CMAJ • July 4, 2006; 175 (1). doi:10.1503/cmaj.1060114.
© 2006 CMA Media Inc. or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters

Hepatitis C: reviewing the options

Samuel S. Lee* and Tom Wong{dagger}

*University of Calgary, Calgary, Alta.; {dagger}University of Ottawa, Public Health Agency of Canada, Ottawa, Ont.

[The authors respond:]

We agree with Drs. Khan and Sewell.

Dr. Khan raises several important issues about the treatment of patients with HCV genotypes 2 and 3, but we stand by our general conclusions. First, the largest randomized study of 24 versus 48 weeks of peginterferon and ribavirin treatment showed similar sustained virological response (SVR) rates for genotype 2/3 patients regardless of baseline viral load and histological stage.1 Although not all studies find the same result, in practical terms whether or not one knows the degree of fibrosis or viral load generally does not affect the decision whether to treat or not. In other words, because of the high expected SVR, even in the cirrhotic genotype 2/3 patient with high viral load, we would still proceed to treatment.

Dr. Pijak's point about potentially shorter courses of treatment (12–16 wk) in genotype 2/3 patients with a rapid viral response (RVR), defined as undetectable HCV-RNA at week 4 is well taken. However, despite promising results from studies with relatively small sample sizes,2–4 we believe it is still premature to adopt this strategy, even in patients with RVR. Our contention is based on the results of the large multicentre ACCELERATE study recently presented at the European Association for Study of Liver annual meeting.5 This study randomized 1469 genotype 2/3 patients to 16 or 24 weeks of treatment. The 16-week treatment group showed a significantly lower SVR rate compared to the 24-wk group (intention-to-treat analysis, 62% v. 70%; p = 0.004).

We agree that there are probably subgroups of highly-responsive patients with both genotypes 2/3 and 1 who may benefit from shorter courses of treatment, but feel that such groups have yet to be definitively identified.

REFERENCES

  1. Hadziyannis S, Sette H, Morgan T, et al. Peginterferon-{alpha}2a and ribavirin combination therapy in chronic hepatitis C: a randomized study of treatment duration and ribavirin dose. Ann Intern Med2004;140:346-55.[Abstract/Free Full Text]
  2. Dalgard O, Bjoro K, Hellum KB, et al. Treatment of pegylated interferon and ribavirin in HCV infection with genotype 2 or 3 for 14 weeks: a pilot study. Hepatology 2004;40:1260-5.[CrossRef][Medline]
  3. Von Wagner M, Huber M, Berg T, et al. Peginterferon {alpha}2a (40KD) and ribavirin for 16 or 24 weeks in patients with genotype 2 or 3 chronic hepatitis C. Gastroenterology 2005;129:522-7.[CrossRef][Medline]
  4. Mangia A, Santoro R, Minerva N, et al. Peginterferon {alpha}2b and ribavirin for 12 vs 24 weeks in HCV genotype 2 or 3. N Engl J Med 2005;352:2609-17.[Abstract/Free Full Text]
  5. Shiffman M, Pappas S, Nyberg L, et al. Peginterferon {alpha}2a (Pegasys) plus ribavirin (Copegus) for 16 or 24 weeks in patients with HCV genotype 2 or 3. Final results of the ACCELERATE trial [abstract]. J Hepatol 2006;44(Suppl 2):S271.



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Correction
Michal R. Pijak
CMAJ, 5 Jul 2006 [Full text]
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