Treatment Choices for Hep C

From the WebMD Archives

It's not often that doctors use terms like "revolutionary" and "groundbreaking" when they talk about medications. But that's exactly what they're doing -- and with much enthusiasm -- when they talk about today's treatments for hep C.

"There is no question, we're amid a revolution in hepatitis C treatment," says William D. Carey, MD, a senior hepatologist at Cleveland Clinic in Ohio. "There is nothing in my 40 years of professional life that comes close to this."

The Problem With Traditional Therapy

Hepatitis C is a contagious viral disease and the No. 1 cause for liver cancer and liver transplants. Treatment involves removing the virus from your body and preventing liver damage. It can be cured, but until just a few years ago, that wasn't easy or comfortable.

For nearly two decades, people with the condition received shots of a medicine called interferon. Along the way, doctors learned that adding a pill called ribavirin worked better. Together these two medicines became known as "traditional dual therapy."

But that duo didn't do a great job of curing the disease. That's because neither worked against the cause of hep C. Instead, they amped up your immune system to help it fight the virus. It’s the same way your body gears up when you get another bug, like the flu.

Some people’s bodies were able to get rid of the virus, but not everyone's could. Cure rates, especially for someone with liver scarring, "were 50% at best," says Ryan Ford, MD, assistant professor of medicine at Emory University School of Medicine.

To make things worse, the side effects of this treatment were a lot like the ones that come with chemotherapy. People got fevers and flu-like symptoms, they lost bone marrow, and had big drops in their white and red blood cell counts. Sometimes they needed blood transfusions.

"Basically, liver doctors and gastroenterologists started to feel like they were cancer doctors," Ford says. "But this was all we had. We put people through this chemotherapy-like regimen for a year and then tossed a coin to see if it worked. It was terrible."

But necessary. Although severe side effects often caused people to drop out of -- or completely avoid -- treatment, doctors urged them to stay with it. Hepatitis C can lead to permanent and life-threatening liver damage if you don't take meds for it.

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The Hope of New Options

But today, we've entered a new era of treatment for the disease. More and more people are being quickly cured without painful shots or toxic side effects.

Since 2014, the FDA has swiftly approved several interferon-free treatments for hep C. The new medicines -- all pills -- are called direct-acting antivirals. Unlike older meds, these drugs specifically attack the processes that help the virus grow. The result? Cure rates now hover around 95%-98%. Bonus: Most people only need treatment for a few weeks, maybe 3 months.

"The cure rates with these new drugs are so high you could even start to imagine eradicating the disease from the planet," Ford says. "It's absolutely conceivable."

The first medication to receive FDA approval was a combination of ledipasvir and sofosbuvir (Harvoni). It’s one of the most-often prescribed drugs today for people with hepatitis C type 1, the most common form in the United States.

"It's one pill, you take it once a day, and there are almost no side effects," Carey says. "How can it get simpler? For the ordinary person with genotype 1 hepatitis C, it's 8 to 12 weeks of therapy and then, boom, you're done."

Then in January of 2016, another once a day pill also received approval. Zepatier combines elbasvir and grazoprevir and like Harvoni, has few side effects.

New drugs include:

  • Daclatasvir (Daklinza)
  • Elbasvir-grazoprevir (Zepatier)
  • Ledipasvir and sofosbuvir (Harvoni)
  • Ombitasvir-paritaprevir-ritonavir (Technivie)
  • Ombitasvir-paritaprevir-ritonavir plus dasabuvir (Viekira Pak)
  • Simeprevir (Olysio)
  • Sofosbuvir (Sovaldi)

Which one you get will depend on many things, including what kind of the virus you have. Genotypes 2 and 3 are less common than type 1 in the U.S, and genotypes 4, 5, and 6 are rare. Your doctor will also look at past treatments and whether you have cirrhosis, kidney disease, or HIV.

These medications generally have few or no side effects. The FDA has issued a warning that Technivie and Viekira Pak can cause a very bad liver injury, especially if you already have severe liver disease.

The new medicines can also interfere with acid-reducing drugs and some cholesterol meds. So it's a good idea to make sure your doctor knows about all the medicines you take.

But overall, doctors say the new treatments are life-changing.

"As a clinician, these medicines have made all the difference in the world. In the past, I had to tell someone who had been stuck with the terrible side effects of interferon that it didn’t work. Now, every day I am talking to people I am able to cure,” Carey says. "It has made my practice so wonderful."

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The Promise of Future Treatment

Despite the enthusiasm and groundswell of good-news reports about hepatitis C therapies, doctors agree there are still a few things that need improvement. For one, "95%-98% is not 100%," Carey says. Sometimes the virus resists the drugs.

Researchers hope to look at how different combinations or durations of treatment might help.

A once-a-day, fixed-dose pill in advanced-stage testing is showing impressive results for all types of hep C, including those with cirrhosis. It combines sofosbuvir with an experimental antiviral drug called velpatasvir and has been given priority review status by the FDA.

"It really is a rapidly changing area. Whatever you write today will change in 6 to 12 months," Carey says.

The Cost of a Cure

These new medicines are pricey, and many insurers won't give the go-ahead to cover them. They're often reserved for people with advanced liver disease.

"Cost does have some bearing on who gets treated and who doesn't," Carey says.

Both Ford and Carey say this could change as new drugs come to market. They encourage you to work with your pharmacy and the drug manufacturer for a discount or compassionate-care pricing.

WebMD Feature Reviewed by Jennifer Robinson, MD on May 17, 2016

Sources

SOURCES:

William D. Carey, MD, senior hepatologist in the department of gastroenterology, Cleveland Clinic, Cleveland, Ohio.

CDC: "Hepatitis C FAQs for the Public."

Ryan Ford, MD, assistant professor of medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta.

News Release, FDA.

News release, Gilead.

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