Treatment of cirrhotic patients in the pegylated interferon era

Chronic hepatitis C is a leading cause of cirrhosis, hepatocellular carcinoma, digestive tract haemorrhage and hepatic insufficiency. The present best strategy to prevent severe complications of chronic hepatitis C is the decrease of fibrosis progression. Recently, pegylated interferon combination treatments of chronic hepatitis C have made it possibly to obtain 60% sustained virological responses. Pooled individual data from 3,010 naïve patients with pre-treatment and post-treatment biopsies from 4 randomised trials have shown that all regimens significantly reduced the fibrosis progression rates in comparison to the pre-treatment ones. Six factors were independently associated with the absence of significant fibrosis after treatment: baseline fibrosis stage, sustained viral response, age <40 years, body mass index <27 kg/m2, no or minimal baseline activity, and viral load <3.5 x 10(6) copies/ml. In virological non-responders after the combination of ribavirin and pegylated interferon, the best strategy is still unknown. From a scientific point of view these patients should be included in randomised trials of maintenance therapy. From a pragmatic point of view, if inclusion in a trial is not possible, treatment with low-dose pegylated interferon can be considered in patients with rapid fibrosis progression rates or high risk factors. Non-invasive biochemical markers of liver fibrosis should facilitate the management.