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December 2012 HCV Advocate

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In This Issue:

AASLD 2012 Part 1: HCV Therapies
Alan Franciscus, Editor-in-Chief

HCV Snapshots: AASLD 2012
Lucinda K. Porter, RN

HealthWise: - 2012 Liver Meeting Update
Lucinda K. Porter, RN


Disability & Benefits:Are There Benefits to a Reverse Mortgage?
Jacques Chambers, CLU




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AASLD 2012 Part 1: HCV Therapies
—Alan Franciscus, Editor-in-Chief

If I had to sum up the data presented at this year’s American Association for the Study of Liver Diseases (AASLD) Liver Meeting it would be:  WOW!  There were many results presented from studies without interferon and/or ribavirin in addition to those with PEG/RBV containing DAA combinations.  What is striking is the number of interferon-free regimes that have high cure rates and lower side effects.  However, it is important to keep in mind that the larger clinical trials will tell the whole story of effectiveness and side effect profile.  This article will include information about interferon and/or ribavirin free regimes presented at the conference.  For information about other studies see this month’s “Snapshots,” by Lucinda K. Porter, RN.

Abbott
Data from Abbott’s Aviator study was presented.  In this trial HCV genotype 1a and 1b patients (naïve and null responders) received various interferon-free combinations of direct acting antivirals with and without ribavirin for treatment durations of 8, 12 or 24 weeks. 

The drugs that were used in the study included:

  • ABT-450 (protease inhibitor) boosted with ritonavir (/r) QD (once a day)

  • ABT-267 (NS5A inhibitor)-QD

  • ABT-333 (polymerase inhibitor)-BID (twice a day)

  • Ribavirin (nucleoside analogue– dosed by body weight)-BID

The sustained virological response 12 weeks post-treatment (SVR12) rates were reported for the 8 and 12 week arms.  The results of the 24 week arm are pending. 

*All of the arms included ABT-450/r with different combinations of ABT-333, ABT267, with and without ribavirin. 

SVR12—null responders (DAAs plus ribavirin): 

  • Genotype 1a – 8 weeks:  81% and 89% (2 arms)

  • Genotype 1b – 12 weeks:  100% (2 arms)

SVR12—naïve (DAAs plus ribavirin):

  • Genotype 1a – 8 weeks:  96%; 12 weeks: 79% to 85% (3 arms)

  • Genotype 1b – 8 weeks:  96%; 12 weeks:  96% to 100% (3 arms)

SVR12—naïve (DAAs without ribavirin):

  • Genotype 1a – 12 weeks:  96% (1 arm)

  • Genotype 1b – 12 weeks:  100% (1 arm)

There were 448 patients in the 8 and 12 week arms.  Four patients (1%) discontinued treatment due to side effects with only one side effect, joint pain, attributed to the study drugs.  The most common side effects reported were fatigue and headache (27, 28 and 28, 31% respectively).  Abbott announced that their DAA interferon-free study with and without ribavirin has begun enrollment in a phase 3 study. 

Comments:  These are excellent results for an interferon-free regime with and without ribavirin. It is a fairly large patient population in a phase 2 study, which means that these results are more likely to be replicated in other trials and in “real world” situations.  The side effects were mild to moderate with a low discontinuation rate. 

Boehringer Ingelheim (BI)
In addition to a BI pegylated interferon, ribavirin and polymerase inhibitor phase 3 study, BI is conducting trials of an interferon-free regime that will soon begin a phase 3 trial.  Final results from the interferon-free phase 2b study of SOUND-C2 that includes faldaprevir (BI 201335 protease inhibitor), BI 207127 (polymerase inhibitor), and ribavirin were presented at AASLD. 

In the study 362 HCV treatment-naïve genotype 1a and 1b patients were enrolled.  Nine percent of the patients had compensated cirrhosis.  The study included 4 treatment arms—3 arms with the study drugs (faldaprevir 120 mg QD, BI 207127 600 mg TID (three times a day)) plus ribavirin and one arm included the study drugs, but without ribavirin.  The treatment durations were 16, 28 and 40 weeks. 

The SVR24 results are listed below by treatment duration for the arms that included ribavirin:  

  • Genotype 1a:

    • 16 weeks – 38%

    • 28 weeks – 43% & 44%

    • 40 weeks – 47%

  • Genotype 1b:

    • 16 weeks – 75%

    • 28 weeks – 69% & 85%

    • 40 weeks – 56%

The SVR24 results for the ribavirin-free arm (28 week treatment duration) were 11% for HCV genotype 1a and 57% for 1b.

Treatment discontinuations due to adverse events were 4.9% in the arm that received 16 weeks to 24.7% in the arms that received 40 weeks of treatment. 

Comments:  The SVR24 results for HCV genotype 1b were good, but the genotype 1a people did not fare as well.  It is interesting that the ribavirin-free arm achieved an SVR24 of 57% in HCV genotype 1b compared to only 11% for genotype 1a – clearly this combination is more effective in genotype 1b.

Bristol-Myers Squibb

  1. A small study of 16 HCV genotype 1 treatment-naïve patients who received triple therapy of daclatasvir (NS5A inhibitor), asunaprevir (protease inhibitor) and BMS-791325 (polymerase inhibitor) for 12 weeks resulted in a 94% (15 out of 16 patients) SVR12.  One patient who completed the 12 week treatment, but was lost to follow-up was subsequently located—HCV RNA was re-tested and reported as negative—this effectively pushed the SVR rate to 100%. There was one adverse event, but the investigators determined that it was not related to the study drugs.  The most common side effect reported was headache that occurred in 31% of the trial participants.  

    Part 2 of the study that included patients who were treated for 12 or 24 weeks is still being conducted and data is expected soon.    

Comments: This is a small study but it is important because it proves that the triple combination without PEG/RBV can provide high cure rates in patients with HCV genotype 1 with minimal side effects.  BMS announced that they expect to start a phase 3 study of this triple combination in 2014. 

  1. Phase II SVR12 data on an all DAA oral study of daclatasvir (NS5A inhibitor) and asunaprevir (protease inhibitor) to treat HCV genotype 1b prior null responders was presented at the conference.  The treatment duration was 24 weeks.  There were two treatment arms:

  • Daclatasvir (60 mg QD) plus asunaprevir (20 mg BID): 78% (14 out of 18 patients) achieved SVR12.  Note:  two of the patients with detectable HCV RNA had undetectable HCV RNA at a later time point.

  • Daclatasvir (60 mg QD) plus asunaprevir (20 mg QD): 65% (13 out of 20 patients) achieved SVR12. 

All of the patients who had viral breakthrough received rescue therapy with PEG/RBV and at the end of the rescue therapy only one patient relapsed. 

The most common side effects were headache, diarrhea, weakness, fatigue and insomnia.  There were no serious adverse events or treatment discontinuations. 

Comments:  These are remarkable results considering the therapy of daclatasvir plus asunaprevir did not contain either interferon or ribavirin in a population that is difficult to re-treat—genotype 1b prior null-responder patients.  The safety profile is also worth noting since there were no serious side effects or treatment discontinuations.  

Gilead
The results of one arm of the ELECTRON phase 2 study that included HCV genotype 1 treatment-naïve treated with sofosbuvir (GS-7977 – polymerase inhibitor) and GS-5885 (NS5A inhibitor) for 24 weeks reported 100% SVR4 (SVR4 – 4 weeks post-treatment) (25 out of 25 patients). 

Additional study arm data for HCV genotypes 1, 2, and 3 treatment-naïve, treatment-experienced, and prior treatment null-responders was also presented.  In these arms sofosbuvir was combined with ribavirin for 8 or 12 weeks.

Treatment-naïve:

  • Genotype 1, 12 weeks:  84% SVR12

  • Genotypes 2 and 3, 8 weeks:  64% SVR12

  • Genotypes 2 and 3, 12 weeks:  60% SVR8

Treatment-experienced:

  • Genotypes 2/3, 12 weeks:  68% SVR12

Prior treatment null-responders:

  • Genotype 1, 12 weeks: 10% SVR12

The treatment was well tolerated – the most common side effects were fatigue, upper respiratory tract infection and nausea. 

Comments:  Sofosbuvir plus ribavirin:  SVR12 results in HCV genotype 1 treatment-naïve patients were excellent.  The other treatment arms, however, were disappointing—the genotype 2 and 3 SVR12 results were not as high as seen in other studies (including those with GS-7977) but results were still good considering it was an interferon-free study.  The best cure rates were seen in the arm that received sofosbuvir and GS-5885.  This is logical since the addition of another HCV DAA inhibits a different viral enzyme that the hepatitis C virus uses to replicate.  

Gilead also announced that a phase III study has begun to evaluate a fixed dose of the combination of sofosbuvir and GS-5885 to treat HCV genotype 1 patients.  The study will include 4 arms, with and without ribavirin for treatment duration consisting of 12 or 24 weeks.  The study will also include about 20% of participants who have cirrhosis. 

 

Citations:

Abbott
A 12-week Interferon-free Treatment Regimen With ABT-450/r, ABT 267, ABT-333, and Ribavirin Achieves SVR12 Rates (Observed Data) of 99% in Treatment-naïve Patients and 93% in Prior Null Responders With HCV Genotype 1 Infection. Lead author:  Kris Kowdley, MD

Boehringer Ingelheim
Interferon (IFN)-free combination treatment with the HCV NS3/4A protease inhibitor BI 201335 and the nonnucleoside NS5B inhibitor BI 207127 ± ribavirin (R): Final results of SOUND-C2 and predictors of response.  Lead author: Stefan Zeuzem, MD

BMS

  1. An Interferon-Free, Ribavirin-Free 12-Week Regimen of Daclatasvir (DCV), Asunaprevir (ASV), and BMS-791325 Yielded SVR4 of 94% in Treatment-Naïve Patients with Genotype (GT) 1 Chronic Hepatitis C Virus (HCV) Infection.  Lead author:  Gregory Everson

  2. Sustained Virologic Response in Chronic HCV Genotype (GT) 1-Infected Null Responders With Combination of Daclatasvir (DCV; NS5A Inhibitor) and Asunaprevir (ASV; NS3 Inhibitor) With or Without Peginterferon Alfa-2a/Ribavirin (PEG/RBV). Lead author:  Ana Lok, MD

Gilead
Once Daily Sofosbuvir (GS-7977) Plus Ribavirin in Patients with HCV Genotypes 1, 2, and 3: The ELECTRON Trial. Lead author:  Edward Gane, MD



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HCV Snapshots: AASLD 2012
—Lucinda K. Porter, RN

This month’s “Snapshots” focuses on abstracts presented at the 2012 Liver Meeting (see “Healthwise”). The research presented here was gathered from conference posters, presentations and abstracts. They represent part of the story and unless and until these studies are published in a peer-reviewed journal, these data and conclusions are considered preliminary.

Abstract #97: Nonalcoholic Fatty Liver Disease without Cirrhosis is an Emergent and Independent Risk Factor of Hepatocellular Carcinoma: A Population Based Study.
  Authors: R.N. Rahman and J.A. Ibdah

Results and Conclusion: Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease, with increasing prevalence and severity. This research looked at the relationship between NAFLD and primary hepatocellular carcinoma (HCC) in surveys from 1993-2007. Cases where there was another HCC risk factor, such as hepatitis B or C infection, were excluded.

The results found that NAFLD was the third most common risk factor for HCC, following viral and alcohol-related hepatitis. HCC from NAFLD has been increasing since 1993.

Editorial Comments: The link between obesity and liver disease was a hot topic at this year’s liver meeting. The bottom line is that if you have hepatitis C, avoid excessive weight gain, high cholesterol or insulin resistance as you risk adding a second liver disease to your health problems.

Note: A related abstract (# 940), “Dietary Cholesterol Intake is Associated with Liver Disease Progression in Hepatitis C Infection: Analysis of the HALT-C trial,”  authored by Yu and Ioannou, showed that high dietary cholesterol intake was associated with increased risk of disease progression in hepatitis C (HCV) patients with advanced fibrosis and compensated cirrhosis.

However, it wasn’t all bad news. Abstract #99, entitled “Coffee Consumption in NAFLD Patients with Lower Insulin Resistance is Associated with Lower Risk of Severe Fibrosis,” by Kiran Bambha et al., reinforced previous studies that found increased coffee intake is associated with reduced risk of NAFLD and insulin resistance.

Abstract #136: Medication Use in Patients with Chronic Hepatitis C (HCV) from a U.S. Commercial Claims Database: Inadequacy of Prescribing Information for Assessment of Potential Drug Interactions
  Lead Author: C.L. Mayer, et al.

Results and Conclusion: Many drugs have the potential to interact with boceprevir (BOC) and telaprevir (TVR) which puts patients at risk for drug-to-drug interactions (DDI). This study looked at the pharmacy records of more than 53,000 HCV patients, and identified twenty of the most commonly prescribed drugs. The prescribing information was reviewed, looking for those that have the potential for DDI with BOC and TVR: 

  • 5% are contraindicated with either BOC or TVR

  • 5% have recommendations to avoid use for BOC; 15% for TVR

  • 25% have recommendations to reduce the dose and/or monitor for BOC; 35% for TVR

  • 65% lack a recommendation in the prescribing information for BOC; 45% for TVR

The researchers concluded that current prescribing information does not adequately prepare practitioners to assess DDI. The most common drugs found were: zolpidem, diazepam, codeine, bupropion, prednisone, trazodone, tramadol, fluconazole, citalopram, sertraline, fluticasone, clarithromycin, methylprednisolone, sildenafil, alprazolam, clonazepam, amlodipine,  simvastatin, escitalopram, and venlafaxine.

Editorial Comments: Although we depend on our medical team to keep us safe, the best course of action is to check any drugs or supplements prior to taking them. Use a drug interaction tool, such as www.hep-druginteractions.org

Note: A related abstract (# 1906), “Active Ingredient Confusion for Acetaminophen-Containing Medications: A Cause of Double Dipping” presented by M. Serper, found that acetaminophen was identified on the prescription label by the abbreviation “APAP” or “ACET” 87% of the time. About 59% of bottles had a warning regarding APAP. Patients are advised not to exceed 4 grams of acetaminophen daily (in divided doses throughout day), and with inadequate labeling, patients may not readily identify that they are taking acetaminophen. Excess acetaminophen is associated with a risk for hepatotoxicity, so if they take a prescribed dose of acetaminophen along with over the counter acetaminophen, they may risk liver damage. The Investigators recommended elimination of abbreviations on prescription labels.

Abstract #942: Response to Treatment as a Predictor of Hepatocellular Carcinoma (HCC) Development among Persons Chronically Infected with Hepatitis C Virus (HCV) Infection: A Meta-Analysis
  Lead Author: Rebecca Morgan, et al.

Results and Conclusion: Patients with HCV have approximately a 1%-3% chance of developing hepatocellular carcinoma (HCC). The HCC risk for patients who have a sustained virologic response (SVR) to treatment is a question that has been analyzed before but merits more analysis. In this study, researchers identified and analyzed 10,580 citations, selecting 304 articles and 29 observational studies.

They found that achieving an SVR reduces the risk of HCC development by more than 75%. Also noted is that the absolute risk of HCC among persons with advanced liver disease is nearly three times the risk among persons with all stages of fibrosis (4.6% and 13.9%, respectively). The researchers concluded that earlier treatment with effective therapies is essential to prevent development of HCC in HCV-infected persons.

Editorial Comments: As we wait for potential improvements in HCV antiviral therapy, one of the dilemmas from postponing treatment is that advanced liver disease is less likely to respond to treatment. Essentially the delay is a calculated risk. The decision of when to do treatment is individualized and should be made with medical advice.  (For more on this, see the last “HCV Snapshot” Abstract #CRW-5 and HCV Advocate’s newest pamphlet, To Treat or Not to Treat?)

Another note: regardless of whether you have or had HCV, take measures to avoid fatty liver disease, which can increase your risk of HCC.

Abstract  # 987: Effect of Chronic Hepatitis C Virus Infection on Bone Mineral Density
  Lead Author: Jung-Chun Lin, et al.

Results and Conclusion: One question about HCV is its affects on bone marrow density. This study enrolled 69 subjects with non-cirrhotic HCV (41% male/mean age of 54 years). Compared to the control group of similar age and gender distribution, HCV patients showed significant bone loss. Bone loss increased with more advanced fibrosis levels. 

Editorial Comments: It would be interesting to see this study done with a third arm measuring the impact of weight-bearing exercise on bone density in people living with HCV. 

Abstract  #1751: Is There a Real Difference in Viral Response of Chronic Hepatitis C between Men and Women?
  Lead Author: Stefan Mauss, et al.

Results and Conclusion: This investigated previous research reporting that premenopausal women are more likely to have an SVR to HCV treatment. Pre and postmenopausal women were matched with men, creating 2093 matched pairs. Compared to men of similar ages, premenopausal AND postmenopausal women were no more likely to have an SVR. However, age did have an effect on SVR; younger subjects of either gender were more likely to achieve an SVR.

Editorial Comments: For many years I have repeated data that premenopausal women are more likely to have an SVR to HCV treatment. This study challenges this, but it also makes me more cautious. I am taking a neutral position on this until this research is peer-reviewed, replicated, and published. These data do argue in favor of earlier, rather than later treatment.

This is a good time to mention something I learned at the Liver Meeting from Cynthia Levy of University of Miami. She said that assuming there is no contraindication, that hormone replacement therapy (HRT) seems to lower the risk of fibrosis for menopausal women. This is not necessarily a reason to start HRT, but HCV positive women who wonder if HRT is hurting their livers may rest-assured.

Abstract #1782: Vitamin D Supplementation Influences Sustained Virological Response Rate in Hepatitis C: A Systematic Review ad Meta-Analysis
  Lead Author: L.M. Villar, et al.

Results and Conclusion:  Recently, a number of studies reported that low vitamin D levels decrease the chance of achieving an SVR to HCV treatment. This research reviewed published data that studied the association between serum 25 hydroxyvitamin D (25 D) and SVR among 1546 HCV infected individuals with or without 25 D supplementation. Results showed that baseline 25 D levels did not influence outcome during HCV treatment BUT that vitamin D supplementation was statistically associated with increased SVR rate.

Editorial Comments: This adds weight to previous evidence that vitamin D supplementation is associated with improved SVR. However, we need concrete protocols for vitamin D supplementation for HCV treatment patients.

Abstract #1830: Preliminary Results of Twice Daily Dosing (Q12 hr) of Telaprevir (TVR) for Treatment Naïve and Previously Treated Patients with Genotype 1 HCV: Comparable RVR, eRVR and SVR12 to Standard Daily Dosing at Q8 hr
  Lead Author: Paul Pockros, et al.

Results and Conclusion: Current HCV triple-therapy requires patients to take the protease inhibitor portion of their treatment three times daily (with food, and in the case of Telaprevir (TVR) food must be at least 20 grams of fat). This study enrolled and treated 118 patients with the same total daily dose of TVR, but divided into 2 rather than 3 doses daily. 27 patients stopped therapy prior to week 12 due to a variety of reasons, particularly adverse events. Nearly 45% of participants needed ribavirin dose reductions for anemia (Hgb<10 g) along with the use of EPO.

Not all of the patients have completed the full 24-week post-treatment follow-up and these results are based largely on 12-week post-treatment SVRs. The bottom line is that twice daily TVR dosing was equivalent to or better than those published using 3 times daily dosing. This was a difficult-to-treat population with mostly advanced fibrosis, genotype 1a and unfavorable IL28B genotypes.

Editorial Comments:

  • DO NOT do this on your own. This is a preliminary abstract and not an FDA-approved treatment guideline. Plus there was a high dropout rate.

  • This is incomplete data. We need final week 24 SVR numbers.

  • If this becomes a protocol, it has three advantages:
    1. It is much easier to remember to take pills twice daily than 3 times, particularly since ribavirin dosing is twice daily.
    2. Eating 20 grams of fat twice daily would be easier than having to do this 3 times daily.
    3. Improved adherence could result in better SVR rates.

Abstract #1834: Does Chemotherapy Cause Hepatitis C Viral Relapse in Cancer Patients Who Achieved Sustained Virological Response?
  Authors: H.A. Torres and P. Mahale

Results and Conclusion: This study looked at medical records of all HCV-infected cancer patients seen at M.D. Anderson Cancer Center from 1/2008 to 12/2011 who had achieved an SVR. No case of post-SVR relapse occurred following chemotherapy of the 48 identified patients.

Editorial Comments: Earlier this year I read a report suggesting that chemotherapy may cause a relapse in cancer patients who had an SVR. My heart sank, as this challenged my assertion that SVR equals cure. This study is more assuring, but frankly, it is small. More research is needed, but I am still using the “cure” word.

Abstract #CRW-5: Should We Prioritize Chronic Hepatitis C Patients For Treatment with Direct-Acting Antiviral Agents?
  Lead Author: J. Chhatwal, et al.

Results and Conclusion: A huge increase in patients seeking HCV treatment occurred after the approval of direct-acting antiviral agents (DAAs). Many medical providers cannot manage this surge and have put patients on waiting lists. Another concept is called warehousing (a term I deplore), which means prioritizing patients and wait-listing patients who may be able to wait.

This study developed a decision-analytic Markov model and recommended the following prioritization order (from highest to lowest):

  • Cirrhosis[a] younger age, [b] prior relapser, [c] treatment naïve, [d] IL28B genotype C/C,  [e] partial responder [f] others)

  • METAVIR score F3 [a] younger age, [b] others

  • METAVIR score F0–F2

Editorial Comments: I hesitated to include this abstract because it raises uncomfortable issues. No one likes to think that they could not get treatment when they want it. In practice, few physicians would turn down a motivated patient. However, when a patient with minimal disease is treated, then someone with more advanced liver disease may have to wait. I am not suggesting that we self-wait list, but I do think we deserve to see the entire picture. As someone with stage 2 fibrosis who is considering HCV treatment for a third time, this study affirms my decision to wait. 

One thing I am sure about is that the term warehousing needs to go. How about prioritizing?

 


New: To Treat or Not to Treat? Brochure
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HEALTHWISE: 2012 Liver Meeting Update
—Lucinda K. Porter, RN

The American Association for the Study of Liver Diseases (AASLD) has hosted The Liver Meeting since 1950. This is an annual, international gathering of researchers and others interested in liver diseases, and this November’s event was larger than ever.

Alan Franciscus and I had the opportunity to attend again this year. My impression can be summarized with a common social media abbreviation—OMG. We have come a long way with treatment and understanding of hepatitis C (HCV) and the progress is nothing short of remarkable.

There were more than two thousand abstracts at this year’s liver meeting. Alan and I featured the most noteworthy in “HCV Snapshots.” Alan highlighted treatments that are in drug development; I wrote about other aspects of HCV. For those wanting to read more, links to information are at the end of this month’s “Healthwise.” 

What really stands out about this year’s meeting are two things: 1) There are many promising HCV treatments in the pipeline, and 2) the use of the word cure was used frequently by top-notch experts. One hepatologist said, “The very nature of viruses is that they replicate. If a virus can no longer replicate, then the patient is cured.” Another remarked, “Now we can look patients in the eye and offer them a genuine cure.”

The term sustained virologic response (SVR) is still the medical term for an HCV cure, a term that will continue to place slight doubt in the minds of many patients as they are told they have an SVR and they are cured. However, I think we will get over that in time, as we add more years between us and the virus.

As I find myself more comfortable using the word cure, I add a strong warning—cure does not mean an end to HCV. The majority of people who have HCV are still undiagnosed and many of those who are diagnosed are still living with HCV. Cirrhosis is on the rise, and our Baby Boomers are especially at risk. A wave of HCV is infecting our younger population, particularly those ages 15 to 30 years old. Cure is not an end to HCV—it is a hope for an end.

Although we have made significant progress in our understanding and treatment of HCV, we must not lose our momentum. We must reach the undiagnosed, giving them basic knowledge to help them live healthier lives. We need better treatment, with a lower risk side effect profile and 100% cure rates for everyone.

We also must continue to advocate for the disadvantaged, ignored, and discarded. The Affordable Health Care Act will help, but it will not fix all of our healthcare and social problems. Healthcare does not cure discrimination, stigma, mental illness, chemical dependency, and other issues that touch the lives of so many of us with HCV. We have much work yet to do.

You can help with this work by supporting HCV organizations. As you plan your charitable giving, please include The Tides Center/Hepatitis C Support Project or other HCV-related organizations. Although I give to HCSP, I admire the work of others, and they too are worthy of support. We are all in this together.

Wishing you a healthy, peaceful end of 2012. See you here in 2013. 

Lucinda K. Porter, RN, author of Free from Hepatitis C, is a long-time contributor to the HCV Advocate. Her blog is http://lucindaporterrn.com

For more information:

  • American Association for the Study of Liver Disease
    www.aasld.org

  • Caring Ambassadors/Hepatitis C www.hepcchallenge.org

  • HCV New Drug Research http://hepatitiscnewdrugs.blogspot.com  This is my favorite blog. It posts a collection of information from other sources, including the press and financial sector, providing other perspectives and analyses.

  • National AIDS Treatment Advocacy Project www.natap.org   This is my favorite AASLD/ hepatitis C coverage. Consider signing up for the mailing list.

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DISABILITY & BENEFITS: Are There Benefits to a Reverse Mortgage?
—Jacques Chambers, CLU

A reverse mortgage on your home is not the type of benefit usually discussed in this column, but in the right situation it can be a benefit by providing much needed money. However, such a loan is not recommended for everyone who has built up equity in his or her home.

The reverse mortgage was specifically created for older homeowners whose primary or only asset is the home they live in, and is pretty much like it sounds. It allows a homeowner to tap into the equity built up in his home by borrowing against it without having to sell or refinance it. That equity simply becomes collateral for the loan – a loan that does not need to be repaid until later; often much later.

It really is just the reverse of a standard homeowner’s mortgage. Instead of making payments to a lender who holds title or a lien on your home, you receive money from a lender and do not have to pay it back as long as you live in that home. The loan is paid back when you die or if you should sell the house.

There are several types of reverse mortgages, some funded by private companies, and others designed for more expensive homes. This article focuses on federally insured reverse mortgages. They are known as Home Equity Conversion Mortgages (HECMs) and, although they are obtained through private financial institutions, they are backed by the U.S. Department of Housing and Urban Development (HUD).

HECM reverse mortgages are only available to homeowners age 62 or older. The maximum amount of the loan varies, but can go up to $625,000. The maximum limit depends on:

  • The value of the home less any outstanding liens plus an estimated amount of money necessary to make needed repairs;

  • The age of the senior owning the home; the older the owner the greater amount available;

  • The interest rate being charged which is determined by the U.S. Treasury 1 year T-Bill and other financial markers; and,

  • How the payments are received, either as a line of credit, fixed period monthly payments, lifetime payments, or lump sum.

Monthly payments can be taken for either a fixed period of time, or for your lifetime. Lifetime payments are similar to an annuity in that they pay the monthly benefit as long as you live, so the amount available will be less, often considerably less, than if taken for a fixed period of time.

You are permitted to switch from one method to another, although there is usually a small fee to switch. If you are collecting or moving to collecting a lifetime of monthly payments, more restrictions may apply.

By federal law, before applying for a reverse mortgage, you must see a counselor at a housing counseling agency that is approved by the government. This is to make sure you, the potential borrower, understand completely how the reverse mortgage works and the costs involved.

The counseling is usually available at little or no cost. The typical fee is $125, which can be paid from the loan proceeds; however, no one is turned away for inability to pay.  Upon completion, the borrower is given a certificate, which is required before a reverse mortgage application can be processed.

Like any other mortgage loan, there are charges involved, substantial charges. There are initial fees such as appraisal and inspection of property, mortgage insurance premium, origination fees, title insurance, and recording fees. These charges can usually be added to the loan with the exception of the real estate appraisal.

When you take out a reverse mortgage, the title to the home does not change. You retain title to your home, and you don’t have to make any monthly repayments. The loan does not have be repaid until the last surviving borrower dies, sells the home, or no longer lives in the home as a principal residence.  Your liability to repay the loan is limited to the value of your home at the time the loan is repaid, only if the house is sold to repay the outstanding loan.

The Federal Trade Commission (FTC), is the body which monitors reverse mortgages and oversees lender practices. They caution potential borrowers to be aware that:

  • Lenders also may charge servicing fees during the term of the mortgage. The interest rate on reverse mortgages is often higher than those on regular home loans.

  • The amount you owe on a reverse mortgage grows over time. Interest is charged on the outstanding balance and is added monthly to the amount you owe. This means that your debt increases as the loan funds are advanced to you and interest and charges on the loan accrue.

  • Although some reverse mortgages have fixed rates, most have variable rates that are tied to a financial index, which are likely to change with the investment market.

  • Interest on reverse mortgages is not deductible on income tax returns until the loan is paid off in part or in full. 

  • Since you retain title to the home, you are responsible for all utilities, property taxes, homeowners insurance, maintenance, and other expenses. Should you not pay property taxes, maintain insurance, or maintain the condition of your home, your loan may become due and payable.

Most importantly, the FTC reminds borrowers that a reverse mortgage can use up all or most of the equity in your home, and leave fewer assets for you and/or your heirs. Once the loan becomes due, either through death of the owner or sale of the home, ownership of the home can be retained only if the loan is repaid in full.

A Note of Caution: If one spouse is the only person on the title, and that spouse should die, the reverse mortgage loan will become due. The surviving spouse can only remain in that home if other funding can be arranged to repay the mortgage. Spouses may want to consider joint title ownership to avoid such situations.

Remember: Proceeds from a reverse mortgage are a loan, and therefore are not taxable income, meaning that it will have no impact on your ability to collect Social Security Disability or Social Security Early Retirement or regular retirement. They will affect eligibility for needs-based benefits such as Medicaid and SSI.

It is up to you to decide if a reverse mortgage is right for you and your family and financial situation. That will depend on your other assets and how liquid they are; what you want to leave to your heirs, if any; and, what other access to money might be available at a lower rate.

If you are considering a reverse mortgage, take the certification counseling. That will give you more information on which to base your decision. For additional information on reverse mortgages:

Federal Trade Commission
Consumer Response Center
600 Pennsylvania Avenue NW
Washington, D.C. 20580
www.ftc.gov/bcp/edu/pubs/consumer
/homes/rea13.shtm
 
1-877-382-4357

Reverse Mortgage Education Project
AARP Foundation
601 E Street NW
Washington, D.C. 20049
www.aarp.org/revmort
1-800-209-8085

U.S. Department of Housing and Urban Development (HUD)
451 7th Street SW
Washington, D.C. 20410
www.hud.gov/offices/hsg/sfh/
hecm/rmtopten.cfm



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