Viral hepatitis: The good, the bad and the ugly of treatment in Canada

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Chronic hepatitis B and C are silent epidemics affecting an estimated 600,000 Canadians of all ages. The statistics are ‘estimated’ because many are unaware that they have these diseases. Of those that have been diagnosed, only a fraction have been treated. Unfortunately, for those who have sought treatment, or are hoping to be treated in the future, the hurdles can be enormous especially if you have hepatitis B.

Recently, hepatitis C treatment has taken a significant leap forward with the approval of two new antiviral drug therapies. This is good news for those who have yet to be treated or have been unsuccessfully treated with current standard of care – pegylated interferon and ribavirin. Added to the current therapy, these new antivirals promise to increase response rates for patients with genotype 1 from about 45 to about 70 per cent. To date, we are still awaiting the Health Canada recommendations regarding reimbursement that may determine whether, and under what restrictions, these drugs will make it onto provincial formularies (and thus eligible for reimbursement) across the country.

Five years ago, we were in the same situation with new treatments for chronic hepatitis B. New drugs came on the market that had been shown to be far more effective than the current standard of care and had a much lower chance of patients developing resistance. The future for hepatitis B treatment looked better than it had in years and physicians treating chronic hepatitis B patients were excited about the prospect of having new options. But then came the bad news. Health Canada recommended that these drugs be reimbursed only for patients with cirrhosis. Provincial governments soon adopted these recommendations with the exception of Quebec and Alberta.

Decisions regarding reimbursement require governments to weigh the potential benefits of a treatment against the costs. This process is meant to be ‘evidence-based’ and yet some of the decisions regarding hepatitis B treatment are not supported by evidence. For example, patients seeking reimbursement are required to have elevated ALTs although there is no evidence supporting delaying treatment for patients with normal ALTs. In fact, the milder the disease, the better the chance of response.

If left untreated both chronic hepatitis C and hepatitis B will lead to cirrhosis (scarring) of the liver, liver failure and liver cancer, ultimately leading to death.  In chronic hepatitis B however, once cirrhosis develops the risk of developing cancer goes up from about 0.4 per cent each year to 4-8 per cent per year. Liver cancer is the most common cause of death of patients with chronic hepatitis B. Currently, liver cancer is one of the few forms of cancer currently on the rise inCanadaand much of this increase is fuelled by chronic hepatitis B. Therefore it is imperative to provide treatment before the development of cirrhosis. Yet governments refuse to fund this.

Chronic hepatitis B is a major problem world-wide. According to the World Health Organization, 350 million people live with chronic hepatitis B and it kills 600,000 per year. A large proportion of chronic hepatitis B sufferers inCanadaare immigrants from countries where hepatitis B affects anywhere from two-17 per cent of the population. The ugly side of this issue is that the majority live in BC andOntarioand these provinces –Ontarioparticularly – have some of the most restrictive reimbursement criteria for hepatitis B treatment. As these groups lack the voice and influence to effect policy, their health is put at risk.

The only way to reduce the impact of hepatitis B or C inCanadais to allow doctors and their patients access to the most effective treatment options. When governments make uninformed reimbursement decisions that limit access to those who have developed life-threatening complications or in some cases refuse access completely, it puts patient health in jeopardy. There is no denying that treating viral hepatitis is expensive but delaying or denying treatment only leads to even higher health care costs. Liver transplants and other interventions for patients with liver cancer cost substantially more than drug therapy.

In November,Canada’s professional association of liver specialists will be meeting to develop new guidelines for the treatment of viral hepatitis. These guidelines will represent the consensus of this country’s experts as to when and how to treat viral hepatitis to ensure the best possible outcomes for patients. If federal and provincial decision-makers heed these recommendations and adopt reimbursement policies based upon them, physicians will have the means to effectively manage the health of their hepatitis patients.

With liver cancer rates rising, demand for liver transplants increasing and hospital wards filling with patients suffering from hepatitis-related complications, now is the time to make changes to the management of viral hepatitis in Canada.