Psychiatric Treatment Considerations With Direct Acting Antivirals in Hepatitis C

Sanjeev Sockalingam; Alice Tseng; Pierre Giguere; David Wong


BMC Gastroenterol. 2013;13(86) 

In This Article


Psychiatric disorders are highly prevalent in patients infected with chronic HCV and until IFNα-free therapies for HCV emerge, it is evident that neuropsychiatric risks of HCV therapy continue to be a significant concern. This review provides further information on the impact of DAAs on the neuropsychiatric sequelae of HCV therapy and clarifies the potential for DDIs with psychotropic medications.

First, DAAs do not appear to confer additional neuropsychiatric risks to patients undergoing HCV triple therapy. However, the use of DAAs warrants careful recognition of potential DDIs with psychotropic agents and an analysis of whether psychotropic regimens should be changed due to significant DDI risks. In addition, the potential for DDIs with psychotropic agents may exacerbate side effects and may interfere with DAA compliance, thus reducing HCV treatment efficacy.

The potential for clinically significant and complex interactions between DAAs and psychotropic drug classes is high. Interactions are primarily pharmacokinetic in nature, and may result in increased or decreased exposures of either/both drug classes. Potential clinical consequences of such interactions may include increased toxicity or potential under dosing. In the case of DAAs, sub-therapeutic concentrations may lead to treatment failure and development of resistance. Whenever possible, non-essential medications should be discontinued for the duration of HCV treatment.

Steps to identifying and managing interactions include ensuring that medication records are up to date at each patient visit (i.e., medication reconciliation), use of a systematic approach to identify combinations of potential concern, consulting pertinent HCV drug interaction resources, and frequent patient monitoring. Other management options include altering dosing frequency or replacing one agent with another drug with lower interaction potential. Given the complexity of this field, clinicians are encouraged to consult with pharmacists or physicians with expertise in HCV pharmacology when managing drug therapy of co-infected patients.

The results of this review can be beneficial in informing the selection of psychotropic agents for common psychiatric presentations in HCV. Using self-report or clinician rated psychiatric scales to measure treatment response to pharmacotherapy can be beneficial in monitoring relapse following psychotropic dose adjustments due to DDIs. For example, both the Beck Depression Inventory-II[89] or Patient Health Questionnaire-9[87] for depression have been used and validated in this patient population. Further, awareness and education of the entire interdisciplinary treatment team is important in order to assist with prompt recognition of psychiatric symptoms, appropriate selection of psychotropic agents with minimal drug interactions and to minimize adverse effects to increased overall treatment adherence. The importance of interdisciplinary models of HCV care is evident from studies showing comparable HCV treatment adherence rates and outcomes for patients with either active substance use[84,90] or severe mental illness[91,92] as compared to controls.