Hepatitis C in the Elderly Todd Wills MD

Hepatitis C in the Elderly Todd Wills, MD ETAC Infectious Disease Specialist HEPATITIS C TREATMENT EXPANSION INITIATIVE MULTISITE CONFERENCE CALL MAY 15, 2013

Epidemiology • • • National Health and Nutrition Examination Survey III (NHANES III) 21, 241 participants • HCV Ab + – 0. 9% 60 -69 yrs – 1. 0% > 70 yrs • Non-Hispanic Blacks/HCV Ab+ – 2. 5% 60 -69 yrs – 2. 8% > 70 yrs • NHANES 1999 -2002 – Largest prevalence group 40 -49 (4. 3%) – 60% of those >60 years old infected via blood transfusion M. J. Alter D. Kruszon-Moran O. V. Nainan The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med. 1999; 341: 556 -562 G. L. Armstrong A. Wasley E. P. Simard The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006; 144: 705 -714

Natural History • • Transfusion acquired HCV and time to development of cirrhosis • Minola et al. – Acquired age 21 -30 yrs, 33 years to cirrhosis – Acquires after 40 yrs, 16 years to cirrhosis • Tong et al. – Acquired before 50 yrs, 23. 6 years to cirrhosis – Acquired after 50 yrs, 9. 8 years to cirrhosis E. Minola D. Prati F. Suter Age at infection affects the long-term outcome of transfusion-associated chronic hepatitis C. Blood. 2002; 99: 4588 -4591 M. J. Tong N. S. el-Farra A. R. Reikes Clinical outcomes after transfusion-associated hepatitis C. N Engl J Med. 1995; 332: 1463 -1466

Differential Treatment Outcomes in the Elderly • • • Less response to pegylated interferon/RBV with increased age – Odds ratio of SVR 0. 13 -0. 21 for age groupings >40 years old versus <40 – Only seen in genotypes 1 and 4; no significant age difference for genotypes 2, 3 • Greater risk of cytopenias requiring dose modifications for patients >60 years versus matched controls (p=0. 031) G. Antonucci M. A. Longo C. Angeletti The effect of age on response to therapy with peginterferon alpha plus ribavirin in a cohort of patients with chronic HCV hepatitis including subjects older than 65 yr. Am J Gastroenterol. 2007; 102: 1383 -1391 C. G. Nudo P. Wong N. Hilzenrat Elderly patients are at greater risk of cytopenia during antiviral therapy for hepatitis C Can J Gastroenterol 20: 2006; 589 -592

Treatment Candidacy • Treatment is proposed to few elderly patients. prospective cohort study screened 4025 patients with HCV at 24 VA Hospitals • 364 (9%) were over the age of 60 • Twenty five per cent of patients over the age of 60 were considered to be treatment candidates • 10% were started on treatment. – age was a strong independent predictor of not being a treatment candidate. Tsui JI, Currie S, Shen H, et al. Treatment eligibility and outcomes in elderly patients with chronic hepatitis C: results from the VA HCV-001 Study. Dig Dis Sci 2008; 53: 809– 814.

Summary • The decision to treat older patients is complex A detailed explanation of the natural history of the disease, the likely rate of progression, the risk of complications is required. • Lower toxicity newer medications may still offer future more tolerable treatment options