NIH Consensus Conference Statement. Management of Hepatitis C. March 24-26, NIH Web site. Available at:

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1 ABC s of Hepatitis C Treatment Today Elizabeth N. Britton, MSN, FNP-BC Hepatology Services Louisiana State University Health Sciences Center ebritt@lsuhsc.edu ANAC CONFERENCE -TUCSON NOV 2012 Hepatitis C BLOOD BORNE VIRUS Unlike HBV - rarely sexually spread Monogamous couples at low risk: 1-3% risk Increasing number of sexual partners HIV co-infection associated with higher rates of sexual spread 20% risk 0 1 SCREENING FOR HEPATITIS C: WHO SHOULD BE CHECKED? PATIENTS SHOULD BE TESTED IF THEY MEET ANY OF THE FOLLOWING HAVE KNOWN RISK FACTORS FOR VIRAL HEPATITIS INDICATE POSSIBLE RISK FACTORS FOR HEPATITIS HAVE ELEVATED LIVER ENZYMES PATIENTS WHO WANT TO BE SCREENED ALL HIV POSITIVE PATIENTS BORN BETWEEN * 1965* NIH Consensus Conference Statement. Management of Hepatitis C. March 24-26, NIH Web site. Available at: Accessed January 24, *CDC MMWR VOL 61/ NO.4 AUGUST 17, 2012 Risk Factors for Contracting Hepatitis C History of ANY IV drug use (even only once ) Blood transfusion PRIOR June 1992 Given blood products before 1987 (ie. clotting factors) History of intranasal drug use ( snorting ) Tattoos (esp if done non-profess, or while incarerated) Body piercing (non-profess) Diagnosed with an STD (HCV NOT classified as STD, BUT can be) Any known blood exposure (work related or otherwise) 2 3 1

2 HCV: Perinatal Transmission Related to viral load Increased with HIV Increased risk with acute infection in 3rd trimester Overall risk approx. 5% Breast feeding is not a risk factor Nosocomial Exposure Contaminated equipment Rare in the U.S. except in hemodialysis (prevalence 10->60%) HCV(+) increase with increasing years on hemodialysis Health-care, emergency medical and public safety workers (needle stick) 1-2% Needle Stick in Health Care Workers HIV 0.4% HCV 3% HBV 30% 4 5 Natural History of Hepatitis C years Acute Hepatitis C Chronic Hepatitis 75%-85 % Cirrhosis 20 % 6 Hoofnagle JH Hepatology. 1997;26 (suppl 1): 15S-20S Di Bisceglie, Hepatology,

3 DON T JUST LOOK AT THE ENZYMES! SCREENING AND DIAGNOSIS OF HEPATITIS C SINGLE NORMAL ALT LEVEL DOES NOT RULE OUT CHRONIC VIRAL HEPATITIS ALT LEVELS MAY BE INTERMITTENTLY NORMAL IN A SIGNIFICANT NUMBER OF PATIENTS WHO HAVE CHRONIC HEPATITIS C A SINGLE NORMAL ALT 8 ALT=alanine aminotransferase. 9 ACUTE HCV INFECTION: PROGRESSION TO RECOVERY DOES HAPPEN - BUT RARELY ACUTE HCV INFECTION: PROGRESSION TO CHRONIC INFECTION MOST LIKELY PATTERN 85% ANTI-HCV ANTI-HCV SYMPTOMS + SYMPTOMS + ITER HCV RNA ITER HCV RNA T T ALT ALT ALT NORMAL NORMAL MONTHS TIME AFTER EXPOSURE YEARS MONTHS TIME AFTER EXPOSURE YEARS RNA=ribonucleic acid. Morbidity and Mortality Weekly. Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease. Centers for Disease Control. October 16, 1998/47(RR19);1-39. Morbidity and Mortality Weekly. Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease. Centers for Disease Control. October 16, 1998/47(RR19);

4 HEPATITIS C VIRUS RNA TESTS DETERMINE PRESENCE OF ACTUAL VIRUS, NOT ANTI-HCV ANTIBODIES HELPFUL IN DIFFICULT CASES ANTIBODY TESTS INCONCLUSIVE COMPROMISED IMMUNE SYSTEM EXPENSIVE AND REQUIRES SPECIAL HANDLING SENSITIVITY MAY VARY BETWEEN LABS; DEPENDS ON TYPE OF ASSAY CHECK LOWER LIMIT OF DETECTION 12 HCV Genotypes and Subtypes Developed countries South Africa Middle East North Africa IVDU Simmonds P, Journal of Hepatology, 1999 Americas + Western Europe Asia LIVER BIOPSY HISTOLOGIC STAGING MAY BE GUIDED BY CT OR ULTRASOUND PROVIDES INFORMATION REGARDING DEGREE OF INFLAMMATION DISEASE SEVERITY TISSUE DAMAGE PRESENCE/ABSENCE OF CIRRHOSIS HELPS DETERMINE DEGREE OF DISEASE PROGRESSION CAUSE OF LIVER DISEASE NEED FOR TREATMENT STAGE 0 NO FIBROSIS STAGE 3 NUMEROUS SEPTA STAGE 1 STAGE 2 PORTAL FIBROSIS FEW SEPTA STAGE 4 CIRRHOSIS CT=computed tomography

5 FACTORS WHICH MAY INFLUENCE THE OUTCOME OF HEPATITIS C VIRUS -LOAD -GENOTYPE -QUASISPECIES HOST -SEX -AGE -RACE -GENETICS -IMMUNE ENVIRONMENT -ALCOHOL - HBV -HIV -DRUGS -STEATOSIS -IRON -NASH 16 HBV=hepatitis B virus; HIV=human immunodeficiency virus; NASH=nonalcoholic steatohepatitis. Alberti A et al. J Hepatol. 1999;31(suppl 1): GOALS OF HCV THERAPY OF HCV T SUSTAINED VIROLOGIC PRIMARY: CLEARANCE OF VIRUS PRODUCE A MAINTAIN A SUSTAIN A AFTER COMPLETION OF TX SECONDARY: INHIBITION OF DISEASE PROGRESSION REDUCTION OF INCIDENCE OF HCC REDUCTION IN NEED FOR LIVER TRANSPLANT VIRAL LO OAD SVR RNA=ribonucleic acid. 18 Adapted from Pawlotsky JM et al. Hepatology. 2000;32:

6 PATTERNS OF HCV RESISTANCE OF HCV R PRODUCE A MAINTAIN A NON D VIRAL LOAD BREAKTHROUGH RELAPSE Adapted from Pawlotsky JM et al. Hepatology. 2000;32: