Back in the old days of interferon based regimens we had patient groups that were considered ‘special’ because they were hard to treat. But is this still the case? International hepatitis expert Professor Coleman Smith answers the question in an address to the conference on state of the art treatment options in hepatitis C.

Speaking during the session on Global Cure of Hepatitis C: Transmission free by 2023? Smith who is a Professor of Medicine at Georgetown University said patients with cirrhosis, renal impairment, genotype 3 patients, those who had failed treatment, were co-infected or had liver transplants were emerging as difficult groups to treat, even with the newer direct acting antiviral agents.

“All of these groups tend to respond less well, but they are slowly disappearing,” he told delegates.

Resistance mutations was one emerging issue that we don’t yet know the significance of, but as with all antivirals, it has to be something in the back of our mind, he said.

In particular resistance to the NS5A inhibitors was a concern because resistance tended to hang around for at least two years.

“If a patient has failed a treatment regimen containing a NS5A inhibitor then you should check for resistance mutations…if they do have resistance mutations then you’re in a bit of trouble” he said.

If they don’t have severe liver disease it’s probably better to wait until something new comes out, Smith advised the audience.

So are these hard to treat patients still special? To some extent some are, but not all, said Smith.

People with cirrhosis may require the addition of RBV or longer duration with current therapy to achieve SVR rates comparable to people without cirrhosis.

Safety and efficacy data are now available for OMV/PTV/RTV plus RBV in haemodialysis patients but the dose of ribavirin needs to be reduced, he told delegates.

Efficacy data was now available for sofosbuvir-based regimens in patients with eGFR ≤ 30 but sofosbuvir metabolite (GS-331007) accumulation was a potential problem.

Genotype 3 patients remained a challenging population although the recent availability of daclatasvir and sofosbuvir improved SVR rates, he noted.

People with both genotype 3 and cirrhosis were still a problem, he added.