Hepatitis C. No disclosures. 1. The USPSTF recommends Hepatitis C screening in which patient populations?

Transcription

1 Hepatitis C Jennifer Acosta PA-C No disclosures 1. The USPSTF recommends Hepatitis C screening in which patient populations? a. All adults at least once b. Immigrants to the US and those over age 65 c. Those born and high-risk populations d. Patients with HIV and/or HBV

2 2. Risk factors for Hepatitis C infection include all of the following except: a. History of alcoholism b. Blood transfusion in 1975 c. Long term hemodialysis d. Being born to an HCV-infected mother e. Intranasal drug use 3. What test should you order for initial screening of Hepatitis C? a. Hep C RNA b. Hep C antibody c. Hep C genotype d. Liver function tests e. Liver ultrasound 4. What is the preferred imaging modality for liver fibrosis staging? a. MRI b. CT c. Liver ultrasound d. Liver ultrasound w elastography e. ERCP

3 5. Pretreatment liver staging is important because it helps determine: a. Drug choice b. Treatment duration c. Post-tx surveillance d. Transplant center referrals e. All of the above Epidemiology Most common chronic blood borne pathogen in the US Most common reason for liver transplant in US About 3.5 million people living with HCV in the US, 75% of which are baby boomers. Over 1 billion globally. Microbiology Hepatitis C - RNA No incorporation into host DNA, no latent phase Lives completely within the cytoplasm Curable Fibrosis > Cirrhosis > Hepatocellular carcinoma

4 Type to enter a caption. HCV RNA Life Cycle of HCV vs HBV and HIV USPSTF Recommended Screening In persons at high risk for infection (>50% prevalence) 1-time screening for adults born between 1945 and 1965 (3-4% prevalence)

5 IVDU and intranasal drug use Long term hemodialysis Being born to an HCV-infected mother Incarceration Unprofessional tattoos Risk Factors Other percutaneous exposures - needle sticks, transfusions prior to 1992 MSM w/ HIV (IDSA/ AASLD recommendations) Screening Hepatitis C Antibody If reactive, check HCV RNA x 2, 6 months apart HIV Why Treat? Prevent advanced fibrosis/cirrhosis and its complications (portal HTN, ascites, esophageal varices, HE, thrombocytopenia) Prevent hepatocellular carcinoma Reduce transmission

6 Acute HCV Jaundice, fatigue, nausea/vomiting Most patients don t recall an acute illness 10-15% of cases will resolve without treatment Counseling Prevention of transmission (don t share razors, toothbrushes, nailclippers, needles) One-time screening of cohabitants No recs to change sexual practices if monogamous No risks with common exposures Diagnostics Initial screening - Hep C antibody, then RNA if reactive (Reactive ab = current or hx of infection, might be resolved) Check RNA x 2, 6 months apart % resolve without treatment HIV, genotype, HBsAg, HBsAg, HBcAb, HepA total Ab, Coags, CBC, CMP, HCG Resistance testing if appropriate

7 NS5A RAS: Genotype 1a Elbasvir/Grazoprevir Ledipasvir/Sofosbuvir, if treatment experienced Genotype 3 Sofosbuvir/Velpatasvir - treatment naive w/ cirrhosis, TE w or w/o cirrhosis. If Y93H present, add weightbased ribavirin, or use Sofosbuvir/Velpatasvir/ Voxilaprevir Diagnostics Cont. Liver ultrasound with elastography - preferred imaging modality for staging Fibrosure FIB4 Used to guide treatment choice, duration and posttreatment surveillance.

8 Monitoring during treatment depends on: Drug choice and duration Pre-treatment labs Comorbid conditions When to check RNA? Before treatment 4 weeks into tx (12+ week treatment) End of treatment 12 weeks after end of treatment (TEST of CURE/ SVR) Indications for Treatment Detectable HCV RNA No fibrosis - Decompensated cirrhosis Discuss any ongoing drug/etoh use with your patient. Not FDA approved in pregnancy or in children under 12yrs

9 Pregnancy All pregnant women should be tested for HCV at the initiation of prenatal care - IDSA/AASLD No treatment recommended during pregnancy Monitor LFTs 3-5% risk of Mother-to-Child-Transmission No specific peri-partum measure noted to reduce transmission. C-section not advised. Breastfeeding is ok, except in the context of cracked/ bleeding nipples Children Hep C antibody after 18mo, then HCV RNA at 3yrs Siblings from same mother should be tested once 25-50% infants spontaneously resolve infection by 3yrs DAA approved for children over 12 yrs History of Treatment Options Pegylated Interferon/Ribavirin Direct-Acting Antivirals - teleprevir, boceprevir Current DAAs No waiting for severe disease No mandatory drug/etoh testing

10 Hep C Drug Targets NS3/4A PIs, NS5B polymerase inhibitor, NS5A inhibitors Treatment Options sofosbuvir/velpatasvir -12, 24 weeks glecaprevir/pibrentasvir - 8,12 weeks elbasvir/grazoprevir - 12 weeks ledipasvir/sofosbuvir - 8, 12 weeks sofosbuvir/velpatasvir/voxilaprevir - 12 weeks (retreatment only) paritaprevir/ritonavir/ombitasvir simeprevir/sofsbuvir daclatasvir/sofsbuvir

11 Treatment Considerations Resistance Side effects (mild) - Headache, GI - usually resolves after the first few weeks Drug interactions - PPIs, statins, HIV meds Liverpool Hep C drug interaction checker After Treatment Cured if undetectable virus at 12 weeks post tx If positive at 12 weeks, relapsed. If positive later on, probably reinfected - recheck genotype. Post-tx surveillance depends on pre-tx fibrosis. F0-F2 - no f/u needed F3-F4 - q6 months US +/- AFP. Annual EGD if hx of bleeding varices. HCV RNA q 6-12 mo if ongoing risk factors, ie IDU, MSM w HIV 1. The USPSTF recommends Hepatitis C screening in which patient populations? a. All adults at least once b. Immigrants to the US and those over age 65 c. Those born and high-risk populations d. Patients with HIV and/or HBV

12 2. Risk factors for Hepatitis C infection include all of the following except: a. History of alcoholism b. Blood transfusion in 1975 c. Long term hemodialysis d. Being born to an HCV-infected mother e. Intranasal drug use 3. What test should you order for initial screening of Hepatitis C? a. Hep C RNA b. Hep C antibody c. Hep C genotype d. Liver function tests e. Liver ultrasound 4. What is the preferred imaging modality for liver fibrosis staging? a. MRI b. CT c. Liver ultrasound d. Liver ultrasound w elastography e. ERCP

13 5. Pretreatment liver staging is important because it helps determine: a. Drug choice b. Treatment duration c. Post-tx surveillance d. Transplant center referrals e. All of the above Questions?