1. Hepatitis C in the Elderly Todd Wills, MD ETAC Infectious Disease Specialist HEPATITIS C TREATMENT EXPANSION INITIATIVE MULTISITE CONFERENCE CALL MAY 15, 2013

2. Epidemiology National Health and Nutrition Examination Survey III (NHANES III) 21,241 participants HCV Ab + – 0.9% 60-69 yrs – 1.0% > 70 yrs Non-Hispanic Blacks/HCV Ab+ – 2.5% 60-69 yrs – 2.8% > 70 yrs NHANES 1999-2002 – Largest prevalence group 40-49 (4.3%) – 60% of those >60 years old infected via blood transfusion M.J. Alter D. Kruszon-Moran O.V. Nainan The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med. 1999;341:556-562 G.L. Armstrong A. Wasley E.P. Simard The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144:705-714

3. Natural History Transfusion acquired HCV and time to development of cirrhosis Minola et al. – Acquired age 21-30yrs, 33 years to cirrhosis – Acquires after 40 yrs, 16 years to cirrhosis Tong et al. – Acquired before 50 yrs, 23.6 years to cirrhosis – Acquired after 50 yrs, 9.8 years to cirrhosis E. Minola D. Prati F. Suter Age at infection affects the long-term outcome of transfusion-associated chronic hepatitis C. Blood. 2002;99:4588-4591 M.J. Tong N.S. el-Farra A.R. Reikes Clinical outcomes after transfusion-associated hepatitis C. N Engl J Med. 1995;332:1463-1466

4. Differential Treatment Outcomes in the Elderly Less response to pegylated interferon/RBV with increased age – Odds ratio of SVR 0.13-0.21 for age groupings >40 years old versus <40 – Only seen in genotypes 1 and 4; no significant age difference for genotypes 2,3 Greater risk of cytopenias requiring dose modifications for patients >60 years versus matched controls (p=0.031) G. Antonucci M.A. Longo C. Angeletti The effect of age on response to therapy with peginterferon alpha plus ribavirin in a cohort of patients with chronic HCV hepatitis including subjects older than 65 yr. Am J Gastroenterol. 2007;102:1383-1391 C.G. Nudo P. Wong N. Hilzenrat Elderly patients are at greater risk of cytopenia during antiviral therapy for hepatitis C Can J Gastroenterol 20:2006;589-592

5. Treatment Candidacy Treatment is proposed to few elderly patients. prospective cohort study screened 4025 patients with HCV at 24 VA Hospitals 364 (9%) were over the age of 60 Twenty five per cent of patients over the age of 60 were considered to be treatment candidates 10% were started on treatment. – age was a strong independent predictor of not being a treatment candidate. Tsui JI, Currie S, Shen H, et al. Treatment eligibility and outcomes in elderly patients with chronic hepatitis C: results from the VA HCV-001 Study. Dig Dis Sci 2008; 53: 809–814.

6. Summary The decision to treat older patients is complex A detailed explanation of the natural history of the disease, the likely rate of progression, the risk of complications is required. Lower toxicity newer medications may still offer future more tolerable treatment options