From the Guidelines
After successful HCV clearance with medication in patients with F3 fibrosis, follow-on treatment is recommended to monitor for potential complications and manage the residual liver damage, with a focus on regular surveillance for hepatocellular carcinoma (HCC) every 6 months using ultrasound examinations, as recommended by the most recent guidelines 1. The goal of this follow-on treatment is to prevent and detect potential complications early, thereby reducing morbidity, mortality, and improving quality of life.
- Patients with advanced fibrosis (F3) should undergo surveillance for HCC every 6 months by means of ultrasound, as the risk of liver cancer remains elevated despite viral clearance 1.
- Liver function tests should be performed every 6-12 months to monitor liver health, and non-invasive fibrosis assessment using FibroScan or similar elastography techniques is recommended annually to track fibrosis regression, which can occur gradually after viral elimination.
- Lifestyle modifications are crucial, including complete alcohol abstention, maintaining healthy weight, controlling diabetes if present, and avoiding hepatotoxic medications when possible.
- Patients may benefit from antioxidants like vitamin E (800 IU daily) if they have concurrent non-alcoholic steatohepatitis, and vaccination against hepatitis A and B is recommended if not already immune. The most recent and highest quality study 1 prioritizes the management of portal hypertension and varices, and recommends that guidelines for this should be implemented, though index variceal bleed is seldom seen in low-risk patients after the achievement of SVR, unless additional causes for ongoing liver damage are present and persist.
- The risk of reinfection should be explained to patients, to positively modify risk behaviour, and monitoring for HCV reinfection through annual HCV RNA assessment should be undertaken in people who inject drugs or men who have sex with men with ongoing risk behaviour 1.
From the Research
Follow-on Treatment for Fibrosis F3
- For patients with advanced fibrosis (Metavir score, F3 or F4), progression to decompensated liver disease occurs at a rate of approximately 5% per year and progression to hepatocellular carcinoma occurs at a rate of 1% to 2% per year 2.
- Patients with advanced fibrosis need to be regularly monitored for evidence of decompensated disease, and complications need to be aggressively managed 2.
- The traditional reference standard for diagnosis of liver fibrosis is liver biopsy, however, this technique is invasive, associated with a risk of sampling error, and has low patient acceptance 3, 4.
- Non-invasive alternatives such as FibroTest and FibroScan have been developed for predicting HCV-related fibrosis, with areas under summary receiver operating characteristics curves (AUC) of 0.81 and 0.83, respectively 5.
- Elastography techniques, including ultrasound and magnetic resonance elastography, offer a noninvasive, objective, and quantitative alternative to liver biopsy for assessing liver fibrosis 3, 6.
Monitoring and Management
- Regular monitoring for evidence of decompensated disease is necessary for patients with advanced fibrosis 2.
- Complications of decompensated liver disease, such as ascites, hepatic encephalopathy, bleeding varices, and coagulopathy, need to be aggressively managed 2.
- Non-invasive imaging modalities, such as ultrasound, computed tomography, and magnetic resonance imaging, can be used for diagnosis and stratification of liver fibrosis 3, 4, 6.