American Gastroenterological Association Institute Clinical Practice Update-Expert Review: Care of Patients Who Have Achieved a Sustained Virologic Response After Antiviral Therapy for Chronic Hepatitis C Infection.
Jacobson IM et al.
Gastroenterology. 2017 May;152(6):1578-1587

Chronic hepatitis C virus infection is well-recognized as a common blood-borne infection with global public health impact affecting 3 to 5 million persons in the United States and more than 170 million persons worldwide. Chronic hepatitis C virus infection is associated with significant morbidity and mortality due to complications of liver cirrhosis and hepatocellular carcinoma. Current therapies with all-oral direct-acting antiviral agents are associated with high rates of sustained virologic response (SVR), generally exceeding 90%. SVR is associated with a reduced risk of liver cirrhosis, hepatic decompensation, need for liver transplantation, and both liver-related and all-cause mortality. However, a subset of patients who achieve SVR will remain at long-term risk for progression to cirrhosis, liver failure, hepatocellular carcinoma, and liver-related mortality. Limited evidence is available to guide clinicians on which post-SVR patients should be monitored vs discharged, how to monitor and with which tests, how frequently should monitoring occur, and for how long.

In this clinical practice update, available evidence and expert opinion are used to generate best practice recommendations on the care of patients with chronic hepatitis C virus who have achieved SVR.
The 11 best practice advise statements :

1. SVR should be confirmed by undetectable HCV RNA at 12 week after completion of an all-oral DAA treatment regimen.
2. Routine confirmation of SVR at 48 week post end of treatment is recommended. Testing for HCV RNA at 24 week post treatment should be considered on an individual patient basis.
3. Routine testing for HCV RNA beyond 48 week after end of treatment to evaluate for late virologic relapse is not supported by available evidence; periodic testing for HCV RNA is recommended for patients with ongoing risk factors for reinfection.
4. Surveillance for HCC with liver imaging ± serum AFP should be pursued twice annually for an indefinite duration in all patients with stage 3 fibrosis or liver cirrhosis post-SVR.
5. Surveillance for HCC is not recommended for patients with stages 0-2 fibrosis post-SVR.
6. Intensification of HCC screening frequency in the immediate post-SVR context is not currently recommended.
7. Initial endoscopic screening for esophagogastric varices is recommended for all patients with liver cirrhosis, independent of SVR.
8. Repeat endoscopic screening should be pursued for cirrhotic patients post-SVR at 2-3 years if no varices or small varices were identified on initial screening examination.
9. If no varices are identified on endoscopy 2-3 years post-SVR, cessation of further endoscopic screening can be considered on an individual patient basis if there are no risk factors for progressive cirrhosis.
10. Fibrosis assessment post-SVR with noninvasive tools, such as liver elastography, can 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.
11. Patients who have achieved SVR should be counseled regarding sources of liver injury, which can independently contribute to liver fibrosis progression, 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.

Expert's Commentary

Universal treatment is now recommended in developed countries for all patients with chronic HCV infection and cure (defined by sustained virologic response 12 weeks after the end of therapy) is achieved in more than 95% of patients. As a consequence, a large number of individuals will be in the situation of being cured from the viral infection while not having developed significant liver fibrosis. Others, also cured, will have a lesser risk of disease progression, even if already at a stage of significant fibrosis. Then, guidelines on how and for how long monitor cured HCV infected patients is of major importance, not only for practical and individual implications, but also for epidemiological and public health consequences.

Pr François Raffi, Nantes