Drugs & Aging

, Volume 25, Issue 1, pp 9–18 | Cite as

Hepatitis C Virus Infection in the Elderly

Epidemiology, Natural History and Management
Therapy In Practice


Hepatitis C virus (HCV) infection frequently occurs in elderly individuals, with a prevalence in individuals aged >60 years of up to approximately 40%. Although progression to cirrhosis is accelerated and occurs more frequently in patients who acquire the infection in old age, this outcome is often not seen because most elderly infected patients acquired HCV when they were young. Data on progression of HCV infection to cirrhosis and eventually to hepatocellular carcinoma are often derived from studies of HCV-infected individuals who present or are referred to hospitals, and which are therefore likely to overestimate the seriousness of the disease; indeed, population-based studies indicate that in many elderly individuals the disease is asymptomatic and runs a fairly benign course. Treatment is based on use of pegylated interferon-α and ribavirin, and is overall less effective and more toxic in the elderly. Therefore, treatment should be carefully considered on an individual basis and proposed only in patients up to the age of 75 years with a significant risk of progression of liver disease, no serious co-morbidities and good life expectancy. All treated patients should be followed long term in order to assess the influence of therapy on the evolution of liver disease (decompensated cirrhosis, hepatocellular carcinoma) and survival. It is hoped that liver biopsy, which is still required in order to assess prognosis appropriately, will be replaced in the future by less invasive methods based on combinations of biochemical markers of fibrosis and/or transient elastography, and that newer and less toxic orally administered drugs for HCV infection will become available.


  1. 1.
    Stroffolini T, Menichelli M, Taliani G, et al. High prevalence of hepatitis C viras infection in a small central Italian town: lack of evidence of parenteral exposure. Ital J Gastroenterol 1995; 27: 235–8PubMedGoogle Scholar
  2. 2.
    Garcia-Fulgueiras A, Tormo MJ, Rodriguez T, et al. Prevalence of hepatitis B and C markers in the south-east of Spain: an unlinked community-based serosurvey of 2,203 adults. Scand J Infect Dis 1996; 28: 17–20PubMedCrossRefGoogle Scholar
  3. 3.
    Dubois F, Desenclos JC, Mariotte N, et al. Hepatitis C in a French population based survey, 1994: seroprevalence, frequency of viremia, genotype distribution, and risk factors. Hepatology 1997; 25: 1490–6PubMedCrossRefGoogle Scholar
  4. 4.
    Osella AR, Misciagna G, Leone A, et al. Epidemiology of hepatitis C virus infection in an area of Southern Italy. J Hepatol 1997; 27: 30–5PubMedCrossRefGoogle Scholar
  5. 5.
    Guadagnino V, Stroffolini T, Rapicetta M, et al. Prevalence, risk factors, and genotype distribution of hepatitis C virus infection in the general population: a community-based survey in Southern Italy. Hepatology 1997; 26: 1006–11PubMedCrossRefGoogle Scholar
  6. 6.
    Maggi G, Armitano S, Brambilla L, et al. Hepatitis C infection in an Italian population not selected for risk factors. Liver 1999; 19: 427–31PubMedGoogle Scholar
  7. 7.
    Bellentani S, Pozzato G, Saccoccio G, et al. Clinical course and risk factors of hepatitis C virus related liver disease in the general population: report from the Dionysos study. Gut 1999; 44: 874–80PubMedCrossRefGoogle Scholar
  8. 8.
    Osella AR, Sonzogni L, Cavallini A, et al. Molecular epidemiology of hepatitis C virus infection in an area of hyperendemicity in Southern Italy: a population-based study. J Clin Microbiol 1999; 37: 2371–2PubMedGoogle Scholar
  9. 9.
    Coppola RC, Masia G, Pradat P, et al. Impact of hepatitis C virus infection on healthy subjects on an Italian island. J Viral Hepat 2000; 7: 130–7PubMedCrossRefGoogle Scholar
  10. 10.
    Maio G, D’Argenio P, Stroffolini T, et al. Hepatitis C virus infection and alanine aminotransferase levels in the general population: a survey in a southern Italian town. J Hepatol 2000; 33: 116–20PubMedCrossRefGoogle Scholar
  11. 11.
    Dominguez A, Bruguera M, Vidal J, et al. Community-based seroepidemiological survey of HCV infection in Catalonia, Spain. J Med Virol 2001; 65: 688–93PubMedCrossRefGoogle Scholar
  12. 12.
    Okayama A, Stuver SO, Tabor E, et al. Incident hepatitis C virus infection in a community-based population in Japan. J Viral Hepat 2002; 9: 43–51PubMedCrossRefGoogle Scholar
  13. 13.
    Armstrong GL, Simard EP, Wasley A, et al. The prevalence of hepatitis C virus (HCV) infection in the United States 1999–2002 [abstract no. 31]. Hepatology 2004; 40Suppl. 1: 176AGoogle Scholar
  14. 14.
    Balogun MA, Ramsay ME, Hesketh LM, et al. The prevalence of hepatitis C in England and Wales. J Infect 2002; 45: 219–26PubMedCrossRefGoogle Scholar
  15. 15.
    Thierfelder W, Hellenbrand W, Meisel H, et al. Prevalence of markers for hepatitis A, B and C in the German population: results of the German National Health Interview and Examination Survey 1998. Eur J Epidemiol 2001; 17: 429–35PubMedCrossRefGoogle Scholar
  16. 16.
    Armstrong GL, Alter MJ, McQuillan GM, et al. The past incidence of hepatitis C infection: implications for the future burden of chronic liver disease in the United States. Hepatology 2000; 31: 777–82PubMedCrossRefGoogle Scholar
  17. 17.
    Seeff LB. Natural history of chronic hepatitis C. Hepatology 2002; 36Suppl. 1: S35–46PubMedCrossRefGoogle Scholar
  18. 18.
    Watson JP, Brind AM, Chapman CE, et al. Hepatitis C virus: epidemiology and genotypes in the north east of England. Gut 1996; 38: 269–76PubMedCrossRefGoogle Scholar
  19. 19.
    Tong MJ, el-Farra NS, Reikes AR, et al. Clinical outcomes after transfusion-associated hepatitis C. N Engl J Med 1995; 332: 1463–6PubMedCrossRefGoogle Scholar
  20. 20.
    Minola E, Prati D, Suter F, et al. Age of infection affects the long-term outcome of transfusion-associated chronic hepatitis C. Blood 2002; 99: 4588–91PubMedCrossRefGoogle Scholar
  21. 21.
    Colombo M, de Franchis R, Del Ninno E, et al. Hepatocellular carcinoma in Italian patients with cirrhosis. N Engl J Med 1991; 325: 675–80PubMedCrossRefGoogle Scholar
  22. 22.
    Tsukuma H, Hiyama T, Tanaka S, et al. Risk factors for hepatocellular carcinoma among patients with chronic liver disease. N Engl J Med 1993; 328: 1797–801PubMedCrossRefGoogle Scholar
  23. 23.
    Bolondi L, Sofia S, Siringo S, et al. Surveillance programme of cirrhotic patients for early diagnosis and treatment of hepatocellular carcinoma: a cost effectiveness analysis. Gut 2001; 48: 251–9PubMedCrossRefGoogle Scholar
  24. 24.
    Bruno S, Silini E, Crosignani A, et al. Hepatitis C virus genotypes and risk of hepatocellular carcinoma in cirrhosis: a prospective study. Hepatology 1997; 25: 754–8PubMedCrossRefGoogle Scholar
  25. 25.
    Ikeda K, Saitoh S, Koida I, et al. A multivariate analysis of risk factors for hepatocellular carcinogenesis: a prospective observation of 795 patients with viral and alcoholic cirrhosis. Hepatology 1993; 18: 47–53PubMedCrossRefGoogle Scholar
  26. 26.
    Degos F, Christidis C, Ganne-Carrie N, et al. Hepatitis C virus related cirrhosis: time to occurrence of hepatocellular carcinoma and death. Gut 2000; 47: 131–6PubMedCrossRefGoogle Scholar
  27. 27.
    Kiyosawa K, Tanaka E, Sodeyama T. Hepatitis C virus and hepatocellular carcinoma. Curr Stud Hematol Blood Transfus 1998; 62: 161–80PubMedCrossRefGoogle Scholar
  28. 28.
    Ben Yehuda A, Globerson A, Krichevsky S, et al. Ageing and the mismatch repair system. Mech Ageing Dev 2000; 121: 173–9PubMedCrossRefGoogle Scholar
  29. 29.
    Poynard T, Ratziu V, Charlotte F, et al. Rates and risk factors of liver fibrosis progression in patients with chronic hepatitis C. J Hepatol 2001; 34: 730–9PubMedCrossRefGoogle Scholar
  30. 30.
    Wall M, Harrison RP, Gow PJ, et al. Advancing donor liver age and rapid fibrosis progression following transplantation for hepatitis C. Gut 2002; 51: 248–52CrossRefGoogle Scholar
  31. 31.
    Neumann UP, Berg T, Bahra M, et al. Fibrosis progression after liver transplantation in patients with recurrent hepatitis C. J Hepatol 2004; 41: 830–6PubMedCrossRefGoogle Scholar
  32. 32.
    Thabut D, Le Calvez S, Thibault V, et al. Hepatitis C in 6,865 patients 65 yr or older: a severe and neglected curable disease? Am J Gastroenterol 2006; 101: 1260–7PubMedCrossRefGoogle Scholar
  33. 33.
    D’Souza R, Glynn MJ, Ushiro-Lumb I, et al. Prevalence of hepatitis C-related cirrhosis in elderly Asian patients infected in childhood. Clin Gastroenterol Hepatol 2005; 3: 910–7PubMedCrossRefGoogle Scholar
  34. 34.
    Brind AM, Watson JP, James OF, et al. Hepatitis C infection in the elderly. QJM 1996; 89: 291–6PubMedCrossRefGoogle Scholar
  35. 35.
    Sawabe M, Arai T, Esaki Y, et al. Persistent infection of hepatitis C virus in the elderly: a clinical and quantitative pathological study of autopsy cases. Liver 1999; 19: 335–42PubMedCrossRefGoogle Scholar
  36. 36.
    Monica F, Lirussi F, Pregun I, et al. Hepatitis C virus infection in a resident elderly population: a 10-year follow-up study. Dig Liver Dis 2006; 38: 336–40PubMedCrossRefGoogle Scholar
  37. 37.
    Seeff LB, Hollinger FB, Alter HJ, et al. Long-term mortality and morbidity of transfusion-associated non-A, non-B, and type C hepatitis: a National Heart, Lung, and Blood Institute collaborative study. Hepatology 2001; 33: 455–63PubMedCrossRefGoogle Scholar
  38. 38.
    Strader DB, Wright T, Thomas DL, et al. Diagnosis, management, and treatment of hepatitis C: American Association for the Study of Liver Diseases. Hepatology 2004; 39: 1147–71PubMedCrossRefGoogle Scholar
  39. 39.
    Poynard T, Imbert-Bismut F, Munteanu M, et al. FibroTest-FibroSURE: towards a universal biomarker of liver fibrosis? Expert Rev Mol Diagn 2005; 5: 15–21PubMedCrossRefGoogle Scholar
  40. 40.
    Castera L, Vergniol J, Foucher J, et al. Prospective comparison of transient elastography, FibroTest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005; 128: 343–50PubMedCrossRefGoogle Scholar
  41. 41.
    Poynard T, McHutchison J, Manns M, et al. Biochemical surrogate markers of liver fibrosis and activity in a randomized trial of peginterferon α-2b and ribavirin. Hepatology 2003; 38: 481–92PubMedCrossRefGoogle Scholar
  42. 42.
    Manns MP, McHutchison JG, Gordon SC, et al. Peginterferon α-2b plus ribavirin compared with Interferon α-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomized trial. Lancet 2001; 358: 958–65PubMedCrossRefGoogle Scholar
  43. 43.
    Fried MW, Shiffman ML, Reddy KR, et al. Peginterferon α-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med 2002; 347: 975–82PubMedCrossRefGoogle Scholar
  44. 44.
    Strader DB. Understudied populations with hepatitis C. Hepatology 2002; 36Suppl. 1: S226–36PubMedCrossRefGoogle Scholar
  45. 45.
    Alessi N, Freni MA, Spadaro A, et al. Efficacy of interferon treatment (IFN) in elderly patients with chronic hepatitis C. Infez Med 2003; 11: 208–12PubMedGoogle Scholar
  46. 46.
    Imai Y, Kasahara A, Tanaka H, et al. Interferon therapy for aged patients with chronic hepatitis C: improved survival in patients exhibiting a biochemical response. J Gastroenterol 2004; 39: 1069–77PubMedCrossRefGoogle Scholar
  47. 47.
    Koyama R, Arase Y, Ikeda K, et al. Efficacy of interferon therapy in elderly patients with chronic hepatitis C. Intervirology 2006; 49: 121–6PubMedCrossRefGoogle Scholar
  48. 48.
    Bacosi M, Russo F, D’innocenzo S, et al. Amantadine and interferon in the combined treatment of hepatitis C virus in elderly patients. Hepatol Res 2002; 22: 231–9PubMedCrossRefGoogle Scholar
  49. 49.
    Shiratori Y, Ito Y, Yokosuka O, et al. Antiviral therapy for cirrhotic hepatitis C: association with reduced hepatocellular carcinoma development and improved survival. Ann Intern Med 2005; 142: 105–14PubMedGoogle Scholar
  50. 50.
    Nudo CG, Wong P, Hilzenrat N, et al. Elderly patients are at greater risk of cytopenia during antiviral therapy for hepatitis C. Can J Gastroenterol 2006; 20: 589–92PubMedGoogle Scholar
  51. 51.
    Floreani A, Minola E, Carderi I, et al. Are elderly patients poor candidates for pegylated interferon plus ribavirin in the treatment of chronic hepatitis C? J Am Geriatr Soc 2006; 54: 549–50PubMedCrossRefGoogle Scholar
  52. 52.
    Antonucci G, Longo MA, Angeletti C, et al. The effect of age on response to therapy with peginterferon alpha plus ribavirin in a cohort of patients with chronic HCV hepatitis including subjects older than 65 yr. Am J Gastroenterol 2007; 102: 1383–91PubMedCrossRefGoogle Scholar
  53. 53.
    Honda T, Katano Y, Urano F, et al. Efficacy of ribavirin plus interferon-alpha in patients aged > or = 60 years with chronic hepatitis C. J Gastroenterol Hepatol 2007; 22: 989–95PubMedCrossRefGoogle Scholar
  54. 54.
    Flamm SL, Jacobson IM, Brown R, et al. Pegylated interferon alfa 2b + ribavirin are equally efficacious and well tolerated in patients >65 years old in comparison to other age groups: subanalysis of a randomized, controlled study (WIN-R trial) [abstract no. 338]. 57th AASLD; 2006 Oct 27–31; Boston (MA)Google Scholar
  55. 55.
    Gupta SK, Glue P, Jacobs S, et al. Single-dose pharmacokinetics and tolerability of pegylated interferon-α2b in young and elderly healthy subjects. Br J Clin Pharmacol 2003; 56: 131–4PubMedCrossRefGoogle Scholar
  56. 56.
    Martin NE, Modi MW, Reddy KR. Characterization of pegylated (40 kDa) interferon α-2A (PEGASYS) in the elderly [abstract no. 755]. Hepatology 2000; 32 (4 Pt 2): 348AGoogle Scholar
  57. 57.
    Horikawa N, Yamazaki T, Izumi N, et al. Incidence and clinical course of major depression in patients with chronic hepatitis type C undergoing interferon-α therapy: a prospective study. Gen Hosp Psychiatry 2003; 25: 34–8PubMedCrossRefGoogle Scholar
  58. 58.
    Roche. Copegus medication guide. Nutley (NJ): Roche, 2007 JunGoogle Scholar
  59. 59.
    Schering Plough. Rebetol product information. Kenilworth (NJ): Schering Plough, 2007 SepGoogle Scholar
  60. 60.
    Salkowski MS, Wasserman R, Brooks L, et al. Changes in hemoglobin during interferon alfa-2b plus ribavirin combination therapy for chronic hepatitis C viral infection. J Viral Hepat 2004; 11: 243–50CrossRefGoogle Scholar
  61. 61.
    Takaki S, Tsubota A, Hosaka T, et al. Factors contributing to ribavirin dose reduction due to anemia during interferon α2b and ribavirin combination therapy for chronic hepatitis C. J Gastroenterol 2004; 39: 668–73PubMedCrossRefGoogle Scholar
  62. 62.
    Nomura H, Tanimoto H, Kajiwara E, et al. Factors contributing to ribavirin-induced anemia. J Gastroenterol Hepatol 2004; 19: 1312–7PubMedCrossRefGoogle Scholar
  63. 63.
    Gish RG, Arora S, Nelson D, et al. End-of-treatment (EOT) response in therapy-naive patients treated for chronic hepatitis C with viramidine in combination with pegylated interferon α-2a [abstract no. 519]. Hepatology 2004; 40 (4 Suppl. 1): 388AGoogle Scholar
  64. 64.
    Schiff ER. Emerging strategies for pegylated interferon combination therapy. Nat Clin Pract Gastroenterol Hepatol 2007; 4Suppl. 1: S17–21PubMedCrossRefGoogle Scholar
  65. 65.
    McHutchison JG, Manns M, Patel K, et al. Adherence to combination therapy enhances sustained response in genotype-1-infected patients with chronic hepatitis C. Gastroenterology 2002; 123: 1061–9PubMedCrossRefGoogle Scholar
  66. 66.
    Iwasaki Y, Ikeda H, Araki Y, et al. Limitation of combination therapy of interferon and ribavirin for older patients with chronic hepatitis C. Hepatology 2006; 43: 54–63PubMedCrossRefGoogle Scholar
  67. 67.
    Ministry of Health, Labour and Welfare. Abridged life tables for Japan, 2006 [online]. Available from URL: http://www.mhlw.go.jp/ [Accessed 2007 Nov 6]
  68. 68.
    Arias E. United States life tables, 2002. Natl Vital Stat Rep 2004; 53: 1–38PubMedGoogle Scholar
  69. 69.
    Tsui JI, Currie S, Shen H, et al. Treatment eligibility and outcomes in elderly patients with chronic hepatitis C: results from the VA HCV-001 study. Dig Dis Sci. Epub 2007 Sep 1Google Scholar
  70. 70.
    Arase Y, Ikeda K, Suzuki F, et al. Long-term outcome after interferon therapy in elderly patients with chronic hepatitis C. Intervirology 2007; 50: 16–23PubMedCrossRefGoogle Scholar
  71. 71.
    Giannitrapani L, Soresi M, La Spada E, et al. Sex hormones and risk of liver tumor. Ann N Y Acad Sci 2006; 1089: 228–36PubMedCrossRefGoogle Scholar
  72. 72.
    Kobayashi S, Takeda T, Enomoto M, et al. Development of hepatocellular carcinoma in patients with chronic hepatitis C who had a sustained virological response to interferon therapy: a multicenter, retrospective cohort study of 1124 patients. Liver Int 2007; 27: 186–91PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2008

Authors and Affiliations

  1. 1.Infectious Diseases Unit“A. Pugliese” HospitalCatanzaroItaly

Personalised recommendations