MONTE TROUTMAN, DO, FACOI, FAME UNTHSC/TCOM ASSOCIATE PROFESSOR OF MEDICINE OBJECTIVES

Transcription

1 MONTE TROUTMAN, DO, FACOI, FAME UNTHSC/TCOM ASSOCIATE PROFESSOR OF MEDICINE OBJECTIVES Know risk factors for HCV Know testing involved How to assess extent of disease Be familiar with complications of HCV Know treatment available 1

2 PRE/POST QUESTIONS Which group has the highest incidence of HCV? a) Females b) Baby boomers c) Alcoholics d) Generation X e) Immigrants What medications are most effective in treatment of chronic HCV? a) Milk thistle b) Direct acting antivirals c) Interferons d) Ribavirin e) Steroids 2

3 Which cancer is the fastest increasing in USA? a) Hepatocellular carcinoma b) Biliary tract cancer c) Colon cancer d) Pulmonary carcinoma e) Gastric cancer What scoring system is used for assessing liver transplant status? a) Ransom b) Winter s c) Child s d) MELD e) Dubois 3

4 HCV VIRUS Spherical, enveloped single stranded RNA virus Flavivirus 6 genotypes and more than 50 subtypes Genotypes 1, 2 and 3 most common in the USA Targets hepatocytes and B lymphocytes Large number of mutants or quasispecies Structural and non-structural portions NS5A portion subject to mutation 4

5 EPIDEMIOLOGY 3.5 million in USA with HCV 50% unaware 800,000 incarcerated, institutionalized, homeless 75% of those affected progress to chronic HCV Worldwide 220 million Liver disease is 11 th leading cause of death in USA US economy affected at $10.6 billion per year 6 genotypes with 50 sub-types 1a 50-60% 1b 15-20% 2 and 3 make up the rest Higher rates in minorities and lower socioeconomic groups 70-80% become chronic 20-50% progress Hepatocellular carcinoma (HCC) in 11-19% 5

6 HCV #1 reason 6,000 per year TRANSPLANTATION 17,000 on waiting list ETOH is #2 250K up front 314K with pre and post-op care Lifelong monitoring TRANSMISSION Percutaneous exposure to blood Vertical Sexual inefficient spread except men with men 29% incarcerated 60% IVDU 6

7 RISK FACTORS Intravenous Drug Use (IVDU) Blood transfusion/organ transplant prior to 7/1992 Received clotting factors prior to 1987 Percutaneous/parental exposure unregulated Tattoos Piercing Branding Acupuncture Risky sexual behavior Multiple partners Man on man sex Athletic sex Exposure to sex workers Vertical transmission Intranasal illicit drug use HIV HBV Hemodialysis Health care workers (especially blood exposure) Baby boomers ( ) Incarceration/ever (29%) Sharing toiletries 7

8 OTHER ISSUES WITH HCV DM Hypertension Fatty liver CAD Co infection (HBV, HIV) Co factors (alcohol, substance abuse, medications) SIGNS/SYMPTOMS OF HCV Fatigue Malaise Pruritis/excoriations Leg cramps Edema Distended abdomen Change in mental status Jaundice Dark urine Bruising Sleep inversion Dyspnea Amenorrhea Arthralgias Myalgias Sicca syndrome Rash Cryoglobulinemia 8

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14 West Haven criteria[edit] The severity of hepatic encephalopathy is graded with the West Haven Criteria; this is based on the level of impairment of autonomy, changes in consciousness, intellectual function, behavior, and the dependence on therapy. [1][9] Grade 1 - Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction Grade 2 - Lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behaviour Grade 3 - Somnolence to semistupor, but responsive to verbal stimuli; confusion; gross disorientation Grade 4 - Coma 14

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16 SCREEN All baby boomers (75% of all + HCV, 3.25% prevalence Annual for + active IVDU Annual for + HIV active unprotected sex Annual for ongoing risk Sex partners of + HCV patients All deceased and living organ donors All increased LFTs (transaminases) All cirrhotics All those with risk factors 16

17 Sexually active non HIV persons before they start prep for HIV prevention CDC and USPSTF do not recommend HCV (Egypt, Pakistan) but do recommend for HBV EHR should help PREVENTION/PROTECT Vaccinate (HAV, HBV, flu, pneumonia, all other routine) Avoid blood to blood contact Alcohol use restriction Check out all medication (Rx and OTC), supplements, herbs Maintain healthy weight Drink caffeinated coffee Avoid tobacco/recreational drugs 17

18 People with liver disease should seek medical attention Check for HBV and HIV Education on how to prevent spread and re infection Notify those at risk Avoid raw seafood Report to Public Health Department OTHER PHYSICAL FINDINGS Changing hair pattern to female distribution Decreased testicular size Small prostate 18

19 COMPLICATIONS OF ADVANCED LIVER DISEASE Ascites Spontaneous Bacterial Peritonitis (SBP) Esophageal varices Portal gastropathy Gastric varices Hepato renal syndrome Hepato pulmonary syndrome Porto pulmonary Hepato pulmonary Membranous glomerulonephritis Lichen planus PCT Muscular wasting Umbilical hernia ITP Decreased libido Testicular atrophy 19

20 Hemorrhoids Hepatic encephalopathy Hepatocellular carcinoma (HCC) Immunocompromised Malnutrition DIFFERENTIAL OF ELEVATED LFTS (AST/ALT) Hemochromatosis HCV HBV Drug induced liver injury (DILI) Autoimmune disease Alcohol Fatty liver Women have lower LFT levels* 20

21 Anti HCV serology TESTING If anti HCV is +, confirm with HCV RNA test If anti HCV is, retest in 6 months if suspect If anti HCV is and immunocompromised needs HCV RNA quantitative HCV genotype if HCV RNA positive Use FDA approved HCV testing FIBROSIS EVALUATION Liver biopsy Serology for METAVIR score (0 4) Imaging Fibroscan (elastography) 21

22 SCORING SYSTEM MELD (Model for End stage Liver Disease) Pugh Childs MELD UNOS and Mayo Total bilirubin INR Serum creatinine Can add sodium for Na MELD Range 6 40 Transplant evaluations in the high teens Can calculate 90 day mortality 22

23 Hepatic encephalopathy Ascites Serum bilirubin Serum albumin INR PUGH CHILDS Graded A, B, C B and C are decompensated A is 5 and 6 SCREEN FOR HCC One of fastest rising cancers in USA Alpha feto protein every 6 months Liver ultrasound every 6 months MRI triple phase if AFP and/or US positive CT triple phase To be done only if cirrhotic 23

24 GOALS OF TREATMENT Viral eradication Reduced progression Decreased transmission Decreased HCC TREATMENTS Interferons Ribovirin Protease inhibitors Direct acting antivirals (DAA) Liver transplant 24

25 Boceprevir Teloprevir PROTEASE INHIBITORS Sofosbuvir Viekira & XR Dasabuvir Ombitasvir Paritprevir Ritonavir Zepatier Elbasvir Grazoirevir DAA 25

26 Harvoni Lepipasvir Sofosbuvir Epclusa Sofosbuvir Velpatasvir More in the pipeline ADVANTAGES OF DAA More effective Shorter duration of action Fewer side effects However more costly 26

27 ACUTE HEPATITIS C Follow algorithm for chronic HCV treatment Contraindications Substance abuse Psychiatric disease Comorbidities Competing priorities Adverse effects Lack of access Lack of expertise BARRIERS 27

28 TAKEAWAY Test Get treated Vaccinate Educate Screen for HCC AASLD.org hcvguidelines.org emedicine.org REFERENCES 28

29 PRE/POST QUESTIONS Which group has the highest incidence of HCV? a) Females b) Baby boomers c) Alcoholics d) Generation X e) Immigrants What medications are most effective in treatment of chronic HCV? a) Milk thistle b) Direct acting antivirals c) Interferons d) Ribavirin e) Steroids 29

30 Which cancer is the fastest increasing in USA? a) Hepatocellular carcinoma b) Biliary tract cancer c) Colon cancer d) Pulmonary carcinoma e) Gastric cancer 30