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Practice Uncertainties

Do direct acting antivirals cure chronic hepatitis C?

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1382 (Published 10 May 2018) Cite this as: BMJ 2018;361:k1382
  1. Janus Christian Jakobsen, chief physician,, director of research1 2 3,
  2. Emil Eik Nielsen, research assistant, medical doctor1,
  3. Ronald L Koretz, emeritus professor of clinical medicine4,
  4. Christian Gluud, head of department1 3
  1. 1Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
  2. 2Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
  3. 3Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
  4. 4Granada Hills, CA, USA
  1. Contact address: Janus C Jakobsen jcj{at}ctu.dk, janusjakobsen{at}mac.com

What you need to know

  • Direct acting antivirals (DAAs) are relatively expensive drugs that have been promoted as a cure for chronic hepatitis C

  • There is insufficient evidence to judge if DAAs reduce mortality or other liver related complications from chronic hepatitis C

  • Discuss with your patient the uncertain clinical benefit, and the risks and costs of these drugs, to make a shared decision on treatment

Globally, an estimated 71 million people have chronic hepatitis C infection, which corresponds to a prevalence of 1.6%.12 Nearly 400 000 people with chronic hepatitis C die each year, mostly from cirrhosis and hepatocellular carcinoma.1 In the United States, hepatitis C is the most common cause of chronic liver disease and the most frequent indication for liver transplantation.3

Direct acting antivirals (DAAs) are relatively new drugs that have been hailed as a cure for hepatitis C.124 DAAs target specific proteins of the hepatitis C virus, thereby disrupting replication.2 The drugs are taken orally and the treatment duration varies between eight and 24 weeks. The chosen DAA regimen is based on several factors, including the infecting genotype and pre-existing viral mutations, natural history and stage of the disease, availability of drugs, prior treatment history, and potential adverse effects.5

Guidelines from the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the World Health Organisation recommend early treatment with DAAs for all patients with chronic hepatitis C.678 These guidelines define successful treatment as sustained virological response—that is, the inability to demonstrate hepatitis C virus RNA in the blood 12-24 weeks after the end of treatment and thereafter.678

However, the clinical implications of achieving sustained virological response are unclear.2 The evidence for using sustained virological response as a …

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