Question: To which of the following patients will you most likely offer Ribavirin and PegInterferon for their HCV?
A. 57 M with stage II fibrosis and congestive heart failure, EF 35%
B. 66 M with cirrhosis and hepatic encephalopathy
C. 51 F with stage III fibrosis and active lymphoma
D. 24 M with new infection from tattoo 12 months ago
Answer: I like this question. It requires a bit of deliberation. Let’s go through the answer choices one at a time. I’d like to treat somebody with stage II fibrosis, but the CHF is prohibitive, not only because of medication intolerance, but because of life expectancy; his liver won’t be causing too much trouble for another 15 years or more.
The woman with hepatic encephalopathy poses another treatment problem- in general, we do not offer treatment to decompensated cirrhotics. After all, the purpose of treatment is to avoid, or at least delay, time to decompensation. In the future, an oral therapy might be offered to such a patient in order to render her viral load negative before transplant (this is not yet common practice).
The woman with stage III fibrosis and lymphoma is a potential candidate. Recall that some indolent (lymphoplasmacytic) lymphomas are driven by chronic infections like HCV, and their resolution depends on effective control of the infection. Caution is required, perhaps with a slow, escalating dose of Ribavirin and PegInterferon, but an attempt at treatment is worthwhile.
Lastly, the young man. If you got to him within 3 months of innoculation of virus, treatment success is on the order of 90%. But, this is one year on, and he has a chronic infection. He certainly has no (or minimal) fibrosis from the HCV. It makes most sense to wait a few years and treat with an all-oral regimen for SVR rates > 90%. That said, if he is anxious and insists on treatment, go ahead, make his day.