During EASL 2018, the annual meeting of the European Association for the Study of the Liver, which was held in Paris from 11 to 15 April last year, Professor Alessio Aghemo, Head of the Centre for the Study and Treatment of Metabolic Diseases of the Liver and Complications of Cirrhosis at Humanitas and Professor at Humanitas University, presented the new recommendations for the diagnosis and treatment of hepatitis C. The professor is in fact one of the experts who worked on the revision of these recommendations.


New indications for therapy

“The new EASL recommendations have been designed with the aim of offering each individual patient with hepatitis C at least one therapeutic possibility based on the combination of direct antivirals, the so-called AADs. The latest recommendations include 2 new regimens: the combination of glecaprevir and pibrentasvir already in use in Humanitas and the combination of sofosbuvir, velpatasvir and voxilaprevir, which will soon be initiated in early patients. The two regimens are pangenotypical (i.e. effective against all HCV strains) and can be administered without ribavirin.

The regimes of sofosbuvir/velpatasvir and grazoprevir/elbasvir, which have been administered in Humanitas for about 12 months, also remain usable.

All regimens are considered overlapping in terms of efficacy and safety, except in selected patient groups (such as immunocompromised or patients with transplants) where treatment with regimens based on sofosbuvir is suggested as the first line; this is because drug interactions are lower and there is more data to support these combinations (especially with sofosbuvir and velpatasvir),” explains Professor Aghemo.


The genotype 3

Patients with genotype 3 hepatitis C are the most difficult to treat. “Genotype 3 is a sensitive issue. We have three regimens available and we believe that the optimal combination in the non-cirrhotic patient is a combination of glecaprevir and pibrentasvir or sofosbuvir and velpatasvir, which have the same efficacy and safety.

In cirrhotic patients, however, the advice is to use glecaprevir and pibrentasvir or sofosbuvir, velpatasvir and ribavirin,” said the professor.


The novelty in diagnosis

Although more than 120,000 people have been treated with HCV in Italy to date (Humanitas has treated about 700 patients), many patients do not know they have chronic hepatitis or even if they are aware of the disease they have not been diagnosed by specialists.

Moreover, as Professor Aghemo explains: “There is much work to be done from this point of view: in fact, our country is a European leader in terms of antiviral treatment and access to treatment, which is universal, but there is no plan for the diagnosis of patients who are not known and for linkage to care (treatment project) of those who are followed only by general practitioners or non-specialist centers.

In addition to screening procedures, there are strategies that we could apply in our clinical practice to simplify diagnosis, such as rapid tests that give results on HCV-RNA in a few hours and that could for example be applied in day hospitals, so as to have the results in real time and directly insert patients into the care pathways. Or we could use remote peripheral blood tests, which the general practitioner could perform in his or her practice and then send the samples to a hospital or peripheral laboratory for analysis. A reflex test could then be used, as is done for example for thyroid alterations, which involves the execution of anti-HCV in the laboratory and in case of positivity, it is tested directly by the laboratory HCV-RNA. The advantage is that it would avoid recalling the patient several times, thereby streamlining the diagnosis process,” Professor Aghemo concluded.