Annals
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27 November 2012 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at acollom@acponline.org

1. Task Force Reviews Evidence to Update Hepatitis C Screening Recommendations for Asymptomatic Adults

In 2004, the United States Preventive Services Task Force recommended against routine screening for hepatitis C virus (HCV) infection in asymptomatic adults who are not at increased risk for infection. At the time, the Task Force also found insufficient evidence to recommend for or against routine HCV screening for adults at high risk for infection. Since then, other groups have recommended screening higher-risk patients, including a recommendation by the Centers for Disease Control and Prevention (CDC) to screen all persons born between 1945 and 1965. To inform an update to the 2004 Task Force recommendations, researchers studied published evidence focusing on research gaps identified in the previous review. The researchers sought to determine if screening for HCV infection in asymptomatic adults at low risk for infection would reduce mortality and morbidity due to HCV infection, affect quality of life, or reduce incidence of HCV infection. They also assessed the benefits, harms, and effectiveness of different screening methods. The researchers found no direct evidence that screening for HCV improves clinical outcomes, but the data suggest that targeted screening misses up to two-thirds of infected patients. Screening tests appear to be accurate for identifying HCV-infected patients with minimal risk of harm. Data on antiviral treatments were evaluated in a separate report and will be included in the recommendation statement. The draft recommendation will be posted to www.uspreventiveservicestaskforce.org on November 27.

2. Task Force Reviews Evidence on Antiviral Treatments to Inform Update of its Hepatitis C Recommendations

There are a number of treatments approved to treat chronic hepatitis C virus (HCV) infection. Researchers reviewed randomized trials of antiviral treatments and cohort studies examining the associations between sustained virologic response (SVR) after therapy with clinical outcomes to determine the benefits and harms of antiviral regimens in patients new to treatment (SVR rates are the primary outcome measure to evaluate comparative effectiveness). For patients new to treatment, dual therapy with pegylated interferon alfa-2b is associated with a lower likelihood of SVR than dual therapy with pegylated interferon alfa-2a, but pegylated interferon alfa-2b was associated with a lower incidence of adverse events. For genotype 2 or 3 infection, longer durations of treatment with standard-dose pegylated interferon as part of dual therapy are more effective than shorter regimens or lower doses. For genotype 1 infection, adding boceprevir or telaprevir to treatment (triple therapy) raised SVR to similar rates as dual therapy for genotype 2 or 3 infection. However, triple therapy is associated with a greater risk of adverse events. The researchers found no published evidence on long-term effectiveness of treatment on clinical outcomes.

3. No Interventions Proven to Reduce Mother-to-child Transmission of Hepatitis C

Researchers have found no clear proof that any intervention reduces the risk for mother-to-child transmission of hepatitis C virus (HCV) infection. More than 40,000 children are born to HCV-positive women each year. Up to 10 percent of those children are HCV-positive due to maternal transmission. Researchers reviewed published evidence on mode of delivery, labor management strategies, and breastfeeding practices to determine their effect on risk of mother-to-infant transmission of HCV. The researchers found no clear evidence that any of the interventions reduce the risk of transmission. There was limited evidence that prolonged rupture of membranes could increase risk of mother-to-child transmission, suggesting that physicians should avoid prolonged rupture of membranes in women with HCV infection. The researchers found that avoidance of breastfeeding is not warranted to reduce risk of vertical transmission.