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Editor's Note
February 2014

Hepatitis C Treatment: Stuck Between a Rock and a Hard Place but Hoping to Be Rescued Soon

JAMA Intern Med. 2014;174(2):212. doi:10.1001/jamainternmed.2013.12418

Hepatitis C poses a challenging dilemma for physicians and patients. On one hand, as well demonstrated by this article, it is a disease with serious morbidity and mortality. The desire to treat patients to prevent these consequences is great. But, the treatments that we have had available are not very effective in clearing the infection, result in serious adverse effects including making patients feel sick during a prolonged treatment course, and are expensive. For these reasons neither I nor my patients have been very enthusiastic about treatment.

Further complicating the issue, I have been reluctant to treat patients who are healthy despite their hepatitis C infection because I have felt that they had time to wait until better treatments were available. Conversely, I have been reluctant to treat patients who have already experienced severe liver damage from hepatitis C because I have feared that they could not tolerate the adverse effects of treatment and because it is unclear whether even if the virus is suppressed their clinical function would improve. This has left me, and many clinicians, in the odd position of feeling that patients are either too healthy or too sick for hepatitis C treatment. It undoubtedly explains why in this Veterans Affairs cohort only 24% of patients had received treatment at any time.

The authors demonstrate that patients who do achieve viral suppression, which almost always required treatment, fared significantly better. The critical issue going forward is whether the new drugs that have been released (eg, hepatitis C protease inhibitors) or are likely to be approved soon (eg, hepatitis C nucleotide polymerase inhibitor) can achieve sustained viral suppression in a high percentage of patients without serious adverse effects. And can these treatments be made available without breaking the bank of safety net health systems across the country that care for large numbers of patients with hepatitis C? I certainly hope so.

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