Successful treatment of chronic hepatitis C virus infection with crushed elbasvir/grazoprevir administered through a nasogastric tube in a patient with hypoxic encephalopathy

The treatment of hepatitis C virus (HCV) infection has promising evolution after the development of direct-acting antiviral therapy. Nevertheless, little was known about therapeutic efficacy and safety for chronic HCV infection in tube-feeding-dependent patients with swallowing disorders in the real world. Here, we present a case with successful treatment of HCV infection with crushed elbasvir/grazoprevir administered via a nasogastric tube in a standard 12-week treatment. A 58-year-old female nursing home resident was referred to our hepatology clinic for evaluation of abnormal liver function tests. She became bedridden and dependent on nasogastric tube feeding at the age of 44 after an episode of multiple cerebral infractions followed by hypoxic encephalopathy. Chronic HCV infection was screened out and eradication therapy was suggested. Before initiation of the treatment, a complete blood count revealed a white blood cell 5280/μl, a hemoglobin level of 12.9 g/dl, and a platelet count of 208,000/μl. The values for creatinine, bilirubin, and albumin were within normal range except the level of aspartate aminotransferase measured as 127 U/L (normal: <40) and the level of alanine aminotransferase as 90 U/L (normal: <41). Resolved hepatitis B virus infection was found based on positive hepatitis B core antibody, positive surface antibody and negative surface antigen. HCV-polymerase chain reaction verified the presence of viral RNA genotype 1b and a viral load 189,000 U/ml. Abdominal sonography showed mild fatty infiltration of the liver parenchyma without evidence of ascites or cirrhosis. The patient was administrated on a 12-week regimen of crushed elbasvir 50 mg/grazoprevir 100 mg combination starting with a single dose daily through a nasogastric tube. The viral load of HCV was <15 U/ml at week 4 and not detected at the end of treatment. She achieved sustained virologic response at 12 weeks post-treatment (SVR12) with improved liver function without serious adverse effects. The elderly population currently represents a larger proportion of HCV patients and historically, older patients with HCV are considered difficult to treat because of comorbid medical conditions, including the difficulty in swallowing whole tablets or receiving a tube feeding for nutrition and medication secondary to neurological or oncological disorders. As the result, such patients may either skip or delay taking medications or employ alternative methods of administration, for example, crushing or splitting the tablets and taking them with liquids or jellies. The results from a phase 1 study showed that crushing the tablets resulted in higher primary pharmacokinetic parameters area under curve (AUC) (12–16%) for both elbasvir and grazoprevir, compared with the whole film-coated tablets. Furthermore, crushing lead to a higher maximum concentration (Cmax) of grazoprevir (42%), but had minimal impact on the Cmax of elbasvir. There was no any serious adverse effects in these 11 healthy adult volunteers. Yap et al. described a successful treatment of a patient receiving a 16-week course of elbasvir/grazoprevir through a percutaneous endoscopic gastrostomy tube. In this report, we presented a clinical case of a noncirrhotic patient with HCV genotype 1b infection treated with crushed elbasvir/grazoprevir administered via a nasogastric tube in a standard treatment course for 12 weeks. The SVR12 was achieved without any adverse events. These findings agree with data in the literature showing the safety and efficacy of crushed elbasvir/ grazoprevir therapy without extension of treatment period.