Direct-acting antiviral (DAA) medication was successful in treating hepatitis C in 74.5% of patients with hepatocellular carcinoma, and 93.4% of patients with HCC who underwent liver transplants, according to a study funded by Veterans Affairs.

In order to study the effectiveness of DAAs in this setting, Lauren A. Beste, MD , and her colleagues studied a cohort of 17,487 veterans; 624 patients reported having HCC, including 142 with HCC and liver transplantation (J Hepatol. 2017. doi. org/10.1016/j.jhep.2017.02.027 ).

Dr. Beste of the general medicine service, Veterans Affairs Puget Sound Health Care System, Seattle, and her colleagues recorded the effects of two treatments on patients, either sofosbuvir or ledipasvir/sofosbuvir (LDV/SOF monotherapy), and paritaprevir/ritonavir/ombitasvir and dasabuvir, with or without ribavirin (PrOD p/m ribavirin).

Effects of the DAAs were also studied based on the genotype of patients’ HCV. According to analysis, patients with the genotype 1 HCV virus were most susceptible to the medication, with sustained virologic response (SVR) rates calculated at 79.1% for patients with HCC, 96.4% for HCC and transplant, and 93.1% for non-HCC.

For patients with genotype 2 virus, the SVR rate was 68.9% for those with HCC, and 86.5% for patients without HCC; for genotype 3, the rate of SVR was 68.9% and 86.5% for patients with and without HCC, respectively; and for genotype 4, the SVR rate was 50% and 90.2% for patients with and without HCC, respectively.

Unlike the genotype 1 population, which had 111 patients with HCC and liver transplantation, genotypes 2, 3, and 4 had only 4, 18, and 0 patients, respectively.

Dr. Beste and her colleagues attribute this to how common genotype 1 is, which made up 11,761 of 11,871 patients (99%) with known genotypes treated with either of the two medications.

An LDV/SOF-based regimen was given to more of those with genotype 1 who had HCC (88.1%) or HCC and liver transplantation (99.1%) than to those without HCC.

When comparing fibrosis and cirrhosis (FIB-4) scores among patients with an LDV/SOF-based and PrOD p/m ribavirin regimens, patients given PrOD regimens were less likely to have a higher FIB-4 score (47.7% vs. 73.1%), thrombocytopenia (23.1% vs. 40.2%), or elevated bilirubin (21.6% vs. 35.9%).

Patients with genotype 4 showed similar results in favor of PrOD treatment and genotype 2 patients only received LDV/SOF-based treatment; however genotype 3 showed the most positive results with LDV/SOF-based regimens, reporting a 100% success rate for the seven patients treated in the specific sample.

Overall, treatment was less successful for patients with HCC, compared with those without or who underwent transplantation. While Dr. Beste and her colleagues could not definitively explain this, the researchers suggested that it might be from the HCC itself. “The association between HCC and treatment failure persisted after adjustment for cirrhosis, markers of liver dysfunction, and genotype,” said Dr. Beste. “Therefore, these factors cannot explain the lower SVR in patients with HCC, and lead us to suspect that HCC itself could be causally linked to antiviral treatment failure.”

The researcher’s presented the hypothesis that “altered hepatic immune processes may predispose both to HCC and to poorer antiviral treatment outcomes.”

While the study was strengthened by the size and scope of the cohort, researchers were limited by a lack of data, including SVR data for 11.6% of HCC patients and 6.3% of HCC patients with transplantations. Researchers were also unable to attain HCC treatment data for nearly 24% of nontransplanted cases. Finally, the sample size was “overwhelmingly” male, which may give the study “limited generalizability to women.”

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