The treatment of hepatitis C has dramatically improved over the past decade. Unlike any other chronic viral infection, a significant proportion of patients with chronic hepatitis C can be cured. However, the current standard therapy—pegylated interferon alpha and ribavirin—has its limitations. Limited efficacy in patients with hepatitis C virus (HCV) genotype 1 and the side effect profile will necessitate the development of new therapeutic approaches. This review describes the efficacy and optimisation of the current standard therapy of hepatitis C and its problems in special patient populations. New treatment directions beyond interferon alpha based therapies are on the horizon.

MANAGEMENT OF ACUTE HEPATITIS C

Early identification of patients with acute HCV infection is important for their optimal management. The rate of chronic evolution is 50–90%, and the natural course of chronic hepatitis C can be associated with severe complications. Patients with chronic hepatitis C have the potential risk of developing liver cirrhosis and hepatocellular carcinoma.¹ The social burden of HCV infection is high, including for health care workers. Extrahepatic manifestations of HCV are often troublesome and may not be reversible with viral eradication.² These are good reasons for the design of a prophylactic vaccine but as this has yet to be accomplished, early treatment of acute HCV infection with interferon alpha (IFN) is the only option to prevent chronicity.

Immediate treatment of patients with symptomatic acute hepatitis C with recombinant IFN or pegylated IFN (PEG-IFN) monotherapy for 24 weeks can prevent the development of chronic hepatitis C in approximately 90% of cases.^3–5 Combination with ribavirin is not necessary.⁶ However, symptomatic patients also have a good chance to clear HCV spontaneously.^7,8 This usually occurs in the first 12 weeks after the onset of symptoms. A wait and see strategy (that is, treatment of only those patients who remain HCV-RNA …