Clinical Gastroenterology and Hepatology
Volume 7, Issue 2 , Pages 128-134, February 2009

Hepatitis C in the Elderly: Epidemiology, Natural History, and Treatment

  • Ayse L. Mindikoglu

      Affiliations

    • Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
    • Corresponding Author InformationAddress requests for reprints to: Ayse Leyla Mindikoglu, MD, MPH, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore VA Medical Center, Baltimore, Maryland 21201-1595
    • ,
  • Ram R. Miller

      Affiliations

    • Department of Epidemiology and Preventive Medicine, Division of Gerontology, University of Maryland School of Medicine, Baltimore, Maryland

published online 15 December 2008.

Article Outline

Hepatitis C continues to be a major public health problem affecting approximately 3% of the global population. According to the World Health Organization, an estimated 170 million people have chronic hepatitis C. Ten percent to 20% of those who are chronically infected with hepatitis C will progress to cirrhosis and 5% will develop hepatocellular carcinoma. Although the safety and efficacy of hepatitis C therapies have been studied extensively in patients between the ages of 18 and 65, patients who are older than 65 still remain an understudied and difficult-to-treat population. This review discusses the epidemiology, natural history, and treatment of chronic hepatitis C in older adults.

Abbreviations used in this paper: HCC, hepatocellular carcinoma, HCV, hepatitis C virus, OR, odds ratio, SVR, sustained virologic response

 

See CME exam on page 124.

Hepatitis C continues to be a major public health problem affecting approximately 3% of the global population.1 According to the World Health Organization, an estimated 170 million people have chronic hepatitis C.1 Ten to 20% of those who are chronically infected with chronic hepatitis C will progress to cirrhosis and 5% will develop hepatocellular carcinoma.1 The prevalence of hepatitis C (HCV) infection in the elderly varies among different studies. According to one study that included 21,241 participants of the National Health and Nutrition Examination Survey III, the prevalence of positive HCV antibody was found to be 0.9% and 1.0% in subjects who were in the age groups of 60 to 69 years, and 70 years and older, respectively.2 Importantly, the prevalence of HCV antibody was significantly higher among the non-Hispanic blacks who were in these age groups, the 60 to 69 years and 70 years and older groups had a prevalence of 2.5% (95% confidence interval, 1.8–3.4) and 2.8% (95% confidence interval, 1.4–5.4), respectively.2

In another study that analyzed data from the National Health and Nutrition Examination Survey, HCV RNA was detected in 87.4% of individuals who were 60 years or older with a history of abnormal serum alanine aminotransferase or blood transfusions before 1992.3 Among the subjects aged 60 years or older, there was a significant association between HCV antibody positivity and being non-Hispanic black, as well as having a history of blood transfusion before 1992, with odds ratios of 4.3 and 4.9, respectively.3

In a study that was performed in Italy among 496 elderly with a mean age of 79.31 years, the prevalence of positive HCV antibody was found to be around 11%.4 HCV-antibody positivity was associated significantly with being between the ages of 70 and 79 (odds ratio [OR], 8.02; P < .001), hepatitis B surface antibody positivity and/or hepatitis B core antibody positivity (OR, 4.00; P < .001), and female sex (OR, 2.86; P < .005).4

In another Italian study, the prevalence of positive HCV antibody was reported to be 3.3% among 1063 people aged 60 years or older.5 From those who were positive for HCV antibody, 19 subjects (54.3%) had detectable HCV RNA.5 HCV genotype 2a was the most common genotype among those who had positive HCV RNA with a prevalence of 68.4%.5 Compared with controls, a history of blood transfusions, surgery, and use of nondisposable syringes was significantly more common among the patients who had positive HCV antibody (blood transfusion, P < .05; surgery, P < .01; and the use of nondisposable syringes, P < .005).5

A study from Japan revealed 8.8% and 13.1% of HCV-antibody seropositivity in hospital and autopsy cases older than 60 years of age, respectively.6

Brind et al7 studied HCV infection in 25 patients who were older than 65 years of age. HCV RNA was detected in 95% of patients. The identifiable potential risk factors for HCV infection were history of blood transfusion, war service, tattoos, hemodialysis, and being a health care worker.7 In this study, HCV genotype 1b was the most prevalent, involving 63% of elderly patients with HCV.7

In a large Italian study that was conducted among 1646 subjects, the prevalence of positive HCV antibody was reported around 5% in patients ages 58 to 67 years and around 2% in patients ages 68 and 77 years.8

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Natural History 

According to an Italian study that included 392 patients with a known history of single blood transfusion in the past, the time from the age at purported infection (blood transfusion) to the development of cirrhosis was shorter if the infection was acquired at an older age.9 The age at the time of infection was associated significantly with the development of cirrhosis at multivariate analysis (P = .001).9 The median time from the age of infection to the onset of cirrhosis was 33 years in patients who acquired the HCV infection at the age of 21 to 30, and was reported to decrease to 16 years in patients who acquired the infection after the age of 40.9

Similar results were found by Tong et al,10 who studied the outcome of transfusion-associated HCV progression in 103 patients who received a blood transfusion before the age of 50, and 28 patients at the age of 50 or older. The mean time from the age of a blood transfusion to the development of cirrhosis was reported to be 9.8 years in patients who had a blood transfusion at the age of 50 or older, whereas the mean time from the age of a blood transfusion to the development of cirrhosis was reported to be 23.6 years in patients who had a blood transfusion before the age of 50.10 In addition, they reported that the mean time from the age of a blood transfusion to the development of hepatocellular carcinoma (HCC) was 14.7 years in patients who had a blood transfusion at the age of 50 or older and 31.5 years in those who had a blood transfusion before the age of 50.10

Investigators from Japan reported a significantly shorter interval between the time of blood transfusion and the diagnosis of HCV-associated HCC if the blood transfusion was received at an older age.11

These results suggest that HCV that is acquired by blood transfusion at an advanced age progresses more rapidly to end-stage liver disease compared with HCV that is acquired at a younger age.

Liver fibrosis is another important complication of chronic HCV infection. Poynard et al12 assessed the progression of liver fibrosis by the Kaplan–Meier method and the rate of fibrosis progression by hazard function in 2313 HCV-positive patients who were not treated previously for HCV. They reported that the progression to all stages of fibrosis including F1, F2, F3, and F4 was faster in patients who were older than 50 years of age.12 Despite the large number of patients enrolled, the study was not a prospective study, but a cross-sectional study.12 The other limitations of this study included the lack of serial liver biopsies in the study participants and uncertainty about the duration of HCV infection.12 Given the accelerated course of HCV infection in the elderly, the investigators recommended that HCV patients should be identified and treated before they reach 50 years of age.12

The investigators from Japan studied the development of liver cancer in HCV-antibody positive patients with chronic liver disease with cirrhosis and without cirrhosis who were 80 years or older.13 According to this study, the cumulative rates for developing liver cancer continued to increase over 7 years of follow-up evaluation in both noncirrhotic and cirrhotic groups.13

Patients with chronic HCV can develop HCC even if they are treated successfully for HCV infection and have a sustained virologic response (SVR) (undetectable serum HCV RNA level by polymerase chain reaction for 6 months after stopping the HCV treatment).14 A study from Japan that investigated the outcome of HCV patients with SVR revealed that 3.5% of these patients developed HCC.14 The patients who developed HCC despite the SVR after HCV treatment were significantly older when they received interferon treatment compared with patients who had SVR and did not have HCC (mean age, 58 vs 49 y; P = .002).14 However, this comparison was performed with a relatively small number of cases (13 patients with SVR who developed HCC) compared with that of controls (360 patients with SVR who did not develop HCC).14

Thabut et al15 conducted a retrospective study in 6865 HCV-positive patients who were age 65 or older. The study showed that older age at infection was associated significantly with higher stages of fibrosis (mean age, 25.4 vs 29.8 y; P < .001).15 Investigators had made the adjustment for the duration of the HCV infection, a potential confounder in the study.15 This result confirmed the findings of the previous studies.9, 10, 12, 15 In addition, the manifestation of HCV infection in the elderly was in the form of a complication of chronic hepatitis and this occurred significantly more often compared with younger patients' initial disease manifestation.15

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Hepatitis C Virus Treatment in the Elderly 

There are few clinical studies conducted in HCV-positive elderly patients. One of the major reasons for this could be the exclusion of subjects who were 75 years or older in HCV-related clinical studies.16, 17, 18 In several randomized trials, the mean age was reported to be around 40 years.19, 20, 21 Other reasons for exclusion of older participants could be the increased comorbid conditions at older age, the fear of facing more adverse effects during the HCV treatment, or reluctance to perform liver biopsies in the elderly population.

Standard Interferon Treatment in the Elderly With Chronic Hepatitis C Virus 

In the first 3 studies listed later, the response to HCV treatment was defined as normalization of serum alanine aminotransferase levels (Table 1).22, 23, 24 Others used SVR to determine the efficacy of HCV treatment.25, 26, 27, 28

Table 1. HCV Treatment in the Elderly
Interferon therapyElderly groupComparison groups
Comparison group 1Comparison group 2Comparison group 3
StudyYearType of studyGenotypeNumber of patientsAge, range, mean ± SDTreatmentSVR, %Patients with adverse events/laboratory abnormalities, %Number of patientsAge, yTreatmentSVR, %Number of patients with side effects, %Number of patientsMean age ± SD, yTreatmentSVR, %Patients with adverse events/laboratory abnormalities, %Number of patientsAgeTreatmentSVR, %Patients with adverse events/laboratory abnormalities, %
Standard
Bresci et al221993Randomized, controlledN/A2268.6±2.2IFN alfa-2b SC 3 MU TIW for 6 moN/Aa4b2143.3±7.2IFN alfa-2b SC 3 MU TIW for 6 moN/Aa0b2271.6±3.9No treatmentN/AN/AN/AN/AN/AN/AN/A
Van Thiel et al241995ControlledN/A2565–81IFN alfa-2b SC 5 MU TIW for 6 moN/AaN/A2535–47IFN alfa-2b SC 5 MU TIW for 6 moN/AaN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A
Horike et al231995Controlled1, 2, 3, and 2 + 3c1960–66, 62.5±1.9Natural IFN alfa (12 patients), recombinant IFN alfa-2a (1 patient), recombinant IFN alfa-2b (1 patient) IM QD for 14 days, then TIW for 12–22 wk, natural IFN β (5 patients) IV QD for 6–8 wkN/AaN/A5217–59, 44.1±10.5Natural IFN alfa (90 patients), recombinant IFN alfa-2a (5 patients), recombinant alfa-2b IFN (3 patients), natural IFN β (4 patients)N/AaN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A
Alessi et al282003Retrospective, controlled1b, others (P = .01)5060–74, 63.8 ± 3.2IFN alfa 3–6 MU TIW for 6–12 mo18N/A6414–59, 47.5±10.2IFN alfa 3–6 MU TIW for 6–12 mo20N/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A
Imai et al382004RetrospectiveN/A64963.3±2.9IFN (type and duration of IFN were not specified by the authors)25N/A5864.1±3.1No treatmentN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A
Iwasaki et al272005Nonrandomized, prospective1, 2c73≥60, 64.8±3.5IFN alfa-2b 6–10 MU SC QD for 2 wk, then IFN alfa-2b 6–10 MU TIW for 22 wk and rlbavirin 600–800 mg qD327d8350–59, 54.5±2.9IFN alfa-2b 6–10 MU SC QD for 2 wk, then IFN alfa-2b 6–10 MU TIW for 22 wk and ribavirin 600–800 mg qD342d52<50, 40.2±6.8IFN alfa-2b 6–10 MU SQ QD for 2 weeks, then IFN alfa-2b 6–10 MU TIW for 22 wk and ribavirin 600–800 mg qD504dN/AN/AN/AN/AN/A
Koyama et al292005Retrospective1b (35), 2a (33), 2b (11), others (5)8465–84IFN alfa or β 3 or 6 MU qD for 6–8 wk (22 patients), TIW for 24–28 wk (18 patients), QD for 2–8 wk, then TIW for 16–22 wk (44 patients)35.717.3bN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A
Arase et al252007Retrospective1b, 2a, 2b, others500>60IFN alfa or β IM 3–12 MU QD for 2–8 wk, then BW/TIW for 16–96 wk (245 patients), TIW for 24–104 wk (116 patients), IV QD for 4–8 wk (108 patients), IFN + rlbavirin (31 patients)28N/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A
Honda et al252007Controlled1, 2, othersc66≥60IFN alfa-2b 6–10 MU QD for 2 wk, then IFN alfa-2b 6–10 MU TIW for 22–46 wk and ribavirin 600–800 mg qD for 24 wk31.821.2b154<60IFN alfa-2b 6–10 MU QD for 2 wk, then IFN alfa-2b 6–10 MU TIW for 22–46 wk and ribavirin 600–800 mg qD for 24 wk38.314.9b47 (monotherapy)≥60IFN alfa-2b 6–10 MU QD for 2 wks, then IFN alfa-2b 6–10 MU TIW for 22–48 wk10.68.5bN/AN/AN/AN/AN/A
Pegylated
Thabut et al152006Retrospective1(12), 2 (1), 3 (2), others, or unknown (5)19≥65PEG-IFN 0.5–1.5 mcg qW + ribavirin 20 mg/kg qD45N/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A
Floreani et al302006ControlledN/A3370.2±1.2PEG-IFN alfa-2b 1.5 mcg/kg QW and ribavirin 10.6 mg/kg QD for 6–12 mo45.524.2b6645.2±8.9PEG-IFN alfa-2b 1.5 mcg/kg QW and ribavirin 10.6 mg/kg QD for 6–12 mo69.712.2bN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A
Antonucci et al312007Retrospective1, 2, 3, 4 (P < .001)30≥65PEG-IFN alfa-2a or alfa-2b + ribavirin700c4150–64PEG-IFN alfa-2a or alfa-2b + ribavirin53.70d4440–49PEG-IFN alfa -2a or alfa-2b + ribavirin68.24.6c38<40PEG-IFN alfa-2a or alfa-2b + ribavirin84.25.3c
Nudo et al332006Retrospective, controlled1, 2, 3, 4, and unknownc30≥60, 65.13, ±4.2IFN (3 patients), IFN + ribavirin (21 patients), PEG-IFN + ribavirin (6 patients) for 24–48 wk33.316.7c41<60, 44.5±8.7IFN (1 patient), IFN+ribavirin (27 patients), PEG-IFN+ribavirin (13 patients) for 24–48 wk51.27.3dN/AN/AN/AN/AN/AN/AN/AN/AN/AN/A

N/A, not available; IFN, interferon; SC, subcutaneously; TIW, three times a week; QD, every day; IV, intravenously; QW, every week.

aReported as normalization of serum ALT level.

bDiscontinuation of treatment owing to adverse events.

cGenotype distribution was not significantly different among the elderly and younger groups.

dDiscontinuation of treatment owing to laboratory abnormalities.

Bresci et al22 compared the therapy response of HCV patients who were 65 years or older with that who were younger than age 65 (Table 1). Each group received interferon alfa-2b 3 MU 3 times a week for 6 months.22 There was no statistically significant difference in therapy response rates in each group (P = .85).22

According to a study conducted in Japan, the response to interferon monotherapy was 26% in patients who were 60 years or older and not significantly different compared with patients who were younger than age 60 (Table 1).23

Van Thiel et al24 treated 25 HCV-positive patients who were older than age 65 with 5 MU interferon alfa-2b 3 times a week for 6 months and compared their treatment response rates with 25 HCV-positive patients with a median age of 44 years (Table 1). The therapy response rates were 32% and 28% in the treatment and control groups, respectively.24 The investigators reported that the severity of the disease did not differ between the groups.24

Alessi et al28 evaluated the efficacy of HCV treatment by both SVR (Table 1) and long-term response that was defined as undetectable serum HCV RNA levels during 14 to 82 months of follow-up evaluation (Table 1). Long-term response rates in the elderly group were 8% compared with 13% in the younger age group (P = .4).28

From a retrospective study from Japan that included 84 patients who were 65 or older, SVR rates were reported as 35.7% of patients who received IFN monotherapy (Table 1).29 The major limitation in this study was the lack of a controlled group.29 In addition, the patients were divided into 3 groups and the dose and the duration of therapy were different for each group.29 The drop out rate secondary to treatment side effects at the end of 24 weeks was reported as 17.3%.29

Honda et al26 compared the efficacy of combined interferon plus ribavirin treatment between 66 patients who were 60 years or older and 154 patients younger than age 60 (Table 1). Both groups received interferon alfa-2b 6 to 10 MU once a day for the first 2 weeks, then 3 times a week for 22 to 46 weeks, and ribavirin 600 to 800 mg (depending on their weight) once a day for 24 weeks.26 The SVR rates were almost identical in patients who were 60 years or older and patients younger than 60: 31.8% and 38.3%, respectively (P = .3589).26 In addition, the investigators compared the SVR rates between patients who were 60 years or older treated with combined interferon plus ribavirin and 47 historical controls who were at the same age range treated with interferon alfa monotherapy 6 to 10 MU once a day for the first 2 weeks, then 3 times a week for 22 to 46 weeks.26 The SVR rates were 31.8% and 10.6% in patients who received combination therapy and monotherapy, respectively (P = .0084).26

In a prospective study conducted in Japan, patients were treated in 3 separate age groups: younger than 50 years, 50 to 59 years, and 60 years and older (Table 1).27 All groups received interferon alfa-2b 6 to 10 MU once a day for the first 2 weeks, then 3 times a week for 22 weeks plus ribavirin 600 to 800 mg/d orally depending on the patient's weight.27 The difference in SVR rates of these 3 groups (50%, 34%, and 32% in patients in the age groups of <50 y, 50–59 y, and ≥60 y, respectively) approached statistical significance (P = .078). However, discontinuation of treatment or dose reduction was significantly more frequent in patients who were 60 years or older compared with patients younger than age 60 (P < .001).27

Pegylated Interferon Treatment in the Elderly With Chronic Hepatitis C Virus 

Floreani et al30 studied the peginterferon plus ribavirin treatment response in 33 HCV-positive patients with a mean age of 70.2 years and 66 patients with a mean age of 45.2 years (control group) (Table 1). Patients were matched by gender, HCV genotype, HCV viral load, grade, and fibrosis stage.30 Patients received pegylated interferon alfa-2b 1.5 mcg/kg weekly and ribavirin 10.6 mg/kg/d for 6 to 12 months depending on their genotype.30 SVR rates were significantly lower in the elderly group compared with the control group (45.5% vs 69.7%; P = .02).30

A retrospective study from Italy investigated the SVR in 4 different age groups (<40 y, 40–49 y, 50–64 y, and ≥65 y) (Table 1).31 Patients were treated with pegylated interferon alfa-2a or 2b plus ribavirin for 6 to 12 months depending on HCV genotype.31 According to multivariate analysis, the odds of having SVR were significantly lower in patients who were 40 years or older compared with patients who were younger than 40 years of age (OR for the age group of 40–49 y: 0.16, P = .006; OR for the age group of 50–64 y: 0.13, P = .002; OR for the age group of ≥65 y: 0.21, P = .0037).31

A study from France reported SVR rates in 45% of patients aged 65 or older who were treated with pegylated interferon plus ribavirin treatment (Table 1).15 According to multivariate analysis, the type of HCV treatment, not age, was found to be a significant factor in predicting SVR response in the elderly.15 The patients were 5.4 times more likely to achieve SVR with peginterferon and ribavirin combination therapy compared with other treatment modalities including classic interferon, ribavirin, peginterferon monotherapy, as well as nonpegylated interferon and ribavirin combined therapy.15 HCV treatment discontinuation rates were reported to be 20% in the elderly and this rate was approximately similar to or even lower than the rates reported in several previous HCV studies conducted in younger patients.15, 19, 21, 32 However, it should be emphasized that HCV treatment in this study was heterogeneous, consisting of different types of interferon as well as mono or combined interferon treatment.15 Some investigators reported higher therapy discontinuation rates owing to adverse effects in the elderly compared with younger adults.20, 30

Another study from France did not show any significant difference in SVR rates between elderly and controlled groups (P = .13) (Table 1).33 Although the number of patients who had abnormal laboratory test results and who required dose modification was significantly higher in the elderly patient group compared with the control group (P = .031); the number of patients who discontinued HCV therapy as a result of laboratory test result abnormalities was not significant among the groups.33

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Conclusions 

Elderly patients with chronic HCV infection have been an understudied population owing to several factors. These factors include exclusion of subjects older than 65 years of age in several clinical trials, reluctance to treat HCV infection in the elderly because of fear of dealing with more HCV therapy–related adverse effects, comorbidities and risk factors of aging such as decreased glomerular filtration rate that might cause more severe hemolytic anemia with ribavirin, and interactions of interferon and ribavirin with several potential geriatric drugs.34, 35, 36, 37 Despite these challenges, previous studies have shown that HCV treatment generally was well tolerated by the elderly and there was little or no significant difference in SVR as well as therapy discontinuation rates secondary to adverse effects compared with younger age groups. However, there is a need for prospective randomized controlled trials to be conducted in HCV patients older than 65 years of age to better evaluate the safety and efficacy of HCV treatment in this age group. In addition, more epidemiologic studies are needed to better assess the prevalence as well as the risk factors of chronic HCV infection in elderly subjects.

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 The authors disclose no conflicts.

PII: S1542-3565(08)00778-7

doi:10.1016/j.cgh.2008.07.017

Refers to article:

  • Exam 1: Hepatitis C in the Elderly: Epidemiology, Natural History, and Treatment , 05 January 2009

    C. Mel Wilcox
    Clinical Gastroenterology and Hepatology February 2009 (Vol. 7, Issue 2, Pages 123-124)

Clinical Gastroenterology and Hepatology
Volume 7, Issue 2 , Pages 128-134, February 2009