Page 34 - EASL Recommendations on Treatment of Hepatitis C 2015 - Full version
P. 34
Recommendations JOURNAL OF HEPATOLOGY
• PWIDs should be routinely and voluntarily tested for HCV Haemoglobinopathies
antibodies and if negative, every 6-12 months (B1) The most frequent haemoglobinopathy associated with
• PWIDs should be provided with clean drug injecting chronic hepatitis C is thalassemia major, which requires frequent
equipment and access to opioid substitution therapy blood transfusions and is prevalent in countries where blood sup-
as part of widespread comprehensive harm reduction ply screening may be, or has been, suboptimal. Chronic HCV
programs, including in prisons (B1) infection is also frequent in individuals with sickle cell anaemia.
Treatment has often been withheld in these patients because
• Pre-therapeutic education should include discussions of
HCV transmission, risk factors for fibrosis progression, both PegIFN-a and ribavirin can cause anaemia. No trials with
treatment, reinfection risk, and harm reduction strategies
(B1) antiviral therapy have been published in this population, but tri-
als are in progress. In the absence of published studies to examine
• PWIDs should be counselled to moderate alcohol intake, the safety of IFN-free treatment regimens in patients with hae-
or to abstain if there is evidence of advanced liver moglobinopathies, there is no reason to consider that these drugs
disease (A1) are specifically contra-indicated. Thus, IFN-free, ribavirin-free
drug regimens should be used in these patients because they
• PWIDs should be counselled to moderate cannabis have the great advantage of not aggravating the anaemia.
use, or to abstain if there is evidence of advanced liver
disease (B2) Recommendations
• HCV treatment for PWIDs should be considered • The indications for HCV therapy are the same in
on an individualized basis and delivered within a patients with and without haemoglobinopathies (A1)
multidisciplinary team setting (A1)
• Patients with haemoglobinopathies should be treated
• Pre-therapeutic assessment should include an evaluation with an IFN-free regimen, without ribavirin (B1)
of housing, education, cultural issues, social functioning
and support, finances, nutrition and drug and alcohol • The anti-HCV regimens that can be used in patients
use. PWIDs should be linked into social support services with haemoglobinopathies are the same as in patients
and peer support, if available (A1) without haemoglobinopathies (B1)
• A history of intravenous drug use and recent drug use at • When the use of ribavirin is needed, careful monitoring
treatment initiation are not associated with reduced SVR is recommended, and blood transfusions may be
and decisions to treat must be made on a case-by-case required (B2)
basis (B1)
Bleeding disorders
• Drug and alcohol users or any other patients with on- Haemophilia is an inherited bleeding disorder caused by a
going social issues and/or history of psychiatric disease,
and those with more frequent drug use during therapy, deficiency of either factor VIII or IX in haemophilia A and B,
are at risk of lower adherence and reduced likelihood of respectively. Patients suffer spontaneous and traumatic bleeds.
achieving SVR. They need to be monitored more closely Treatment is based on intravenous replacement of these factors
during therapy and need more intensive multidisciplinary which, until recently, were prepared from plasma donations.
support (B1) Clotting factor concentrates are prepared from pools of plasma
containing up to 30,000 donations and prior to 1985 were infused
• Evaluation of safety and efficacy of new IFN-containing into recipients without any viral inactivation. Haemophiliacs
and IFN-free regimens in PWIDs is needed (C1) exposed to non-virally inactivated concentrates prior to 1985
had an almost 100% chance of being infected with HCV with their
• PWIDs on opioid substitution therapy should receive an first exposure to concentrate. There are a number of other inher-
IFN-free regimen (B1) ited bleeding disorders treated with concentrates, including von
Willebrand disease, and deficiencies of fibrinogen and factors II,
• The anti-HCV regimens that can be used in PWIDs are VII, X, XI, and XIII.
the same as in non-PWIDs. They do not require specific
methadone and buprenorphine dose adjustment, but Progression to end-stage liver disease in patients with haemo-
monitoring for signs of opioid toxicity or withdrawal philia is similar to HCV-positive individuals in the general pop-
should be undertaken. More data is needed with ulation. The investigation of chronic liver disease in
daclatasvir (B1) haemophilia is the same as in non-haemophilic individuals.
Transjugular liver biopsies have enhanced the safety of the proce-
• Awareness should be raised that liver transplantation is dure. Non-invasive methods can be utilised to monitor disease
a therapeutic option in those with a history of intravenous progression. Death from liver failure in HCV-positive individuals
drug use (B1) is among the commonest causes of death in patients with inher-
ited bleeding disorders. With the exception of unavailability of
• Opioid substitution therapy is not a contra-indication for liver histology, the management of chronic hepatitis C in haemo-
liver transplantation and individuals on opioid substitution philia is similar to the non-haemophilic population. New HCV
should not be advised to reduce or stop therapy (B1) DAAs are applicable to patients with haemophilia.
33
• PWIDs should be routinely and voluntarily tested for HCV Haemoglobinopathies
antibodies and if negative, every 6-12 months (B1) The most frequent haemoglobinopathy associated with
• PWIDs should be provided with clean drug injecting chronic hepatitis C is thalassemia major, which requires frequent
equipment and access to opioid substitution therapy blood transfusions and is prevalent in countries where blood sup-
as part of widespread comprehensive harm reduction ply screening may be, or has been, suboptimal. Chronic HCV
programs, including in prisons (B1) infection is also frequent in individuals with sickle cell anaemia.
Treatment has often been withheld in these patients because
• Pre-therapeutic education should include discussions of
HCV transmission, risk factors for fibrosis progression, both PegIFN-a and ribavirin can cause anaemia. No trials with
treatment, reinfection risk, and harm reduction strategies
(B1) antiviral therapy have been published in this population, but tri-
als are in progress. In the absence of published studies to examine
• PWIDs should be counselled to moderate alcohol intake, the safety of IFN-free treatment regimens in patients with hae-
or to abstain if there is evidence of advanced liver moglobinopathies, there is no reason to consider that these drugs
disease (A1) are specifically contra-indicated. Thus, IFN-free, ribavirin-free
drug regimens should be used in these patients because they
• PWIDs should be counselled to moderate cannabis have the great advantage of not aggravating the anaemia.
use, or to abstain if there is evidence of advanced liver
disease (B2) Recommendations
• HCV treatment for PWIDs should be considered • The indications for HCV therapy are the same in
on an individualized basis and delivered within a patients with and without haemoglobinopathies (A1)
multidisciplinary team setting (A1)
• Patients with haemoglobinopathies should be treated
• Pre-therapeutic assessment should include an evaluation with an IFN-free regimen, without ribavirin (B1)
of housing, education, cultural issues, social functioning
and support, finances, nutrition and drug and alcohol • The anti-HCV regimens that can be used in patients
use. PWIDs should be linked into social support services with haemoglobinopathies are the same as in patients
and peer support, if available (A1) without haemoglobinopathies (B1)
• A history of intravenous drug use and recent drug use at • When the use of ribavirin is needed, careful monitoring
treatment initiation are not associated with reduced SVR is recommended, and blood transfusions may be
and decisions to treat must be made on a case-by-case required (B2)
basis (B1)
Bleeding disorders
• Drug and alcohol users or any other patients with on- Haemophilia is an inherited bleeding disorder caused by a
going social issues and/or history of psychiatric disease,
and those with more frequent drug use during therapy, deficiency of either factor VIII or IX in haemophilia A and B,
are at risk of lower adherence and reduced likelihood of respectively. Patients suffer spontaneous and traumatic bleeds.
achieving SVR. They need to be monitored more closely Treatment is based on intravenous replacement of these factors
during therapy and need more intensive multidisciplinary which, until recently, were prepared from plasma donations.
support (B1) Clotting factor concentrates are prepared from pools of plasma
containing up to 30,000 donations and prior to 1985 were infused
• Evaluation of safety and efficacy of new IFN-containing into recipients without any viral inactivation. Haemophiliacs
and IFN-free regimens in PWIDs is needed (C1) exposed to non-virally inactivated concentrates prior to 1985
had an almost 100% chance of being infected with HCV with their
• PWIDs on opioid substitution therapy should receive an first exposure to concentrate. There are a number of other inher-
IFN-free regimen (B1) ited bleeding disorders treated with concentrates, including von
Willebrand disease, and deficiencies of fibrinogen and factors II,
• The anti-HCV regimens that can be used in PWIDs are VII, X, XI, and XIII.
the same as in non-PWIDs. They do not require specific
methadone and buprenorphine dose adjustment, but Progression to end-stage liver disease in patients with haemo-
monitoring for signs of opioid toxicity or withdrawal philia is similar to HCV-positive individuals in the general pop-
should be undertaken. More data is needed with ulation. The investigation of chronic liver disease in
daclatasvir (B1) haemophilia is the same as in non-haemophilic individuals.
Transjugular liver biopsies have enhanced the safety of the proce-
• Awareness should be raised that liver transplantation is dure. Non-invasive methods can be utilised to monitor disease
a therapeutic option in those with a history of intravenous progression. Death from liver failure in HCV-positive individuals
drug use (B1) is among the commonest causes of death in patients with inher-
ited bleeding disorders. With the exception of unavailability of
• Opioid substitution therapy is not a contra-indication for liver histology, the management of chronic hepatitis C in haemo-
liver transplantation and individuals on opioid substitution philia is similar to the non-haemophilic population. New HCV
should not be advised to reduce or stop therapy (B1) DAAs are applicable to patients with haemophilia.
33
