Can a patient with hepatitis C undergo treatment if they have a concurrent hepatitis B infection?

Treatment of Hepatitis C in Patients with Concurrent Hepatitis B Infection

Patients with HCV-HBV coinfection should be treated with the same anti-HCV regimens, following the same rules as HCV monoinfected patients, but concurrent HBV nucleoside/nucleotide analogue therapy is indicated for HBsAg-positive patients to prevent HBV reactivation.

Understanding HCV-HBV Coinfection

• In patients with HCV-HBV coinfection, HBV DNA levels are often low or undetectable, with HCV usually being the main driver of chronic inflammatory activity 1
• The viruses may interact in the liver, with HCV typically predominating and suppressing HBV replication 2
• Coinfected patients have a higher risk of developing advanced liver disease, including hepatocellular carcinoma, liver fibrosis, and cirrhosis compared to those with monoinfection 2

Pre-Treatment Assessment

• Before starting HCV treatment, patients should be carefully characterized for the replicative status of both HBV and HCV 1
• Testing should include:
  • HBs antigen
  • Anti-HBc antibodies
  • Anti-HBs antibodies
  • HBV DNA (if indicated)
  • HCV RNA 1
• Hepatitis D virus infection should also be ruled out in these patients 1
• HIV status should be determined if unknown 1

Treatment Approach

• HCV infection should be treated following the same rules and using the same direct-acting antiviral (DAA) regimens as for HCV monoinfected patients 1
• The selection of HCV treatment regimen should be based on:
  • HCV genotype
  • Prior therapy history
  • Severity of underlying liver disease 1
• Treatment efficacy appears comparable to HCV monoinfection, with studies showing high sustained virological response (SVR) rates in coinfected patients 2, 3

Managing Risk of HBV Reactivation

• There is a potential risk of HBV reactivation during or after HCV clearance 1
• In a prospective study of 111 Taiwanese patients with HBV-HCV coinfection treated with sofosbuvir and ledipasvir, approximately two-thirds experienced an increase in HBV DNA levels, though most were asymptomatic 1
• HBV reactivation management depends on HBsAg status:

For HBsAg-positive patients:

• Concurrent HBV nucleoside/nucleotide analogue therapy is indicated 1
• Treatment should continue at least until week 12 post anti-HCV therapy 1
• Monthly monitoring is required if HBV treatment is stopped 1

For HBsAg-negative but anti-HBc antibody-positive patients:

• Serum ALT levels should be monitored monthly 1
• Both HBsAg and HBV DNA should be tested if ALT levels do not normalize or rise during or after anti-HCV therapy 1
• If "occult" HBV infection is detected (HBsAg-negative but HBV DNA detectable), concurrent HBV nucleoside/nucleotide analogue therapy is indicated 1

Monitoring During and After Treatment

• Regular monitoring of liver function tests, particularly ALT levels, is essential 1
• For patients on HBV treatment, monitor for efficacy and safety of the nucleoside/nucleotide analogue therapy 1
• After completion of HCV therapy, continued monitoring for HBV reactivation is necessary, particularly in the first 12 weeks 1
• Drug-drug interactions should be considered when selecting treatment regimens 4, 5

Special Considerations

• Patients with decompensated cirrhosis require careful selection of both HCV and HBV therapies 1
• For patients with renal impairment, dose adjustments may be necessary for certain DAA regimens 1
• Some patients may experience HBsAg seroclearance during or after treatment, which is a favorable outcome 3

Potential Pitfalls and Caveats

• Failure to screen for HBV before HCV treatment could lead to unrecognized HBV reactivation 4, 5
• The FDA has issued warnings about the risk of HBV reactivation in coinfected patients receiving DAA therapy 4
• Not providing prophylactic HBV treatment for HBsAg-positive patients could result in hepatitis flares, potentially leading to liver failure 1
• Discontinuing HBV monitoring too early after HCV treatment completion may miss delayed HBV reactivation 1