Hepatitis c: THE UP & COMING DISEASE IN YOUR primary care CLINIC
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Transcript of Hepatitis c: THE UP & COMING DISEASE IN YOUR primary care CLINIC
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Penny R. Thayer, FNP, BC
Gastro/Hepatology NP
James H. Quillen, VAMC
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OBJECTIVES
PREVALENCE IDENTIFY RISK FACTORS TREATMENT OPTIONS COMMON SIDE EFFECTS OF
ANTIVIRAL THERAPY APPROPRIATE CODING
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FACES OF THE DISEASE
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PREVALENCE NHANES IV (1999-2002)1
1.6% anti-HCV positive (95% CI 1.3-1.9%) = 4.1 million persons (95% CI 3.4-4.9 million)
1.3% chronic infection = 3.2 million personsPeak prevalence age 40-49 (4.3%)Three characteristics identified 85.1% all
infections: abnormal serum ALT, ever IVDU, transfusion <1992
Most persons born 1945-1964
Armstrong GL, Wasley A, Simard E, et al. Ann Intern Med 2006; 144: 705-14.
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TESTING FOR HCV AB 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
Children born to women infected with HCV
Healthcare, public safety, and emergency medical personnel following needle injury or mucosal exposure to HCV-infected blood
Current sexual partners of individuals infected with HCV
Persons who have used illicit drugs by noninjection routes
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DIAGNOSIS
Positive Hepatitis C antibody-exposure Positive Hepatitis C RNA (PCR) RIBA Generally asymptomatic Acute Hepatitis C
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PROGRESSION
ACUTE HEPATITIS C15-40% will spontaneously resolve, generally
within the first 6-18 months after acute onset.60-85% will progress to chronic infection
CHRONIC85-90% stable10-15% progress to cirrhosis
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PROGRESSION
CIRRHOSIS75% slowly progressive25% progress to HCC2-4% liver failure
HCCRisk increases for every year for a patient
with chronic hepatitis C.Patients without signs of cirrhosis can
develop HCC
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PREDICTIONS BY 2019 193,000 HCV deaths
720,700 million years of advanced liver disease 1.83 million years of life lost
$11 billion in direct medical care costs
$21.3 and $54 billion societal costs from premature disability and mortality
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RISK FACTORS
IVDU-Even ONCE ETOH ABUSE-includes binge drinking Multiple sex partners Tattoos Snorting cocaine-Even ONCE Blood transfusions before 1991 Dialysis
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INITIAL WORKUP
CBC CMP TSH HCV PCR (VIRAL LOAD) HCV GENOTYPE Hepatitis A and Hepatitis B vaccine panel HIV AFP Liver Ultrasound
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MELD SCORE
http://www.mayoclinic.org/meld/mayomodel6.html
survival probability of a patient with end-stage liver disease is estimated based on the following variables.
INR, Bilirubin, Creatinine, on dialysis twice per week
Score greater 11
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GENOTYPES Genotype 1
Treatment naïveRelapse, partial response, null responder
Genotype 2 & 3Treatment naïve, usually 24 weeksRelapse, partial response, null response
Genotype 4Treatment naïve, 48 weeksRelapse, partial response, null responder
*Those not treatment naïve, treated on a case by case basis.
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TREATMENT
MonitoringUltrasound every 6 monthsCBC, CMP, PT/INR, AFP every 6 monthsEGD or ESO cam to check for varices at least
onceEducationLiver biopsy?Every patient gets treatment, not every patient is
a candidate for antiviral treatment
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TREATMENT Antiviral Treatment
Goal is achieving SVRAsk ‘when’ not ‘if’ a candidate for treatmentNo marijuana or other illicit drug useAbstinence from ETOH for at least 3 monthsHCV PCR (viral load)Depression screening before and during
treatmentLiver biopsy if not already done for GT 1Education class to review expectations of
frequent visits, labs and possible side effects.
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STANDARD ANTIVIRAL THERAPY Pegylated interferon therapy (PegIFN)
PegasysPegIntronInjections one time per week, duration based on
genotype and responseMust be kept cool (in the fridge!)Can be taken alone, although sustained viral
response is diminished. Ribavirin
Tablets taken every day, dose based on genotypeNot used as monotherapy
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DIRECT ACTING ANTIVIRAL/ PROTEASE INHIBITOR ONLY GT 1 PATIENTS ARE
CANDIDATES NO PRESCRIPTIONS TO BE FILLED
WITHOUT FIRST CHECKING WITH PROVIDER WHO IS TREATING THE HEPATITIS C.
MULTIPLE SIDE EFFECTS AND DRUG INTERACTIONS.
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DIRECT ACTING ANTIVIRAL/ PROTEASE INHIBITOR
BOCEPREVIR/VICTRELIS○ Treatment naïve
Lead in phase 4 weeks, response guided therapy, generally 28 weeks of triple therapy
○ Relapse, partial responder, null responderLead in phase 4 weeks, response guided therapy,
36-48 weeks of triple therapy
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DIRECT ACTING ANTIVIRAL/ PROTEASE INHIBITOR
TELAPREVIR/INCIVEK○ Treatment naïve
No lead in phaseTriple therapy for 12 weeksRGT—generally done in 24 weeks
○ Relapse, partial responder, null responderNo lead in phaseTriple therapy for 12 weeksRGT-completed in 36-48 weeks
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SIDE EFFECTS
Multiple side effects that can be mild to severe
Flu like symptoms, depression, dry skin, insomnia, hair loss, increased pain
Flu like symptoms most common Will make autoimmune disorders worse
i.e. Psoriasis—needs Derm monitoring Depression: increased risk for suicidal
ideation, worsening anxiety etc
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ADDITIONAL SIDE EFFECTS WITH USE OF DAA/PI Profound anemia Increased risk of neutropenia Increased risk of significant rash Ano-rectal pain Dysguesia
**this is NOT intended to be a complete list, see prescribing information for these medications.
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APPROPRIATE CODINGEIA RESULT
PCR RESULT
RIBA RESULT
HEP C STATUS
ICD-9 CODE
NEG NEG (w/o Tx)
NEG Negative, not exposed to HCV
NONE
NEG NEG(w/o Tx)
POS Previously exposed to Hep C, at time of testing, not chronically infected
V01.79
POS NEG(w/o Tx)
NEG False positiveAb-not exposed
NONE
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APPROPRIATE CODINGEIA RESULT
PCR RESULT
RIBA RESULT
HEP C STATUS
ICD-9 CODE
POS NEG(w/o Tx)
POS Previously exposed to hepatitis C, at time of testing, not chronically infected
V01.9
ANY NEGWITH TX
ANY Cleared virus in response to treatment
070 series
ANY POS ANY Chronic Hepatitis C
070 series
NONE NONE NONE UNKNOWN If test ordered: V73.9Counseling: V65.49
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RESOURCES
Several websites
www.hepatitis.va.gov
www.hepatitiscnewdrugs.blogspot.com
www.aasld.org Hepatitis C Resource Centers (HCRC)
www.hepatitis.va.gov
Support Groups
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CASE STUDY # 1 48 yo african american male with Hepatitis
C type 1a, previously treated with peginterfon and ribavirin in 2009, relapsed within 3 months of stopping therapy, HCV PCR 500,000, PLT count 120, Albumin 3.2. Previous history of IVDU, marijuana, and ETOH use. Has been clean and sober for the last 5 years.
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CASE STUDY #1 cont.
What treatment options would you discuss with him?
A. None—it is more likely he would not respond to treatment and the risks/benefits are too great.
B. Liver biopsy and consider treatment to include a direct acting antiviral.
C. Retreatment with standard therapy and continue for 72 weeks
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??QUESTIONS??