Clearing Hepatitis C Linked to Better Diabetes Control

Veronica Hackethal, MD

July 06, 2017

Eradicating hepatitis C virus (HCV) infection with new antiviral medication may improve glycemic control in patients with type 2 diabetes, according to a new study published online June 28 in Diabetes Care.

"Our study shows that there is a significant change in HbA1c in diabetics after treatment of hepatitis C with direct-acting antivirals," first author Justine Hum, MD, of Portland Veterans Affairs Medical Center, Oregon, told Medscape Medical News via email.

This is the first large study to look at whether eradicating HCV improves glycemic control in patients who already have diabetes, although past studies have suggested that clearing HCV with older regimens including interferon and ribavirin may improve insulin resistance in patients without diabetes.

Results showed that glucose control improved to the greatest degree among patients with poorly controlled diabetes at the start of the study. The need for insulin also decreased in patients who cleared their HCV infection as the result of treatment with antivirals. 

"What was really impressive was the nearly 1% drop in HbA1c in diabetics who had an HbA1c ≥7.2% prior to their treatment of hepatitis C with direct antivirals. Imagine treating your hepatitis C and getting a 1% reduction in your HbA1c and being able to stop insulin, along with all the other hepatic benefits of eradicating hepatitis C infection," Dr Hum added.

Hepatitis C and Diabetes Highly Prevalent in US

Both type 2 diabetes and HCV are highly prevalent in the United States, affecting about 29.1 million and 3.5 million people, respectively. People who  are infected with HCV are four times more likely to develop type 2 diabetes than those who are not. And HCV infection has also been linked to worsening glycemic control in patients who already have diabetes, according to background information in the article.   

The study included 2435 people with diabetes and HCV infection who received treatment with interferon-free direct-acting antivirals at Veterans Affairs facilities between January 2014 and June 2015. The average age was 62.2 years. Most (97.5%) were male and non-Hispanic black (43.6%) or white (38.3%). A large percentage (42.2%) needed insulin and already had cirrhosis (37.3%).

The study excluded patients who received older antiviral regimens containing interferon or ribavirin, both of which may decrease HbA1c. That could have muddied results, making it difficult to tease out whether glycemic control improved due to eradication of HCV or the treatment.

The drug regimens that patients received in the study included ledipasvir/sofosbuvir monotherapy, paritaprevir/ritonavir/ombitasvir and dasabuvir monotherapy, or sofosbuvir plus simeprevir combination therapy.

Eradication of HCV has been shown to reduce the risk of liver cancer, improve liver fibrosis, and reduce the risk of other complications of chronic liver disease, but the effects of HCV clearance on the extrahepatic manifestations of HCV have not been well studied in the new era of direct-acting antivirals, the authors note.

The study compared changes in average HbA1c and use of antidiabetes medication 1 year before and 1 year after treatment for HCV. Results were adjusted for age, sex, race/ethnicity, markers of renal and liver function, amount of liver scarring, and body mass index (BMI).

The results show that patients with elevated HbA1c (≥7.2%) at the beginning of the study who cleared their HCV infection had a significantly larger drop in HbA1c (from 8.5% to 7.6%) than those with did not clear their HCV infection (from 8.5% to 7.9%) (P = .02).

The drop in HbA1c was significant only for patients without cirrhosis and with elevated HbA1c at the start of the study, and not for those with cirrhosis and with better controlled diabetes.

Patients who eradicated their HCV also had a larger decrease in the overall need for antidiabetes medications than those who did not clear their infection, but the difference was not statistically significant.

However, there was a reduction in the proportion of patients using insulin among those who cleared their infection (from 41.3% to 38%), and these results were significantly different (= .04) from patients who did not eradicate their infection, the proportion of whom using insulin increased slightly, from 49.8% to 51%.

Treatment of HCV Cost-effective in the Long Run

The results justify the consideration of treating HCV with direct-acting antivirals in all patients with HCV and diabetes, according to the authors. This may be feasible within the VA system, which funds treatment for all patients with chronic HCV infection, but what about outside the VA?

The new direct-acting antivirals are incredibly expensive, although generic versions are being manufactured in places like India and China.

US insurance companies have been expanding their scope of coverage for HCV treatment, Dr Hum explained. The results of this study could support adding glycemic control to the criteria used in decisions about whether to cover HCV treatment.

"Perhaps we should consider treating patients who have HCV and type 2 diabetes sooner in their course of HCV and not wait until someone has severe fibrosis or complications of cirrhosis from HCV or diabetes," she commented.

Also, if earlier treatment of HCV results in improved glycemic control, it could potentially decrease diabetes complications, like cardiovascular disease, kidney disease, and retinal disease, thereby saving money later on.

The authors note, however, that the current study was limited to 15 months after antiviral treatment was stopped and could not evaluate long-term outcomes like the development of diabetic micro- and macrovascular complications.

"We need to consider the cost implications of improving diabetes and possibly preventing downstream effects of diabetes such as heart attacks or amputations or dialysis requirements. The impact could be substantial and needs to be studied in the future," Dr Hum concluded.

The study was supported by the Veterans Affairs. The authors report no relevant financial relationships.  

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Diabetes Care. Published online June 28, 2017. Abstract

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