Pa$ent w/ HCV 5/26/2016

Transcription

1 Ini$al of a Evalua$on(s) Pa$ent w/ HCV 5/26/2016

2 Objec$ves To discuss the issues involved in the ini/al encounters of a pa/ent w/ Hepa//s C Learning how to provide pa/ent educa/on about hepa//s C transmission, natural history, and avoidance of hepatotoxins Learning how to assess fibrosis, and who needs to be screened for hepatocellular carcinoma Awareness of cofactors for progressive disease Awareness of clinical manifesta/ons of hepa//s C Awareness of signs and/or symptoms of advanced liver disease Awareness of issues of HCV and pregnancy Planning for treatment

3 First things first: confirm Dx and $meline Hepa//s C Ab and PCR tes/ng Known exposure? Recent/current symptoms of acute HCV? Most of those who will clear infec/on, do so in first 3 months (some take longer) Define risk factor and /meline If possible Define if any prior treatments

4 Issue One: Looking for Co-infec$ons Screen for other chronic illnesses that share similar transmission mechanisms: Hepa//s B HIV

5 Addi$onal Ini$al Laboratory Evalua$on Labs CBC, liver panel, kidney panel, electrolytes HCV genotype HCV Fibrosure (or similar serum biomarker) HIV, Hepa//s A, and Hepa//s B serologies Vitamin D level Urinalysis Cryoglobulins Rheumatoid Factor Other tests for addi/onal chronic liver dz (iron studies, autoimmune hepa//s, etc.) Urine Tox Screen

6 Hepa$$s C Natural History Educa$on Hepa))s C Natural History Educa)on Efforts should be made to educate pa/ents on the natural history of Hepa//s C infec/on AASLD guidelines: the risk of developing cirrhosis ranges from 5 to 25% over a period of 25 to 30 years Can o\en alleviate fears with educa/on usually decades not days needed for Hepa//s C to cause significant liver damage

7 Transmission Educa$on and Preven$on Blood dona/on Pa/ents should be advised to never donate blood or semen Preven/on of transmission to household contacts avoid sharing toothbrushes, or other dental devices never share sharp items used for personal hygiene razors or other shaving equipment, scissors, nail clippers cover any bleeding wounds

8 Transmission Educa$on and Preven$on Transmission through further drug use: Besides counseling on cessa/on of drug use, pa/ents should be counseled to avoid reusing or sharing syringes and needles, as well as other drug paraphernalia Sexual transmission: Hepa//s C infec/on itself is not o\en cited as reason to change sexual prac/ces However, CDC data indicates that sexual transmission of HCV can occur, especially among HIV-infected persons (especially men who have sex with men) All pa/ents should be counseled about the importance of condom use to prevent transmission of HIV, other sexually transmibed infec/ons, and hepa//s C

9 Don t Forget to Address the Pa$ent s Risk Factor for Hepa$$s C Acquisi$on O\en it is the pa/ent s addic)on that causes the most harm A 2011 study showed that the leading cause of death in pa/ents with Hepa//s C was not liver-related illnesses 1 72% of deaths were the result of drug overdose or suicide 1. J. Hepatol, 2011 May; 54(5): Trends in mortality a\er diagnosis of hepa//s B or C infec/on:

10 Establishing Degree of Liver Disease and Screening for Hepatocellular Carcinoma (HCC) If Needed Not something that a clinician can always do through rou/ne history, physical exam, or blood work unless cirrhosis is already present Imaging (ex. ultrasound) alone is also o"en not adequate either Goal is to establish degree of liver fibrosis

11 Establishing Degree of Liver Disease and Screening for Hepatocellular Carcinoma (HCC) If Needed Fibrosis stage is o\en reported according to the METAVIR system ( F-score ) F0, no fibrosis F1, portal fibrosis without septa F2, portal fibrosis with few septa F3, numerous septa without cirrhosis F4, cirrhosis The risk of liver-related morbidity and mortality in an individual HCV-infected pa/ent increases with the severity of liver fibrosis

12 Establishing Degree of Liver Disease and Screening for Hepatocellular Carcinoma (HCC) If Needed Assessing for Liver Fibrosis Recommended for all HCV infected pa/ents predict HCV disease progression and clinical outcomes help determine the need for hepatocellular carcinoma & varices screening if cirrhosis is suggested facilitate appropriate decision making regarding HCV treatment urgency Various modali/es: liver biopsy is the diagnos/c standard, but is an invasive test and is being done less o\en for HCV alone serum biomarkers of fibrosis (examples: Fibrosure, FibroTest) Vibra/on-controlled transient liver elastography (example: FibroScan) AST-to-Platelet Ra/o Index (APRI), Fibrosis 4 (FIB4) score

13 Establishing Degree of Liver Disease and Screening for Hepatocellular Carcinoma (HCC) If Needed Assessing for Liver Fibrosis No single method is recognized to have high accuracy alone Common approach to fibrosis assessment is to combine non-invasive modali/es: Serum biomarkers and liver elastography and APRI Liver biopsy should be considered for any pa/ent who has discordant results between the modali/es that would affect clinical decision making

14 Establishing Degree of Liver Disease and Screening for Hepatocellular Carcinoma (HCC) If Needed In pa/ents with Hepa//s C and cirrhosis, screening for hepatocellular cancer is warranted American Associa/on for the Study of Liver Diseases (AASLD) guideline on the management of hepatocellular carcinoma (HCC) recommends that surveillance be performed using ultrasonography at six-month intervals the combined use of Alpha-fetoprotein (AFP) and ultrasonography is not recommended by the AASLD Pa/ents with advanced fibrosis or cirrhosis (F3/F4) who have cleared HCV (either spontaneously or in response to treatment) are s3ll at risk for developing hepatocellular cancer con)nue to offer HCC surveillance

15 Be aware of other factors that increase rate of progression of HCV infec$on HIV or HBV co-infec/on ETOH use Older Age Faby liver / obesity / DM Gender Vit D deficiency

16 Vaccina$on for Pa$ents with Hepa$$s C Pa/ents with Hepa//s C should receive any immuniza/on that is recommended for a healthy individual of their age For pa/ents with chronic liver disease, the Advisory Commibee on Immuniza/on Prac/ces (ACIP) recommends the following vaccina/ons: hepa//s A hepa//s B pneumococcal vaccine yearly influenza vaccine tetanus, diphtheria, and acellular pertussis

17 Awareness of Clinical Manifesta$ons of Hepa$$s C, Including Extra-hepa$c Chronic HCV is usually asymptoma/c The most frequent complaint in pa/ents with chronic hepa//s C is fa/gue Other common complaints include nausea, anorexia, myalgias, arthralgias, and abdominal pain Pa/ents may also present with symptoms and signs of chronic liver disease and cirrhosis Chronic infec/on with hepa//s C has also been associated with many extra-hepa2c manifesta2ons In general these may involve the skin, joints, nerves, kidney, hematologic system, or other organs Specific examples include cryoglobulinemia, porphyria cutanea tarda, leukocytoclas/c vasculi/s, glomerulonephri/s, lymphoma, diabetes, and autoimmune disorders

18 Evaluate for chronic liver disease Evaluate for signs and/or symptoms of chronic liver disease - ascites, edema - GI bleeding - encephalopathy Calculate scores: Childs Pugh MELD score If per/nent, introduce concept of liver transplant

19 Avoidance of Alcohol and Cau$on with Medica$ons/Supplements Alcohol and HCV appear to act together in promo/ng progression to cirrhosis and increasing the risk of hepatocellular carcinoma A safe threshold of alcohol consump/on has not been established Therefore abs/nence of alcohol in pa/ents with chronic HCV is suggested Prescrip/on and over-the-counter medica/ons usually do not require a dose adjustment in pa/ents who have normal hepa/c func/on and Hepa//s C NSAIDS should be avoided in pa/ents at risk for GI bleeding (cirrho/c pa/ents) Acetaminophen, but should not exceed 2 g per 24 hours Ask about herbal and alterna/ve therapies or other supplement use Check for drug/drug interac/ons if Hepa//s C treatment is ini/ated

20 Pregnancy Ver$cal Transmission; Hepa$$s C Treatment Logis$cs According to the CDC pa/ents should be advised that approximately 6 of every 100 infants born to HCV-infected women become infected Unfortunately there is no known strategy to decrease this risk Transmission rates are higher if HIV co-infec/on is present If a pa/ent is planning treatment and pregnancy several issues must be considered: Currently available treatments for Hepa//s C treatment are not indicated for pa/ents who are pregnant, contempla/ng pregnancy, or are unwilling to assure contracep/on due to significant teratogenic and embryocidal effects of ribavirin Pa/ents should also be made aware that they must wait at least 6 months a\er ribavirin is stopped before becoming pregnant. This warning is extended to men as well as women Pa/ents with HCV on treatment should avoid breaspeeding. Pa/ents with HCV not on treatment can safely breaspeed.

21 Planning for Treatment Introduce treatment concepts Dispel rumors from interferon days Assess financial challenges Insurance Prepare pa/ent for possible difficulty w/ obtaining HCV medica/ons Drug and alcohol counseling

22 Thank You!