Question
I have seen several patients with chronic hepatitis C who also have sickle cell anemia. What are the options for management of these patients?
|
|
Response from David Bernstein, MD Chief, Digestive Disease Institute, North Shore University Hospital-Long Island Jewish Medical Center, Manhasset, New York; Associate Professor of Medicine, New York University School of Medicine, New York, NY |
Patients with sickle cell anemia are at high risk for the acquisition of hepatitis C infection due to the need for frequent blood transfusions. The prevalence of hepatitis C in transfused patients with sickle cell anemia is estimated to be more than 10%. Having said that, this prevalence applies to patients who received blood transfusions prior to 1992. Patients who received blood transfusions in the United States after 1992 are not at increased risk for the acquisition of chronic hepatitis C. The iron overload seen in sickle cell disease may lead to a more rapidly progressive liver disease, which is a concern in patients with sickle cell anemia and hepatitis C infection.
The current approved therapy for chronic hepatitis C is a combination of pegylated interferon and ribavirin. Ribavirin typically leads to the development of hemolytic anemia that could limit the drug's use in sickle cell disease or even precipitate a sickle cell crisis. Therefore, combination pegylated interferon and ribavirin therapy is listed in the drug package inserts as being contraindicated in patients with both sickle cell anemia and hepatitis C. No large studies have evaluated combination interferon and ribavirin therapy in patients with hepatitis C and sickle cell anemia.
Pegylated interferon monotherapy is not contraindicated in patients with sickle cell anemia and hepatitis C; however, no large clinical trials to guide this therapy have been conducted. Recently, however, a small study from Europe described the safe use of combination pegylated interferon and low-dose ribavirin in 11 patients who had either sickle cell disease or beta-thalassemia major. None of the patients with sickle cell anemia required blood transfusions and the therapy appeared to be tolerated. At this point, however, combination pegylated interferon and ribavirin is contraindicated in sickle cell disease and should not be attempted unless administered in the setting of a clinical trial.