Hepatitis CUpdate on New Treatments
Kevork M. Peltekian, MD, FRCPC
44th Annual Dalhousie Spring Refresher Course - Therapeutics
April 5 - April 7, 2018
Halifax Convention Centre
Disclosures
Conflicts of Interest
Neither I, nor any
immediate family
member has any
financial relationship
with, or interest in, any
commercial interest
connected with this
presentation.
Off-Label Drug Use
The of material in this CPD activity will not include discussion of unapproved or investigational uses of products or devices.
Why Do We Need To Engage You?
Modelled Prevalence is 1.0%
(Plausibility Range 0.6 - 1.3%)
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When Do We Need To Engage You?
4
How Do We Need To Engage You?
5
The Canadian Liver Foundation
recommends that all adults
(baby-boomers) born between
1945 and 1975 be tested for
hepatitis C once.
Is There Another Reason To
Engage You?
6
1. Yehia BR, et al. PLoS One. 2014;9:e101554.
HCV in the US: Gaps in Practice
Questions I Will Try Answer…
• What is new regarding HCV treatment?
• Who is eligible for treatment of HCV?
• Why should every primary care providor
be diligent in identifying HCV cases and
treating them?
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Case: 56-Yr-Old Woman Presenting to Primary Care
• A 56-yr-old woman visits your office
• She has recently moved to the area following a promotion and is
looking for a primary care clinician
• She is not aware of having been tested for hepatitis C virus
infection previously
The Canadian Liver Foundation
recommends that all adults
(baby-boomers) born between
1945 and 1975 be tested for
hepatitis C once.
Talking to Patients About Hepatitis C Testing
CDC. Guide to Comprehensive Hepatitis C Counseling and Testing.
Current All-Oral Therapies Highly
Effective
Back to Our Case
• A 56-yr-old woman visits your office
• She has recently moved to the area following a promotion and is
looking for a primary care clinician
• Routine hepatitis C antibody test: reactive (positive) and her HCV
RNA by PCR is detectable with HCV viral load reported in Log10
is 5.78 IU/L or 600,000 IU/L
Counseling for HCV-Infected Individuals
AASLDIDSA. HCV Guidelines 2017.
Recommendations for Additional Follow-up of
Initial HCV Testing
• Testing for hepatitis C
genotype—all genotypes can
be treated, but genotype will
guide choice of antiviral
therapy
• Ultrasound to look for signs
of portal hypertension
(advanced cirrhosis) and
identify fatty liver disease
• Testing for HBsAg and HIV
• Testing for CBC, renal (Cr) +
liver functions (INR,
Bilirubin, Albumin) and
enzymes (ALT, AST, ALP)
• Assess presence of cirrhosis
by:
Clinical or Laboratory Testing
• Liver Biopsy (invasive)
• FIB-4 Index (simple)
Imaging by Elastography
• VCTE Fibroscan (long wait
list)
• MR Elastography (limited and
expensive)
Back to Our Case
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FIB-4 Index = (54 × 64) ÷ (155 × √68) = 2.70 (F2-3)
Recommendations for When and in Whom to
Initiate HCV Treatment
• Treatment for all: Unless pts already have short life expectancy,
treatment is recommended for all pts with chronic HCV
infection, regardless of genotype and fibrosis level[1]
• Treatment even at lower-stage fibrosis (F0-F1) improves
survival[1]
• Barriers to access: Contrary to these recommendations, some
insurers including provincial pharmacare restrict coverage to pts
with F2-F4 (moderate fibrosis or cirrhosis)[2]
1. AASLD/IDSA. HCV Guidelines. April 2017. 2. DHHS National Viral Hepatitis Action Plan 2017-2020.
Potential Future Scenario “When to Refer to an
Experienced Hepatitis C Treater”
• Treatment naïve
HCV infection
• Re-infection (not
relapse) with HCV
• No advanced
fibrosis
• Renal impairment
• Active substance use
• Prior treatment with
pegylated
interferon/ribavirin
• HIV or HBV co-
infection
• Compensated or
decompensated (ascites,
encephalopathy or
bleeding varices)
cirrhosis
• Recurrent HCV after liver
transplantation
• Liver mass
HCV Therapy Regimens
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Maverit
Vosevi
Epclusa
Zepatier
Harvoni
Recommendations for First Line
Therapy for HCV
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Adverse Events
• Newer hepatitis C medications do not have same adverse events
as interferon and are generally well tolerated
• Most common adverse events and management strategies in
pre-education session
• Headaches: nonpharmacologic management strategies, limits of
OTC pain relievers and liver disease
• Anemia: still a concern when ribavirin needed (not used as first
line therapy anymore)
• Other common adverse events: fatigue, nausea, diarrhea
• Encourage pts to report bothersome or unusual adverse events
Pretreatment: Look for Potential
Drug–Drug Interactions
• Review all herbals/supplements, prescription and OTC
medications, including contraceptives and proton pump inhibitors
• Ask about PRN usage of other drugs
Consult with clinical pharmacist when possible
Key resource: www.hep-druginteractions.org
Recommended Follow-up After Hepatitis C
Treatment
AASLD/IDSA. HCV Guidelines 2017.
Virologic cure does not protect against reinfection
Benefits of Curing HCV Extend Beyond the Liver
1. Smith-Palmer J, et al. BMC Infect Dis. 2015;15:19. 2. Negro F, et al. Gastroenterology.
2015;149:1345-1360. 3. George SL, et al. Hepatology. 2009;49:729-738.
SVR 12 weeks after completing Rx
Key Points
• All pts born 1945-1975 should be screened for
hepatitis C virus infection
• Virtually all pts with hepatitis C virus infection
should be treated, regardless of genotype and
fibrosis
Prevents morbidity, progression of fibrosis, hepatocellular carcinoma
• Many pts can be treated in primary care setting
Refer pts with decompensation (ie, ascites)
• Current treatments include pangenotypic and
ribavirin-free options
More than 95% rate of cure for most genotypes
Most therapies are 8-12 wks, ribavirin free, all oral, once daily
Questions or Comments
Send me an email if
you are interested in
becoming HCV treater