Agenda. Hepatitis C: Evaluation & Treatment. Background. Natural History of Hepatitis C. Epidemiology 9/23/2014

Transcription

1 Hepatitis C: Evaluation & Treatment Amanda DeVoss, MMS, PA-C WAPA Conference Fall 2014 Background Epidemiology Transmission Screening Agenda Diagnosis Evaluation Treatment Background Natural History of Hepatitis C What is hepatitis? Single-stranded RNA virus Acute Disease Chronic Disease Symptoms Resolved Exposure (Acute phase) 15% 80% Stable 85% Chronic 75% 20% Cirrhosis HIV, alcohol, other liver disease 25% Slow Progression HCC Transplant Death Picture courtesy of NPR Alter, MJ. Epidemiology of Hepatitis C in the West. SeminLiver Dis Feb;15(1):5-14 Management of Hepatitis C. NIH Consensus Statement 1997 March 24-26, 15(3) Epidemiology Epidemiology Reference: CDC Reference: CDC 1

2 U.S HCV Treatment Cascade Transmission of HCV 60% 50% 40% 30% 20% 10% 0% Overall: 3.2 million of U.S. population with chronic HCV 50% 35% 8.50% 6% Diagnosed Referred to Care Treated Successfully Treated PWID/IVDU Vertical HIV+ Opioid use Medical settings Dialysis, healthcare needlestick, others Tattoos Incarceration Blood transfusion/blood products/solid organ transplant Holmberg et al. Hepatitis C in the U.S. N EnglJ Med 2013; 368: Screening WHICH PATIENTS DO YOU SCREEN? Image courtesy of Saturday Evening Post Screening Birth cohort Regardless of risk Risk factors IVDU (current/ever) Medical Conditions Clotting factors prior to 1987 Long-term hemodialysis Abnormal ALT HIV+ Transfusion / organ transplants prior to July 1992 Known exposure Healthcare Child born to HCV+ mother NOW THAT YOU HAVE IDENTIFIED THE PATIENTS, HOW DO YOU TEST FOR HEPATITIS C? Ref: CDC 2

3 Anti-HCV EIA Enzyme immunoassay >99% specific Screening/Testing Quantitative HCV RNA Testing Hepatitis C genotype Testing Hepatitis C Genotype: US Hepatitis C Genotype: World Image courtesy of Johns Hopkins Importance of Genotype Length of treatment Response to treatment Medication YOU HAVE DIAGNOSED A PATIENT WITH HEPATITIS C. WHAT COUNSELING CAN YOU PROVIDE BEFORE THEY ARE REFERRED? 3

4 Counseling Referral Transmission Vaccination Curbing other behaviors Screen for other liver diseases Biopsy Imaging Treatment Who is a candidate for treatment? Goals of Treatment Adherence Alcohol/other drugs Weight loss Engagement Image courtesy of Wordpress Goals of Treatment Evolution of HCV Therapy Source: Veldt BJ, Heathcote EJ, WedemeyerH, et al. Sustained virologic response and clinical outcomes in patients with chronic hepatitis C and advanced fibrosis. Ann Intern Med. 2007;147:

5 FDA Approved Treatment Sofosbuvir Trial Telaprevir(protease inhibitor) Vertex Pharmaceuticals Incorporated will be discontinuing the sale and distribution of INCIVEK (telaprevir) in the United States by October Boceprevir(protease inhibitor) Sofusbuvir(polymerase inhibitor) Simeprevir(protease inhibitor) LawitzE et al. N EnglJ Med 2013;368: Simeprevir Trial Future Treatments SVR12 Among Patients with Genotype 1 HCV and Advanced Liver Fibrosis 12 weeks of treatment Regimen Simeprevir/Sofosbuvir (%) Simeprevir/Sofosbuvir + RBV Overall Genotype 1a * Genotype 1b METAVIR *denotes differences due to Q80K polymorphism Final Data from the Phase 2 COSMOS Study of Janssen s Once-Daily Simeprevirin Combination with Sofosbuvir Presented at The International Liver Congress 2014 of the European Association for the Study of the Liver (EASL) Graph courtesy of CVS ABT-450/r-Ombitasvir Sustained Virologic Response at 12 Weeks & after the Dasabuvir End of Treatment. with and without Ribavirin Ledipasvir and Sofosbuvir for 8 or 12 Weeks for Chronic HCV without Cirrhosis ring and after FerenciP et al. N EnglJ Med 2014;370:

6 Summary Many patients need screening/testing If Anti-HCV is positive, follow-up with an HCV RNA Quantitative and HCV genotype test Referral for treatment and prognosis Education and Vaccination Thank you! 6