[Difficult-to-treat patients with chronic hepatitis C]

Combination therapy with pegylated interferon-alpha plus ribavirin is the current standard of care. Undetectable HCV-RNA in serum by a sensitive molecular test six months after the end of treatment is the primary aim of antiviral therapy in patients with hepatitis C. The group of "difficult-to-treat" patients is heterogeneous and comprises patients with a difficult indication for antiviral therapy (asymptomatic, minimal histological activity, persistently normal aminotransferase levels, etc.), patients with low chances for achieving a sustained virologic response (HCV genotype 1 infection, high baseline viral load, liver cirrhosis, immunosuppression, HIV coinfection, etc.), patients without sustained virologic response in a previous treatment course (nonresponder, relapser), patients who cannot tolerate interferon-alpha and/or ribavirin, and patients with poor compliance. Councelling in an experienced center is advised in the case of a difficult decision whether to treat or not. Options in patients with low chances for a sustained virologic response and in nonresponders are retreatment with a pegylated interferon and ribavirin at a higher dose and/or a longer treatment duration. Clinical trials with new antiviral agents are highly relevant for this patient population as for those patients who cannot tolerate (peg)interferon-alpha and/or ribavirin. Side effects in patients receiving pegylated interferon-alpha and ribavirin should be actively treated (e.g. serotonine re-uptake inhibitors for depression, erythropoetin for ribavirin-associated anemia, etc.). In addition, optimisation of adherence and compliance is always mandatory.