How to Treat Patients with Chronic Hepatitis C Virus Infection and Decompensated Cirrhosis

Patients with chronic hepatitis C virus infection (HCV) and decompensated liver disease are not uncommon and present a considerable therapeutic challenge. Interferon-alfa-based regimens, standard therapy for HCV until recently, are plagued by worse tolerability and efficacy in patients with decompensated disease than others. Recent data have emerged with direct-acting anti-viral agents (DAAs) that are currently available including sofosbuvir, ledipasvir, and ribavirin; sofosbuvir, daclatasvir +/− ribavirin; and sofosbuvir, simeprevir +/− ribavirin that reveal excellent tolerability and efficacy in this patient population. In fact, sofosbuvir, ledipasvir, and ribavirin demonstrated sustained virologic response (SVR) rates of 87 and 89 % in CTP B and C patients, respectively, with a 12-week course. The current HCV guidance document from the AASLD/IDSA addresses treatment regimen recommendations for patients with decompensated disease. Ongoing long-term studies that assess quality of life, effect on the complications of ESLD, the rates of de-listing for liver transplantation, rates of development of hepatocellular carcinoma, and mortality after SVR in patients with decompensated disease will help address the question of who to treat when. Data should be forthcoming, including data on emerging therapies. The decision to treat patients with decompensated disease may be difficult, and such patients present complex clinical issues that dictate that experienced personnel administer therapy if at all possible.