Hepatitis C: tackling the silent killer

About 200,000 people are living with hepatitis C in the UK, but it is estimated that around half of these remain undiagnosed. Identifying those at risk, offering tests and connecting those infected with treatment are crucial to tackling the disease.

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Direct-acting hepatitis C antivirals begin to have an impact

Following the introduction of newer, all oral, direct-acting antivirals (DAAs) in 2014, the number of patients starting treatment has increased by almost 90%, which may be responsible for the fall in end-stage liver disease (ESLD)- and hepatocellular carcinoma (HCC)-related deaths seen over the past two years.

 

Natural history of hepatitis C

Illustration by Juliet Percival

Hepatitis C is known as the “silent killer” because most people with the disease do not know they are infected until symptoms develop 20–30 years later

 

Identifying those at risk of hepatitis C

Hepatitis C is a blood-borne virus that is most commonly transmitted during injecting drug use, but other groups are also at risk.

Timeline: From discovery to cure

1989: Hepatitis C virus is identified as the cause of non-A, non-B hepatitis

1990: A hepatitis C test is developed to detect antibodies in the blood but it is not 100% reliable because it can take up to three months to develop antibodies after infection

1991: Screening of donated blood, blood products, organs and tissues for hepatitis C is introduced in the NHS

1997: The first alpha interferon, Schering-Plough’s Intron A (interferon alpha-2B), is approved for treatment of hepatitis C in the UK

1999: European blood services begin screening blood with nucleic acid amplification testing (NAT), because it detects tiny hepatitis C virus RNA particles

2000: Peglyated interferon (PEGIntron; Schering Plough) is approved for treatment of hepatitis C in Europe

2001: The first combination of pegylated interferon injection and oral ribavirin is approved in Europe for treatment of all genotypes. Treatment lasts 24–48 weeks and has around a 50% cure rate in genotype 1 and 75% in genotypes 2/3

2007: The World Hepatitis Alliance is founded and launches the first world hepatitis day in July the following year

2009: The first rapid antibody test OraQuick (OraSure Technologies), which gives results in 20 minutes, receives a CE mark allowing sale in Europe

2011: The first two direct-acting antivirals (DAAs), boceprevir (Victrelis; MSD) and telaprevir (Incivek/Incivo; Vertex/Johnson & Johnson), are approved in Europe in combination with peginterferon alpha and ribavirin for genotype 1-infected patients. They improve cure rates to about 70% but worsen side effects. Treatment lasts 24–48 weeks

2014:

  • Second-generation DAAs sofosbuvir (Sovaldi; Gilead), simeprevir (Olysio; Janssen-Cilag), daclatasvir (Daklinza; Bristol-Myers Squibb) and ledipasvir/sofosbuvir (Harvoni; Gilead) are approved in Europe allowing interferon-free regimens for various genotypes. Treatment usually lasts 12–24 weeks, and is effective in an average of 90% of patients
  • Vertex discontinues telaprevir because of competition from newer DAAs

2015: Ombitasvir/paritaprevir/ritonavir (Viekirax; AbbVie), in combination with other medicines, is approved in Europe for treatment of patients infected with genotypes 1 and 4. Dasabuvir (Exviera; AbbVie), in combination with Viekirax, is also approved for genotype 1

2016: 

  • A combination of velpatasvir and sofosbuvir (Epclusa; Gilead), the first single treatment licensed for all genotypes, is approved in Europe, along with a combination of elbasvir and grazoprevir (Zepatier; MSD) for genotypes 1 and 4
  • MSD discontinues boceprevir because of the introduction of Zepatier
  • The World Health Assembly approves a global strategy to achieve elimination of hepatitis C as a public health threat by 2030. To do this, and starting from the 2015 baseline, countries and regions need to reduce new infections by 90% and reduce deaths by 65% by 2030

 2017:

  • Combinations of sofosbuvir, velpatasvir and voxilaprevir (Vosevi; Gilead), and glecaprevir and pibrentasvir (Maviret; AbbVie) are approved in Europe for treatment of all genotypes
  • Johnson & Johnson’s Janssen and MSD announce they are halting development of new hepatitis C treatments because of the growing number of treatment options

References

Sources: Public Health England, International Journal of Medical Sciences 2006;3:47, National Institute for Health and Care Excellence, Journal of Hepatology 2014;61:S58, Department of Health, Medicines and Healthcare products Regulatory Agency, European Medicines Agency, Journal of Clinical Oncology 2009;27:1485, Liver International 2012;32:1407.

Editorial advisers: Andrew Radley, consultant in public health pharmacy, NHS Tayside; Ryan Buchanan, hepatology research fellow, University of Southampton; Sarah Sawieres, senior clinical pharmacist —liver and private patients, King’s College Hospital.

Illustration: Juliet Percival. 

 

 

Last updated
Citation
The Pharmaceutical Journal, PJ, April 2018, Vol 300, No 7912;300(7912):DOI:10.1211/PJ.2018.20204764