Module 6: Treatment options - section 6

In this document:

Contraindications to treatment and re-treatment

Activity: Presentation, large group work and discussion
Section Time: Approximately 10 minutes

This section looks at the conditions and presentations that may disqualify individuals from treatment and under what circumstances re-treatment is recommended for those who have previously undergone HCV therapy.

Using Slide 6.21 (Group work) ask the large group how familiar they are with contraindications to both interferon and ribavirin:

Record answers and then refer to Slide 6.22 (Contraindications to interferon and ribavirin) to confirm and add to these as required:

There are a range of main medical reasons which might disqualify individuals from treatment. Some contraindications may allow treatment to continue but only with more regular and closer monitoring than might usually required.

Contraindications to interferon
  • Heart disease, because interferon can cause arrhythmia (irregular heartbeat)
  • Cirrhosis, because, in this condition platelet and white blood cell counts tend to be low and interferon can reduce the level further
  • Autoimmune diseases such as rheumatoid arthritis or autoimmune hepatitis, because these are caused by an overactive immune system, which interferon would only stimulate further.
  • Severe depression or psychosis, which interferon could make worse.
  • Some forms of eye disease, as interferon has been known to cause sight problems.
  • Organ transplant (except liver transplant) as treatment may cause rejection of the organ
Contraindications to ribavirin
  • Heart disease, because ribavirins major side effect, anaemia, can make this worse.
  • Pregnancy, because ribavirin is mutagenic and can cause serious deformities in a foetus.
  • Impaired renal function as ribavirin is excreted via the kidneys

Showing Slide 6.23 (Treatment failure and retreatment) briefly establish that there is a growing group of people who fail to clear the virus after one or more rounds of interferon based treatment. For some there may be opportunity for further treatment but for others, current treatment opportunities are limited:

Despite improvements in treatment there are some people who have fail to clear the virus after one or more rounds of interferon based treatment. Someone who relapses after treatment is defined as having achieved a sustained virologic response (SVR) during the course of treatment but in whom the virus was again detectable during the three or six month follow up period. For people who relapse after treatment, variations in dosage and length of interferon-based treatments can offer some chance of clearing the virus.

Amongst those people who do not achieve SVR there are two groups and it is important to differentiate between them to determine what further treatment options would be available.

The first group are nil responders who do not show an appreciable decline in HCV RNA during treatment. These people can be recognised within 12 weeks of starting peg-interferon/ribavirin therapy as they do not achieve expected reduction of viral load from the level at the start of treatment after 12 weeks. Continued treatment of these nil responders rarely results in further decline in viral load and there is therefore little justification for continuing the treatment.

The second group are partial responders. These are people who have an early virologic response where their HCV RNA does reduce from the level at the start of treatment within the first 12 weeks, but then slows down or evens out. Partial responders have a better chance of responding and achieving SVR during retreatment than nil responders. Partial responders have some chance of achieving SVR if treatment is extended to 72 weeks.

For people who have not responded to (non-pegylated) interferon therapy without ribavirin there is about a 30% chance of a SVR when they are treated with pegylated interferon and ribavirin. However, for those people who have failed to respond to (non-pegylated) interferon plus ribavirin the rate of SVR is only 10-20%. For people who have not responded to pegylated interferon and ribavirin the options are more limited.

Improvements in HCV therapy raise the possibility that being retreated with new and better regimens might help people for whom earlier attempts at treatment have failed.

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