Heavy alcohol use among hepatitis C patients does not weaken response to DAAs

Among patients with hepatitis C virus (HCV) infection, the likelihood of achieving sustained virologic response (SVR) with direct-acting antivirals (DAAs) does not appear to be reduced among those who use alcohol or have alcohol use disorder (AUD), according to a study.

The odds of SVR were similar across the following alcohol use categories, with lower-risk alcohol consumption (AUDIT-C* score of 1-3 and absence of AUD diagnosis) as reference: abstinent without AUD history (odds ratio [OR], 1.09, 95 percent confidence interval [CI], 0.99–1.20), abstinent with AUD history (OR, 0.92, 95 percent CI, 0.82–1.04), moderate-risk consumption (AUDIT-C score of 4-7 and absence of AUD diagnosis; OR, 0.96, 95 percent CI, 0.80–1.15), and high-risk consumption/AUD (OR, 0.95, 95 percent CI, 0.85–1.07). [JAMA Netw Open  2023;6:e2335715]

There was no evidence that the effect of alcohol use on response to DAA treatment for HCV varied depending on the stage of liver fibrosis as measured by fibrosis-4 score (p=0.30 for interaction).

The analysis was based on data from 69,229 HCV patients (mean age 62.6 years, 97.0 percent men, 50.1 percent non-Hispanic White, 84.5 percent with HCV genotype 1) who initiated DAA therapy. Of these, 32,290 (46.6 percent) were abstinent without AUD history, 9,192 (13.3 percent) were abstinent with AUD history, 13,415 (19.4 percent) had lower-risk consumption, 3,117 (4.5 percent) had moderate-risk consumption, and 11,215 (16.2 percent) had high-risk consumption/AUD. A total of 65,355 patients (94.4 percent) achieved SVR.

According to the investigators, the patients who achieved SVR comprised an older population with multiple comorbidities who are typically underrepresented in clinical trials. Furthermore, some of these patients were treated with older DAA regimens such as sofosbuvir and ribavirin, which have been associated with less favourable tolerability profile and a lower percentage of patients achieving SVR.

Alcohol use not a reason to deny DAA therapy

“Our results support the current AASLD/IDSA** recommendations that current or prior alcohol use is not a contraindication to HCV DAA therapy,” the investigators said.

“Despite these recommendations, some clinicians continue to delay or withhold HCV therapy from patients who consume alcohol. Furthermore, some payers include alcohol abstinence as a requirement for reimbursement of DAA therapy for HCV,” they added. [Am J Prev Med 2021;61:716-723; JAMA Netw Open  2022;5:e2246604; Public Health Rep 2023;138:467-474; https://stateofhepc.org/2023-national-snapshot-report/]

The investigators believe that restricting access to DAA therapy based on alcohol consumption or AUD is unnecessary and counterproductive, thus making it more difficult to achieve HCV elimination goals.

“[C]linicians and policy makers should encourage HCV treatment in those with unhealthy alcohol consumption or AUD, rather than creating barriers to HCV treatment. Given the high rates of SVR across all alcohol use categories … DAA therapy should be provided and reimbursed despite alcohol consumption or history of AUD,” they pointed out.

The study had several limitations, including the potential for residual confounding owing to the observational nature of the study as well as the potential misclassification of some patients with high-risk consumption at lower levels of consumption as alcohol use measurement may have been influenced by both patient-level and practitioner-level factors.

*Alcohol Use Disorders Identification Test–Consumption questionnaire

**American Association for the Study of Liver Diseases/Infectious Diseases Society of American