0521779407-09 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:12
692 Hepatitis Cselected circumstances. Gradual dose escalation may be helpful,
adjunct/supportive therapy (e.g., erythropoietin for anemia) often
necessary.
■Non-responders: No approved “salvage” Rx. Chronic suppressive Rx
with peginterferon being explored in ongoing clinical studies but not
yet approved or established to confer clinical benefit.
■Acute infection: Rx with peginterferon lowers risk of chronic infec-
tion and should be initiated within 12 weeks; ribavirin not shown to
be of benefit with acute infection
follow-up
During Rx
■Regularly assess potential complications of therapy; hemolysis,
thrombocytopenia, hypothyroidism
■peginterferon/ribavirin: CBC at 2–4 weeks;
➣CBC, hepatic panel monthly
➣TSH every 3–6 months
➣quantitative HCV RNA at week 12 (if <2 log drop in HCV-RNA,
likelihood of SVR low, strongly consider stopping therapy)
■peginterferon mono Rx: Same as for combination therapy
■ALT, albumin, PT, bilirubin, CBC every 6–12 months
■follow-up liver biopsy is discretionary; may be considered every 3–5
years in patients with mild diseasecomplications and prognosis
■Cirrhosis: develops in 10–30% of patients 10 to 40 years after infection
■treat as per liver failure due to other causes (see liver transplantation)
■consider liver transplantation for end-stage
■cirrhosis; HCV infection usually recurs in the transplanted organ;
transplant is beneficial only for highly selected patients with hepa-
tocellular cancer (e.g., small/early cancer)
■Hepatocellular carcinoma: annual incidence in 2–4% of patients with
cirrhosis; screening with alpha-fetoprotein plus ultrasound every 6
months standard
■Membranoproliferative glomerulonephritis: rare; consider inter-
feron and ribavirin
■Essential mixed cryoglobulinemia: rare; consider interferon and rib-
avirin
Prognosis
■Good in the absence of cirrhosis or liver cancer
■a minority of patients develop life-threatening complications