Triple combination treatment for chronic hepatitis C with protease inhibitors, pegylated interferon and ribavirin: 'lead-in or no lead-in'?

Direct acting antiviral agents for the management of chronic hepatitis C infection have recently been licensed. These new protease inhibitors are combined with pegylated interferon and ribavirin and markedly increase the proportion of patients who respond to antiviral therapy. The protease inhibitors may be used with a ‘lead-in’ phase of pegylated interferon and ribavirin and the value of this approach has been much debated with those supporting ‘lead in’ citing the advantages of assessing the early response to therapy before commencing the direct acting antiviral agent. Those opposed to the ‘lead-in’ phase cite the complexity of the regime and the lack of robust evidence showing an improvement in clinical outcome in those treated in this fashion.