Pharmacokinetics, Efficacy, and Safety of Hepatitis C Virus Drugs in Patients with Liver and/or Renal Impairment.
Hepatitis C virus (HCV)-infected patients often suffer from liver cirrhosis, which can be complicated by renal impairment. Therefore, in this review we describe the treatment possibilities in HCV patients with hepatic and renal impairment. Cirrhosis alters the structure of the liver, which affects drug-metabolizing enzymes and drug transporters. These modifications influence the plasma concentration of substrates of drugs metabolized/transported by these enzymes. The direct-acting antivirals (DAAs) are substrates of, for example, cytochrome P450 enzymes in the liver. Most DAAs are not studied in HCV-infected individuals with decompensated cirrhosis, and therefore awareness is needed when these patients are treated. Most DAAs are contraindicated in cirrhotic patients; however, patients with a Child-Pugh score of B or C can be treated safely with a normal dose sofosbuvir plus ledipasvir or daclatasvir, in combination with ribavirin. Patients with renal impairment (glomerular filtration rate [GFR] <90 mL/min) or who are dependent on dialysis often tolerate ribavirin treatment poorly, even after dose adjustments. However, most DAAs can be used at the normal dose because DAAs are not renally excreted. To date, grazoprevir plus elbasvir is the preferred DAA regimen in patients with renal impairment as data are pending for sofosbuvir patients with GFR <30 mL/min (as for ledipasvir and velpatasvir). However, sofosbuvir has been used in a small number of patients with severe renal impairment and, based on these trials, we recommend sofosbuvir 400 mg every day when no other DAA regimen is available. Ledipasvir and velpatasvir are not recommended in patients with severe renal impairment.
Department of Pharmacy, Radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
Elise J
EJ
Smolders
Department of Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.
Clara T M M
CT
de Kanter
Department of Gastroenterology and Hepatology, Leids University Medical Center, Leiden, The Netherlands.
Bart
B
van Hoek
Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands.
Joop E
JE
Arends
Department Gastroenterology and Hepatology, Radboud university medical center, Nijmegen, The Netherlands.
Joost P H
JP
Drenth
Department of Pharmacy, Radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands. david.burger@radboudumc.nl.
David M
DM
Burger
D000998:Antiviral Agents / Q000009:adverse effects / Q000493:pharmacokinetics* / Q000627:therapeutic use; D019698:Hepatitis C, Chronic / Q000188:drug therapy / Q000378:metabolism* / Q000821:virology; D006801:Humans; D007676:Kidney Failure, Chronic / Q000378:metabolism* / Q000821:virology; D008103:Liver Cirrhosis / Q000378:metabolism* / Q000821:virology
D000998:Antiviral Agents