Treatment of Chronic Hepatitis C in Patients With Cirrhosis

Tianyan Chen; Norah Terrault


Curr Opin Gastroenterol. 2016;32(3):143-151. 

In This Article

Abstract and Introduction


Purpose of review This article reviews treatment options of the approved and soon-to-be approved direct-acting antivirals (DAA)-based therapies in individuals with hepatitis C virus (HCV) cirrhosis.

Recent findings DAA-based therapies have been shown to be well tolerated and effective in achieving viral cure in individuals with compensated and decompensated cirrhosis. Preliminary studies suggest that viral eradication arrests fibrosis progression and could lead to fibrosis regression. Long-term benefits of successful HCV treatment in this population translate into less frequent hepatic decompensation and hepatocellular carcinoma development, improvements in liver disease severity, reduction of liver-related mortality, and potential obviation of the need for transplantation. The optimization of viral eradication rates requires longer duration therapy and/or more complex combinations of drugs, including ribavirin. Treatment decisions are guided by HCV genotype, renal function, drug–drug interactions, and the severity of cirrhosis. Safety concerns are paramount in individuals with advanced liver disease and continued vigilance for hepatotoxicity and other complications is warranted, especially in those with decompensated cirrhosis.

Summary The availability of high potency DAA-based therapies with excellent safety profiles has transformed the HCV-infected cirrhotic population into a group that is no longer 'difficult-to-treat'. Understanding the pretreatment factors that predict clinical benefits vs. harm remains key in treating this population.


Chronic hepatitis C virus (HCV) infection affects at least 170 million persons worldwide[1] and at least 3.5 million Americans are living with chronic hepatitis C.[2] In the United States, the highest prevalence of chronic hepatitis C is among those born between 1945 and 1965 (baby boomers) and more than 25% of these adults are estimated to have cirrhosis.[3] If untreated, those with cirrhosis have a risk of 3–5% per year of progressing to liver decompensation and 1–5% risk of developing hepatocellular carcinoma (HCC).[4] Indeed, infection with chronic HCV remains the most common indication for liver transplantation in many countries, including the United States.[5] Thus, identifying those with HCV and cirrhosis is a high priority to provide access to curative therapy and reduce the HCV-associated morbidity and mortality.

Historically, treatment of HCV in patients with cirrhosis was characterized by low efficacy and poor tolerability, especially among those with hepatic decompensation. With the advent of safe and highly effective direct-acting antivirals (DAA) (Table 1), HCV eradication is achievable in the majority of patients providing an unprecedented opportunity to change the natural history of cirrhosis and prevent liver-related complications. However, the presence and severity of cirrhosis influence the likelihood of achieving sustained viral clearance and Child–Pugh class determines treatment options. For those patients with Child–Pugh B or C cirrhosis, use of protease inhibitors is not recommended.[6]

Potential treatment benefits among patients with cirrhosis include a reduced risk of progression to decompensation, HCC and liver-related death. In patients with decompensated cirrhosis, the ability to reverse symptoms of decompensation, improve quality of life and obviate the need for liver transplantation are additional potential benefits.