Hepatitis C Virus Clearance in Older Adults

Antonio Massimo Ippolito, MD; Angelo Iacobellis, MD; Michele Milella, MD; Fabio Conti, MD; Vincenzo Messina, MD; Maria Rosa Valvano, PhD; Grazia Anna Niro, MD; Filomena Morisco, MD; Michele Barone, MD; Antonio Patrizio Termite, MD; Giuseppina Brancaccio, MD; Angelo Andriulli, MD

Disclosures

J Am Geriatr Soc. 2018;66(1):85-91. 

In This Article

Discussion

Elderly adults with chronic HCV infection are more likely to develop cirrhosis and HCC and several non-liver-related comorbidities, including diabetes mellitus and kidney and cardiovascular disease, that decrease overall survival.[4] In the interferon era, antiviral treatment has been prescribed reluctantly because of it low efficacy and side effects.[23,24]

Current HCV treatment with DAAs regimens is more efficient and better tolerated than interferon-based therapies, and the number of elderly adults who will receive anti-HCV treatment is likely to increase.[25–27] Its safety profile and the more effective DAA regimens received Food and Drug Administration approval for use in all individuals regardless of age.[28] The question is whether viral clearance in advanced age is cost effective, considering the degree of liver impairment, comorbidities, and life expectancy in elderly adults.

Although several studies have documented an overall survival benefit for individuals with HCV who achieved SVR,[15,29,30] none questioned whether this paradigm is applicable also in individuals aged 80 and older, who are normally underrepresented in registration clinical trials.

The current study provides evidence supporting positive clinical outcomes after therapy with DAAs in individuals aged 80 and older with HCV infection. In the entire cohort of 253 participants, 213 of them with cirrhosis, 86.6% of the overall population was free of events 23 months after HCV clearance. The cumulative incidence of events was higher in participants with D'Amico Stage 4 or 5, in those in CPT Class B or C, in those with a MELD score of 16 or greater, and in those with 3 or more comorbidities and a baseline albumin level of 3 g/dL or less. During clinical observation after SVR, 10.6% of participants had first events, 44.7% of which were not liver related. Our analysis found that the benefit was more robust in a subset of participants and that improvement in the quality of life was observed only in these participants. The influence of serum albumin level and the presence and number of comorbidities were most predictive of performance and possible influences of antiviral treatment. Participants with fewer than 3 comorbidities and albumin levels in the normal range had a high rate of cumulative survival (93.2%) and the lowest rate of cumulative events (6.8%). In these participants, obtaining SVR, we observed a decrease in fatigue and a feeling of relief regarding the state of their health. Cumulative survival (45.5%) and cumulative events (54.5%) were significantly worse for individuals with albumin serum levels of 3.5 g/dL or less and three or more comorbidities; in this subset of participants, in spite of obtaining SVR, no changes were observed in perception of quality of life. This is statistically a significant difference can be used to make a decision whether to treat or not elderly patients with HCV infection and liver cirrhosis. Based on these findings, we suggest the following approach for the treatment of individuals aged 80 and older with liver cirrhosis secondary to chronic HCV infection. For those with fewer than three comorbidities and good liver function (serum albumin level >3.5 g/dL), there is the possibility of offering treatment. Alternatively, in those with low serum albumin and 3 or more comorbidities, treatment is marginally effective, which needs to be communicated to the individual. For the remaining two categories of individuals falling between these two extremes, consideration about treatment needs to be discussed before a final decision is made.

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