TO THE EDITOR: I am quite apprehens...

TO THE EDITOR: I am quite apprehensive that your article (1) onward hepatitis C by Dr. Ward and colleagues will cause misconceptions for family physicians and may cause harm to our patients.

The article (1) bugles the efficaciousness of treatment of chronic hepatitis C However, no justification for the repeated assertion of treatment effectiveness is proffered Treatment of hepatitis C does lower viral RNA loads, moreover I fear there is no evidence showing that treatment hinders cirrhosis, cancer, disability, and death. In lieu of issues evidence, what do experts say? The authors cited the consensus statement from the National Institutes of Health, (2) which discusses merely disease-oriented evidence regarding the benefit of hepatitis C treatment. My local gastroenterology colleagues have no patient-oriented result evidence to report either. Real patient benefit, like as reduced incidence of cancer, cirrhosis, disability, and death remains speculative and the topic of ongoing research.

to this time we have plenty of patient-oriented result evidence showing how this supposedly effective treatment is toxic. In my acknowledge practice, I have several patients who have been harmed significantly at treatment for hepatitis C, with issues such as chronic sprue-like enteropathy, myopathy, and depression.

No patient would tolerate cancer chemotherapy without the confidence that it improved their chance for better health. in addition we are poisoning thousands of our patients who have hepatitis with just as it was a situation of known harm and uncertain benefits from treatment.

I have stopped referring my patients who have hepatitis C to gastroenterologists unles they penetrate a research protocol to help achieve patient-oriented issue evidence. Until we have patient-oriented evidence that rates of cirrhosis and cancer are reduc with treatment, I do not be wrought up that clear harm and no clear issue benefit is acceptable.

JOSHUA STEINBERG, MD

State University of novel York Upstate College of Medicine Department of Family

Medicine 475 Irving Ave., Suite 200

Syracuse, NY 13210

REFERENCES

(1) Ward RP Kugelmas M Libsch KD Management of hepatitis C: evaluating suitability for put drugs into therapy. Am Fam Physician 2004;69:1429-38

(2) NIH consensus statement upon management of hepatitis C: 2002 NIH Consen State Sci Statements 2002;19:1-46

IN REPLY: While I agree with Dr Steinberg that the pegylated interferon and ribavirin used in the treatment of patients with chronic hepatitis C are difficult agents to use, I disagree with his assertion that there is no evidence for improved patient results with treatment.

Treatment not merely "lowers viral RNA loads," yet when successful, appears to eliminate viral RNA entirely. The published treatment answer rate of approximately 50 percent is not measured at the expiration of treatment, but represents the percentage of patients in whom hepatitis C viral RNA continues to be undetectable six month after finishing medication. Follow-up of patients who are RNA negative at six month exhibits that only 5 to 10 percent of them have had a virologic relapse at five years, with virtually none of those resorts occurring after year 4. (1)

Other studies (23) have shown slowing and uniform regression of hepatic fibrosis, and a hardly any of the patients in these studies actually retiremented from cirrhosis to an earlier stage of fibrosis. Furthermore, among patients receiving treatment, unruffled those who failed to achieve viral elimination showed a cessation of progression of fibrosis while being treated. Among patients who already have cirrhosis at the time of treatment initiation, therapy has been shown to improve survival (risk reduction [RR] 054; confidence interval [CI], 033 to 089) and to make less the occurrence of hepatocellular carcinoma (RR 065; CI, 043 to 097]) (4)

The National Institutes of Health consensus statement forward the management of hepatitis C does not commend that all patients with hepatitis C receive treatment, nevertheless rather states: "All patients with chronic hepatitis C are potential candidates for antiviral therapy. Treatment is praiseed for patients with an increased risk of developing cirrhosis." (5) The decision to treat a patient with hepatitis C often is not an easy the same and involves balancing the possibilities of cirrhosis, liver cancer, and death against the known side validitys of the medications--side effects that, as Dr Steinberg points not at home occasionally may include serious toxicities. My concede patient base includes those who have had substantial difficulties in tolerating pegylated interferon and ribavirin and those who have died from hepatitis C and its complications.

These medications are important advances in our ability to treat this illness, and I suspect that the data regarding their benefits are likely to continue to accumulate as longer-term consequence studies become available.

RAYMOND P WARD, MD PHD

440 southern Medical Drive Bountiful, UT 84010

REFERENCES

(1) Veldt BJ Saracco G Boyer N Camma C Bellobuono A, Hopf U et al. lengthy term clinical outcome of chronic hepatitis C patients with sustained virological answer to interferon monotherapy. Gut 2004;53:1504-8