The American Association for the Study of Liver Diseases (AASLD) launched a new edition of the Guidelines for the Diagnosis and Management of Hepatitis C in April 2009, updating its 2004 edition of the Hepatitis C Guidelines. The article was published in its official journal, Hepatology [Hepatology 2009, 49(4): 1335]. Hepatitis C is the leading cause of death among patients who die from liver disease in the United States. It is estimated that the mortality rate associated with HCV infection will continue to climb over the next 20 years. In the face of the severe epidemiological trend of hepatitis C, societies such as AASLD have paid extra attention to the recommendations for prevention and control of hepatitis C. The new guidelines launched this time are exhaustive, covering all aspects of hepatitis C screening, diagnosis, treatment and prevention, with 65 recommendations and 419 references. Anti-HCV and HCV RNA When diagnosing acute and chronic hepatitis C, two indicators are involved – anti-HCV and HCV RNA. Both are positive with recent ALT elevation, which can be diagnosed as acute HCV infection or chronic HCV infection based on clinical data; anti-HCV positive and HCV RNA negative suggests HCV elimination or In the third case, a negative anti-HCV but positive HCV RNA suggests early acute infection or chronic HCV infection in immunosuppressed patients, which may also be a false positive, and it is recommended to retest anti-HCV and HCV RNA in 4-6 months. The guideline recommends that the following patients should be tested for Their HCV RNA: anti-HCV positive individuals, patients with anti-HCV negative but unexplained liver disease, immunosuppressed or suspected acute HCV infection when the patient is considered for antiviral therapy. Liver biopsy versus noninvasive markers Can transient elastography (Fibroscan), a noninvasive diagnostic method for liver fibrosis that has emerged in recent years, and serologic indicators replace liver biopsy? The Guidelines suggest that serologic markers are only useful for evaluating the two extremes of liver fibrosis – mild fibrosis and cirrhosis – and are of little relevance for evaluating fibrosis in intermediate stages or tracking the progression of liver fibrosis. Transient elastography has not been approved by the FDA and is currently not a substitute for liver biopsy; in addition, the method has a low success rate in diagnosing fibrosis in obese patients. In addition there is current evidence that patients with acute viral hepatitis with high necroinflammatory activity have increased transient elastography scores even in the absence of fibrosis. Guideline Recommendations: Available noninvasive tests are helpful in determining the presence of advanced fibrosis in patients with chronic HCV infection, but are not a substitute for liver biopsy in clinical practice. Dose Increase and Duration of Therapy In patients with refractory hepatitis C, does increasing the dose of pegylated interferon and/or ribavirin, or extending the duration of therapy, improve sustained virologic response rates? The Guidelines concluded that studies have shown that high-dose interferon induction regimens are not as effective, and that although virus is cleared at an accelerated rate, there is no increase in undetectable HCV RNA rates at the end of treatment. A small sample study evaluated the effect of high-dose ribavirin on sustained virologic response (SVR). Although SVR rates were elevated, all patients developed severe anemia requiring the application of growth factors or blood transfusions. However, for patients with delayed virologic response or who did not achieve rapid virologic response (RVR), extending the course of therapy from 48 to 72 weeks improved SVR rates. The Guidelines recommend: Delayed viral clearance (negative HCV RNA test at 12 to 24 weeks) after treatment in patients with genotype 1 HCV infection, consider extending treatment to 72 weeks. Treating patients with mental disorders In the treatment of special populations, the updated guidelines add anti-HCV therapy for patients with mental disorders. The incidence of psychiatric disorders is higher in people with chronic HCV infection, 4 to 20 times higher than in the general population. Interferon combined with ribavirin treatment itself can cause neuropsychiatric adverse effects such as depression, irritability, suicidal tendencies, mania, and unstable mood, etc. Patients with psychiatric disorders are more likely to experience such adverse effects after receiving antiviral therapy. Recent studies have shown that a multidisciplinary strategy to manage HCV-infected patients with co-morbid psychiatric disorders resulted in SVR rates similar to those without psychiatric disorders. However, it is important to note that drug-drug interactions should be considered in patients with advanced liver disease. The Guidelines recommend that when treating HCV-infected patients with co-morbid neuropsychiatric disorders, it is important to have the support of a multidisciplinary team that includes psychiatrists.