hepatitis c (and aging) martine stomp rn hepatitis c treatment nurse sanguen health centre
TRANSCRIPT
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Hepatitis C (and Aging)
Martine Stomp RNHepatitis C Treatment Nurse
Sanguen Health Centre
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Hepatitis C: History
• 1940’s –Occurrence of hepatitis after transfusion of prison-sourced blood.
• 1950’s –Named “non-A non-B”hepatitis.• 1989 –Hep C virus identified. Specific antibody
tests for Hep C developed.• 1990 –Screening of blood supply in Canada
introduced.• 1995 –Hep C virus is first seen using electron
microscope.
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U.S.A. 4 M
SOUTHAMERICA10 M
AFRICA 32 M
EAST MEDITERRANEAN20M
SOUTH EAST ASIA30 M
AUSTRALIA0.2 M
SOURCE, WHO 1999
WEST EUROPE 9 M
FAR EAST ASIA60 M
170 Million Carriers Worldwide, 3 - 4 MM new cases/year
3% of World Population
HCV: A Global Health Problem
CANADA 300,000
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Hepatitis C in Canada
• Estimated 300,000 HCV infections in Canada
• 110,000 in Ontario (1 in 170 people)
• 5,000 in Waterloo/Wellington
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Risk Factors for HCV
• IDU• Travel to/residence in endemic countries• Sharing equipment for inhalation drug use• Tattooing/ body piercing• Sharing personal hygiene items• Street involvement• Incarceration• Sexual/perinatal transmission• Occupational blood exposure• Contaminated blood products
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Distribution of mutually exclusive risk factors for newly-acquired HCV infection among cases with known risk factor information in EHSSS,
2004-2008
PHAC. Epidemiology of Hepatitis C Infection in Canada. Results from the EHSSS. 2008
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Natural History of Hep C
Adapted from Lauer and Walker, NEJM 2001
Healthy Liver
Acute Infection
Chronic Infection
20% Clear the
Virus
80% Virus Continues to Damage
Liver
Only 20% willshow symptomsInitially !
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Natural History Con’t
ChronicHepatitis
Cirrhosis20-30%
LiverCancer
1-4%/year
Most symptoms begin to show only when liver is more severely damaged
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Signs and Symptoms• Individuals may have one or more of the
following symptoms, while others experience no symptoms:
–Tiredness–Nausea–Muscle or joint pain–Trouble sleeping–Loss of appetite
–Weight loss–Abdominal pain–Itchiness–Depression–Dark urine
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Hep C Treatment
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Goals of Therapy
Primary objective =
cure
• No virus1
• Stop progression
(necrosis/fibrosis)
• No symptoms
Secondary objective =
delay/prevent
• Reduce progression of fibrosis1
• Reduce progression to cirrhosis2
• Prevent decompensation
• Prevent HCC2
1. Worman. Hepatitis C: Sourcebook 2002. 2. Peters et al. Medscape HIV/AIDS eJournal. 2002;8(1).
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Therapy for Chronic Hepatitis C before November 2011
• Best results with combination Pegylated IFN plus Ribavirin
• Two pegylated IFN products available: Peginterferon alfa-2a (Pegasys©) Peginterferon alfa-2b (Pegetron©)
• Hep C treatment can be problematic for former users because of the possibly triggering effect of the injections.
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Treatment duration varied according to genotype and mono- or co-infection
24 weeksHCV mono-infected, genotype 2 or 3
48 weeksHCV mono-infected, genotype 1 or 4
48 weeksHIV/HCV co-infected (regardless of genotype)
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Cure Rates before November 2011
HCV Genotype 1: 40-50%HCV Genotype 2: 80-90%HCV Genotype 3: 70-80%HCV Genotype 4: 60-70%
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Since November 2011
Triple therapy for genotype 1:Pegylated Interferon, Ribavirin and a protease inhibitor (Boceprevir/Telaprevir)
Treatment length depends on the following factors:• Previously treated or never treated before• Previous response to treatment ( if previously treated)• Response to current treatment• Amount of liver damage
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Protease Inhibitors
Boceprevir Telaprevir
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Treatment with PI’s
Pros
• More effective• Shorter treatment
duration possible
Cons
• High pill burden• Additional side-
effects
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Additional Issues
• Limited coverage• Not straight forward
(Regimen differences/Algorithms)
• Drug/Drug Interactions• Timing of medications• Adherence/Resistance
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Side-effects
• Fever/Chills• Muscle & Body Aches• Headaches• Fatigue• Depression• Anxiety• Irritability• Insomnia• Dry Mouth/Ulcers
• Bad Taste in Mouth• Poor appetite• Nausea/Vomiting• Diarrhea• Cough• Dry Skin/Rashes• Injection Site Reactions• Ano-rectal discomfort• Anaemia
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Factors Affecting Treatment Response
• HCV genotype 1• High viral load • Increasing fibrosis • Being male • Black race
• Age > 40 years • Insulin resistance• Steatosis• Renal failure• High BMI
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The Aging HCV Patient
• Most of the older adults with chronic hepatitis C virus infection acquired the disease earlier in life
• They often present with complications of liver disease like cirrhosis and HCC
• Chronic infection is prevalent and may be more severe in the elderly population
• Persons <20 years old at time of infection progress very slowly during the subsequent 10 years, whereas for those aged >50 years, fibrosis progression is rapid.
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The Aging HCV Patient Cont’d
• The burden of chronic hepatitis C virus infection in elderly persons is expected to increase significantly during the next 2 decades
• The management of chronic HCV infection in older adults is complex in terms of comorbidities and quality of life.
• Hepatitis C is the leading cause of both liver transplantation and hepatocellular carcinoma (HCC, liver cancer)
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Cognitive Impairment
• Chronic HCV infection is associated with cognitive impairment, which is reported in patients aged 28–69 years with mild liver disease.
• The prevalence of cognitive impairment among older patients may be higher as they might have a higher susceptibility to this complication.
• Because depression, fatigue, and cognitive impairment are common among the general elderly population, they may be overlooked in those with HCV infection or may not attributed to the disease.
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Healthy Aging with HCV
• Cultivate a positive attitude• See your doctor for regular check-ups• Get protection from the flu, pneumonia and hepatitis A
and B. Talk to your doctor or nurse about immunization for these conditions
• Be careful about mixing any drugs especially with alcohol
• Eat a healthy and well-balanced diet• Talk to your doctor or nurse about whether you need
to be treated for hepatitis C
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Healthy Aging with HCV Cont’d
• Keep physically fit. Ask your doctor about an exercise program that is right for you.
• Maintain a healthy diet. Eat a low fat, low cholesterol, low sodium high-fiber diet with lots of fruits and vegetables. Try to lose weight sensibly if it’s advised
• Aim for 7 to 9 hours of sleep every night• Learn to manage stress• Drink generous amounts of water – 6 to 8 glasses a day• Seek support. Join a support group. Maintain friendships and
social contacts• Engage in activities that actively stimulate your brain• Maintain a sense of humor
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Questions?