Issue: 2008 > July-August > special report

Treatment of chronic hepatitis C virus infection - Dutch national guidelines

J. de Bruijne, E.H.C.J. Buster, H.C. Gelderblom, J.T. Brouwer, R.J. de Knegt, K.J. van Erpecum, S.W. Schalm, C.M. Bakker, H.L. Zaaijer, H.L.A. Janssen, H.W. Reesink


The development of this guideline was initiated and
coordinated by the Netherlands Association of Gastroenterologists and Hepatologists (Nederlandse
Vereniging van Maag-Darm-Leverartsen). The aim is the
establishment of practical guidelines in the evaluation and antiviral treatment of patients with chronic hepatitis C virus (HCV) infection. This includes recommendations for the initial evaluation of patients, the choice and duration of antiviral therapy and the follow-up after antiviral therapy.
Hepatitis C is a slowly progressive disease. The initial
evaluation of chronically HCV-infected patients should
include liver biochemistry testing, virological testing and
abdominal ultrasound imaging. Liver biopsy is no longer a routine procedure.
Antiviral treatment should be considered for all HCV-infected patients. Current antiviral treatment is a long-term process and is associated with substantial side effects. When deciding whether to start treatment or not,
the chance of successful treatment (80% with hepatitis
C genotype 2 and 3 and 50% with hepatitis C genotype
1 and 4), the fibrosis stage, the expected side effects
and the compliance of the patient should be taken into
consideration. In the absence of significant fibrosis and
necroinflammation in liver biopsy, postponing treatment
is an option. Current antiviral treatment is contraindicated in patients with Child-Pugh-class B or C cirrhosis. The possibility of a liver transplantation should be investigated in these patients. Significant comorbidity with a limited life expectancy is an absolute contraindication for antiviral treatment Treatment of chronic hepatitis C consists of administration of peginterferon and ribavirin for 24 or 48 weeks. Patients
with hepatitis C genotype 1 or 4 are treated for 48 weeks.
Patients with hepatitis C genotype 2 or 3 are treated for
24 weeks. In patients with undetectable HCV RNA after
four weeks (28 days) of treatment, a shorter treatment is equally effective (12 to 16 weeks for hepatitis C genotype 2 or 3; 24 weeks for hepatitis C genotype 1 or 4). Outpatient clinic visits are recommended at the start and after 2, 4, 8, and 12 weeks of treatment, and thereafter every four to six weeks until the end of treatment. It is recommended to stop treatment if the HCV RNA level has not decreased by at least 2 log<sub>10</sub> IU/ml (c/ml) after 12 weeks of treatment or when HCV RNA is still detectable after 24 weeks of treatment.
The recommended frequency of outpatient clinic visits for
patients who are not being treated is once every six months in patients with cirrhosis, otherwise every 12 months.
It is expected that new anti-HCV-medication (STAT-C,
specifically targeted antiviral therapy for HCV) will become available in the near future. Therefore treatment of chronic HCV infection will probably be more effective in the future.