hepatitis c: closer to cure · acute hepatitis c acute hepatitis c refers to the first 6 months...
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Hepatitis C: Closer to CureLYNN RAPSILBER DNP APRN ANP-BC FAANP
NP WELLNESS CARE
NPAA CONFERENCE
SEPTEMBER 14, 2018
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DisclosuresSpeaker for:
Gilead
No financial support for this presentation
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Objectives1) What hepatitis C is and who is at risk
2) Identify testing as part of the work-up for hepatitis
3) Identify the long term complications of hepatitis C
4) Knowledge of the current treatments and management options for hepatitis C
5) Management of cured patient with cirrhosis
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What is Hepatitis C?
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What is Hepatitis C?Identified in 1989
First tests approved in 1992 by the FDA
Known as Non A, Non B Hepatitis
Looked at cause of liver disease in patient who received transfusions in the 1970’s
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Hepatitis C Virus(2017, April 22). Retrieved from https://www.google.com/imgres?imgurl=https://fthmb.tqn.com/I7W68jDfM6B9xxzcVOvCmuFumgs%3D/768x0/filters:no_upscale()/about/GettyImages-462126629-56
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Facts About the Virus
Hepatitis C virus can be detected 2 weeks after exposure
Can be detected in >97% by 6 months
Virus can live @ room temperature on surface for 3 weeks
Clean surfaces with 1: 9 bleach and water
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Acute Hepatitis CAcute hepatitis C refers to the first 6 months after infection with HCV. 25% of the patients will spontaneous clear virus without
treatment.Between 60% to 70% develop no symptoms during the
acute phase.
In the minority of patients who experience acute phase symptomsmild and nonspecific75%-85% of acute hep c will persist with chronic infection
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(2017, April 23) Retrieved from: https://www.cdc.gov/hepatitis/statistics/2014surveillance/commentary.htm#bkgrndC
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What are the signs and symptoms of acute HCV infection?
Fever
Fatigue
Dark urine
Clay-colored stool
Abdominal pain
Loss of appetite
Nausea
Vomiting
Joint pain
Jaundice
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(2017, April 23). Retrieved from: https://www.cdc.gov/hepatitis/hcv/cfaq.htm#cFAQ11
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Most Common Signs and Symptoms of Acute Hepatitis C (If Present)
Time Frame Wks from Exposure
2-12 weeks•Exposure and symptoms if present
4-10 weeks •Seroconversion
4-12 weeks•Elevated or fluctuating ALT (sign of liver injury)
RAPSILBER 2018 DO NOT REPRODUCE WITHOUT PERMISSION(2017, April 23). Retrieved from: http://www.who.int/mediacentre/factsheets/fs164/en/
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Treatment Acute Hepatitis C
Interferon and Ribavirin
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Treatment Acute Hepatitis C
Interferon and Ribavirin
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Treatment Acute Hepatitis C
No longer treat
Wait to convert to Chronic
Treatments are curative
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Chronic Hepatitis C Infection
Was know as “Hepatitis non-A non-B”
Not recognized until asymptomatic persons are identified as HCV-positive:when screened for blood donationwhen elevated alanine aminotransferase (ALT, a
liver enzyme) levels are detected during routine examinations
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Chronic HCV infection
Many have chronic liver disease◦ range from mild to severe
◦ cirrhosis and liver cancer
Chronic liver disease in HCV-infected persons is◦ usually insidious
◦progresses slowly without any signs or symptoms for several decades.
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Chronic HCV InfectionOf those infected…
25-30% will-develop Cirrhosis
Of those >25% will develop either:◦end stage liver disease requiring liver transplantation
◦hepatocellular carcinoma (HCC)
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Seeff LB. Natural history of chronic hepatitis C, Hepatology , 2002, vol. 36 Suppl 1(pg. S35-46)
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Prevalence
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Prevalence of Hepatitis Cin the US
CDC uses data from the National Health and Nutrition Examination Survey (NHANES).
During 1988–2002, an estimated 2.4–3.9 million persons chronic infection
Seroprevalence highest among adults aged 40–49 years (4.3%), males (2.1%), and black non-Hispanics (3.0%).
NHANES data indicate that a cohort of new infections during 1980s higher prevalence of chronic infection decades later among persons born from 1940 to 1965.
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Armstrong GL, Wasly A, Simard EP, McQuillan GM, Kuhnet WL, Alter MJ.The prevalence of hepatitis C virus infection in the United States, 1999 through 2002, Ann Intern Med , 2006, vol. 144 (pg. 705-14) 19
More People Die from HCV than from 60 Other Infectious Diseases Combined (Including HIV, Pneumococcal Disease, and Tuberculosis)
ANNUAL NUMBER OF HCV-RELATED DEATHS VS. OTHER
NATIONALLY NOTIFIABLE INFECTIOUS CONDITIONS
IN THE UNITED STATES, 2003-2013
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Source: Centers for Disease Control and Prevention. Annual number of HCV-related deaths vs. other nationally notifiable
infectious conditions in the United States, 2003-2013
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Underdiagnosed and UndertreatedOf those infected…
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Yahya BR et al. PLoS One. 2014;9(7):1-7.
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Underdiagnosed and UndertreatedOf those infected…
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Yahya BR et al. PLoS One. 2014;9(7):1-7.
18%
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Only 9%-18% are treated!!!!
We need to do a better job of identifying
patients!!
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Transfusions 10% / Tissue organ transplant before 1992
Organs of HCV +
Mother to Infant *
(*higher viral ct and co-HIV)
Clotting factors before 1987 (99%)
Chronic Hemodialysis Patient
High risk sexual activity (15-20%)
IVDA 84% / INC
Sharing personal items
Tattoos /Body piercings
Nosocomial / occupational exposures
Endoscopy
Transmission of Hepatitis C
(2017, April 27). Retrieved from: http://www.hepatitisc.uw.edu/pdf/screening-diagnosis/epidemiology-us/core-concept/all
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Blood Testing
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Blood testing
First available in 1992
Only way to know if have Hepatitis C
Antibody Test◦ HCV antibody testing is sensitive and inexpensive
◦ Positive results should be confirmed with repeat antibody test
◦ Signal-to-cutoff ratio may be used to “confirm”
◦ Positive test results are often reportable
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Fingerstick in the OfficeRapid Results
Point-of-care testing results in 20 minutes
Laboratory Accuracy
Greater than 98% accurate
Tests for multiple HCV genotypes
Easy-to-Use
Fingerstick and venipuncture whole blood collection
CLIA-waived
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(2017, April 23). Retrieved from: http://www.orasure.com/products-infectious/products-infectious-oraquick-hcv.asp
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HCV Antibody TestingHCV RNA**Preferred Supple-mentalTesting
HCV ribonucleic acidQualitative (yes or no) Quantitative (how much virus) Measures virus in the blood streamA negative cannot determine status
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Blood testing: beyond the positive antibody testHCV PCR RNA or viral load◦ Amount of measurable virus in the blood
◦ Confirm spontaneous clearance 15-45%◦ Remain antibody positive
Liver function tests◦ AST/ALT (30% will have normal levels)
Genotyping◦ Genotype 1,2 and 3 are most common in US
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Genotypes 1-11
Genotypes 1-3 have a worldwide distribution.
Types 1a and 1b are the most common, accounting for about 60% of global infections.
They predominate in Northern Europe and North America, and in Southern and Eastern Europe and Japan, respectively.
Someone could be infected with more than one genotype
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Genotypes
Genotype 2 is less frequently represented than type 1.
Genotype 3 is endemic in south-east Asia and is variably distributed in different countries. Worse prognosis******
Genotype 4 is found in the Middle East, Egypt, and central Africa.
Genotype 5 is almost exclusively found in South Africa
Genotypes 6-11 are distributed in Asia
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(2017, April 22). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303918/figure/fig01/32
Genotypes: US Distribution Genotype 1 is the most common in the United States and accounts for approximately 76% of HCV infections
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(2017, April 23). Retrieved from: http://www.hepatitisc.uw.edu/pdf/screening-diagnosis/epidemiology-us/core-concept/all
76%1
2
34,5,6
12%
10%2%
Messina JP et al. Hepatology. 2015;61(1):77-87.
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Genotype 1 Subtypes
GT 1a 55%
GT 1b 35%
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Screening
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Ghany MG, et al. Hepatology. 2009;49:1335-1374.
Centers for Disease Control and Prevention. MMWR Recomm Rep. 1998;47:1-39.
Groups Recommended for HCV Testing by AASLD and USPHS (Class 1 Level B)*
Recent/past injection drug users—even if only used once
Groups with high HCV prevalence
◦ HIV-infected individuals
◦ Hemophiliacs treated with clotting factor concentrates before 1987
◦ Hemodialysis recipients
◦ Patients with unexplained aminotransferase abnormalities
◦ Recipients of transfusion or transplantation before July 1992
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Ghany MG, et al. Hepatology. 2009;49:1335-1374.
Centers for Disease Control and Prevention. MMWR Recomm Rep. 1998;47:1-39.
Groups Recommended for HCV Testing by AASLD and USPHS (Class 1 Level B)*
Children born to women infected with HCV
Healthcare, public safety, and emergency medical personnel
◦ needle injury or mucosal exposure to HCV-infected blood
Current sexual partners of individuals infected with HCV
◦ MSM
Persons who have used illicit drugs by noninjection routes
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Grading of Recommendations, Assessment, Development and Evaluation (GRADE)
Criteria Strength of Recommendation (CLASS)
◦ Strong [1]Factors influencing the strength of the recommendation included the quality of the evidence, presumed patient-important outcomes, and cost
◦ Weak [2]Variability in preferences and values, or more uncertainty. Recommendation is made with less certainty, higher cost or resource consumption
Quality of Evidence (LEVEL)
◦ High [A]Further research is unlikely to change confidence in the estimate of the clinical effect
◦ Moderate [B]Further research may change confidence in the estimate of the clinical effect
◦ Low [C]Further research is very likely to impact confidence on the estimate of clinical effect
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(2017, April 22). Retrieved from: http://www.gradeworkinggroup.org/
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CDC Recommendations (2012) (Class 1 Level B)Individuals born between 1945 and 1965
Three-fourths of all chronic HCV
Accounts for 75% of HCV mortality (55-64 yrs)
35% who are undiagnosed, already progressed to advanced stages of liver disease and hepatocellular carcinoma
One-time testing is recommended without prior ascertainment
90% of people awaiting transplant
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https://www.cdc.gov/hepatitis/statistics/2014surveillance/commentary.htm#bkgrndC
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DTC AdvertisingGilead TV Spot, 'Hepatitis C and Baby Boomers' Original
Baby Boomers: Why You Need to Get Tested for Hep C
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Forget Me Not | HepCHope.com
Hepatitis C: The Hidden Epidemic
Why have so many baby boomers
developed hepatitis C? For some of
them, the answer goes back to
youthful experimentation during the
hippie era.
By Judith Horstman, M.L.A.
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AASLD Guideline Recommendations for Screening and Counseling“As part of a comprehensive health evaluation, all persons should be screened for behaviors that place them at high risk for HCV infection
Persons who are at risk should be tested for the presence of HCV infectionUniversal testing is not justifiable by current measures of
HCV prevalence, disease burden, and treatment effectiveness
Persons infected with HCV should be counseled on how to avoid HCV transmission to others”
RAPSILBER 2018 DO NOT REPRODUCE WITHOUT PERMISSIONGhany MG, et al. Hepatology. 2009;49:1335-1374.
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Complications of HCV
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Consequences of Hepatitis CChronic Hepatitis
Hepatic Fibrosis
Cirrhosis
Hepatocellular Carcinoma
End-Stage Liver Disease requiring Transplant
Extrahepatic manifestations
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Liver Scarring: Fibrosis and Cirrhosis
◦Hepatitis C causes inflammation
◦ fibrosis > scarring
◦affect liver function > progresses to cirrhosis
◦ liver failure > transplant
◦Ultrasound can identify this process
◦Liver biopsy can stage this process
◦Non invasive options are available
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Progression of fibrosis to cirrhosis
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http://www.hepatitisc.uw.edu/go/evaluation-staging-monitoring/natural-history/core-concept/all
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(2017, April 23). Retrieved from: http://www.hepatitisc.uw.edu/go/evaluation-staging-monitoring/natural-history/core-concept/all
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Who is at greater risk?Genotype 3 associated with more fibrosis
Rapid progression from stage to stage
Liver failure 5 % (children)
25-30% (adults) of HCV population will develop cirrhosis
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Cirrhosis of the Liver
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Cirrhosis of the Liver
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Cirrhosis
Compensated
vs
Decompensated
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Symptoms of Cirrhosisfatigue
weight loss
nausea
abdominal pain
pruritus
jaundice (yellow discoloration of the skin and eyes)
ascites
hepatic encephalopathy
bleeding
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(2017, April 23). Retrieved from: http://hepc.liverfoundation.org/what-is-hepatitis-c/what-can-happen-complications-of-hep-c/
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Hepatocellular Carcinoma (HCC)Risk increases with Cirrhosis
3% of HCV population will develop◦ Increase in incidence over last 2 decades
Identify by◦ imaging studies MRI best
◦S/S such as jaundice
◦Alpha Fetoprotein is elevated
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Hepatocellular Carcinoma
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Hepatocellular Carcinoma (HCC)10%-20% of tumors are surgical resection or ablation /offer best chance of cure
Ablation procedures more common
Introduce heat into the tumor
Liver transplant can increase survival
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Radio Frequency AblationMinimally invasive
Repeatable procedure
High rate to tumor necrosis
Great long term survival data
Performed under US or CT guidance
Needle inserted into liver
Heat generated by rapidly agitating cells causing necrosis
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Liver tumor before RFA
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(2017 December 15). Retrieved from: http://emedicine.medscape.com/article/1390475-overview#a2
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After RFA
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http://emedicine.medscape.com/article/1390475-overview#a2
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Extrahepatic ManifestationsHematologic◦ Anemia, lymphoma
Dermatologic
◦ Lichen planus, Vasculitits
Renal◦ Glomerular nephritis,
nephrotic syndrome
Endocrine◦ Hypothyroidism,DM
Neuropsychiatric
Ocular◦ Corneal ulcer, uveitis
Vascular
◦ Polyarteritis, necrotizing vasculitis
Neuromuscular
◦ Arthralgias, myalgias
Autoimmune◦ CREST syndrome
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End Stage Liver Disease Signs and Symptoms
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Advanced Liver Disease in Chronic HCV–Infected US Population: 2009-2028
▪ Total number of patients with advanced liver disease in 20 yrs projected to
be > 4-fold higher than today
Milliman, Inc. Consequences of HCV: costs of a baby boomer epidemic, 2009. Graphic reproduced with
permission.
Assuming no changes in standard of care
0
50,000
100,000
150,000
200,000
250,000
Indiv
iduals
2009 2012 2015 2018 2021 2024 2027
Yr
Hepatocellular
carcinoma
Decompensated
cirrhosis
Liver
transplantation
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Annual US Medical Costs for Chronic HCV Infection: 2009-2028
▪ Total medical costs for patients with HCV infection expected to more than
double, from $30 billion to > $85 billion USD, over the next 20 yrs
0
60
100
US
D$,
Bill
ions 80
40
20
2009 2012 2015 2018 2021 2024 2027
MedicareUninsuredVAMedicaidCommercial
Assuming no changes in standard of care
Yr
Milliman, Inc. Consequences of HCV: costs of a baby boomer epidemic, 2009. Graphic reproduced with
permission. 61
Prevention
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Avoiding Transmission to Others(Class 1 Level C)
Avoid sharing toothbrushes
Avoid sharing shaving equipment i.e. razors
Avoid sharing nail files and clippers
Avoid tattoos and body piercings
Do not donate blood, organs, tissue, or semen
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Avoiding Transmission to Others
Cover bleeding wounds to prevent contact with others
Discontinue illicit injection drug use; if injection drug use continues:◦ Avoid reusing/sharing needles/syringes and other drug
paraphernalia and dispose of syringes/needles after single use in puncture-proof container
◦ Clean injection site with fresh alcohol swab
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Avoiding Transmission to OthersDue to low sexual transmission rate, barrier protection not needed in monogamous relationships; otherwise, safe sex practices warranted
Worry about other STI/STD
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Alcohol and Hepatitis C
Alcohol use should be avoided (Class 2a Level B)– > 50 grams* per day clearly increases HCV-fibrosis progression
–Alcohol consumption > 50 grams* per day appears to increase HCV RNA level[2]
Males 30 gms per day
Females 20 gms per day
Clean and/or sober at least 6 months
* 50 grams of alcohol is approximately 48 ounces of beer,
[2] 4.5 ounces of 80 proof, or 15 ounces of wine.
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Alcohol and Hepatitis C
Alcohol use should be avoided (Class 2a Level B)– > 50 grams* per day clearly increases HCV-fibrosis progression
–Alcohol consumption > 50 grams* per day appears to increase HCV RNA level[2]
Males 30 gms per day
Females 20 gms per day
Clean and/or sober at least 6 months
* 50 grams of alcohol is approximately 48 ounces of beer,
[2] 4.5 ounces of 80 proof, or 15 ounces of wine.
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Alcohol & Cirrhosis
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(2017, April 24). Retrieved from: http://www.hepatitisc.uw.edu/go/evaluation-staging-monitoring/natural-history/core-concept/all
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Hepatitis can be CURED!!!!!
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Goals in Treating Hepatitis CVirologic Cure!!!!!!
Defined as SVR after HCV treatment
Finally possible with newer therapies!!!!!
****Patients with advanced fibrosis or cirrhosis need life long monitoring even after treatment (Shiffman 2009)****SVRhttp://www.inpractice.com/Textbooks/Hepatology/ch8_Mgmt_of_Hep_C_Infection/References/Shiffman%202009?view=token
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Targeted treatments work in the cell
RAPSILBER 2018 DO NOT REPRODUCE WITHOUT PERMISSIONIllustration courtesy of Alison Jazwinski, MD.
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What is a Cure?
Cure, also known as sustained virologic response (SVR), is defined as no detectable HCV in the blood at least 12 weeks after completion of therapy
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Initial Work-up: Lab
CBC with differential
Hepatic panel
Chemistry Panel
Thyroid studies
Pregnancy test
Screen: alcohol, drug use, depression
PT/INR
HIV
Hepatitis A Total AB
Hepatitis B core AB
Hepatitis B surface AG
Hepatitis B surface AB◦ Vaccinate
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Liver Biopsy
Fallen out of favor!
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Non-invasive measures of fibrosis: Now Recommended
◦FibroScan◦FibroTest◦Fibrosure◦APRI score◦Transient elastography
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Fibrosis Stage (FibroTest)
F0 - No fibrosis 0.00 - 0.21
F0 - F1 0.21 - 0.27
F1 - Portal fibrosis 0.27 - 0.31
F1 - F2 0.31 - 0.48
F2 - Bridging fibrosis with few septa 0.48 - 0.58
F3 - Bridging fibrosis with many septa 0.58 - 0.72
F3 - F4 0.72 - 0.74
F4 - Cirrhosis 0.74 - 1.00
Activity Grade (ActiTest)
A0 - No activity 0.00 - 0.17
A0 - A1 0.17 - 0.29
A1 - Minimal activity 0.29 - 0.36
A1 - A2 0.36 - 0.52
A2 - Moderate activity 0.52 - 0.60
A2 - A3 0.60 - 0.63
A3 - Severe activity 0.63 - 1.00
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Lab Corp. (2017, April 22). Retrieved from: http://www.hemophilia.co.il/documents/Fibrotest.pdf
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Apri Score
AST level
-----------------
APRI= ALT level X 100
_______________________
Platelet Count
76% sensitivity/ 72% specificity for predicting cirrhosis
(2017, April, 23). Retrieved from: http://www.hepatitisc.uw.edu/page/clinical-calculators/apri
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Shear Wave Elastography
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https://iame.com/online/breast_elastography/content.php
http://www.usa.philips.com/healthcare/resources/feature-detail/shear-wave-elastography
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What is Current Today?
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Treat Now
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Where we came from…….
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HCV Treatment Has Evolved Over Time
1. Chen CH, Yu ML. Hepat Res Treat. 2010;2010:140953. 2. Franciscus A. HCV Advocate site. March 2012. 3. Lawitz E, et al. N Engl J Med. 2013;368(20):1878-1887. 4. Ferenci P, et al. N Engl J Med. 2014;370(21):1983-1992. 5. Afdhal N, et al. N Engl J Med. 2014;370(20):1889-1898. 6. Feld JJ, et al. N Engl J Med. 2015;373 (27):2599-2607. 7. Foster GR, et al. N Engl J Med. 2015;373(27):2608-2617. 8. US Department of Health and Human Services, Center for Drug Evaluation and Research. Guidance for Industry. Chronic Hepatitis C Virus Infection: Developing Direct-Acting Antiviral Drugs for Treatment. November 2017.
First DAAs
approved1998 Ribavirin (plus IFN)
approved
1991 IFN approved
2011
2001Pegylated interferon
approved
~55% SVR1,2
PEG-IFN+RBV
66%-86% SVR2
PEG-IFN+RBV+PI~40% SVR1,2
~20% SVR1,2
• Scientific advances have led to all-oral, fixed-dose daily HCV regimens,
which are shorter (average of 12 weeks) and more effective8
• Cure, also known as sustained virologic response (SVR), is defined as no
detectable HCV in the blood at least 12 weeks after completion of therapy8
IFN, interferon; PEG-IFN, pegylated interferon; PI, protease inhibitor; RBV, ribavirin.
1990 1995 2000 2005 2010 2015
82
2013
-Present
All-oral
DAA agents
approved
≥90% SVR3-7
How Far Are We?
One Size . . . . . . Fits All?
Same treatment regardless of
fibrosis Same treatment regardless of
fibrosis level, previous treatment experience, or HCV
genotype?
Slide credit: clinicaloptions.com
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What are the treatment recommendations?GENOTYPE 1
Harvoni
Epclusa
Zepatier
Olysio & Sovaldi
Veikera
Mavyret
GENOTYPE 2
Sovaldi & Ribavirin
EPCLUSA
Mavyret
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(2017, April 23). Retrieved from: http://hepc.liverfoundation.org/treatment/the-basics-about-hepatitis-c-treatment/medication-regimens-according-to-genotype/
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What are the treatment recommendations?GENOTYPE 1
Harvoni
Epclusa
Zepatier
Olysio & Sovaldi
Veikera
Mavyret
GENOTYPE 2
Sovaldi & Ribavirin
EPCLUSA
Mavyret
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http://hepc.liverfoundation.org/treatment/the-basics-about-hepatitis-c-treatment/medication-regimens-according-to-genotype/
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What are the treatment recommendations?GENOTYPE 3
Daklinza & Sovaldi
EPCLUSA
Sovaldi & Ribavirin
Mavyret
Cost: $90K on average
GENOTYPE 4,5,6
Technivie (4)
EPCLUSA
Zepatier
Mavyret
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http://hepc.liverfoundation.org/treatment/the-basics-about-hepatitis-c-treatment/medication-regimens-according-to-genotype/
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What are the treatment recommendations?GENOTYPE 3
Daklinza & Sovaldi
EPCLUSA
Sovaldi & Ribavirin
Mavyret
GENOTYPE 4,5,6
Technivie (4)
EPCLUSA
Zepatier
Mavyret
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http://hepc.liverfoundation.org/treatment/the-basics-about-hepatitis-c-treatment/medication-regimens-according-to-genotype/
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What are the treatment recommendations?PANGENOTYPIC
EPCLUSA
12 weeks
1 pill once a day
Treating Heartburn
Renal Insufficiency
OPTIONS
Mavyret
8 weeks
3 pills once a day
Birth control
Renal insufficiency
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Response rates and side effectsRESPONSE RATES ARE 95-100% EVEN IN CIRRHOTIC PATIENTS!
Side effects are minimal as the effects of treatment are in the cell not systemic
LESS THAN 16%
Fatigue
Nausea
Diarrhea
Headache
Insomnia
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Who Should Be Treated for HCV Infection?Short answer: everyone
AASLD/IDSA: “the panel continues to recommend treatment for all pts with chronic HCV infection, except those with short life expectancies who cannot be remediated by treating HCV, by transplantation, or by other directed therapy”
RAPSILBER 2018 DO NOT REPRODUCE WITHOUT PERMISSIONSlide credit: clinicaloptions.comAASLD/IDSA. HCV guidance. September 2016.
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What is the treatment process?Assess patient for treatment readiness◦ Compliance◦ Substance abuse / ETOH
Genotype and viral load
Fibrotic score◦ F0-F4◦ cirrhosis
Urine tox screen***
Contraindicated medications
Vaccinate
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What is the treatment process?Prior authorization
Specialty Pharmacy
Foundation support
Coverage overall
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Who should be administering treatment?GI Specialist
Infectious Disease
Primary care◦Low risk
◦Compliant
◦Non-cirrhotic
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Can we reverse the effects of HCV damage on the liver?Achieving cure, or SVR
Lower rates of hepatocellular carcinoma
Improvements in disease complications: ◦ascites
◦hepatic encephalopathy
◦variceal bleeding
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Bruno S et al. Hepatology. 2007;45(3):579-587.Singal AG et al. Clin Gastroenterol Hepatol. 2010;8(3):280-288.e1
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Management of F3-F4 CuresFollowed every 6 months
US
Labs: PT, CMP, CBC
MELD◦Determines morality risk
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MELDDialysis at least twice in the past week
Creatinine: Norm: 0.7 - 1.3 mg/dL
Bilirubin: Norm: 0.3 - 1.9mg/dL
INR: Norm: 1 - 2
Sodium: Norm: 136 – 145 mEq/L
The four MELD levels are:◦ greater than or equal to 25
◦ 24-19
◦ 18-11
◦ less than or equal to 10
No Yes__
_________________
_________________
_________________
_________________
Average MELD for Transplant
26-33
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(2017, April 24). Retrieved from: https://www.mdcalc.com/meld-score-model-end-stage-liver-disease-12-older
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Management of CirrhosisLabs: q3-6 months
US/MRI HCC screening Q6 months
EGD: assess for varices
Alcohol
Vaccination
Hepatic Encephalopathy
Bleeding◦ Thrombosis
Paracentesis for ascites◦ Albumin
◦ SBP
◦ SBP prophylaxis
Weights
Diuretics
Sodium restriction
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Takeaways
Screen
Diagnose
Refer
Treat
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Screen
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Screen1945 – 1965
Ask about blood transfusions
Surgeries◦ GYN
◦ Ortho
Do not miss opportunities to screen
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~
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ScreenRegardless of Liver Enzymes
• Patients can have HCV but have normal LFT results
• Approximately 30% of patients with chronic HCV infection have persistently normal ALT levels
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Healey CJ et al. Gut. 1995;37(2):274-278.Puoti C et al. J Viral Hepat. 2012;19(4):229-235.
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Diagnose
If the Result Is Negative
• It is highly unlikely your patient has been exposed to HCV
• However, if exposure is suspected in the past 6 months, consider re-testing for HCV antibodies or ordering an HCV RNA test
If the Result Is Positive• Your patient has been exposed to HCV
• You will need to confirm a chronic HCV diagnosis with an HCV RNA test
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Diagnose
• The patient has been exposed to HCV but is not chronically infected
• Approximately 20%-50% of patients clear HCV spontaneously
• Such patients do not need further medical evaluation for HCV infection
POSITIVE RESULTS FROM HCV ANTIBODY TEST
• The patient should be referred to an HCV specialist for additional tests and treatment evaluation
• Further testing includes a genotype test and may include a liver biopsy and/or liver ultrasound to determine disease progression
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Refer to a SpecialistNP WELLNESS CARE, LLC
BRINGING TREATMENT TO THE PATIENT
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Always Follow Up25% TO 50% OF HCV PATIENTS MISS THEIR F IRST APPOINTMENT WITH A SPECIALIST
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. Holmberg SD et al. N Engl J Med. 2013;368(20):1859-1861. 2. McGowan CE, Fried MW. Liver Int. 2011;32(suppl 1):151-156.
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Thank you!Questions?LRAPSILBER@OPTONLINE.NET
NPWELLNESSCARE@GMAIL.COM
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