Hiding from Hep C? Dive in with experts Dr. Gina Simoncini, MD, MPH Associate Professor of Clinical Medicine at Temple University Hospital, & Dr. David Koren, PharmD, BCPS, AAHIVP, board-certified pharmacotherapy specialist and infectious diseases clinical pharmacist at Temple University Hospital. They walk us through a simplified approach on whom to screen, how to start antiviral therapy, what to follow up on, and how to navigate insurance waters along the way.
Special thanks to Sarah Roberts and Jordana Kozupsky who wrote and produced this episode and the show notes!
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Case from Kashlak Memorial: A 38 year old male presents to the outpatient clinic complaining of a month of worsening fatigue. Past medical history includes depression, high blood pressure, and diabetes. He currently takes an antidepressant and a blood pressure medication. Patient lives in a men’s shelter after being evicted from his house. Patient smokes marijuana and reports past experimentation with cocaine and injection drug use. His urine tox screen is positive for cannabinoids. His HIV assay is non-reactive. His hepatitis C (HCV) antibody test is reactive.
Always start by ordering an HCV antibody test with reflex viral load testing
Lab assessment prior to initiating treatment: CBC, CMP, coags, genotyping, NS5A resistance, HBsAg, HBsAb, anti-HBc, liver ultrasound, biomarkers for fibrosis
If a person has HCV and a low platelet count, they have cirrhosis until proven otherwise.
Use validated lab markers (FibroTest™ or Fibrosure™) to check for Fibrosis; biopsies are more invasive and have a 15% inherent sampling error. Scores will be reported as a range from F0-F4 (no cirrhosis – cirrhosis); some insurances require a certain score before covering antiviral therapy.
Be aware of state restrictions for covering treatment, including who can prescribe, what degree of fibrosis the patient must have to qualify, and if the patient must be sober prior to treatment.
You can extend length of treatment based on resistance patterns dictated in the NS5A resistance test.
3 main HCV therapeutic targets and drug endings:
NS5A protein: “-asvir”
NS5B RNA-dependent polymerase: “-buvir,”
NS3/4A protease: “-previr’”
Common drug interactions: watch for statins, PPIs/high dose H2 blockers, and anti-epileptics
Side effects of treatment: mild fatigue, GI upset, myalgias and rhabdomyolysis if taken concurrently with statin. Usually very well tolerated.
Follow up visits on directing-acting antivirals (DAA):
Obtain a HCV RNA, CBC, CMP at 1 month, end of treatment, and 3 month post treatment.
“Cure Labs”- check a HCV viral load, CBC, CMP at 3 months post treatment to assess for sustained virologic response (SVR12)
Post-SVR: dependent on harmful activities
IVDU: check yearly HCV RNA.
If cirrhotic, move to HCC screening
HCC screening: screen for > 3 years post treatment with US Q 6-12 months
Lifetime reinfection rate is 5-10%; cure rates are 95-97%
Watch out for Hepatitis B reactivation in exposed patients! e.g. Core Ab positive
Patient Counseling: risk reduction (clean needle exchanges if applicable), overdose prevention (Narcan), methods of transmission, lifetime reinfection risk
If you’re just starting to treat Hep C, establish a network of experienced providers for clinical advice, and do your research ahead of time (insurance regulations, cost of medication, charting requirements)
ASCEND study: PCPs and NPs were just as successful as their specialist colleagues when it came to safely and effectively treating HCV patients
Goal: Listeners will develop a standardized approach to the diagnosis, management, treatment options, and follow up care for patients with hepatitis C infection (HCV).
Learning objectives: After listening to this episode listeners will…
Recognize who to screen, and how, for Hepatitis C
Understand pre-treatment workup, including different methods for staging fibrosis
Recognize main antiviral groups based on genotyping.
Have an organized framework for follow-up visits and laboratory monitoring
Learn what you’ll need to know prior to treating your first Hep C patient, including how to approach insurance carriers, required documentation, and establishing an interdisciplinary network of providers.
Recall important discussion points for patient counseling, including methods of transmission and recurrence/cure rates.
Disclosures: Dr Simoncini receives research support from Gilead Sciences.
Time Stamps 00:00 Intro 01:00 Guest bios 03:00 Getting to know our guests 05:35 Picks of the week 10:05 Clinical case 10:54 Diagnosing HCV 12:00 ASCEND study 13:14 Restrictions on HCV treatment 15:17 Ordering and interpreting pre-treatment tests 19:30 Prescribing medication 22:00 Genotyping and drug resistance 24:10 Patient counseling 25:49 Understanding drug classes 27:33 Drug interactions 30:06 Multidisciplinary approach to treatment 33:01 Follow-up 36:47 Reinfection/cure rates 39:35 Patient counseling revisited 41:25 Side effects of treatment 42:53 Screening 44:02 Take home points