New HCV Guidance: Rapid Updates for Clinicians

Laura A. Stokowski, RN, MS, Helen W. Boucher, MD; Paul Martin, MD


March 21, 2014

In This Article

The Treatment of Hepatitis C

Medscape: In the section about initiating treatment, as written today, what would you most like to draw clinicians' attention to?

Dr. Martin: The most important point is endorsing the use of the combination of sofosbuvir and simeprevir in the treatment of hepatitis C and discouraging the use of telaprevir- and boceprevir-containing regimens. These drugs are still approved for use, although they are associated with higher rates of adverse effects, such as rash and anemia.

Medscape: If a patient has already been started on a regimen involving either telaprevir or boceprevir, would you switch to a different combination, or allow the patient to complete the treatment?

Dr. Martin: If a patient is already doing well on treatment, there is no need to switch therapy.

Medscape: How important is genotyping in tailoring treatment to the patient?

Dr. Martin: Genotyping is key to picking the optimal regimen.

Medscape: Can you speak a little about the progress toward an all-oral, interferon-free treatment for hepatitis C?

Dr. Martin: In my mind, it has already arrived. We are in the first phase of it already. Obviously, interferon is still part of a number of regimens, but as we speak, many patients are receiving all oral therapies.

It depends on the genotype. For patients with genotype 1, we have the COSMOS protocol, which is a combination of simeprevir and sofosbuvir. For patients with some non-genotype 1 infections, there is the option of using sofosbuvir with ribavirin, for instance.

In general, therefore, we are seeing an increased use of these all-oral regimens. This reflects what has been approved as of the date that the guidance was generated. A drug such as the NS5A replication complex inhibitor daclatasvir will be part of the revised treatment strategy if and when it has been approved.

Medscape: We hear talk of an "avalanche" of drugs in the HCV pipeline, and that some of the drugs are pan-genotypic: For example, a drug such as the NS5A replication complex inhibitor daclatasvir might become part of a revised treatment strategy if approved. Can we really expect this many new drugs, and how will you keep this manageable for clinicians who must keep up to date with new drugs all the time?

Dr. Martin: "Avalanche" might be overstating it. I would describe it as a very good developmental pipeline, and I think we are going to see continued advances related to the licensing of new drugs. We will probably see several more drugs licensed in the next 1-2 years. It will certainly be challenging to help clinicians keep them all straight, but that is one of the reasons we were interested in developing these guidelines and, in fact, the reason that they are called hepatitis C "guidance" rather than "guidelines." It is a huge amount of information, and it needs to be updated frequently.

Medscape: How much concern do you have about the development of resistance to these drugs?

Dr. Martin: When we are seeing sustained virologic response rates now routinely in excess of 90%, clearly resistance is going to be substantially less of a concern, because most patients are going to be cured by a single course of treatment. That being said, I don't think anybody thinks resistance is going to go away. However, the key to managing or preventing resistance is to very effectively treat the infection with the best drug combination available and to eradicate the infection the first time around.


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