what every pcp needs to know about hepatitis c_dr. paul pinto
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What every PCP should know about Hepatitis CTRANSCRIPT
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Hepatitis-CWhat to Know in 2014
Clinical Presenter: Paul C. Pinto, MD
Southern Colorado GI Health and Wellness Summit & CME Event – February 22nd, 2014
Why should I care about Hepatitis C?
Hepatitis C affects 3 million Americans
It accounts for 40% of chronic liver disease in the US
HCV-cirrhosis is the leading indication for liver transplantation
It disproportionately affects African-Americans and Latinos
We CAN cure this infection in most individuals
We will be caring for more patients cured of the infection who have advanced fibrosis-they still need us!
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
Most persons infected with Hepatitis C are Baby Boomers
75% of those infected were born between 1945 and 1965
Persons with these years of birth should be screened once for hepatitis C with an HCV-antibody test regardless of risk factors
Continue to screen high risk individuals
A positive antibody test usually means chronic infection
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
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Natural history of Hepatitis C progression
100 infections--80% (80) become chronic
25% of the 80 (20) will develop cirrhosis (tell them this)
5 will require transplant or die from liver disease
Cirrhosis may not end life due to death from other causes
Most who spontaneously clear infection do so early, leaving them with little liver damage
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
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How to test for Hepatitis C
ELISA or other test for antibodies against Hepatitis C• Antibody Positive---> Perform HCV-
RNA• Antibody Negative---> No further
testing required(caveat: a negative antibody test can miss acute infection)
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
What to tell a patient who is both antibody and RNA positive
Chronic infection is likely, and it will not resolve spontaneously (< 1%)
Blood is infectious; take steps to prevent transmission
Tell them the infection is curable in most persons
Help them remain positive-discuss steps to stay healthy
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
Advice and education for the Hepatitis C-infected individual
Limit alcohol consumption-it is synergistic with hepatitis C
Achieve normal body weight and control diabetes
Limit marijuana use-it worsens hepatic fibrosis
Stop smoking-it increases risk of liver cancer
Get a HIV test done – co-infection worsens hepatitis C outcomes
Get vaccinated against hepatitis A and B
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology Associates, PC
Commonly used medications-The relationship to Hepatitis C
Acetaminophen limit to 2,000 mg per day
NSAIDs - avoid in advanced liver disease idiosyncratic hepatotoxicity (uncommon) renal dysfunction (common)
Statins - Acceptable in patients with compensated cirrhosis, and stable liver disease-may improve response to antivirals
Opiates and sedative-hypnotics Do not worsen liver disease, but their clearance is slowed
by liver disease-start with lower dose, increase slowly
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology Associates, PC
Antiviral treatment of Hepatitis C-Historical perspective
Drug-year first in use Response-genotype 1
Interferon alfa-1991 15%
Interferon alfa and ribavirin-1998 25%
Pegylated Interferon & Ribavirin-200 40%
PIFN/R/Telaprevir or Boceprevir-2011 60%
PIFN/R/sofosbuvir-2013 70-80%
PIFN/R/simeprevir-2013 80%
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology Associates, PC
Eradication of Hepatitis C saves lives
• Data from the HALT-C Trial-patients with advanced fibrosis*
• Followed for 7.5 years after completion of PIFN/R treatment
140 patients who cleared virus Death or transplant in 2.2%
309 patients who did NOT clear virus Death or transplant in 21.3%
*Morgan TR; PMID 20364351
Eradication of Hepatitis C helps prevent liver cancer
307 French patients with advanced fibrosis treated with PIFN/R*
Patients followed for an average of 3.5 years after treatment completion
Incidence of Liver Cancer per 100-person years
Those cured of infection 1.24
Those NOT cured of infection 5.85
*Cardoso, et al. PMID 20546533Copyright (c) 2014 Paul C. Pinto,
MD | Peak Gastroenterology Associates, PC
Treatment of Hepatitis C may help Hepatitis C comorbidities
Fatigue - in a study of 431 patients, 59% of which had fatigue at baseline-fatigue improved in 35% of responders, and 22% of non-responders*
Little Data in the following conditions-consider treatment
Mixed Cryoglobulinemia - and renal disease Porphyria Cutanea Tarda Leucocytoclastic Vasculitis Necrolytic Acral Erythema
*Cacoub P; J Hepatol: 2002; 36(6):812
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
Regimens for Genotype 1 Hepatitis C in 2014
All Regimens are given with Pegylated Interferon and Ribavirin
Regimen Best Response Clinical Issues
Telaprevir/PIFN/R 65% Rash, anemia-both can be severe24-48 weeks Drug-Drug interactions extensive
Pill burden-fat required with meds
Boceprevir/PIFN/R 60% Anemia-can be severe32-48 weeks Many Drug-Drug interactions
Sofosbuvir/PIFN/R 80% Untested in previously treated patients12 weeks Low pill burden
Side effects similar to PIFN/R alone
Simeprevir/PIFN/R 70-80% Tested in previously treated patients24-48 weeks Low pill burden
Few side effects over PIFN/R alone
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
Treatment of Genotypes 2 and 3 Hepatitis C-2014
Genotype 2: Sofosbuvir/Ribavirin for 12-16 weeks
Clinical Parameters Response Rate
Treatment naïve 97%Naive with cirrhosis 83%Non-naïve 90%Non-naive with cirrhosis 60%*
Genotype 3: Sofosbuvir/Ribavirin for 16-24 weeks
Naïve 93% Non-naïve 85%Naive with cirrhosis 92% (12 pts)Non-naive with cirrhosis 60% (24
pts)*
*may do better with a regimen that includes pegylated interferon
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How to help someone taking Hepatitis C treatment
Fatigue-remain active both mentally and physically; consider interferon dose decrease if severe
Anemia -do not prescribe iron or vitamins-they will not work; consider dose modifications of ribavirin and/or interferon
Depression - treat as usual with SSRI or SNRI agents; avoid St John's Wort
If depression occurred on previous treatment, begin antidepressant with the antiviral treatment; Involve psychiatrist if concerned
Any new medication should be reviewed for drug-drug interactions
Discuss avoidance of pregnancy in both women and men who are on treatment
Remind them to comply with laboratory tests needed on therapy-these help us help themCopyright (c) 2014 Paul C. Pinto,
MD | Peak Gastroenterology Associates, PC
Exactly what do we mean by “Cure”?
In clinical trials of hepatitis C treatment, cure means that HCV-RNA is non-detectable in the serum when performed by an assay that can detect as few as 25 IU/ml of virus, 24 weeks after completion of treatment.
The chance that the virus will return after this is less than 1% per year.
I personally stop testing for virus recurrence after two years of treatment completion.
Hepatitis C is the ONLY curable chronic viral infection in 2014. It is the speaker's experience that patients will frequently refer to themselves being in "remission" after a course of therapy, regardless of viral test results. This term should not be used in hepatitis C-you are either cured, or not-period.
Avoiding vague terms may help those with persistent infection return for re-treatment-speaker's opinion.
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
What do we do after a patient is cured of Hepatitis C?
Test for thyroid disorders six months after treatment completion-(hypothyroidism may occur)
Wean off antidepressants as appropriate
Repeat HCV-RNA one and two years after treatment completion
Confirm that HIV testing as well as Hepatitis A and B vaccination are completed
Screen those with advanced fibrosis as follows: --for esophageal varices, with every two year upper
endoscopy --for liver cancer with every six month imaging (US or TP-CT)
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology
Associates, PC
Copyright (c) 2014 Paul C. Pinto, MD | Peak Gastroenterology Associates, PC
Thank you!
We are available to assist you!
Peak Gastroenterology Associates, PC719-636-1201
www.peakgastro.com