Should we treat HCV carriers with normal ALT levels? The ‘5Ws’ dilemma

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http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2893.2011.01485.x/abstract

Should we treat HCV carriers with normal ALT levels? The ‘5Ws’ dilemma

C. Puoti1, R. Guarisco1, L. Spilabotti1, L. Bellis2, O. Mitidieri Costanza3, O.

Dell’ Unto1, M. G. Elmo4

Article first published online: 6 JUL 2011

DOI: 10.1111/j.1365-2893.2011.01485.x

© 2011 Blackwell Publishing Ltd

Issue

Journal of Viral Hepatitis

Early View (Online Version of Record published before inclusion in an issue)

Summary.  Approximately 30% of patients with chronic HCV infection have

persistently normal ALT levels. Although formerly referred to as ‘healthy’

or ‘asymptomatic’ HCV carriers, and thus historically excluded from

antiviral treatment, it has now become clear that the majority of these patients

have some degree of histological liver damage that may be significant in up to

20% of cases and might progress towards a more severe degree of liver fibrosis.

A significant proportion of patients experience periods of increased serum ALT

associated with enhanced disease progression. However, controversies still exist

in clinical practice regarding the definition of ‘persistent’ ALT normality,

the virological and histological features of these subjects, the need for liver

biopsy, the role of noninvasive tools for the assessment of liver fibrosis, the

natural history and the usefulness of antiviral treatment. The advent of new

therapeutic options (pegylated interferon plus ribavirin) has shifted treatment

targets towards the eradication of underlying infection, with therapy decision

based on age, severity of disease and likelihood of response rather than on

aminotransferase levels. This review is aimed at approaching the main unresolved

issues on this topic, trying to give evidence-based answers to the more

frequently asked questions from patients and their physicians.