A middle aged woman presents for management of HCV. She has cirrhosis w/ portal hypertension; she was treated unsuccessfully 20 years ago with IFN + ribavirin, then again with addition of a third agent in 2012. With the advent of new therapies, she was re-treated and achieved SVR; however, she continued to require active management of decompensated cirrhosis and HCC screening.
*See this excellent NEJM take on updates in treatment of patients with cirrhosis: https://resident360.nejm.org/content_items/treatment-of-patients-with-cirrhosis
1. Who qualifies for HCV treatment?
-With the new therapies, EVERYONE! Asymptomatic patients, cirrhotics, AND decompensated cirrhotics can all be treated; if someone has decompensated cirrhosis, they should be listed for transplant in addition to being treated.
2. Who is at risk of treatment failure?
-Cirrhotics and patients on BID PPI.
-Patients with HBV are at risk of HBV flare during HCV treatment; hence all patients must be tested for HBV prior to treatment initiation.
3. Once someone achieves SVR, are they cured for life?
-In short, yes (99% sustained cure for life) but they can always be re-infected (with same or different genotype)
4. When should beta blockers be used for varices in cirrhotics?
-Though BB used to be given to any cirrhotic with varices, new data shows a decline in survival when these are used in end stage cirrhotics, thought due to negative effects on already poor cardiac reserve. This has led to the “window hypothesis”, which essentially states that BB should be used during a specific period when someone has known medium to large varices but does not yet have refractory ascites or hypotension.