Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–42 | Clinical Manual for Management of the HIV-Infected Adult/2006
Alanine aminotransferase
Monitoring of ALT is used to assess liver inflammation,
although levels may be low in patients with advanced
liver disease.
Imaging
Ultrasonography can be performed to screen for
cirrhosis or mass lesions. Computed tomography (CT),
magnetic resonance imaging (MRI), and single-photon
emission computed tomography (SPECT) are more
expensive and are generally reserved for evaluation of
liver masses. Some specialists recommend screening for
HCC every 6 months.
Liver biopsy
Liver biopsy is used to stage the degree of inflammation
and fibrosis to determine the need for HCV treatment.
Biopsy should be considered in patients who are
candidates for HCV treatment, after education about
HCV therapy (including the expected success rates
given the genotype, potential adverse effects, and the
duration and logistics of treatment). Recently, blood
tests have been used as noninvasive markers of hepatic
fibrosis and have shown reasonable ability to identify
patients with either mild or advanced liver fibrosis
(currently about 40% of patients with HCV), allowing
them to avoid liver biopsies.
Treatment
Treatment of chronic HCV
The recommendations of the National Institutes of
Health (NIH) from June 2002 suggest that current
alcohol users, pregnant women, patients with untreated
depression, patients with renal disease, and patients
with advanced cirrhosis are not candidates for HCV
treatment. However, more recent data suggest that
patients in several of these “special groups” can be
treated on a case-by-case basis. Although pregnant
women and persons with active alcohol use should
not receive HCV treatment, certain individuals with
renal disease, depression, injection drug use, and
lower degrees of hepatic fibrosis (ie, Child-Pugh class
A) should be considered for HCV treatment. These
comorbid conditions should, of course, be treated to the
degree possible.
HIV-infected patients with low CD4 counts should not
be excluded from HCV treatment on the basis of CD4
count alone. Some studies do not support an association
between absolute CD4 cell counts and treatment
response.
Patients with a high risk of progression to cirrhosis
should receive higher priority for treatment. Risk is
indicated by portal or bridging cirrhosis, moderate
inflammation and necrosis, measurable HCV RNA
levels, or persistently elevated ALT levels. However,
because ALT levels do not correlate with liver damage
and some patients with normal ALT levels have
abnormal liver biopsies, many experts treat patients who
have normal ALT levels. For patients with minimal
findings on liver biopsy and minimal ALT elevations,
therapy should be deferred and the patients should
be monitored. Patients with decompensated liver
disease generally should not receive HCV treatment;
appropriate candidates can be considered for clinical
studies of liver transplantation in HIV/HCV-coinfected
patients.
The most effective treatment for HCV in patients with
or without HIV is combination therapy with pegylated
interferon-alfa (PEG-IFN) plus ribavirin. Among HIVuninfected
patients, approximately 50% with genotype
1 achieve HCV viral clearance using this combination.
HCV/HIV-coinfected patients with genotype 1 have a
22% rate of sustained virologic response to PEG-IFN
plus ribavirin if treated for 48 weeks, whereas patients
with other genotypes have approximately a 55% rate
of sustained virologic response. Data suggest that early
virologic response (EVR), defined as a >2 log 10 decrease
in HCV viral load 12 weeks into treatment, predicts
sustained virologic response to treatment; treatment
may be stopped if patients do not demonstrate EVR.
The recommended duration of treatment in patients
with genotype 1 HCV and EVR is 48 weeks. For
genotype 2 or 3, the optimal duration of treatment is
not clear; some specialists treat for 24 weeks, whereas
others treat for 48 weeks.
Adverse effects of treatment
HCV therapy may cause significant adverse effects. IFN
reduces total white blood cell counts, and can cause
neutropenia. It also decreases CD4 cell counts, although
the CD4 percentage usually does not change. IFN can
reduce HIV RNA somewhat (approximately a 0.5 log 10
decrease). IFN may also produce flulike symptoms,
depression, peripheral neuropathy, and other symptoms.
Ribavirin can cause anemia and other adverse effects.
Zidovudine and didanosine should be avoided, if
possible, in patients taking HCV treatment.
HCV treatment should not be given during pregnancy,
and women receiving HCV treatment should avoid