong N.S. el-Farra A.R. Reikes Clinical outcomes after transfusion-associated hepatitis C. N
Engl J Med. 1995;332:1463-1466
Differential Treatment Outcomes in
the Elderly
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Less response to pegylated interferon/RBV with
increased age
– Odds ratio of SVR 0.13-0.21 for age groupings >40
years old versus <40
– Only seen in genotypes 1 and 4; no significant age
difference for genotypes 2,3
• Greater risk of cytopenias requiring dose
modifications for patients >60 years versus matched
controls (p=0.031)
G. Antonucci M.A. Longo C. Angeletti The effect of age on response to therapy with
peginterferon alpha plus ribavirin in a cohort of patients with chronic HCV hepatitis including
subjects older than 65 yr. Am J Gastroenterol. 2007;102:1383-1391
C.G. Nudo P. Wong N. Hilzenrat Elderly patients are at greater risk of cytopenia during antiviral
therapy for hepatitis C Can J Gastroenterol 20:2006;589-592
Treatment Candidacy
• Treatment is proposed to few elderly patients. prospective
cohort study screened 4025 patients with HCV at 24 VA
Hospitals
• 364 (9%) were over the age of 60
• Twenty five per cent of patients over the age of 60 were
considered to be treatment candidates
• 10% were started on treatment.
– age was a strong independent predictor of not being a
treatment candidate.
Tsui JI, Currie S, Shen H, et al. Treatment eligibility and outcomes in elderly patients
with chronic hepatitis C: results from the VA HCV-001 Study. Dig Dis
Sci 2008; 53: 809–814.
Summary
• The decision to treat older patients is complex
A detailed explanation of the natural history
of the disease, the likely rate of progression,
the risk of complications is required.
• Lower toxicity newer medications may still
offer future more tolerable treatment options