de Bruijne J, Buster E H C J, Gelderblom H C, Brouwer J T, de Knegt R J, van Erpecum K J, Schalm S W, Bakker C M, Zaaijer H L, Janssen H L A, Reesink H W
Department of Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, the Netherlands.
Neth J Med. 2008 Jul-Aug;66(7):311-22.
The development of this guideline was initiated and coordinated by the Netherlands Association of Gastroenterologists and Hepatologists (Nederlandse Vereniging van Maag-Darm-Leverartsen). The aim is the establishment of practical guidelines in the evaluation and antiviral treatment of patients with chronic hepatitis C virus (HCV) infection. This includes recommendations for the initial evaluation of patients, the choice and duration of antiviral therapy and the follow-up after antiviral therapy. Hepatitis C is a slowly progressive disease. The initial evaluation of chronically HCV-infected patients should include liver biochemistry testing, virological testing and abdominal ultrasound imaging. Liver biopsy is no longer a routine procedure. Antiviral treatment should be considered for all HCV-infected patients. Current antiviral treatment is a long-term process and is associated with substantial side effects. When deciding whether to start treatment or not, the chance of successful treatment (80% with hepatitis C genotype 2 and 3 and 50% with hepatitis C genotype 1 and 4), the fibrosis stage, the expected side effects and the compliance of the patient should be taken into consideration. In the absence of significant fibrosis and necroinflammation in liver biopsy, postponing treatment is an option. Current antiviral treatment is contraindicated in patients with Child-Pugh-class B or C cirrhosis. The possibility of a liver transplantation should be investigated in these patients. Significant comorbidity with a limited life expectancy is an absolute contraindication for antiviral treatment Treatment of chronic hepatitis C consists of administration of peginterferon and ribavirin for 24 or 48 weeks. Patients with hepatitis C genotype 1 or 4 are treated for 48 weeks. Patients with hepatitis C genotype 2 or 3 are treated for 24 weeks. In patients with undetectable HCV RNA after four weeks (28 days) of treatment, a shorter treatment is equally effective (12 to 16 weeks for hepatitis C genotype 2 or 3; 24 weeks for hepatitis C genotype 1 or 4). Outpatient clinic visits are recommended at the start and after 2, 4, 8, and 12 weeks of treatment, and thereafter every four to six weeks until the end of treatment. It is recommended to stop treatment if the HCV RNA level has not decreased by at least 2 log10 IU/ml (c/ml) after 12 weeks of treatment or when HCV RNA is still detectable after 24 weeks of treatment. The recommended frequency of outpatient clinic visits for patients who are not being treated is once every six months in patients with cirrhosis, otherwise every 12 months. It is expected that new anti-HCV-medication (STAT-C, specifically targeted antiviral therapy for HCV) will become available in the near future. Therefore treatment of chronic HCV infection will probably be more effective in the future.
本指南由荷兰胃肠病学家和肝病学家协会（Nederlandse Vereniging van Maag-Darm-Leverartsen）发起并协调制定。其目的是建立慢性丙型肝炎病毒（HCV）感染患者评估和抗病毒治疗的实用指南。这包括患者初始评估、抗病毒治疗的选择和疗程以及抗病毒治疗后的随访建议。丙型肝炎是一种进展缓慢的疾病。慢性HCV感染患者的初始评估应包括肝脏生化检测、病毒学检测和腹部超声成像。肝活检不再是常规检查项目。所有HCV感染患者均应考虑抗病毒治疗。目前的抗病毒治疗是一个长期过程，且伴有大量副作用。决定是否开始治疗时，应考虑治疗成功的几率（丙型肝炎基因2型和3型患者为80%，丙型肝炎基因1型和4型患者为50%）、纤维化阶段、预期副作用以及患者的依从性。肝活检显示无明显纤维化和坏死性炎症时，可选择推迟治疗。Child-Pugh B级或C级肝硬化患者目前禁忌抗病毒治疗。应调查这些患者进行肝移植的可能性。合并严重疾病且预期寿命有限是抗病毒治疗的绝对禁忌证。慢性丙型肝炎的治疗包括给予聚乙二醇干扰素和利巴韦林，疗程为24或48周。丙型肝炎基因1型或4型患者治疗48周。丙型肝炎基因2型或3型患者治疗24周。治疗4周（28天）后HCV RNA检测不到的患者，较短疗程同样有效（丙型肝炎基因2型或3型为12至16周；丙型肝炎基因1型或4型为24周）。建议在治疗开始时、治疗2周、4周、8周和12周后进行门诊随访，此后每4至6周随访一次直至治疗结束。如果治疗12周后HCV RNA水平未至少下降2 log10 IU/ml（c/ml）或治疗24周后HCV RNA仍可检测到，则建议停止治疗。未接受治疗的患者，肝硬化患者建议每6个月门诊随访一次，否则每12个月随访一次。预计在不久的将来会有新的抗HCV药物（STAT-C，针对HCV的特异性靶向抗病毒疗法）问世。因此，未来慢性HCV感染的治疗可能会更有效。
