Hepatitis C Choices in Care Nutrition and Hepatitis C Lyn Patrick, ND.
Hepatitis C Choices in Care
description
Transcript of Hepatitis C Choices in Care
![Page 1: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/1.jpg)
Testing of Patients with Chronic Hepatitis C:
What do I really need?
Hepatitis C Choices in Care
Greg Everson, MD
![Page 2: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/2.jpg)
Main Reasons for Testing
Defining disease severity Defining likelihood of response to
antiviral therapy Screening for early stage
hepatocellular carcinoma (HCC)
![Page 3: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/3.jpg)
Defining Disease Severity
![Page 4: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/4.jpg)
A Healthy Liver
![Page 5: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/5.jpg)
A Cirrhotic Liver
![Page 6: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/6.jpg)
Standard Clinical Evaluation
![Page 7: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/7.jpg)
Standard Lab Tests Suggesting Cirrhosis
AST:ALT ratio > 1 Elevated total bilirubin > 2
mg/dL INR > 1.5 Platelet count < 125,000/μL
Note: If the AST:ALT ratio > 2, then alcohol-related liver injury is likely!
![Page 8: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/8.jpg)
Liver Enzymes: AST & ALT
Elevated blood levels of liver enzymes (AST, ALT) indicate ongoing liver injury – the membrane of the liver cells is damaged and liver enzymes leak into the blood stream
The degree of elevation in liver enzymes in the blood correlates with the severity of liver cell injury.
However, blood levels of liver enzymes do not correlate with the degree or severity of hepatic fibrosis. Patients with cirrhosis often have relatively lower enzyme elevations than patients with earlier stages of fibrosis.
![Page 9: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/9.jpg)
Standard Evaluation – Staging Disease
History and Physical ExaminationAST:ALT, Alk Phos, Bilirubin, INR, Platelet Count
ObviousCirrhosis
Minimal DiseaseVery Likely
IndeterminateStage of Disease
20Actual Stage 0-1 = 40
75Actual Stage 2-3 = 45
5Actual Stage 4 = 15
N = 100Patients with Chronic Hepatitis C Presenting for Initial Evaluation
After standard evaluation, the stage of disease is indeterminate in 75%!
![Page 10: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/10.jpg)
Noninvasive Tests and Models
![Page 11: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/11.jpg)
Noninvasive Tests
Serum Fibrosis Tests - very low scores correlate with lack of significant fibrosis and very high scores, with cirrhosis Fibrosure, Fibrospect, Fibrotest, APRI HALT-C model (standard labs) Platelet count
![Page 12: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/12.jpg)
HALT-C Model to Predict Cirrhosis log odds (predicting cirrhosis) =
-5.56 - 0.0089 x platelet (x103/mm3) + 1.26 x AST/ALT ratio + 5.27 x INR.
The formula to calculate predicted probability is exp(logodds)/(1+exp(logodds)).
Website: www.haltctrial.org/cirrhosis.htmlCaution: May not be generalized to all patients with chronic hepatitis C!
![Page 13: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/13.jpg)
Noninvasive Tests
Elastography – measures liver stiffness Fibroscan - Validation studies ongoing Gaining popularity due to marked ease of use Probably best at the extremes of no fibrosis and
cirrhosis
Radiologic Imaging – inaccurate for staging except for the most advanced disease
![Page 14: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/14.jpg)
Noninvasive Tests
Quantitative Liver Function Tests (QLFT’s) - measure liver function Breath ID, metabolic tests SPECT liver-spleen scans Cholate Test (HepQuant-Dual and HepQuant-
Oral)
![Page 15: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/15.jpg)
Noninvasive Tests of Fibrosis
Smith JO, Sterling RK. Aliment Phamacol Ther 2010
![Page 16: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/16.jpg)
Noninvasive Tests of Fibrosis
Smith JO, Sterling RK. Aliment Phamacol Ther 2010
![Page 17: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/17.jpg)
Minimal DiseaseVery Likely
IndeterminateStage of Disease
Noninvasive Tests ofFibrosis/Cirrhosis
80% Accuracy for Minimal and Cirrhosis
Stage 0-1 IndeterminateStage of Disease
Stage 4
Noninvasive Tests – Staging Disease
8
20 75
1010
34 53After noninvasive testing, the stage of disease is indeterminate in 53%!
![Page 18: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/18.jpg)
Liver Biopsy
![Page 19: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/19.jpg)
Staging of Disease Severity byLiver Biopsy
Grading degree of Inflammation
Staging degree of fibrosis
Define risk for future decompensation
Identify patients at risk for HCC
![Page 20: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/20.jpg)
Hepatitis C Caring Ambassadors Program
![Page 21: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/21.jpg)
Hepatitis C Caring Ambassadors Program
![Page 22: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/22.jpg)
Hepatitis C Caring Ambassadors Program Stage 2
![Page 23: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/23.jpg)
Hepatitis C Caring Ambassadors Program Stage 3
![Page 24: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/24.jpg)
Hepatitis C Caring Ambassadors Program Stage 4
![Page 25: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/25.jpg)
Defining Likelihood ofResponse to Antiviral
Therapy
![Page 26: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/26.jpg)
HCV Genotype
![Page 27: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/27.jpg)
HCV Genotype What is genotype and why should I be
tested? Genotypes are genetic subclasses of HCV – there
are 6 common genotypes, 1 through 6.
The greatest predictor of response to PEG(IFN)/RBV therapy is genotype. Geno 1 is least responsive, but still has 40 - 50% chance for SVR. Geno 2 is most responsive, 80 – 90% SVR.
Genotype does not predict rate of progression, severity of liver disease, or risk for HCC.
![Page 28: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/28.jpg)
SVR Rates with Peg-IFN/RBV:According to Genotype
0
20
40
60
80
100
42%-46%
76%-82%
Genotype 1 Genotype Non-1
Adapted from Strader DB et al. Hepatology. 2004;39:1147-1171.
SVR (%)
![Page 29: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/29.jpg)
Virologic Response duringAntiviral Therapy
“Viral-response Guided Treatment”
![Page 30: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/30.jpg)
HCV RNA Blood Level (“Viral Load”)
What is “viral load” and why should I be tested? HCV RNA blood level, commonly called “viral load”, is
monitored throughout the course of treatment – early virologic response to interferon-based treatment is associated with greatest chance for SVR and cure. The main purpose of measuring viral load is monitoring response to treatment.
In patients with Geno 1 infection, low viral load, particularly less than 400,000 IU/ml, is associated with greatest chance for SVR with interferon-based therapy. In patients with Geno 3 infection, high viral load may identify patients who might benefit from prolongation of treatment beyond 24 weeks.
Viral load does not predict rate of progression or severity of liver disease.
![Page 31: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/31.jpg)
Virologic Response to Antiviral Therapy
Rapid Virologic Response (RVR) Definition: HCV RNA negative by pcr at week 4 of
treatment Implications:
RVR identifies patients with highest likelihood of achieving SVR
RVR may also identify patients who can be treated with shorter courses of therapy
Early Virologic Response (EVR) Definition: HCV RNA has dropped 2 logs (100 fold) or more
from baseline at week 12 of treatment Implications:
EVR identifies responders - excellent chance of achieving SVR
Stop Guideline – patients without EVR have only 2% chance of SVR with continued treatment. Generally, treatment is stopped in those patients who fail to achieve EVR.
![Page 32: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/32.jpg)
RVR and EVR: Geno 1, 48 wks Rx
0
1
2
3
4
5
6
7
0 20 40 60 80
RVR SVRRVR RelEVR SVREVR Rel
Log HCV RNA
< 10% Relapse
35% Relapse
![Page 33: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/33.jpg)
IL28b Polymorphism
Role in Assessing Patients for
Treatment is under study
![Page 34: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/34.jpg)
IL28B Genetic Variation and Genotype 1 Response
1137 patients from the IDEAL trial
IL28B polymorphims: C/C C/T T/T
Ge D, et al. Nature. 2009;461(7262):399-401.
![Page 35: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/35.jpg)
Percentage of SVR by Genotypes of rs12979860
100
75
50
25
0
European-Americans
African-Americans
Hispanics CombinedT/T T/C C/C T/T T/C C/C T/T T/C C/C T/T T/C C/C
SVR
(%of
pat
ient
s)
Ge D, et al. Nature. 2009;461(7262):399-401.
Genotype:
![Page 36: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/36.jpg)
Screening for Early-StageLiver Cancer (Hepatoma,
HCC)
![Page 37: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/37.jpg)
Blood Tests for HCC Alpha-fetoprotein (AFP)
Insensitive – elevated in only 1/3 of cases of HCC
Nonspecific – may be elevated due to HCV One AFP subtype, AFP-L3, may be more
specific Other tests (DCP, proteome/genome) If used, measure q 3 – 6 months
![Page 38: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/38.jpg)
Radiologic Imaging Most reliable method for screening
Candidates for radiologic screening for HCC should have bridging fibrosis or cirrhosis on liver biopsy – and, they should be candidates for treatment (chemoembolization, RFA, chemotherapy, liver resection, or transplantation) if HCC diagnosed.
Based on cost, US is preferred over CT. Based on imaging, CT is favored over US.
Frequency of imaging – US/CT every 6 months
Cirrhotic/bridging fibrotic patients should be screened in long-term followup, even after SVR
![Page 39: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/39.jpg)
CT Scan of Normal Healthy Liver
![Page 40: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/40.jpg)
CT Scan of Hepatoma (HCC)
![Page 41: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/41.jpg)
Summary - Testing For defining disease severity
Standard clinical and laboratory evaluation Noninvasive Testing – Fibrotest, Fibroscan, QLFT Liver biopsy – for indeterminate cases
Defining likelihood of response to antiviral therapy HCV Genotype HCV RNA blood level prior to treatment HCV RNA response during treatment (RVR, EVR) IL28b polymorphism?
Screening for Hepatoma (HCC) Radiologic imaging – q 6 to 12 mo for advanced
fibrosis/cirrhosis
![Page 42: Hepatitis C Choices in Care](https://reader035.fdocuments.in/reader035/viewer/2022062812/568163c9550346895dd4fff4/html5/thumbnails/42.jpg)
For more information
Visit us on line at www.HepCChallenge.org
Chapter 6: Laboratory Tests and Procedures
http://www.hepcchallenge.org/choices/pdf/Chapter_06_OL.pdf