Attar Bashar M, Van Thiel David H
Bashar M Attar, Cook County Health and Hospitals System, Rush University Medical Center, Chicago, IL 60612, United States.
World J Gastrointest Pharmacol Ther. 2016 Feb 6;7(1):33-40. doi: 10.4292/wjgpt.v7.i1.33.
Cirrhosis is the most important risk factor for hepatocellular carcinoma (HCC) regardless of the etiology of cirrhosis. Compared to individuals who are anti-hepatitis C virus (HCV) seronegative, anti-HCV seropositive individuals have a greater mortality from both hepatic as well as nonhepatic disease processes. The aim of this paper is do describe the burden of HCV infection and consider treatment strategies to reduce HCV-related morbidity and mortality. The newly developed direct acting antiviral (DAA) therapies are associated with greater rates of drug compliance, fewer adverse effects, and appear not to be limited by the presence of a variety of factors that adversely affect the outcome of interferon-based therapies. Because of the cost of the current DAA, their use has been severely rationed by insurers as well as state and federal agencies to those with advanced fibrotic liver disease (Metavir fibrosis stage F3-F4). The rationale for such rationing is that many of those recognized as having the disease progress slowly over many years and will not develop advanced liver disease manifested as chronic hepatitis C, cirrhosis, and experience any of the multiple complications of liver disease to include HCC. This mitigation has a short sided view of the cost of treatment of hepatitis C related disease processes and ignores the long-term expenses of hepatitis C treatment consisting of the cost of treatment of hepatitis C, the management of cirrhosis with or without decompensation as well as the cost of treatment of HCC and liver transplantation. We believe that treatment should include all HCV infected patients including those with stage F0-F2 fibrosis with or without evidence of coexisting liver disease. Specifically, interferon (IFN)-free regimens with the current effective DAAs without liver staging requirements and including those without evidence of hepatic diseases but having recognized extrahepatic manifestations of HCV infection is projected to be the most cost-effective approach for treating HCV in all of its varied presentations. Early rather than later therapy of HCV infected individuals would be even more efficacious than waiting particularly if it includes all cases from F0-F4 hepatic disease. Timely therapy will reduce the number of individuals developing advanced liver disease, reduce the cost of treating these cases and more importantly, reduce the lifetime cost of treatment of those with any form of HCV related disease as well as HCV associated all - cause mortality. Importantly, HCV treatment regimens without any restrictions would result in a substantial reduction in health care expenditure and simultaneously reduce the number of infected individuals who are infecting others.
肝硬化是肝细胞癌（HCC）最重要的危险因素，无论肝硬化的病因如何。与抗丙型肝炎病毒（HCV）血清学阴性的个体相比，抗HCV血清学阳性的个体因肝脏及非肝脏疾病进程导致的死亡率更高。本文旨在描述HCV感染的负担，并探讨降低HCV相关发病率和死亡率的治疗策略。新开发的直接作用抗病毒（DAA）疗法具有更高的药物依从率、更少的不良反应，而且似乎不受多种对基于干扰素的疗法结果产生不利影响的因素限制。由于当前DAA的成本，保险公司以及州和联邦机构已严格限制其使用，仅用于患有晚期纤维化肝病（梅塔维纤维化分期F3 - F4）的患者。这种配给的基本原理是，许多被认定患有该疾病的人多年来病情进展缓慢，不会发展为表现为慢性丙型肝炎、肝硬化的晚期肝病，也不会经历包括HCC在内的多种肝病并发症。这种缓解措施对丙型肝炎相关疾病进程的治疗成本持短视观点，忽视了丙型肝炎治疗的长期费用，包括丙型肝炎治疗费用、有或无失代偿的肝硬化管理费用以及HCC治疗和肝移植费用。我们认为治疗应包括所有HCV感染患者，包括那些F0 - F2纤维化分期、有或无并存肝病证据的患者。具体而言，使用当前有效的DAA且无需肝脏分期要求的无干扰素方案，包括那些无肝病证据但有公认的HCV感染肝外表现的方案，预计是治疗各种HCV表现形式最具成本效益的方法。对HCV感染个体尽早而非推迟治疗比等待更有效，特别是如果治疗包括所有F0 - F4肝病病例。及时治疗将减少发展为晚期肝病的个体数量，降低治疗这些病例的成本，更重要的是，降低任何形式的HCV相关疾病患者的终身治疗成本以及HCV相关全因死亡率。重要的是，无任何限制的HCV治疗方案将大幅降低医疗保健支出，同时减少正在感染他人的感染个体数量。
