Hepatitis C Therapy: Sobriety & Drug Abstinence as Criteria

Announcer:
You’re listening to GI Insights on ReachMD. I’m Dr. Peter Buch, and I recently had the chance to catch up with hepatologist Dr. Colin Swales about hepatitis C. Here’s just a brief snippet of our conversation focusing on a rather controversial topic, and that’s whether sobriety and drug abstinence should be criteria for denial of hepatitis C therapy. Let’s hear from Dr. Swales now.

Dr. Swales:
This is no doubt controversial, there is no right answer about this. What I’ll try to do is propose arguments for both sides. I think at the end of the day, people are gonna have to do what is gonna pass the pillow test, in other words, what’s gonna make you sleep easy at night when you put your head on the pillow. Put differently, you know, your own personal ethics about the issues.

So, treating people who use drugs or PWIDs, P-W-I-D, that’s the new buzz word, has become a hotly proposed treatment paradigm. And the pharmaceutical manufacturers have tried to study this to a certain degree to their credit. The concern is that people who continue to use drugs, they continue to have an ongoing risk factor for reinfection. In the interferon days, we also used to worry that people who used alcohol might have diminished efficacy in response to interferon; that is probably not going to be an issue in the modern era because there is no really biologically plausible reason to think that drug and alcohol abuse would impact the effect of these directly-acting anti-viral agents. But people can certainly get reinfected. And so there were what I would call real-world data from last couple of, maybe 10, 15 years ago, looking, especially at co-infected patients having somewhere between a 20 to 30% reinfection rate, if they continued to use. And that is high. But the more recent data, which were in a sort of  clinical trial experience suggest that that is much lower; it’s probably under 10%. Now people will split hairs with you and say, “Well that’s clinical trial data, that’s not real-world data;” we really need to see the long-term observational data to know what the real-world experience is gonna be and I respect that argument.

Now the upside of treating hepatitis C is both that the patient may have better liver outcome. There’s also a public health piece to it, which is that if you can decrease the active infections out there, then you can through, not herd-immunity but a similar concept,  prevent hepatitis C dissemination and that’s a valid argument. I think the counter argument to that is that in an individual patient/clinician relationship, your concern is not the public’s health, it’s the health of the patient. And so that brings up, I think, the important issue with ongoing drug use, which is that hepatitis C is yes, it’s a threat to your liver cells, but over a long term, hepatitis C is a disease of, as I like to say, years and decades, it’s not a disease of minutes and hours. And so is the hepatitis C infection gonna threaten your patient’s well-being in the next 12 months? It’s unlikely. But is ongoing drug use going to threaten the patient’s well-being in the next 12 months? Yes. It could. Not only from the bio-psychosocial perspective, but we’ve all seen patients get endocarditis from active drug use and that’s obviously life-threatening and, you know, the list goes on. And so I think that the contrarian argument is to say, you know, the most impressing issued is ongoing drug use and that’s where the energy ought to be focused. If you say it’s better to delay hepatitis C treatment pending sobriety, it could potentially be used as a motivator, which might be positive.

I think at the end of the day, you’re gonna have to decide, as I said, you know, which way you feel more comfortable with and I’ve done both and I’ve seen all the permutations and it’s not an easy decision.

Announcer:
That was Dr. Colin Swales talking about whether sobriety and drug abstinence should be criteria for denial of hepatitis C therapy. For ReachMD, I’m Dr. Peter Buch, and to hear my full conversation with Dr. Swales along with other episodes in our series, visit ReachMD.com/GI-Insights, where you can Be Part of the Knowledge. Thanks for listening!