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Hepatitis C in the Elderly

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 +

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Hepatitis C in the Elderly

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

  2. 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

  3. Natural History • Transfusion acquired HCV and time to • development of cirrhosis • • Minola et al. • – Acquired age 21-30yrs, 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

  4. 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

  5. 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.

  6. 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

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