treatment of hcv - npaihb · “the goal of treatment of hcv-infected persons is to reduce...
TRANSCRIPT
![Page 1: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/1.jpg)
Treatment of HCV
Jorge Mera, MD, FACPDirector, Infectious DiseasesCherokee Nation
![Page 2: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/2.jpg)
¡Rationale and goals for the universal need of HCV treatment
¡Describe FDA approved antivirals used in HCV treatment, their strengths and weaknesses
¡ Interpret decision trees to determine treatment options
OBJECTIVESTreatment
![Page 3: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/3.jpg)
GOAL OF TREATMENT
“The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-
related health adverse consequences, including end-stage liver disease and hepatocellular
carcinoma, by the achievement of virologic cure as evidenced by an SVR”
SVR: sustained virological response hcvguidelines.org
![Page 4: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/4.jpg)
30
20
10
00 1
Non-SVR
SVR
P<.001
2 3 4 5 6 7 8 9 10Time (years)
Perc
ent
All-Cause Mortality
International, multicenter, long-term follow-up study from 5 large tertiary care hospitals in Europe and Canada. Patients with chronic HCV infection started an interferon-based treatment regimen between 1990 and 2003 (n=530).van der Meer AJ, et al. JAMA. 2012;308:2584-2593.
SVR WAS ASSOCIATED WITH REDUCED LONG-TERM RISK OF ALL-CAUSE MORTALITY IN AN
INTERNATIONAL, MULTICENTER STUDY
Treatment
![Page 5: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/5.jpg)
WHY DO WE NEED TO TREAT HCV
¡SVR (cure) of HCV is associated with: •70% Reduction of Liver Cancer•50% Reduction in All-cause Mortality•90% Reduction in Liver Failure
Lok A . N E JM 2012 ; Ghany M. H epa to l 2009 ; V an de r Mee r A J . JA MA 2012
Treatment
![Page 6: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/6.jpg)
767,000
407,000
651,000
63,000
317,000
154,000198,000
31,000
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
Liver-related Death
HCC Decomp. Cirrhosis
Liver Transplants
Dis
ease
Bur
den
(201
5–20
50)
No TreatmentPre-DAA EraDAA Era
6
HCV-ASSOCIATED DISEASE BURDEN (2015–2050)
50–70% reduction in HCV-associated disease burdenChhatwal et al. AASLD 2015 Abstract 104
Treatment
![Page 7: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/7.jpg)
IMPACT OF TREATMENT COMPARED TO OTHER COMMON DISEASES
¡ HCV cirrhosis risk = 40% over 30 years¡ Hepatocellular carcinoma (HCC) risk in HCV
Cirrhosis = 17% over 5 years¡ When we cure 30 patients with HCV we will prevent:
§ 12 cases of HCV related cirrhosis§ 2 case of HCV related HCC
If we treat 104 patients with hypercholesterolemia with statins (For 5 years), we will prevent 1 first time
heart attack and ¾ of a stroke
www.thennt.com
Treatment
![Page 8: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/8.jpg)
Ribavirin
NS4ACore E1 E2 NS2 NS4BNS3 NS5A NS5B
Daclatasvir (DCV)Ledipasvir (LDV)Ombitasvir (OMV)Elbasvir (ELB)Velpatasvir (VEL)Pibrentasvir (PIB)
NS5AReplication Complex Inhibitors
Boceprevir (BOC)Telaprevir (TVR)Simeprevir (SMV)Paritaprevir (PTV)Grazoprevir (GRZ)Glecaprevir (GLE)Voxilaprevir (VOX)
NS3Protease Inhibitors
Protease
DIRECT-ACTING ANTIVIRAL AGENTS (DAA):KEEPING THEM STRAIGHT
Sofosbuvir (SOF)
Dasabuvir(DSV)
NS5BNUC
Inhibitors
NS5BNon-NUC Inhibitors
p7
PolymeraseNon-Enzyme
Target
![Page 9: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/9.jpg)
HCV THERAPIES - DAAS
Medication NS5B NS5A Inh NS3 PI Other
Sovaldi® sofosbuvir
Harvoni® sofosbuvir ledipasvir
Epclusa® sofosbuvir velpatasvir
Zepatier® elbasvir grazoprevir
Viekira Pak® dasabuvir ombitasvir paritaprevir ritonavir
Daklinza® daclatasvir
Olysio® simeprevir
Ribavirin ribavirin
Vosevi® sofosbuvir velpatasvir voxilaprevir
Mavyret® pibrentasvir glecaprevir
![Page 10: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/10.jpg)
¡ NS5B nucleotide inhibitor ¡ Few drug interactions¡ Genotypes 1,2,3,4¡ Contraindicated in
patients with GFR < 30¡ Most common reported SE
§ Headache§ Fatigue (with ribavirin)
¡ Pangenic in combination§ Not used as monotherapy
SOFOSBUVIR (SOVALDI®)
Sovaldi® [package insert]. Gilead Sciences, Foster City, CA
Treatment
SE: Side Effects
![Page 11: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/11.jpg)
¡ Once daily single oral tablet¡ Genotype 1 and 4¡ Minimal DDIs, no food effect¡ 8 week treatment available
§ Naïve/Non cirrhotic/VL < 6 million
¡ Do not use in patients with GFR < 30
¡ Avoid use with anti acids § May use with 20 mg of omeprazole
if necessary
LEDIPASVIR/SOFOSBUVIR(HARVONI®)
LDVNS5A inhibitor
SOF - NS5B nucleotide polymerase inhibitor
Approved: Oct 10, 2014
Harvoni® [package insert]. Gilead Sciences, Foster City, CA
Treatment
DDI: Drug-Drug Interactions
![Page 12: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/12.jpg)
¡ Once daily single oral tablet
¡ Minimal DDIs, no food effect
¡ Genotype 1,2,3,4
¡ Do not co-administer with PPI§ If medically necessary, take Epclusa
with food 4 hours before omeprazole 20 mg
¡ Do not use in patients with GF<30
VELPATASVIR/SOFOSBUVIR(EPCLUSA®)
VELNS5A inhibitor
SOF - NS5B nucleotide polymerase inhibitor
Approved: June 28, 2016
Epclusa® [package insert]. Gilead Sciences, Foster City, CA
Treatment
DDI: Drug-Drug Interactions
![Page 13: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/13.jpg)
¡ Includes 3 direct acting antivirals and ritonavir, triple therapy or PrOD§ Ombitasvir, paritaprevir, dasabuvir
¡ Ritonavir (No HCV activity)§ Used to boost the paritaprevir
¡ Genotype 1 and 4¡ Administer orally twice a day with
food¡ Many pharmacological interactions¡ GT1a requires addition of RBV¡ May use with GFR < 30
OBV/PTV/R AND DSV(VIEKIRA PAK)
VIEKIRA PAK [package insert]. North Chicago, IL: AbbVie Inc. FDA approval Dec 19, 2014
2 tablets of ombitasvir/paritaprevir/ ritonavir (12.5/75/50 mg) combination tablet every am 1 dasabuvir 250 mg tablet every am and pm
Treatment
![Page 14: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/14.jpg)
¡Extended Release§All 3 tablets at the same time§Take with food
Same precautions as Viekira Pak
§Do not split, crush or chew
§Alcohol should not be consumed within 4 hours of taking VIEKIRA XR
OBV/PTV/R AND DSV XR(VIEKIRA XR)
Treatment
![Page 15: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/15.jpg)
¡ NS5A inhibitor ¡ High barrier to resistance¡ Once daily oral tablet
§ In combination with sofosbuvir¡ With or without food¡ Genotype 1,2,3,4¡ May use with antiacids
DACLATASVIR (DAKLINZA)
No DDIs: 60 mg once dailyDDIs with strong CYP3A inhibitors: 30 mg once dailyDDIs with moderate CYP3A inducers: 90 mg once daily
Daklinza [package insert]. Princeton, NJ: Bristol-Myers Squibb Company DDI: Drug-Drug Interaction
Treatment
![Page 16: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/16.jpg)
¡ Genotypes 1 and 4¡ Elbasvir/Grazoprevir
§ NS5A inhibitor - NS3/4A protease inhibitor
¡ Oral and once daily¡ Must perform resistance
testing in genotype 1A§ If resistance present must add Ribavirin and
extend therapy from 12 to 16 weeks
¡ DO NOT use in advanced liver disease (Child Pugh B or C
¡ May use with GFR < 30 ml/min¡ May use in Dialysis¡ May use with PPI
ELBASVIR/GRAZOPREVIRZEPATIER
FDA-approved Jan 28, 2016
Treatment
![Page 17: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/17.jpg)
¡ 55 year old HCV positive male with a hx of IVDU 10 years ago
¡ Genotype 1a¡ VL 2.4 million/ML¡ Treatment naïve¡ Fibrosis Stage F0-F1¡ Labs: GFR of 65 ml/min, Hg 13 Platelets 245¡ Other medical conditions
§ HTN on amlodipine
¡ What are your options?
CLINICAL CASE #1Treatment
![Page 18: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/18.jpg)
![Page 19: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/19.jpg)
Antacids§aluminum hydroxide§magnesium hydroxide
¡Separate administration by four hours
H2RAs§ famotidine§ ranitidine
¡Administer concurrently or 12 hours apart
¡Not to exceed doses >40 mg famotidine twice daily
SOFOSBUVIR/LEDIPASVIR (HARVONI)
AND ACID SUPPRESSING AGENTS
Harvoni® [package insert]. Gilead Sciences, Foster City, CA
Treatment
![Page 20: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/20.jpg)
¡Consider discontinuation of acid suppression therapy if patient is able to tolerate¡ Reduce PPI by 50% per week to lowest dose, then
discontinue to minimize rebound acid hypersecretion
¡If you have to use a PPI and Harvoni is the best option ¡Administer simultaneously on an empty stomach§Only doses < omeprazole 20 mg§Pantoprazole mg ≠ omeprazole mg
SOFOSBUVIR/LEDIPASVIR (HARVONI)
AND PROTON PUMP INHIBITORS
Harvoni® [package insert]. Gilead Sciences, Foster City, CA
Treatment
![Page 21: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/21.jpg)
Treatment
![Page 22: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/22.jpg)
¡ 65 year old HCV positive female with a hx of a post partum blood transfusion 40 years ago
¡ Genotype 1a¡ VL 8.8million/ML¡ Treatment naïve
§ Fibrosis Stage F3-F4§ No history of
§ Esophageal varices/ encephalopathy or ascitis
§ Labs: GFR of 28 ml/min, Hg 13 Platelets 109§ Other medical conditions
§ Barrett's esophagus (on omeprazole 40 mg once a day)
¡ What are your options?
CLINICAL CASE # 2Treatment
![Page 23: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/23.jpg)
![Page 24: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/24.jpg)
¡ Genotypes 1 and 4¡ Elbasvir/Grazoprevir
§ NS5A inhibitor - NS3/4A protease inhibitor
¡ Oral and once daily w or wo food¡ Must perform resistance
testing in genotype 1A§ If resistance present must add Ribavirin and
extend therapy from 12 to 16 weeks
¡ DO NOT use in advanced liver disease (Child Pugh B or C
¡ May use with GFR < 30 ml/min¡ May use in Dialysis¡ May use with PPI
ELBASVIR/GRAZOPREVIRZEPATIER
FDA-approved Jan 28, 2016
Treatment
![Page 25: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/25.jpg)
¡ 73 year old HCV positive male with no risk factors§ Genotype 2§ VL 3.4 million/ML§ Treatment naïve§ Fibrosis Stage F3-F4§ History of ascites§ Labs: GFR of 69 ml/min, Hg 13.4, Platelets 88§ Other medical conditions
§ Prediabetes/40 pack/year smoking/HTN on amlodipine Hypercholesteremia on atorvastatin
¡ What are your options?
CLINICAL CASE # 3Treatment
![Page 26: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/26.jpg)
Do I need any workup before I start Ribavirin?What are his Drug - Drug Interactions with Epclusa?
![Page 27: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/27.jpg)
¡ Once Daily Single Oral Tablet¡ Minimal DDIs, no food effect¡ Genotype 1,2,3,4¡ Do not co-administer with PPI
§ If medically necessary, take Epclusawith food 4 hours before omeprazole 20 mg andOnly doses < omeprazole 20 mg
¡ Do not use in patients with GFR < 30
VELPATASVIR/SOFOSBUVIR(EPCLUSA®)
VELNS5A inhibitor
SOF - NS5B nucleotide polymerase inhibitor
Approved: June 28, 2016
Epclusa® [package insert]. Gilead Sciences, Foster City, CA
Treatment
![Page 28: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/28.jpg)
SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR(VOSEVI®)
¡ 400mg/100mg/100mg tablet§ One tablet daily with food
¡ sofosbuvir§ NS5B polymerase inhibitor
¡ velpatasvir§ NS5A Inhibitor
¡ voxilaprevir§ NS3/4A protease inhibitor
¡Pan-genotypic§ genotypes 1,2,3,4,5,6
¡Approved for treatment failures¡ FDA approved on July 20, 2017Vosevi® [package insert]. Gilead Sciences, Foster City, CA
![Page 29: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/29.jpg)
SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR -TREATMENT FAILURES
Genotype Previous Regimen Included
Duration of Treatment
1, 2, 3, 4, 5, 6 NS5SA inhibitor1 12 weeks
1a, 3 Sofosbuvir without NS5A inhibitor2
12 weeks
1—NS5A medications included in clinical trials: daclatasvir, elbasvir, ledipasvir, ombitasvir, or velpatasvir2—Regimen tested in clinical trials inlcuded sofosbuvir with or without any of the following: peginterferonalfa/ribavirin, ribavirin, NS3/4A protease inhibitor (boceprevir, simeprevir or telaprevir). Additional benefit of VOSEVI over sofosbuvir/velpatasvir was not shown in adults with genotype 1b, 2, 4, 5, or 6 infection previously treated with sofosbuvir without an NS5A inhibitor.
Vosevi® [package insert]. Gilead Sciences, Foster City, CA
![Page 30: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/30.jpg)
SOFOSBUVIR/VELPATASVIR/VOXILAPREVIR -PRECAUTIONS
¡ Not recommended in patients with moderate or severe hepatic impairment (Child-Pugh B or C)§ Due to higher exposure to protease inhibitor voxilaprevir
¡ Bilirubin increased ≤ 1.5 x ULN in ~10% of patients in clinical studies§ No jaundice§ Levels decreased after completing treatment
Vosevi® [package insert]. Gilead Sciences, Foster City, CA
![Page 31: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/31.jpg)
GLECAPREVIR/PIBRENTASVIR(MAVYRET®)
¡100mg/40mg tablet§ Take 3 tablets once daily with food
¡glecaprevir§ NS3/4A protease inhibitor
¡pibrentasvir§ NS5A inhibitor
¡Pan-genotypic§ Genotypes 1,2,3,4,5,6
¡Approved for some treatment failures¡No dosage adjustment in patients with mild,
moderate, or severe renal impairment, including dialysis
• FDA Approval August 3, 2017
Mavyret® [package insert]. North Chicago, IL: AbbVie Inc.
![Page 32: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/32.jpg)
GLECAPREVIR/PIBRENTASVIR - TREATMENT NAÏVE
¡All genotypes (no cirrhosis)§8 weeks
¡All genotypes (with cirrhosis - Child-Pugh A)§12 weeks
![Page 33: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/33.jpg)
GLECAPREVIR/PIBRENTASVIR - TREATMENT EXPERIENCED
Genotype Previous Treatment Treatment Duration(No Cirrhosis)
Treatment DurationCompensated
Cirrhosis (Child-Pugh A)
1 NS5A inhibitor1 withoutprior treatment with
NS3/4A protease inhibitor
16 weeks 16 weeks
NS3/4A protease inhibitor2 without prior treatment with NS5A
inhibitor
12 weeks 12 weeks
1,2,4,5,6 PRS3 8 weeks 12 weeks
3 PRS3 16 weeks 16 weeks
1 – In clinical trials, subjects were treated with ledipasvir/sofosbuvir or daclatasvir +interferon+ribavirin2 – In clinical trials, subjects were treated with simeprevir+sofosbuvir, or simeprevir, boceprevir, or telaprevir with interferon+ribavirin3 – Prior treatment experience with interferon, ribavirin, and/or sofosbuvir, but no prior experience with NS3/4A protease inhibitor or NS5A inhibitor
Mavyret® [package insert]. North Chicago, IL: AbbVie Inc.
![Page 34: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/34.jpg)
GLECAPREVIR/PIBRENTASVIR ADVERSE EFFECTS AND CAUTIONS
¡Most common adverse effects (~10%)¡Headache¡Fatigue¡Child-Pugh B¡Not Recommended¡Contraindicated in Child-Pugh C¡No additional monitoring parameters provided
in package insert
![Page 35: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/35.jpg)
GLECAPREVIR/PIBRENTASVIR - DRUG INTERACTIONS
¡ Glecaprevir is inhibitor of P-gp§ May increase concentration of drugs that are
substrates§ Digoxin, dabigatran
¡ Ethinyl estradiol-containing products§ Coadministration of Mavyret may increase the risk
of ALT elevations and is not recommended¡ Inducers of P-gp/CYP3A decrease plasma
concentrations§ rifampin, carbamazepine, efavirenz, St. John’s Wort
¡ HIV medications – see package insert
Mavyret® [package insert]. North Chicago, IL: AbbVie Inc.
![Page 36: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/36.jpg)
GLECAPREVIR/PIBRENTASVIR - DRUG INTERACTIONS
¡ HMG-CoA Reductase Inhibitors§ Levels of statin drugs are increased; doses should be
adjusted per package insert
¡ Omeprazole§ Package insert states no dose adjustments required
§ 40mg daily is highest dose studied§ 20mg: Coadminister with GLE/PIB § 40mg: Give one hour before GLE/PIB
¡ No interaction with antacids or H2 blockers
Mavyret® [package insert]. North Chicago, IL: AbbVie Inc.
![Page 37: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/37.jpg)
¡ Administration§ Weight-based dosing (Twice daily)
§ 1000 mg if > 75 kg§ 1200 mg if ≥ 75 kg
§ Take evening dose (8 hours apart) in the afternoon to keep from disturbing sleep
¡ Pregnancy category X§ Contraindicated in pregnant women or male partners of pregnant
women§ Use 2 effective forms of contraception during treatment and for at
least 6 months after completion of therapy (both male and female patients)
RIBAVIRIN (RBV)
LexiComp
Treatment
![Page 38: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/38.jpg)
¡ Adverse Events§ Headache§ Fatigue§ Nausea§ Insomnia§ Depression
¡ Lab abnormalities:§ Hemolytic anemia
§ Decrease ribavirin dose by 200 mg daily for a 2g or more drop in HgB
¡ Monitoring RBV§ CBC & CMP§ At baseline, weeks 2 and
4, as clinically indicated§ TSH at week 12§ Preexisting cardiac issue
¡ Ophthalmic exam§ Preexisting opthalmic
disorders¡ HCG
§ At baseline§ Monthly during treatment
and for 6 months after treatment
RIBAVIRIN Treatment
![Page 39: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/39.jpg)
WHO TO TREAT, AND WHEN?WHO TO PRIORITIZE?
¡ Who to treat?§ All patients with chronic HCV should be treated, unless:
§ Life expectancy is < 1 year that cannot be remediated by treating HCV or liver transplantation (AASLD)
§ Uncontrolled comorbidities that can cause HCV treatment discontinuation (Dr. Mera’s Opinion)
¡ When to Prioritize§ Limited resources for medication procurement§ Limited clinical capacity to treat
Treatment
![Page 40: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/40.jpg)
¡ Prioritize treatment only if limited by clinical capacity§ Decompensated cirrhotic§ Non decompensated cirrhotic first, then F3, F2, F0-F1§ HCV related nephropathy/vasculitis§ PWID
WHO TO PRIORITIZE
AASLD/ IDSA HCV Guidelines
Highest Priority for Treatment Owing to Highest Risk for Severe Complications
Strength of Recommendation
Advanced fibrosis (Metavir F3 or F4) Class I, Level A
Organ transplant Class I, Level B
Type 2 or 3 essential mixed cryoglobulinemia with endo organ manifestations (vasculitis)
Class I, Level B
Proteinuria, nephrotic syndrome, or MPGN Class IIa, Level B
Dr. Mera’s Opinion
Treatment
![Page 41: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/41.jpg)
SPECIAL TREATMENT CONSIDERATIONS
![Page 42: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/42.jpg)
¡ Most anti convulsants are contraindicated§ Due to decreased antiviral levels
¡ Regimens with protease inhibitors tend to have more drug interactions§ PrOD (Viekira Pak) (has 2 PI), Simeprevir (Olysio)
elbasvir/grazoprevir (zepatier). glecaprevir/pibrentasvir (Mavyret) Sofosbuvir/velpatasvir/voxilaprevir (Vosevi)
¡ Daclatasvir (Daklinza) has numerous DDI and may need dose adjustment
¡ Sofosbuvir/velpatasvir (Epclusa) and sofosbuvir/ledipasvir(Harvoni)
§ Decreased absorption with anti acids specially Proton Pump Inhibitors
SPECIAL TREATMENT CONSIDERATIONSDRUG-DRUG INTERACTIONS
Treatment
![Page 43: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/43.jpg)
¡Renal Impairment: § elbasvir/grazoprevir (Zepatier) and glecaprevir/pibrentasvir
(Mavyret) is approved in ESRD and dialysis§ PrOD (Viekira Pak) is approved with CrCl <30
¡ Hepatic Impairment (Child Pugh B/C): § PrOD (Viekira Pak) (has 2 PI), Simeprevir (Olysio)
elbasvir/grazoprevir (zepatier) glecaprevir/pibrentasvir(Mavyret) and Sofosbuvir/velpatasvir/voxilaprevir (Vosevi)are contraindicated
§ May require addition of ribavirin or treatment extension
SPECIAL TREATMENT CONSIDERATIONSRENAL AND HEPATIC IMPAIRMENT
Treatment
![Page 44: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/44.jpg)
¡ Genotype 1a
§ Will require Ribavirin if PrOD (Viekira Pak) is used§ May treat for 8 weeks with sofosbuvir/ledipasvir
(Harvoni) if viral load is < 6 million, treatmente naïve and non cirrhotic
§ If elbasvir/grazoprevir (zepatier) is used resistance testing needed
§ Glecaprevir/pibrentasvir (Mavyret) recently approved. § 8 week treatment for patients without cirrhosis.
¡ Genotype 2 and 3§ Sofosbuvir/velpatasvir (Epclusa) is first line therapy but PPI
use and low GFR are a problem,§ Glecaprevir/pibrentasvir (Mavyret) recently approved
SPECIAL TREATMENT CONSIDERATIONSGENOTYPES
Treatment
![Page 45: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/45.jpg)
SPECIAL TREATMENT CONSIDERATIONSHEPATITIS B STATUS
Treatment
![Page 46: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/46.jpg)
¡ Genotype¡ Viral load for GT1a (< 6 million ?)¡ Liver Fibrosis Staging
§ Cirrhosis vs no Cirrhosis§ If Cirrhotic
§ Compensated vs Decompensated
¡ Previous treatment status ¡ Kidney function
§ CrCl < or > 30 § Dialysis
¡ Drug interaction check§ Anti seizure meds, PPI, etc.
¡ Check Hepatitis B status to monitor reactivation
SUMMARY:WHAT DO YOU NEED TO KNOW TO SELECT
THE BEST TREATMENT OPTION
Treatment
![Page 47: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/47.jpg)
WHAT NOW?
Join the ECHO Community and start Paving the Road to HCV Elimination in Native America
![Page 48: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/48.jpg)
TELEMEDICINE IMPROVES ACCESSBY USING TECHNOLOGY TO BRIDGE DISTANCE
Specialist
Primary Care Clinician OR Patient
Treatment
![Page 49: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/49.jpg)
THE ECHO MODEL IMPROVESCAPACITY AND ACCESS SIMULTANEOUSLY
Treatment
![Page 50: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/50.jpg)
50
Treatment
MOVING KNOWLEDGE INSTEAD OF PATIENTS
![Page 51: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/51.jpg)
Treatment SHARING EVIDENCE BASED BEST MEDICAL PRACTICES
![Page 52: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/52.jpg)
• Professional interaction with colleagues with similar interest‒ Less isolation with improved recruitment and retention
• A mix of work and learning • Obtain HCV certification • Access to specialty consultation with GI, hepatology,
psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator
Benefits to Rural CliniciansTreatment
![Page 53: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/53.jpg)
¡ Quality and Safety¡ Rapid Learning and best-practice dissemination¡ Reduce variations in care¡ Access for Rural and Underserved Patients, reduced
disparities¡ Workforce Training and Force Multiplier¡ De-monopolize Knowledge¡ Improving Professional Satisfaction/Retention ¡ Supporting the Medical Home Model¡ Cost Effective Care- Avoid Excessive Testing and Travel¡ Prevent Cost of Untreated Disease (e.g.: liver transplant or
dialysis)¡ Integration of Public Health into treatment paradigm
Benefits of ECHO® model to Health System
Treatment
![Page 54: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/54.jpg)
CNHS HCV PROGRAM: CLINICAL CAPACITY EXPANSION* 1/2014 – 6/2017
10 8 7
68 7149 47 42
70 64 5538 45 38
10 18 25
93
164
213
260
302
372
436
491
529
574
612
0
100
200
300
400
500
600
700
Jan - Mar 2014
Apr - Jun 2014
Jul - Sep 2014
Oct - Dec 2014
Jan - Mar 2015
Apr - Jun 2015
Jul - Sep 2015
Oct - Dec 2015
Jan - Mar 2016
Apr - Jun 2016
Jul - Sep 2016
Oct - Dec 2016
Jan - Mar 2017
April - Jun
Quarterly
Cumulative
HCV ProjectECHOIntroduced
HCV EliminationStarted
1 Specialist2 Physicians2 APRN2 Pharmacists
7
1 Specialist6 Physicians5 APRN8 Pharmacists
201 Specialist
Num
ber o
f Pat
ient
s Tr
eate
d
*preliminary data
![Page 55: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/55.jpg)
¡http://www.hcvguidelines.org/
¡http://www.hepatitisc.uw.edu/§On-line curriculum on liver disease and HCV, includes clinical studies, clinical calculators, slide lectures
¡ECHO guidelines
HELPFUL RESOURCES
![Page 56: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/56.jpg)
1 . “ H C V E p i d e m i o l o g y i n t h e U n i t e d S t a t e s . ” H e p a t i t i s C o n l i n e . U n i v e r s i t y o f W a s h i n g t o n . h t t p : / / w w w . h e p a t i t i s c . u w . e d u / . A c c e s s e d 1 0 A p r i l 2 0 1 6 .
2 . C e n t e r s f o r D i s e a s e C o n t r o l a n d P r e v e n t i o n ( C D C ) . ” P e o p l e B o r n 1 9 4 5 - 1 9 6 5 & H e p a t i t i s C ” . 3 1 M a y , 2 0 1 5 W e b . A c c e s s e d 1 0 A p r i l 2 0 1 6 .
3 . W o r l d H e a l t h O r g a n i z a t i o n ( W H O ) . “ H e p a t i t i s C ” M e d i a C e n t r e , F a c t S h e e t # 1 6 4 , J u l y 2 0 1 5 , W e b . A c c e s s e d 1 0 A p r i l 2 0 1 6 .
4 . H C V G u i d a n c e : R e c o m m e n d a t i o n s f o r T e s t i n g , M a n a g i n g , a n d T r e a t i n g H e p a t i t i s C . h t t p : / / h c v g u i d e l i n e s . o r g
5 . M a y l i n S , e t a l . E r a d i c a t i o n o f h e p a t i t i s C v i r u s i n p a t i e n t s s u c c e s s f u l l y t r e a t e d f o r c h r o n i c h e p a t i t i s C . G a s t r o e n t e r o l o g y . 2 0 0 8 ; 1 3 5 ( 3 ) : 8 2 1 - 8 2 9
6 . S i n g a l A G , e t a l . A S u s t a i n e d V i r a l R e s p o n s e I s A s s o c i a t e d W i t h R e d u c e d L i v e r - R e l a t e d M o r b i d i t y a n d M o r t a l i t y i n P a t i e n t s W i t h H e p a t i t i s C V i r u s . C l i n i c a l G a s t r o e n t e r o l o g y a n d H e p a t o l o g y . 2 0 1 0 ; 8 ( 3 ) : 2 8 0 - 2 8 8
7 . M o r g a n T R , e t a l . O u t c o m e o f S u s t a i n e d V i r o l o g i c a l R e s p o n d e r s w i t h H i s t o l o g i c a l l y A d v a n c e d C h r o n i c H e p a t i t i s C . H e p a t o l o g y . 2 0 1 0 ; 5 2 ( 3 ) : 8 3 3 - 8 4 4
8 . K w o n g A D , e t a l . C u r r e n t O p i n P h a r m a c o l o g y . 2 0 0 8 ; 8 ( 5 ) : S 2 2 - 3 1¡ L y K N , e t a l . R i s i n g m o r t a l i t y a s s o c i a t e d w i t h h e p a t i t i s C v i r u s i n t h e U n i t e d S t a t e s , 2 0 0 3 – 2 0 1 3 .
C l i n i c a l I n f e c t i o u s D i s e a s e s B r i e f R e p o r t . P u b l i s h e d 1 7 M a r c h 2 0 1 6 . 1 . S o v a l d i ® [ p a c k a g e i n s e r t ] . G i l e a d S c i e n c e s , F o s t e r C i t y , C A2 . H a r v o n i ® [ p a c k a g e i n s e r t ] . G i l e a d S c i e n c e s , F o s t e r C i t y , C A3 . V i k e i r a P a k [ p a c k a g e i n s e r t ] . N o r t h C h i c a g o , I L : A b b V i e I n c .4 . D a k l i n z a [ p a c k a g e i n s e r t ] . P r i n c e t o n , N J : B r i s t o l - M y e r s S q u i b b C o m p a n y5 . L e x i c o m p O n l i n e , H u d s o n , O h i o : L e x i - C o m p , I n c . ; 2 0 1 6 ; A c c e s s e d 1 J a n u a r y 2 0 1 6 .6 . N A T A P C o n f e r e n c e R e p o r t . h t t p : / / w w w . n a t a p . o r g / 2 0 1 5 / A A S L D / A A S L D _ 1 6 8 . h t m . A c c e s s e d 1 7 J a n u a r y
2 0 1 6 .7 . P r o j e c t E C H O . U n i v e r s i t y o f N e w M e x i c o . h t t p : / / e c h o . u n m . e d u /8 . T h e N N T . S t a t i n D r u g s G i v e n f o r F i v e Y e a r s f o r H e a r t D i s e a s e P r e v e n t i o n .
h t t p : / / w w w . t h e n n t . c o m / n n t / s t a t i n s - f o r - h e a r t - d i s e a s e - p r e v e n t i o n - w i t h o u t - p r i o r - h e a r t - d i s e a s e / . A c c e s s e d 1 7 J a n u a r y 2 0 1 6 .
REFERENCES
![Page 57: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/57.jpg)
![Page 58: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/58.jpg)
ECHO DECISION TREES
![Page 59: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/59.jpg)
![Page 60: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/60.jpg)
![Page 61: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/61.jpg)
![Page 62: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/62.jpg)
![Page 63: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/63.jpg)
![Page 64: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/64.jpg)
![Page 65: Treatment of HCV - NPAIHB · “The goal of treatment of HCV-infected persons is to reduce all-cause mortalityand liver-related health adverse consequences, including end-stage liver](https://reader036.vdocument.in/reader036/viewer/2022070720/5ee10cdbad6a402d666c12bd/html5/thumbnails/65.jpg)