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Outpatient Management of Hepatitis C

Outpatient Management of Hepatitis C. Brian Wisnoski, MS4 Baylor College of Medicine. Goals. Identify who to screen Provide appropriate counseling Determine who to treat Choose appropriate treatment Explain side effects of treatment Identify candidates for HCC screening

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Outpatient Management of Hepatitis C

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  1. Outpatient Management of Hepatitis C Brian Wisnoski, MS4 Baylor College of Medicine

  2. Goals • Identify who to screen • Provide appropriate counseling • Determine who to treat • Choose appropriate treatment • Explain side effects of treatment • Identify candidates for HCC screening • Describe key differences between management of chronic Hep C and Hep B

  3. Background on Hep C • 2.7 million people with ongoing infection in USA • Leading cause of death from liver disease in USA • 55-85% with Acute Hep C will develop Chronic Hep C • Flavivirus: RNA virus, Enveloped, Single stranded, + sense

  4. Question #1, Screening • Who to screen for Hep C infection? • Persistently elevated ALT/AST without Hep C risk factor for exposure. • 3 day old infant born to HCV+ mother. • Hx of IVDU but now with normal LFTs. • Person with extensive piercings/tattoos. • Sexual partner of HCV+ individual.

  5. Transmission • Mainly via blood products • IVDU (most common) • Blood transfusion before 1992 • Perinatal • Needle stick (note: unlike Hep B, no prophylaxis recommended) • Rarely transmitted sexually (unlike Hep B) • Rarely transmitted via tattoos/piercings

  6. Who to Screen • History of IV drug use • Persistently elevated aminotransferases • Children of HCV+ mothers • HIV infection • Current Sexual partner of HCV-infected person (mainly for reassurance)

  7. Who to Screen, Continued • Post needle stick • Transfusion/Organ transplant b/f 1992 • Received clotting factors b/f 1987 • Chronic hemodialysis

  8. Screening Children Born to Mothers with Hep C • 1-5% risk or perinatal transmission • High rate of clearance of HCV virus within first year of life • May screen with anti-HCV at >18 mo • If desire earlier diagnosis, can test HCV RNA at >1 mo • Treatment contraindicated in children less than 3 yrs

  9. Correct Answers #1 • Who to screen for Hep C infection? • Persistently elevated ALT/AST without Hep C risk factor for exposure.10% w/o risk factor • 3 day old infant born to HCV+ mother.too early, screen after 18 mo. • Hx of IVDU but now with normal LFTs.IVDU is high risk • Person with extensive piercings/tattoos low risk if used licensed establishment • Sexual partner of HCV+ individual.low risk of transmission, screen for reassurance

  10. Question #2, Screening • The screening test shows that your patient is anti-HCV Ab +. What is your next step? • Initiate antiviral treatment • Order HCV RNA level • Inform the patient he has chronic Hep C and counsel how to avoid transmission • Order an HCV genotype

  11. How to Screen 1) Screen for anti-HCV antibodies 2) Confirm chronic Hep C with HCV RNA • May consider HCV RNA even if antibody (-) if: • Suspect acute Hep C infection • Decreased Ab production in HIV or chronic hemodialysis

  12. Test Interpretation

  13. Test Interpretation

  14. Test Interpretation

  15. Test Interpretation

  16. Test Interpretation

  17. Correct Answer #2 • The screening test shows that your patient is anti-HCV Ab +. What is your next step? • Initiate antiviral treatment • Order HCV RNA leveleither qualitative or quantitative HCV RNA • Inform the patient he has chronic Hep C and counsel how to avoid transmission • Order an HCV genotype

  18. Question #3, Counseling • Which of the following are appropriate counseling for a patient with chronic Hep C? • Stop IVDU • Avoid alcohol • Don’t share toothbrushes • Don’t donate blood • Use condoms during sex

  19. Hep C Counseling • Stop IVDU • Avoid alcohol • Don’t share toothbrushes/razors • Don’t donate blood/organs/semen • Low risk of sexual transmission (condoms not recommended just because Hep C positive)this is different from Hep B and HIV!

  20. Hep C treatment • Peg-IFN Alfa (weekly subQ) • Note: Peg=added PolyEthylene Glycol • Ribavirin (PO daily) • Duration • 48 wks (~1 yr) for Genotypes 1, 4, 5, 6 • 24 wks (~6 mo) for Genotypes 2 & 3

  21. IFN ALFA Depression Neutropenia/ thrombocytopenia Thyroid disorder Flu-like symptoms Alopecia RIBAVIRIN Birth defects Hemolytic Anemia Itching/Rash Gout Fatigue Side Effects of Therapy Side Effects usu more severe in first weeks of therapy May manage with APAP (<2 gram/d), antidepressants, and occasionally hematopoietic growth factors

  22. Why Treat Chronic Hep C? • 5-20% will develop cirrhosis over 20-25 yrs • Those with HCV-related cirrhosis have • 30% with end stage liver disease over 10 yrs • 1-2% chance of hepatocellular carcinoma per yr • Extrahepatic complication: cryoglobulinemia • Vasculitis affecting kidneys and skin

  23. Question #4, Rx Efficacy • What percent of people completing the recommended treatment will eradicate the HCV virus? a) 25% b) 50% c) 75% d) 90%

  24. Therapy Outcomes • Overall ~50% eradicate HCV (achieve sustained response) • Worse outcomes for Genotype 1 (~40% sustained response) • However ~90% in USA have Genotype 1 • Better outcomes for Genotype 2 & 3 (~80% sustained response)

  25. Who to Treat

  26. Who Not to Treat Therapy for everyone else is “individualized”

  27. Therapy Principles • Test HCV Genotype to determine duration • Liver Biopsy Optional: may obtain if will affect decision to treat (more common with genotype 1) • Quantitative HCV RNA • Prior to starting therapy • At 12 weeks: Need 2 log (100 fold) decrease (early virologic response=EVR) • At end of therapy: Should be undetectable • 24 wks after therapy complete: Still undetectable (sustained virologic response=SVR)

  28. Question #5, HCC Screening • Who should be screened for hepatocellular carcinoma in the setting of chronic Hep C infection? • Cirrhosis on biopsy • Significantly elevated ALT (10x normal) • HCV Genotype 1 • Infected for greater than 20 years

  29. Correct Answer #5 • Who should be screened for hepatocellular carcinoma in the setting of chronic Hep C infection? • Cirrhosis on biopsy • Significantly elevated ALT (10x normal) • HCV Genotype 1 • Infected for greater than 20 years

  30. Hepatocellular Carcinoma Screening in Chronic Hep C • Benefit established in Hep C with cirrhosis • Similar screening for Hep B with cirrhosis • Additional HCC screening guidelines for those with Hep Bwithout cirrhosis based on • Ethnicity • Age • FHx of HCC

  31. How to Screen for HCC • Recommended to screen q 6-12 months with sonography (65-80% sensitive) • AFP screening may be used if sonography not available (60% sensitive) • Combination screening improves sensitivity but also false positives

  32. What if you forget some of this? Refer to American Assn for Study of Liver Diseases at AASLD.org, Google “AASLD”, or the Sanford Guide

  33. Bibliography • Strader DB et al; American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C. Hepatology. 2004 Apr;39(4):1147-71. • Bruix J et al; American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma. Hepatology. 2005 Nov;42(5):1208-36. • Gilbert D et al; The Sanford Guide to Antimicrobial Therapy 2008. Tables 14a, 14b, and 15d. Antimicrobial Therapy, Inc.

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