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Mixed cryoglobulinemia is strongly associated with hepatitis C virus (HCV) infection and ranges from being asymptomatic to causing life-threatening vasculitis. In those with symptoms, treatment with pegylated interferon (pegIFN) and ribavirin (RBV) reduces mortality. However, few data are available on the safety and efficacy of antiviral therapy with direct acting antivirals in the treatment of HCV-related cryoglobulinemia. Dr Jordan Feld and colleagues from Canada retrospectively evaluated at a tertiary care center of patients treated for HCV-related cryoglobulinemia with DAA±pegIFN. The researchers primary outcomes were virological, immunological, and clinical response.  | | Cryoglobulins disappeared in 29% symptomatic patients | | American Journal Gastroenterology |
Complete, partial, or non-response were used to describe change in cryocrit or vasculitic manifestations at week 12 post treatment. Side effects, hospitalizations, and decompensating events were recorded. The research team examined 18 symptomatic and 65 asymptomatic patients were reviewed including 10 with severe/life-threatening vasculitis. The team found that 80% of patients received pegIFN-free therapy. Sustained virological response was attained in 89% symptomatic, and 91% were asymptomatic patients. The research team observed that cryoglobulins disappeared in 29% symptomatic, and 53% asymptomatic patients. Of symptomatic patients with sustained virological response, clinical response was complete in 39%, and partial response in 22%. Of the 5 viral relapsers, the research team found that 1 had a complete response during therapy with no symptomatic recurrence, while the other patients had no clinical response. Among 7 with severe vasculitis, 6 achieved sustained virological response but only 1 had a complete clinical response, with 3 showing a partial response and 2 showing no improvement. All 4 with life-threatening vasculitis required plasmapheresis, and 3 received rituximab. All achieved sustained virological response leading to partial clinical response in two, but no response in 2. Skin manifestations were most likely to completely resolve with lower responses seen in renal, and neurological symptoms. The researchers noted that 99% of patients completed therapy, with 23% reporting adverse events. Hospitalization for decompensation or worsening vasculitis occurred in 6%, and 22% patients, respectively. Dr Feld's team concludes, "Direct acting antivirals resulted in high rates of sustained virological response in patients with cryoglobulinemia." "Safety and tolerability were excellent." "However, most patients did not have a complete clinical or immunological response, suggesting a delay to clinical response particularly in those with severe/life-threatening vasculitis." "Further follow-up will be required to determine if clinical improvement continues after viral clearance."
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