Hepatitis C: reviewing the options

[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.