Hepatitis C: Screening changes, treatment advances

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Applied Evidence

Hepatitis C: Screening changes, treatment advances

J Fam Pract. 2017 March;66(3):136-140,142-144

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References

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17. US Food and Drug Administration. FDA Drug Safety Communication: FDA warns about the risk of hepatitis B reactivating in some patients treated with direct-acting antivirals for hepatitis C. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm522932.htm. Accessed December 15, 2016.

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22. Afdhal N, Zeuzem S, Kwo P, et al. Ledipasvir and sofosbuvir for untreated HCV genotype 1 infection. N Engl J Med. 2014;370:1889-1898.

23. Wyles DL, Ruane PJ, Sulkowski MS, et al. Daclatasvir plus sofosbuvir for HCV in patients coinfected with HIV-1. N Engl J Med. 2015;373:714-725.

24. Feld JJ, Jacobson IM, Hézode C, et al. Sofosbuvir and velpatasvir for HCV genotype 1, 2, 4, 5, and 6 infection. N Engl J Med. 2015;373:2599-2607.

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34. AASLD-IDSA. Unique patient populations: patients with HIV/HCV coinfection. HCV guidance: recommendations for testing, managing, and treating hepatitis C. Available at: www.hcvguidelines.org/full-report/unique-patient-populations-patients-hivhcv-coinfection. Accessed February 6, 2017.

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Which regimen is most likely to be successful?

Many factors influence the choice of regimen and likelihood for SVR. These factors include whether the patient has cirrhosis and any comorbidities, the hepatitis C genotype involved, and any prior treatment the patient may have received. (See TABLE 3^{7,12,18,28,30,33} for a comprehensive list.)

The easiest patients to treat are treatment-naive, with minimal liver disease and a favorable genotype. For example, combination therapy with the NS5B inhibitor sofosbuvir and an NS5A inhibitor (ledipasvir, daclatasvir, or velpatasvir) administered for 12 weeks has an SVR rate of >95% in genotype-1, treatment-naive, non-cirrhotic patients.^22-24 Patients with prior treatment failure, especially failure on DAA therapy, or who have genotype 3, may be less responsive to standard therapies and may require more complex regimens or a longer duration of therapy.

Patients requiring special attention. It’s preferable to manage patients with decompensated liver disease in a specialized hepatology center due to the possibility of further decline and need for transplant prior to completion of therapy. Patients with HIV are another population that requires special attention. As many as 25% of HIV-infected patients are co-infected with HCV; their treatment follows the same principles as that in non-HIV patients, with extra attention paid to avoiding drug-drug interactions. Elbasvir/grazoprevir, for example, should not be used with any protease inhibitors, with nevirapine, or with efavirenz, and sofosbuvir should not be used with efavirenz, nevirapine, or tipranavir.³⁴

Beyond medication regimens: The advice you’ll offer

In addition to counseling about antiviral therapy, patients with HCV infection require other types of advice and care that are often best administered by a primary care physician who is familiar with the patient and his or her family and community.

Prevention of transmission

Many patients have concerns about transmission of the virus to family members, co-workers, and sexual partners. You can assure patients that they are not likely to spread the virus in the workplace, even in health care environments.

Consider screening all HCV patients for diabetes mellitus because patients with chronic HCV infection have a higher prevalence of insulin resistance than those in the general population.Close contacts are also not at risk as long as basic prevention measures, such as not sharing toothbrushes or razors, are established to avoid transmission of blood and bodily fluids. Patient handouts can be found at the Centers for Disease Control and Prevention Web site (http://www.cdc.gov/hepatitis/hcv/patienteduhcv.htm#cdc).³⁵

Patients and their sexual partners, however, must be counseled about the risk of sexual transmission. In monogamous relationships between serodiscordant partners who practice vaginal intercourse, there is a low, but clinically important, risk of transmission of HCV—up to 0.6% per year.³⁶Anal intercourse and co-infection with HIV increase this risk significantly.³⁷ Pregnant women must be advised on the currently non-modifiable risk of transmission to newborns, which is approximately 6% in mono-infected women, but may be at least twice as likely in HIV/HCV co-infected women.^38,39

Staying healthy. In addition to pneumococcal and standard age-appropriate vaccines, vaccination against hepatitis A and HBV is recommended for all HCV-infected patients to reduce the risk of a severe acute hepatitis.^40,41 Advise patients to avoid alcohol, to consume a healthy diet, and to participate in regular activity and exercise. Review the patient’s medication list for hepatotoxic drugs and counsel the patient on the risks of excessive use of acetaminophen, non-steroidal anti-inflammatory drugs, and herbal medicines such as kava kava. Because obesity and metabolic syndrome are known risk factors for hepatic steatosis, which hastens the progression to cirrhosis and liver failure, counsel overweight and obese patients on the importance of healthy weight loss.⁴²^,43

Disease-related screenings. Consider screening all HCV patients for diabetes mellitus (DM) because people with chronic HCV infection have a higher prevalence of insulin resistance than those who are HCV-negative, and patients with type 2 DM are at higher risk for worse outcomes of their HCV infection.⁴⁴ In addition, screen all patients with a METAVIR score of F3 or higher every 6 months for HCC using liver ultrasound, and recommend upper endoscopy to patients with cirrhosis to screen for esophageal varices.^45,46

Health maintenance after treatment

Once patients have achieved SVR 12 weeks after completion of therapy, they are deemed cured. However, those patients who were already METAVIR F3 or higher maintain sufficient risk of HCC to recommend ongoing screening with ultrasound.^47,48

CORRESPONDENCE
Mark Shaffer, MD, 3209 Colonial Drive, Columbia, SC 29206; Mark.Shaffer@uscmed.sc.edu.