Hepatitis C Updated Treatment Protocol

By:-

Sayed Hanzal Ass. Lecturer of Hepatogastroenterology

fayoum univ.

5 Questions …..???

1) Why should we treat HCV ?2) Endpoint of therapy ??3) Drugs available and it’s mech. ???4) Egyptian guidelines for HCV ttt ?????

Amazing patient’s questions

Why should we treat HCV ?80 million people are chronically infected worldwide (3%)

More then 350 000-500 000 people die every year from Hepatitis C related end-stage liver disease (cirrhoses, HCC,

liver failure)

3-4 million people become infected with HCV annually

HCV in Egypt• Prevalence : 7%• Total number of cases: 6 million• Number of patients aware of infection:

1million• Number of yearly new diagnosed cases :

120,000• Newly yearly infected cases:

120,000 – 150,000

• Number of yearly liver cancer cases caused by HCV : 16,000

Endpoint of therapy

• undetectable HCV RNA 12 weeks (SVR12) and 24 weeks (SVR24) after the end of treatment

Drugs available and there mech. ????

HCV Life Cycle and DAA Targets

Adapted from Manns MP, et al. 2007

Transportand release

(+) RNA

Translation andpolyprotein processing RNA replication

Virionassembly

NS3/4A protease inhibitors

NS5B polymerase inhibitors

NS5A inhibitors

“Previr’s” Boceprevir, Telaprevir, Simeprevir, Faldaprevir

“Buvir’s” Sofosbuvir, Deleobuvir

“Asvir’s” Daclatasvir, Ledipasvir

DAA

Uncoating

Receptor binding

Egyptian guidelines for HCV ttt ?????

• All PCR +ve , ≥ 18 years except 1. Child C2. Plt < 503. HCC, except 6 months after cure with no

evidence of activity by dynamic (CT or MRI).4. Extra-hepatic malignancy except after two years

of disease-free interval except lymphomas5. Pregnancy6. (HbA1c>9 %)

Prvious ttt with DAAs

naive

easy difficult

experienced

Sof +dac Sof +sim

DAAs naïve (12Ws)

Easy to treat group:

• Treatment naïve • Total s. bil ≤ 1.2 mg/dl. • S. albumin ≥ 3.5 g/dl. • INR≤ 1.2. • Platelet ≥150.000/mm3.

Difficult to treat group:

• Peg-IFN ttt experienced • Total s. bil >1.2 mg/dl. • S. albumin <3.5 g/dl. • INR>1.2. • Platelet <150.000/mm3.

SOF/DAC orQurevo/RBV SOF/DAC/RBV

DAAs experience (12Ws)RBV ineligible: extend (24 Ws)

• SOF/Qurevo/RBV ORSOF/SIM/DAC/RBV

• Child’s B (specialized centers)

SOF/DAC/RBV for 24Ws.

• SOF/DAC/RBV

SOF/DAC FailureSOF/SIM Failure

Ribavirin dose : 1000 mg <75 kg. 1200 mg >75 kg

CKD according to eGFR

• eGFR > 30 ml/min

by the usual ttt regimens

• eGFR ≤ 30 ml/min

Qurevo/RBVIn the conition that

Child A or no cirrhosisHb at least 10 g/dLno uncont. co-morbidityA nephrologist consult

post organ transplantation

SOF/DAC/RBV for 24Ws

Combined HCV and HBV

• treated with the same regimens

If HBV replicates at significant levels before, during or after HCV clearance,

concurrent HBV therapy is indicated.

Amazing patient’s questions

• Did hcv reach my liver• Does hcv affect liver only • Does ttt curative or suppresive to the virus• What about relapse • Are there follow up after end of ttt (if there ,whome

and how) • possibilty of Re-infection • What about hcv antibodies (presence ,

risk ,clearance )