People with a hepatitis C cure still face substantial risk of death

People who have been cured of hepatitis C infection still face a substantially greater risk of death compared with the general population, research led by Glasgow Caledonian University has revealed.

The largest study of its kind, funded by the Medical Research Foundation and published in the prestigious British Medical Journal (BMJ), found that deaths were three to 14 times higher in patients cured of hepatitis C, depending on liver disease stage.

Based on data from more than 20,000 patients with a hepatitis C cure, the results show that drug and liver-related causes of death were the main drivers of excess deaths, and highlight the importance of continued support to fully realise the benefits of a hepatitis C cure.

Hepatitis C is a virus that can infect the liver which, if left untreated, can cause serious and potentially life-threatening liver damage over many years.

New medications called direct acting antivirals (DAA) were developed in 2011 and now more than 95% of patients treated with DAAs achieve a ‘virological cure’ and have a significantly lower risk of death than untreated patients.

However, Glasgow Caledonian researchers leading the study have raised concerns that antiviral treatment for hepatitis C is not enough to save lives and more must be done to support patients post-cure.

The study’s Principal Investigator Dr Hamish Innes, Senior Research Fellow in the University’s School of Health and Life Sciences’ Research Centre for Health (ReaCH), said: “Our research shows that cured patients continue to face very high mortality rates after achieving a hepatitis C cure, driven by liver and drug-related causes.

“While antiviral therapies are crucial, it is clear they are not a panacea. The UK and other countries are on course to eliminate hepatitis C, but after it is eliminated, we will still be left with high mortality rates.

“The question is what can we do to pre-empt this? Hepatitis C treatment is an opportune time to address competing health problems, including alcohol and drug use, and to establish life-saving screening for liver cancer.

“We should be doing much more to support patients after cure. Otherwise, when we look back in years to come, we may see hepatitis C elimination not only as a great achievement, but as a great missed opportunity too.”

Co-lead authors in the research were biostatisticians Dr Victoria Hamill, from Glasgow Caledonian, and Dr Stanley Wong, from the British Columbia Centre for Disease Control in Canada, with his colleague Dr Naveed Janjua, also playing a key role.

Dr Hamill said the study took more than two years of hard work to complete and involved 31 experts from around the world.

“This research is very important because it is the largest of its kind that shows people cured of hepatitis C still face a high risk of death in terms of complications they might experience afterwards. Death rates won’t fall unless these patients are given continued support,” she added.

In Scotland, the death rate for all patients was 4.5 times greater than the general population, with 442 deaths versus 98 expected. In British Columbia, rates were 3.9 times greater, with 821 deaths versus 209 expected. In England, the total number of observed deaths was five times higher than the number expected.

Death rates increased from three times higher in pre-cirrhosis patients from British Columbia up to 14 times higher for end stage liver disease patients in British Columbia.

A total of 1,572 (7%) of participants died during follow-up. The leading causes of death were drug-related (24%), liver failure (18%) and liver cancer (16%).

Rachel Halford, CEO of The Hepatitis C Trust, said: “This important research demonstrates the need for meaningful follow-up and support for patients who have had hepatitis C.

“The high number of liver cancer deaths found in this study highlights the importance of diagnosing hepatitis C as early as possible to treat the virus before it causes irreversible damage to the liver. Adherence to treatment and follow-up to make sure the virus has been cleared are crucial.”

The research paper, entitled Mortality rates among patients achieving a hepatitis C cure in the interferon-free treatment era: population based cohort study, has been published in the BMJ's flagship journal.