Hepatitis C treatment has undergone a sea change over the last several years, and the progression of treatment is likely to continue – even accelerate. Drug regimens have become shorter and outcome outlooks have improved. But the improvements come at a cost. A new drug combination costs more than $100,000 per regimen, putting an unsustainable burden on patients, health plans, plan sponsors and the healthcare system.
As is the case with any new therapy class, the newest drug isn’t always the right one for all patients. And while hepatitis C therapy has changed significantly already, there are even more options in the pipeline.
The specialist pharmacists in the Accredo Hepatitis Therapeutic Resource Center® counsel patients on therapy options and disease and medication management. The right medication regimen for a particular patient depends on various factors, including:
- HCV genotype (genetic structure of the virus)
- Past treatment experience
- Eligibility to take the drug interferon
- Disease progression and health of the liver
- Patient's ability to stay adherent to therapy
The goal of treatment is to achieve a sustained virologic response (SVR) or persistent absence of the virus six months or more after completing treatment.
Different medications achieve this by different modes of action and have different side effects and risks:
Pegylated interferon: Interferon is a protein made by the immune system, so named because it interferes with viral reproduction. It also signals the immune system to recognize and respond to microorganisms, including viral and bacterial infections. Infected cells release interferon to trigger the immune response. There are three types of interferon: alfa, beta and gamma. Pegylated interferon is administered through weekly injections at a higher dose than what the body produces naturally. Side effects of pegylated inteferons include flu-like symptoms, anemia, neutropenia, psychiatric problems such as depression, irritability, insomnia and moodiness.
Ribavirin: Ribavirin is a nucleoside analog, which is a drug that inhibits the ability of the hepatitis C virus to replicate. It is available in pill, capsule or liquid form. Ribavirin is taken twice daily, and dosing is based on weight. Although it is not effective against hepatitis C when used alone, it plays an important role in combination treatment. The major side effect of ribavirin is anemia, which is dose-dependent and can be managed by taking red blood cell growth factors or by lowering the dose of ribavirin. Additional side effects include heart problems, depression, dry skin, itching, rash, headache, cough and sinus problems, fatigue, diarrhea, dizziness, loss of appetite, nausea and vomiting.
NS3/4A protease inhibitors: These drugs block an important step in the HCV replication process. During the normal course of a hepatitis C infection, the virus uses its protease enzyme to cut long strands of virus into shorter pieces so they can be rearranged and reassembled to form new viruses. Protease inhibitors stop viral cleavage by binding to the protease enzyme. Some of the most common side effects of these drugs include rash (including photosensitivity for some), itching, nausea and anemia.
Nucleoside and nucleotide HS5B polymerase inhibitors: These drugs mimic a nucleotide, which the virus would ordinarily use to help copy itself. When the nucleotide analog is substituted for the normal nucleotide, the virus cannot replicate. These drugs are often used in combination therapy with other medications. The most common side effects when administered in combination with ribavirin were fatigue and headache. When given with ribavirin and pegylated interferon-alfa, the most common side effects reported were fatigue, headache, nausea, insomnia and anemia.
Starting in late 2014, newer hepatitis C therapies may be available on the market that will not need to be used in combination with interferon and possibly ribavirin as well.
Patients who are asymptomatic may not need to begin therapy immediately and could wait until additional options are available.
Patients should talk to their physician or a specialist pharmacist to better understand whether now is the right time for their treatment and which regimen is right for them.
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