Hepatitis C. Is treatment in primary care possible/feasible (desirable)?

Transcription

1 Hepatitis C Is treatment in primary care possible/feasible (desirable)?

2 Objectives Understand the unique characteristics of HCV Understand the complications of HCV infection Know who is at risk and who should be screened Describe treatment history and future options Understand who should be treated and by whom

3 What is the Hepatitis C Virus? HCV was identified in 1989 RNA virus Prior: 90% of post transfusion non A/non B hepatitis Incubation rate for acute HCV days but not usually associated with acute symptoms or illness Thought to be directly cytopathic to the hepatocyte HBV: T-lymphocytes are thought to mediate liver injury

4 HCV: Hepatitis B vs C Up to 80% develop chronicity The rest will likely continue to test HCV Ab+ BUT immunity is not inferred HBV: if acquired as adult, only 20% develop acute symptoms (can be severe) Only 5-10% develop chronic virus The remainder are immune

5 HCV is a diverse virus 6 genotypes identified (with subtypes) Genotype 1 most common in US Genotype 2 - YEA! He has genotype 2!! Genotype 3 more in far east Genotype 4 in Africa and middle east, increased frequency in Europe Genotype 5 in South Africa Genotype 6 in Hong Kong, Vietnam and Australia Genotype 1 is the nemesis of treaters, researchers and pharmaceutical manufacturers IL28B genetic polymorphism? Huh?

6 Who Should Be Screened? Persons born between Persons who currently inject drugs or who have injected drugs in the past, even once or in the distant past Recipients of clotting factor concentrates before 1990s Recipients of blood transfusion or donated organs before July 1992 Long term hemodialysis patients Persons with known exposures to HCV (e.g., healthcare workers after needle sticks, recipients of blood or organs from a donor who later tested positive for HCV) HIV-infected persons Children born to infected mothers Patients with signs or symptoms of liver disease (e.g., abnormal liver enzyme tests) Donors of blood, plasma, organs, tissues or semen

7 Birth Cohort Per the CDC, anyone born between 1945 and 1965 should be screened, regardless of risk factor According to data from 1999 to 2008, three fourths of patients in the United States living with HCV infection were born between 1945 and 1965 (US Preventative Task Force web site) grade B recommendation

8 Incidence of HCV Estimates in 2005: 185 million people globally infected(1) In United States, from a high of 250,000 new cases annually (1980s), down to 17,000 new cases annually(3) Per CDC, current overall incidence 0.3 per 100,000 (1) Global epidemiology of hepatitis C virus infection: new estimates of age-specific antibody to HCV seroprevalence. Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST Hepatology. 2013;57(4):1333 (2) Surveillance for acute viral hepatitis--united States, Wasley A, Grytdal S, Gallagher K, Centers for Disease Control and Prevention (CDC) MMWR Surveill Summ. 2008;57(2):1

9 Why Do We Care New cases are declining Infections from 1960s, 70s, 80s are suffering the consequences and complications Cirrhosis Hepatocellular Carcinoma Diminished quality of life

10 Symptoms of HCV Typically asymptomatic Symptoms often not attributed to HCV Most common: fatigue Along with anemia and thyroid issues, put HCV in differential Also nausea, anorexia, myalgias, arthralgias, weakness Rarely debilitating

11 Quality of Life Even without specific symptoms of the virus, HCV diminishes health related quality of life(4) Successful treatment improves quality of life (3) Impact of hepatitis C on health related quality of life: a systematic review and quantitative assessment Spiegel BM, Younossi ZM, Hays RD, Revicki D, Robbins S, Kanwal F Hepatology. 2005: 41(4): 790

12 Extrahepatic manifestations of HCV A study of 321 patients with chronic HCV, 38% had extrahepatic manifestations (4) Dermatologic: purpura, porphyria cutanea tarda, psoriasis Rheumatologic: arthropathies Other: neuropathies, uveitis (4) Extrahepatic manifestations associated with hepatitis C virus infection. A prospective multicenter study of 321 patients. The GERMIVIC. Groupe d'etude et de Recherche en Medecine Interne et Maladies Infectieuses sur le Virus de l'hepatite C. Cacoub P, Renou C, Rosenthal E, Cohen P, Loury I, Loustaud-Ratti V, Yamamoto AM, Camproux AC, Hausfater P, Musset L, Veyssier P, Raguin G, Piette JC Medicine (Baltimore). 2000;79(1):47.

13 Natural History of HCV Infection Stable Acute HCV Chronic HCV 55 to 85% Resolved 15 to 45% 75 to 95% Cirrhosis 5 to 25% Stable HCC or Decompensation 1-3% /yr

14 Complications of advanced liver disease Cirrhosis once advanced fibrosis has developed, risk of progression to cirrhosis ~10% /year Synthetic failure Hypoalbuminemia Jaundice Prolonged bleeding time Portal Hypertension Ascites, peripheral edema Varices and bleeding encephalopathy Hepatocellular carcinoma

15 Complications continued Hepatitis C accounts for nearly one-third of deaths annually from hepatocellular carcinoma in US Higher risk of death from complications of decompensated cirrhosis

16 Factors associated with disease progression Acquiring the virus after age 40 Male Blood transfusion may be a higher risk Steatosis ALCOHOL Maintaining abstinence (hx of abuse) can improve histology in the presence of chronic virus

17 Burden of Disease In a study present at The Liver Meeting in 2011, the annual health care costs of a patient with hepatitis C (without cirrhosis) is nearly $18,000. (5) According to the United Network for Organ Sharing (UNOS)' Transplant Living Web site, the estimated U.S. average in 2011 of billed charges per liver transplant is $577,100. ~$25,000 annually for anti-rejection drugs (5)Disease burden in patients with chronic hepatitis C virus (HCV) infection in a United States (US) private health insurance claims database analysis from 2003 to (11/15/11) AASLD Nov SF, SC Gordon,1 PJ Pockros,2 NA Terrault,3 RS Hoop,4 A Buikema,5 D Nerenz,1 FM Hamzeh4 1Henry Ford Health System, Detroit, MI, USA; 2Scripps Clinic Torrey Pines, La Jolla, CA, USA; 3University of California at San Francisco, San Francisco, CA, USA; 4Genentech, South San Francisco, CA, USA; 5i3 Innovus, San Francisco, CA, USA

18 Still wondering why we treat?

19 Treatment objectives Sustained viral response (SVR) CURE! Avoid complications of cirrhosis and/or hepatocellular carcinoma Success measured by No viremia Normalized ALT Improved histology Decreased necroinflammatory action Stable or improved level of fibrosis

20 Success measured by No viremia Normalized ALT Improved histology Decreased necroinflammatory action Stable or improved level of fibrosis

21 Evolution of Treatment (or how I have tortured 100s of unsuspecting souls over the years)

22 Medieval Standard interferon alpha, monotherapy Mechanism of action: stimulates immune response FDA approved in 1991 Subcutaneous injection TIW 50% respond with normalized ALT and undetectable viral load but 24 week course ~ 12% success rate 48 week course ~ 24% success rate

23 Addition of Ribavirin 1998 FDA approval for combination therapy with interferon Mechanism of action: decreases replication by inhibiting pro (?) Ribavirin oral agent, interferon still TIW SQ 35% cure rate VERY exciting

24 Pegylation Polyethylene glycol added to the interferon Improved half-life Allowed for weekly SQ combined with daily ribavirin Cure rates increased to ~40% in genotypes 1,4,5,6 ~70% in genotypes 2,3

25 Side effects of Peg/RBV

26 Fatigue Anemia May require Procrit or transfusion Dose reductions decrease response pancytopenia insomnia Hyper somnolence Alopecia (rarely irreversible( Dyspnea Cough fatigue Nausea Diarrhea Arthralgias Depression fatigue Anxiety suicidal ideation Exacerbation of autoimmune disease Dry skin Pruritus +/- rash Thyroid dysfunction (+/- reversible) Retinal hemorrhage fatigue uveitis Leukocytoclastic vasculitis Prophyria cutanea tarda Migraine Polyarteritis nodosum Worsening of diabetes Teratogenicity (RBV)

27 Newer Agents Protease inhibitors approved May 2011 Direct Acting Anti-virals Approved for genotype 1 only NS 3/4A inhibitors with activity against HCV encoded serine protease required for cleavage of viral polyprotein= no replication Telaprevir and Boceprevir: very similar efficacy $$$$$ SVR increased to >70%

28 Treatment regimens Boceprevir Treatment course wks depending on response 200 mg 4 every 7-9 hours (with food) RBV 200 mg 4-6 divided BID Pegylated interferon alfa Weekly SQ Telaprevir Treatment course wks depending on response 375 mg 2 TID every 7-9 hours with 20g fat RBV 200 mg 4-6 divided BID Pegylated interferon alfa Weekly SQ

29 BUT more side effects More anemia More pruritus More fatigue Dysgeusia Anal/rectal complaints Anal pruritus Diarrhea (fire-rrhea) Hemorrhoids Anal pain More rash Mild, moderate, severe Serious: SJS TEN: Toxic Epidermal Necrolysis DRESS: Drug reaction with eosinophilia and systemic symptoms

30 Patient Selection Your most important (and often most difficult) decision

31 Not everyone wants treatment Not everyone needs treatment Some patients should not be treated Everyone should be evaluated and know their status

32 AASLD Recommendations(6) At least 18 years of age and HCV RNA + and Liver biopsy showing significant fibrosis and Compensated liver disease and Acceptable hematologic and biochemical indices and Willing to be treated and adhere to treatment requirements

33 AASLD continued Individualize Decision to Treat(6) Failed previous therapy Current alcohol or illicit substance users No or mild fibrosis by liver biopsy Coinfection with HIV Chronic renal disease Decompensated cirrhosis Liver transplant recipients

34 Contraindications to HCV Therapy(7) Uncontrolled depressive illness, psychosis, or epilepsy Untreated anemia Autoimmune hepatitis or other autoimmune condition known to be exacerbated by interferon Untreated thyroid disease Pregnancy or unwillingness to comply with adequate contraception Severe concurrent medical disease (7) Ghany MG, et al. Hepatology. 2009;49: EASL Clinical Practice Guidelines: Management of hepatitis C virus infection. June 2011.

35 Lab markers of concern: Albumin <3.7 can predict decompensation on treatment even if biopsy does not reflect cirrhosis Platelets <75

36 Preparing Patients for Therapy Clear understanding of treatment options Review, explain, review, explain side effects and management (consent form to treat?) Clear description of treatment protocol, duration and administration schedule for medications Clear understanding of lab requirement and office visit expectation Free drug possible and no-charge office visit but labs are not free

37 Job related issues Support system Clear understanding of prognosis, predicted response per treatment protocol Your expectations regarding alcohol, drug use This is a two way discussion treatment is elective, no matter how necessary you think it is Reluctant patients are not adherent to therapy

38 New therapies on the horizon Will likely be multi-drug cocktails Goals High SVR Pan genotypic All oral Clean SE profiles Short duration of therapy Smaller pill burden

39 Specific treatment targets NS3/4 A protease inhibitors NS3 protease inhibitors NS5A nonnucleoside inhibitor NS5B nonnucleoside polymerase inhibitors NS5B nucleotide polymerase inhibitors NS5A inhibitor

40 American Companies Most with more than one compound Gilead Merck AbbVie Bristol-Myers Squibb Janssen Roche Vertex Kadmon

41 The end is near!

42 Final thoughts Screen per birth cohort/risk factor If +HCV Ab get genotype, viral load to establish chronicity If negative, repeat in 6 months to confirm If positive and treatment not an option, don t check viral load yearly HCV replicates 1 trillion virions daily: numbers fluctuate dramatically and do not correlate with fibrosis or inflammation

43 The temporary normalization of ALT levels should not be equated with improvement of disease nor should it be used as a justification for not seeking treatment. Melissa Palmer, MD (Dr Melissa Palmer s Guide to Hepatitis & Liver Disease)

44 Markers of deterioration Albumin dropping less than 3.7 indicates worsening fibrosis and synthetic function Watch platelets Monitor synthetic function Increasing INR, bilirubin