Monitoring for regression of advanced fibrosis or cirrhosis
Best Practice 10
Fibrosis assessment post-SVR with non-invasive tools such as liver elastography may be considered on an individual patient basis to assess for interval fibrosis progression or regression to guide clinical management, although improved fibrosis measurements should not alter the frequency of HCC surveillance at the present time.
Many patients who have achieved SVR are anxious to know if pre-treatment liver fibrosis can be reversed, independent of HCC risk. For this reason, non-invasive post-SVR assessment may be attractive to many patients. Nevertheless, available evidence does not support a broad recommendation for routine fibrosis testing, and the decision to conduct such testing should be “individualized, according to clinicians’ judgment and/or patient preference.”
Counseling and Patient Education
Best Practice 11
Patients who have achieved SVR should be counseled regarding sources of liver injury that may independently contribute to liver fibrosis, including alcohol, fatty liver, and other potential hepatotoxins, and should be evaluated for these and other sources of liver injury if serum levels of liver enzymes are elevated.
Although most patients who attain SVR have a “favorable clinical course,” some may experience the progression of liver fibrosis, hepatic decompensation and/or HCC, so all patients should undergo evaluation for modifiable risk factors for liver injury (eg, alcohol, drug use, fatty liver, and diabetes mellitus). Patients with fatty liver and/or diabetes should be counseled to avoid alcohol consumption and should be advised regarding liver-related complications of diabetes and the importance of continuing disease-specific management to optimize weight loss and glycemic control.
The authors state that they “expect and encourage long-term studies of outcomes after interferon-free DAA therapy, which will further refine our concepts of appropriate management and, like the guidelines governing antiviral treatment itself, should lead to dynamic reassessment of the best practices for management of patients post-SVR in the years ahead.”
1. Jacobson IM, Lim JK, Fried MW, AGA Institute Clinical Practice Update: care of patients who have achieved a sustained virologic response (SVR) following antiviral therapy for chronic hepatitis C infection. Gastroenterology (2017), doi: 10.1053/j.gastro.2017.03.018.
2. AASLD-IDSA. HCV Guidance: Recommendations for testing, management, and treating hepatitis C. Available at: www.hcvguidelines.org. Accessed: April 9, 2017.