Download Hepatitis c

Penny R. Thayer, FNP, BC
Gastro/Hepatology NP
James H. Quillen, VAMC
OBJECTIVES
PREVALENCE
 IDENTIFY RISK FACTORS
 TREATMENT OPTIONS
 COMMON SIDE EFFECTS OF
ANTIVIRAL THERAPY
 APPROPRIATE CODING

FACES OF THE DISEASE
PREVALENCE

NHANES IV (1999-2002)1
 1.6% anti-HCV positive (95% CI 1.3-1.9%) =
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4.1 million persons (95% CI 3.4-4.9 million)
1.3% chronic infection = 3.2 million persons
Peak 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.
TESTING FOR HCV AB

Recent/past injection drug
users—even if only used
once

Recipients of transfusion
or transplantation before
July 1992

Groups with high HCV
prevalence

Children born to women
infected with HCV
 HIV-infected individuals

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
 Hemophiliacs treated
with clotting factor
concentrates before
1987
 Hemodialysis recipients
 Patients with
unexplained
aminotransferase
abnormalities
DIAGNOSIS
Positive Hepatitis C antibody-exposure
 Positive Hepatitis C RNA (PCR)
 RIBA
 Generally asymptomatic
 Acute Hepatitis C

PROGRESSION

ACUTE HEPATITIS C
 15-40% will spontaneously resolve, generally
within the first 6-18 months after acute onset.
 60-85% will progress to chronic infection

CHRONIC
 85-90% stable
 10-15% progress to cirrhosis
PROGRESSION

CIRRHOSIS
 75% slowly progressive
 25% progress to HCC
 2-4% liver failure

HCC
 Risk increases for every year for a patient
with chronic hepatitis C.
 Patients without signs of cirrhosis can
develop HCC
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
RISK FACTORS
IVDU-Even ONCE
 ETOH ABUSE-includes binge drinking
 Multiple sex partners
 Tattoos
 Snorting cocaine-Even ONCE
 Blood transfusions before 1991
 Dialysis

INITIAL WORKUP

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CBC
CMP
TSH
HCV PCR (VIRAL LOAD)
HCV GENOTYPE
Hepatitis A and Hepatitis B vaccine panel
HIV
AFP
Liver Ultrasound
MELD SCORE
http://www.mayoclinic.org/meld/mayomo
del6.html
 survival probability of a patient with endstage liver disease is estimated based
on the following variables.
 INR, Bilirubin, Creatinine, on dialysis
twice per week
 Score greater 11

GENOTYPES

Genotype 1
 Treatment naïve
 Relapse, partial response, null responder

Genotype 2 & 3
 Treatment naïve, usually 24 weeks
 Relapse, partial response, null response

Genotype 4
 Treatment naïve, 48 weeks
 Relapse, partial response, null responder
 *Those not treatment naïve, treated on a case
by case basis.
TREATMENT

Monitoring
 Ultrasound every 6 months
 CBC, CMP, PT/INR, AFP every 6 months
 EGD or ESO cam to check for varices at least
once
 Education
 Liver biopsy?
 Every patient gets treatment, not every patient is
a candidate for antiviral treatment
TREATMENT

Antiviral Treatment
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Goal is achieving SVR
Ask ‘when’ not ‘if’ a candidate for treatment
No marijuana or other illicit drug use
Abstinence from ETOH for at least 3 months
HCV PCR (viral load)
Depression screening before and during
treatment
 Liver biopsy if not already done for GT 1
 Education class to review expectations of
frequent visits, labs and possible side effects.
STANDARD ANTIVIRAL THERAPY

Pegylated interferon therapy (PegIFN)
 Pegasys
 PegIntron
 Injections one time per week, duration based on
genotype and response
 Must be kept cool (in the fridge!)
 Can be taken alone, although sustained viral
response is diminished.

Ribavirin
 Tablets taken every day, dose based on genotype
 Not used as monotherapy
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.

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 responder
 Lead in phase 4 weeks, response guided therapy,
36-48 weeks of triple therapy
DIRECT ACTING ANTIVIRAL/
PROTEASE INHIBITOR
 TELAPREVIR/INCIVEK
○ Treatment naïve
 No lead in phase
 Triple therapy for 12 weeks
 RGT—generally done in 24 weeks
○ Relapse, partial responder, null responder
 No lead in phase
 Triple therapy for 12 weeks
 RGT-completed in 36-48 weeks
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

ADDITIONAL SIDE EFFECTS WITH
USE OF DAA/PI
Profound anemia
 Increased risk of neutropenia
 Increased risk of significant rash
 Ano-rectal pain
 Dysguesia

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**this is NOT intended to be a complete
list, see prescribing information for these
medications.
APPROPRIATE CODING
EIA
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
positive
Ab-not
exposed
NONE
APPROPRIATE CODING
EIA
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
NEG
WITH TX
ANY
Cleared
070 series
virus in
response to
treatment
ANY
POS
ANY
Chronic
Hepatitis C
NONE
NONE
NONE
UNKNOWN If test
ordered:
V73.9
Counseling:
V65.49
070 series
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
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.
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
??QUESTIONS??