Update on the Treatment of Chronic viral hepatitis

The burden of chronic liver disease caused by hepatitis B virus (HBV) and hepatitis C virus (HCV) is substantial. Effective therapies aimed at reducing the rate of chronic infection and the risk of complications of cirrhosis are desirable. In the last few years, significant advances in the treatment of chronic HBV and HCV have been achieved. In this edition of Gastroenterology Clinics of North America, an update on treatment of these chronic viral infections is the focus. The issue is divided into three sections: the first on the management of chronic HCV; the second on management of chronic HBV; and the third on special treatment topics relevant to both viral infections.

An overview of the general approach to patients with chronic HCV and HBV serves as the introduction to each of the treatment sections. These overview articles, written by Dr. Dove (HCV) and Drs. Ghany and Doo (HBV) provide details on the diagnostic work-up of infected individuals, recommendations for routine follow-up, and factors to consider when making decisions to treat patients. Subsequent articles are devoted to state-of-the-art reviews on the treatment of treatment-naı̈ve and treatment-experienced patients, as well as special patient groups including those with HIV coinfection, cirrhosis, renal failure, and extrahepatic disease.

Antiviral therapy for chronic hepatitis C has advanced to the point where viral eradication can be achieved in about half of the treated patients overall, albeit with significant variability by genotype and other factors. The improvement in treatment outcomes has led to recommendations to consider antiviral therapy in every person with chronic HCV infection. Therefore, it is more critical than ever that clinicians be updated on the latest approaches to treatment. The therapeutic options and factors influencing treatment decisions in treatment-naive HCV patients are reviewed by Drs. Oh and Afdhal. The next two articles focus on a growing group of patients in clinical practice, namely patients who have relapsed or not responded to prior treatment with interferon (IFN)-based therapy. Drs. Ahmed and Jacobsen look at the treatment of relapsers and provide an excellent and balanced prospective on the approach to this patient subgroup. Dr. Fontana addresses the treatment of nonresponders to prior combination therapy, the use of hepatic fibrosis as a treatment endpoint, and new therapeutic approaches for this patient group. The final articles in the HCV section are on the treatment of special patient populations. Dr. Khalili looks at treatment of HCV in patients with HIV coinfection, highlighting the issues of tolerability, efficacy, and drug interactions. Drs. Arenas and Vargas provide a comprehensive review of treatment of HCV in patients with cirrhosis.

The number of therapeutic options for chronic HBV infection is greater than for chronic HCV infection. Three different drugs, IFN, lamivudine, and adefovir, are approved for treatment of HBV. The issues of who to treat and what drug to use for treatment are important. Both the American Association for the Study of Liver Diseases and American Gastroenterological Association (AGA) have published practice guidelines on the management of chronic HBV infection, in part prompted by the growing number of antiviral agents, evolving concepts of disease progression, and indications for treatment. Drs. Lau and Membreno provide a detailed review of treatment of patients who are naı̈ve to antiviral therapy. Drs. Hui, Zhang and G. Lau review the treatment of drug-experienced patients, an increasingly frequent occurrence in clinical practice. Dr. Benhamou reviews the unique challenges posed by the common occurrence of lamivudine resistance in HBV-infected patients with HIV, and the last article in this section by Dr. Lai and me looks at the treatment of chronic HBV infection in cirrhotic patients. The latter group has benefited significantly from the availability of safe and effective antiviral agents such as lamivudine and adefovir.

The last section is devoted to special treatment topics. Drs. Fabrizi, Martin, and Bunnapradist look at the role of antiviral therapy in patients with renal disease, both those on dialysis and those who have undergone renal transplantation. Hepatocellular carcinoma is a serious risk for those with chronic viral hepatitis, and treatment options have expanded in recent years. Drs. Sherman and Takayama examine critically the role of hepatoma surveillance strategies for patients with chronic HBV and HCV and provide an overview of available treatment options and their outcomes. The final article in this section, by Drs. Kim and Sherker, is a review of the extrahepatic manifestations of chronic HCV and HBV and current treatment approaches.

I hope that clinicians will find this issue of Gastroenterology Clinics of North America to be a useful update and reference on the management of patients with chronic viral hepatitis. I am extremely grateful to all the authors for their superb contributions. I would also like to acknowledge the excellent editorial support of Kerry Holland and the staff at Elsevier.