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Hepatitis C When, how and which patients should be treated. Graham R Foster Professor of Hepatology Queen Marys School of Medicine Barts and The London. JC. 34 year old man Infected with genotype 1 HCV (ALT 120) Refuses liver biopsy. JC. 34 year old man Infected with genotype 1 HCV

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hepatitis c when how and which patients should be treated

Hepatitis CWhen, how and which patients should be treated

Graham R Foster

Professor of Hepatology

Queen Marys School of Medicine

Barts and The London

slide2
JC
  • 34 year old man
  • Infected with genotype 1 HCV (ALT 120)
  • Refuses liver biopsy
slide3
JC
  • 34 year old man
  • Infected with genotype 1 HCV
  • Refuses liver biopsy
  • Single
  • Lives in a rented flat does not drink
slide4
JC
  • 34 year old man
  • Infected with genotype 1 HCV
  • Refuses liver biopsy
  • Single
  • Lives in a rented flat does not drink
  • Methadone prescription – 80 mls/day
slide5
JC
  • 34 year old man
  • Infected with genotype 1 HCV
  • Refuses liver biopsy
  • Single
  • Lives in a rented flat does not drink
  • Methadone prescription – 80 mls/day
  • Injects heroin x3 per week/ crack

‘ occasionally’

slide6
JC

Should we treat him ?

hcv in 2006
HCV in 2006
  • Not treating Jason
  • Good reasons/Bad reasons
hcv in 20061
HCV in 2006
  • Not treating Jason
  • Good reasons/ Bad reasons
  • He does not have bad disease
slide9
HCV in East LondonPrevalence of cirrhosis in Pakistani/Bangladeshi patients presumably infected at birth

D’Souza et al Clin Gastro Hep 2005

slide10
HCV in East LondonPrevalence of cirrhosis in Pakistani/Bangladeshi patients presumably infected at birth

D’Souza et al Clin Gastro Hep 2005

slide11
HCV in East LondonPrevalence of cirrhosis in Pakistani/Bangladeshi patients presumably infected at birth

D’Souza et al Clin Gastro Hep 2005

hcv in 20062
HCV in 2006 ()
  • I am seeing increasing numbers of patients from Bangladesh and Pakistan with advanced liver disease from HCV
hcv in 2006 are we missing something
HCV in 2006 ()Are we missing something ?
  • The government tells us that this is a drug users disease
  • I am seeing non-drug users with liver cancer secondary to HCV
  • Are we missing something important ?
hcv in 20063
HCV in 2006
  • Not treating Jason
  • Good reasons/ Bad reasons
  • He does not have bad disease – but he will get it!
hcv in 20064
HCV in 2006
  • Not treating Jason
  • Good reasons/ Bad reasons
  • He does not have bad disease – but he will get it!
  • He is unlikely to respond
sustained response rates in hcv genotype 1 40 kd peg ifn 2a ribavirin
Sustained Response Rates in HCVGenotype 1 – 40 KD PEG IFNα2a + Ribavirin

51%

41%

40%

29%

SVR (%)

n=101

n=118

n=250

n=271

PEG IFNRBV 800

PEG IFNRBV 1000/1200

PEG IFNRBV 800

PEG IFNRBV 1000/1200

24 weeks

48 weeks

Hadziyannis et al Ann Intern Med 2004:140;346-355

effects of age and svr data from patients treated with 40 kd peg ifn 2a and ribavirin

90

80

70

60

Calculated SVR Rate (%)

50

40

30

20

60

55

50

45

40

35

30

25

20

Age (completed life-years)

Effects of age and SVR(Data from patients treated with 40 KD PEG IFNα2a and Ribavirin)

Foster et al AASLD 2003

sustained response rates in hcv genotype non 1 40 kd peg ifn 2a ribavirin
Sustained Response Rates in HCVGenotype non 1 – 40 KD PEG IFNα2a + Ribavirin

78%

78%

77%

73%

SVR (%)

n=106

n=162

n=111

n=165

PEG IFNRBV 800

PEG IFN

RBV 1000/1200

PEG IFNRBV 800

PEG IFNRBV 1000/1200

24 weeks

48 weeks

Hadziyannis et al Ann Intern Med 2004:140;346-355

treating the non 1 patient can we use shorter durations of therapy
Treating the non-1 patientCan we use shorter durations of therapy ?
  • Pilot study of 14 weeks therapy in patients with an early virological response
  • Used Peg-Intron 1.5mg/kg + Normal dose ribavirin

Dalgard et al Hepatology 2004:40:1260-1265

treating the non 1 patient can we use shorter durations of therapy1
Treating the non-1 patientCan we use shorter durations of therapy ?

SVR (by per protocol analysis) of patients with an early

virological response receiving 14 weeks therapy

peg ifn and ribavirin today
Peg-IFN and Ribavirin Today
  • The standard algorithms are being revised
  • Easy to treat patients may need shorter durations of therapy
peg ifn and ribavirin today1
Peg-IFN and Ribavirin Today
  • The standard algorithms are being revised
  • Easy to treat patients may need shorter durations of therapy
  • Easy to treat patients are young with no fibrosis!
hcv therapy tomorrow
HCV therapy tomorrow

BILN 2061

New protease and polymerase inhibitors are on the way

hcv in 20065
HCV in 2006
  • Not treating Jason
  • Good reasons/ Bad reasons
hcv who should we treat opinion based medicine
HCV – Who should we treat?(Opinion based medicine)

We should NOT treat active drug users

They will not comply

They will get reinfected

(They are not worth it)

hcv in drug users evidence

Treatment of chronic hepatitis C in injecting drug users: 5 years' follow-up.Dalgard O, Bjoro K, Hellum K, Myrvang B, Skaug K, Gutigard B, Bell H; The Construct Group.Eur Addict Res 2002 Jan;8(1):45-9

  • Treatment of hepatitis C infection in injection drug users Markus Backmund, Kirsten Meyer, Michael Von Zielonka, Dieter Eichenlaub HepatologyJuly 2001 • Volume 34 • p188 to p193
HCV in drug users - evidence
hcv in drug users
HCV in drug users
  • Drug users infect others !
  • Not treating drug users encourages the spread of HCV
treating the untreatable
Treating the untreatable

27 patients started therapy (13 Genotype 1)

Early cessation = 2

Completed = 10

Completed 3 months = 11

ETR = 9 (SVR 3/3)

7 PCR -ve

4 PCR +ve

i.e. by Intent to treat analysis 16/23 = 70% have an EVR

treating the untreatable1
Treating the untreatable

27 patients started therapy (13 Genotype 1)

Early cessation = 2

Completed = 10

Completed 3 months = 11

ETR = 9 (SVR 3/3)

7 PCR -ve

4 PCR +ve

ALL patients have benefited from the attention – two are looking for work!

therapy for hcv summary i
Therapy for HCV Summary (I)
  • The natural history of HCV is of glacial progression
  • Many patients will eventually develop cirrhosis
  • Delaying therapy may reduce response rates
therapy for hcv summary ii
Therapy for HCV Summary (II)
  • We have effective therapies available and these can be given to ALL patients with chronic HCV
therapy for hcv
Therapy for HCV
  • Who would treat Jason ?
therapy for hcv post script
Therapy for HCV Post Script
  • JC was offered therapy
  • He agreed to undergo therapy and has completed 9 months treatment
  • He has not injected for 3 months
  • He has been offered a job in his brothers shop