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Chronic Hepatitis C in the Elderly

During the past decade, knowledge of the pathogenesis, clinical course and treatment of chronic hepatitis C virus (HCV) infection has expanded enormously, but there are few data on the course of the disease and its treatment in the elderly population (age >/= 60 years).

The burden of chronic hepatitis C virus infection in elderly persons is expected to increase significantly in the United States during the next 2 decades. Chronic infection is prevalent in elderly patients and may be more severe than in younger adults. As middle aged patients with HIV infection become elderly, the number of individuals with liver disease related to chronic hepatitis C will grow.

In an article appearing in the December 1, 2005 issue of Clinical Infectious Diseases [1], two Israeli researchers review the data on the epidemiology, immunology, and clinical manifestations of chronic HCV infection in older adults and suggest an approach to management of the infection in this population.

Most of the older adults with chronic hepatitis C virus infection have acquired the disease earlier in life. These patients often present with complications of liver disease, mainly cirrhosis and hepatocellular carcinoma (HCC)..

It is estimated that, each year, HCC will develop in 1%-2% of patients with chronic HCV infection and cirrhosis [2]. The risk of HCC increases significantly with age, probably owing to age-related changes in the ability to repair DNA [3] and to the prolonged interval from the time of infection. The interval between infection and diagnosis of HCC may be shorter when the infection is acquired at an older age.

Up to 30% of patients had psychological disorders, including depression, and up to 67% complained of fatigue [2,4,5]. These symptoms may appear even in the absence of clinically significant liver disease. Age of >50 years was found to be associated with fatigue [5]. Chronic HCV infection was associated with cognitive impairment, which was reported in patients aged 2869 years with mild liver disease [6]. The prevalence of cognitive impairment among older patients, who may have a higher susceptibility to this complication, has not been studied.

Despite the decrease in the incidence of acute hepatitis C, the prevalence of long-standing chronic hepatitis C infection is increasing among older adults. The management of chronic HCV infection in older adults is complex in terms of comorbidities and quality of life.

There are few data on the efficacy of antiviral therapy for elderly persons. Therefore, the study authors recommend that patients up to the age of 75 years be included in trials of chronic hepatitis C treatment.

For elderly patients with chronic hepatitis C, risk-benefit of antiviral therapy should be assessed on an individual basis. There is a need for research on treatments with efficacy that is at least the same as that of pegylated IFN and ribavirin but with fewer adverse effects. In large, multicenter, randomized trials of therapy with pegylated IFN and ribavirin involving cohorts with a mean age of 4243 years, older age was associated with poorer response to treatment [7,8]. Age of >40 years was an independent predictor of poor response to treatment.

Assessment should be performed in all cases before considering treatment, and it should include evaluation of the degree of liver fibrosis by means of liver biopsy or, possibly, by means of noninvasive methods, such as FibroTest-ActiTest, which combines the quantitative results of 6 serum markers together with age and sex. Other methods for assessing fibrosis is transient elastography (FibroScan; Echosens), which measures liver stiffness through pulse-echo Ultrasonography.

In the not-too distant future, novel antiviral drugs that may have fewer adverse effects are expected to be developed, such as HCV protease inhibitors, may serve as potential alternatives to peginterferon/ribavirin. Early access to these drugs prior to their approval should be available to elderly patients (as well as to younger patients) who are non responders to currently approved therapies.

It is also recommended by the authors that elderly patients (up to the age of 75 years) be included in randomized trials of chronic hepatitis C virus infection treatment.

Acute Geriatric Department, Herzog Hospital, The Hebrew University-Hadassah Medical School, Jerusalem, and Department of Medicine D and 3Liver Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

E-L Marcus and R Tur-Kaspa. Chronic Hepatitis C Virus Infection in Older Adults. Clinical Infectious Diseases 41(11): 1606-1612. December 1, 2005.

Marcus E-L and Tur-Kaspa R. Chronic Hepatitis C Virus Infection in Older Adults. Clinical Infectious Diseases 2005; 41(11): 1606-1612.

McHutchison JG. Understanding hepatitis C. Am J Manag Care 2004; 10(2 Suppl):S21-29.

Ben Yehuda A, Globerson A, Krichevsky S, et al. Ageing and the mismatch repair system. Mech Ageing Dev 2000; 121:173-179.

Poynard T, Cacoub P, Ratziu V, et al. Fatigue in patients with chronic hepatitis C. J Viral Hepat 2002; 9:295-303.

Hassoun Z, Willems B, Deslauriers J, Nguyen BN, Huet PM. Assessment of fatigue in patients with chronic hepatitis C using the Fatigue Impact Scale. Dig Dis Sci 2002; 47:2674-2681.

Forton DM, Thomas HC, Murphy CA, et al. Hepatitis C and cognitive impairment in a cohort of patients with mild liver disease. Hepatology 2002; 35:433-439.

Manns MP, McHutchison JG, Gordon SC, et al. Peginterferon -2b plus ribavirin compared with interferon -2b plus ribavirin for initial treatment of chronic hepatitis C: a randomized trial. Lancet 2001; 358:958-65.

Fried MW, Shiffman ML, Reddy KR, et al. Peginterferon 2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med 2002; 347:975-982.


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