Hepatitis C virus infection in the elderly: epidemiology, natural history and management

Hepatitis C virus (HCV) infection frequently occurs in elderly individuals, with a prevalence in individuals aged >60 years of up to approximately 40%. Although progression to cirrhosis is accelerated and occurs more frequently in patients who acquire the infection in old age, this outcome is often not seen because most elderly infected patients acquired HCV when they were young. Data on progression of HCV infection to cirrhosis and eventually to hepatocellular carcinoma are often derived from studies of HCV-infected individuals who present or are referred to hospitals, and which are therefore likely to overestimate the seriousness of the disease; indeed, population-based studies indicate that in many elderly individuals the disease is asymptomatic and runs a fairly benign course. Treatment is based on use of pegylated interferon-alpha and ribavirin, and is overall less effective and more toxic in the elderly. Therefore, treatment should be carefully considered on an individual basis and proposed only in patients up to the age of 75 years with a significant risk of progression of liver disease, no serious co-morbidities and good life expectancy. All treated patients should be followed long term in order to assess the influence of therapy on the evolution of liver disease (decompensated cirrhosis, hepatocellular carcinoma) and survival. It is hoped that liver biopsy, which is still required in order to assess prognosis appropriately, will be replaced in the future by less invasive methods based on combinations of biochemical markers of fibrosis and/or transient elastography, and that newer and less toxic orally administered drugs for HCV infection will become available.