Ledipasvir and sofosbuvir combination for hepatitis C virus infection in three patients aged 85 years and older

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We read with interest the article of Su et al.1. Their real-life study, along with a recent study 2, showed that direct-acting antiviral regimens had high efficacy and tolerability in hepatitis C virus (HCV)-infected elderly patients aged 75 years and older. Yet, data for patients aged 80 years and older are still lacking 3. Here, we report fixed-dose ledipasvir (90 mg)/sofosbuvir (400 mg) treatment of 12 weeks for three HCV-infected patients aged 85 years and older (Table 1).
The first patient (86 years old) was diagnosed with chronic hepatitis C 2 years ago when he underwent bilateral femoral head replacement surgery. Detailed clinical evaluation led to the decision to initiate ledipasvir/sofosbuvir treatment. By week 4, his aminotransferase normalized and HCV-RNA became undetectable. Sustained virological response at 12 weeks after treatment completion (SVR12) was subsequently achieved. Although the patient experienced a decrease in the estimated glomerular filtration rate (eGFR) to 63.2 ml/min/1.73 m2, it rebound to 74.3 ml/min/1.73 m2 by 12 weeks after treatment. The second patient (85 years old) was diagnosed with HCV-related compensated cirrhosis 1 year ago. Her history included ischemic heart disease and complete right bundle branch block diagnosed 13 years ago and hypercholesterolemia diagnosed 10 years ago; the latter was being treated with candesartan, simvastatin, and aspirin. After treatment week 9, the patient represented to the clinic with palpitations and precordial discomfort. ECG examination showed complete right bundle branch block without myocardial infarction and the symptoms were relieved by a 7-day course of coenzyme Q10 and trimetazidine. The antiviral treatment was not interrupted and the patient achieved SVR12. The third case is an 89-year-old patient with decompensated cirrhosis. Over the past 2 years, he had experienced several episodes of liver decompensation that required repeated hospitalizations. Clinical evaluation indicated a model for end-stage liver disease score of 12. Laboratory tests showed an elevated α-fetoprotein (104.9 ng/ml). Contrast-enhanced computed tomography examination was used to exclude hepatocellular carcinoma. After appropriate management of the liver decompensation, ledipasvir/sofosbuvir treatment was initiated. At treatment week 7, the patient experienced another episode of spontaneous bacterial peritonitis accompanied by increased serum creatinine (1.71 mg/ml) and decreased eGFR (40.0 ml/min/1.73 m2). The antiviral regimen was not interrupted or reduced, with close monitoring. At treatment week 6, α-fetoprotein increased to 143 ng/ml, after which it gradually reduced to 81 ng/ml at the end of treatment. The patient achieved SVR4, with improved liver function (Child–Pugh score: 7) and eGFR (61.2 ml/min/1.73 m2). The patients continued to receive follow-up.
The current guidelines suggest that all patients with HCV infection should be considered for therapy, except individuals with limited life expectancy because of nonliver-related comorbidities 4. The overall age of the HCV-infected population is increasing, and the need for the management of elderly individuals with HCV infection will increase accordingly 1,5. The expected reduction in costs of direct-acting antiviral drugs, as it becomes more established and widely available, will improve the cost-effectiveness of interferon-free regimens 5, allowing for greater accessibility to any HCV-infected individual, including the extremely elderly, with or without end-stage liver disease.

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