Reply:
Authors: Leonard B. Seeff, Marc G. Ghany, Doris B. Strader, David L. Thomas
Journal: Hepatology (2009)

We would like to thank the authors of the three submitted letters for their comments regarding the updated guidelines on the management and treatment of infection with hepatitis C virus (HCV), and we are happy to respond to the issues they raise. Concerning the letter from Dr. Puoti and colleagues about what constitutes a normal alanine aminotransferase (ALT) level, we agree that the definition we used of two normal values on two to three occasions separated by at least 1 month over a 6-month period is somewhat arbitrary. We agree also that that their proposal of more frequent ALT measurements over an 18-month period more accurately defines persistent ALT normality. However, we do not believe that the widely accepted definition we use negates the concept of the presence of generally normal ALT values and its significance. Indeed, among studies in which this definition is used and liver biopsies are performed, advanced liver disease is reportedly found in only 5%-15% of subjects.1-3 Moreover, we do advocate continued monitoring of persons with normal ALT values so that, if the values should become abnormal, further evaluation would be warranted. Regarding the issue of treatment of persons with normal ALT values, we indicate that "the treatment regimen for HCV-infected persons with normal aminotransferase levels should be the same as that used for persons with elevated serum aminotransferase levels." We agree and so state that for patients with genotype 1 HCV infection and "normal" ALT levels, a liver biopsy is appropriate in order to detect the minority with advanced chronic liver disease who would then merit treatment. We indicate also in these guidelines that, because of the high response rate to treatment of those with genotype 2 infection, therapy can be offered them without the need for a liver biopsy, regardless of the ALT status. The letter from Swan and Curry identifies a regrettable error in the area devoted to treatment of HCV-infected injection drug users who continue to use illicit drugs. We indicate in Recommendation 59 of that section that treatment can be considered even if such persons continue to use illicit drugs, contingent upon certain requirements.4 However, we neglected to change a holdover from the previous iteration of these guidelines which states, in Table 11, that treatment can be offered current users of illicit drugs and alcohol, but that, "Candidates should be abstinent for a minimum period of 6 months." This sentence should be struck and will so appear in the online version of these guidelines. Finally, we note that Drs. Dalgard and Mangia disagree with our recommendation that all patients with genotype 2 or 3 HCV infection should be treated for 24 weeks, suggesting that, even though there is a higher relapse rate with a 12-week to 14-week treatment course, this could be compensated for by careful patient selection, and that furthermore, this would result in improved cost-effectiveness of the treatment. They point to two of their own publications to support these views,5, 6 one of which had not yet been published when the literature search of these guidelines was completed.6 While acknowledging the additional relevant data of these publications, we believe that our recommendation for treatment for 24 weeks remains appropriate for most patients with genotype 2 or 3 HCV infection. In making our recommendation, we placed greater emphasis on treatment efficacy as determined in a large international, multicenter trial7 than on data from smaller trials or on considerations of cost.5, 6 We agree that some patients with HCV genotype 2 and 3 may prefer to receive the 12-week to 14-week treatment regimen or there may be specific instances in which 12-14 weeks of treatment might be justifiable. For example, treatment might be appropriately abbreviated in a nonobese person who achieved a rapid virologic response and has significant adverse events. Such decisions should be made on a case-by-case basis after careful consultation with the patient. Thus, until more data demonstrate at least equivalency in sustained virologic response rates between those treated for 12-14 weeks compared to those treated for 24 weeks, we will continue to recommend the 24-week course. Leonard B. Seeff M.D.*, Marc G. Ghany M.D. , Doris B. Strader M.D. , David L. Thomas M.D.§, * Liver Disease Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, Liver Disease Branch, NIDDK, NIH, Bethesda, MD, Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington, VT, § The Johns Hopkins University School of Medicine, Baltimore, MD.