Hepatitis B and C

With the advent of potent antiviral compounds against hepatitis B virus (HBV) with low susceptibility to resistant mutation, the choice of first-line treatment has become quite clear. However, selection of treatment candidates remains less straightforward. As with any clinical circumstance, individual patient management decisions must be based on risks and benefits of treatment. On the one hand, the main benefit to be achieved with therapy is avoidance of long term sequelae (cirrhosis and hepatocellular carcinoma) of HBV infection through durable suppression of the virus. On the other hand, disadvantages associated with antiviral therapy include potential long term safety concerns, emergence of resistant mutants and financial burden. Available data and clinical experience guide the physician to balance these factors in individual patients. While the introduction of the new class of direct agents against hepatitis C virus (HCV) is eagerly awaited, clinicians rely on optimal use of the current standard-of-care medications to maximize patient's response. First, recent evidence points to the need for weight-based therapy. This is especially true of ribavirin-there are benefits of increasing ribavirin doses up to 1400 mg per day in genotype 1 patients with a body weight greater than 105 kg. Even for genotype 2 or 3 patients for whom the standard ribavirin dose is 800mg per day, weight-based dosing similar to genotype 1 patients may be more effective. Second, treatment duration may be tailored based on on-treatment response. In genotype 1 patients whose serum HCV RNA is negative at week four ('rapid viral response'), treatment may be shortened to 24 weeks. If HCV RNA becomes negative at week 12, the standard 48 week duration is applicable, whereas in those whose HCV RNA does not become negative until 24 weeks, prolonging the duration to 72 weeks may increase the response rate by up to 20%. Shortening therapy duration to 12-16 weeks in genotype 2/3 patients with rapid viral response is a bit more controversial-it may be considered in patients whose tolerance is poor, especially if ribavirin is dosed according to the weight