Comorbidity and Drug-Drug Interactions
The researchers also sought to allay concerns commonly correlated with, but separate from, age, such as concomitant health issues and the potential for drug-drug interactions.
“While older adults experience less drug-drug interactions (DDIs) and adverse events on DAA regimens compared to interferon-based regimens, these events may still occur and discourage clinicians from pursuing guideline-concordant treatment,” they wrote. “Older adults are at a particular risk for experiencing DDIs with DAA therapy compared to younger adults as older adults are more susceptible to polypharmacy, corresponding to having more comorbidities.”
Given the importance of managing these issues, the study examined patients who received care at clinics that used clinical pharmacists in the management of HCV. “Pharmacists are positioned to address many drug-related problems that older adults may be at higher risk for, such as DDIs, side effects, and medication nonadherence that are typically of concern with patients starting DAA therapy,” they explained.
The team compared SVR rates for older and younger patients with 19 comorbid medical, psychiatric and substance use conditions that frequently co-occur with HCV. Comorbid conditions included chronic pain, hepatitis B, hypertension, coronary artery disease, chronic heart failure, chronic kidney disease, chronic pulmonary disease, diabetes, depression, anxiety, bipolar disorder, post-traumatic stress disorder, schizophrenia, alcohol use disorder and several substance use disorders.
In the older group, 93.4% had at least one comorbid diagnosis, whereas 87.1% of the younger patients did, but the researchers determined that the difference was not statistically significant. “Older adults shared a greater burden of having at least one comorbid diagnosis, but both age groups achieved SVR12 at a similar rate,” the researchers said.
More advanced liver fibrosis did not impair response to treatment, the authors noted. “However, there is some urgency regarding when to start therapy for an older patient with chronic HCV, as older adults do have a greater risk for HCV-related intrahepatic and extrahepatic disease,” they said.
In a side note, the high rate of tobacco use also stood out to the researchers. Previous studies have shown that individuals with HCV are three times more likely to use tobacco than people without the infection, which the researchers linked to higher rates of cardiovascular disease and cardiovascular and respiratory-related deaths among HCV patients. Consequently, they called for tobacco cessation counseling in patients undergoing treatment for HCV.
Overall, though, the team emphasized the importance of treating all patients in concordance with established guidelines which recommend DAA therapy for any individual with chronic HCV who is expected to live for more than 12 months.
“Our findings suggest that HCV cure is possible for both younger and older patients with chronic HCV and is not limited by a patient’s age or the comorbid illnesses evaluated in this study,” they said. “Given the longer duration of infection in older patients with HCV and the efficacy and tolerability of DAA therapy, it is imperative to treat older patients, who are at the highest-risk for HCV-related liver morbidity and mortality.”
Overall, VA has led the nation in making sure HCV patients have been cured.
“The VA has done a phenomenal job trying to treat all veterans with hepatitis C, and it is on its way to treating all those who are candidates for treatment. The VA should be a model for how to treat all patients with hepatitis C,” Akbar K. Waljee, MD, director of the Inflammatory Bowel Disease Program at the VA Ann Arbor Healthcare System, previously told U.S. Medicine.
- Francis AK, Beaudoin FL, Naidjate SS, Berard-Collins C, Zullo AR. Comparing Treatment Response Between Older and Younger Patients with Chronic Hepatitis C Virus Infection on Direct-acting Antiviral Agents. RI Med J. 2020 June 1;103(5):35-40.