Update on New Treatments · Recommended Follow-up After Hepatitis C Treatment AASLD/IDSA. HCV...
Transcript of Update on New Treatments · Recommended Follow-up After Hepatitis C Treatment AASLD/IDSA. HCV...
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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
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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.
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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?
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How Do We Need To Engage You?
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The Canadian Liver Foundation
recommends that all adults
(baby-boomers) born between
1945 and 1975 be tested for
hepatitis C once.
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Is There Another Reason To
Engage You?
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1. Yehia BR, et al. PLoS One. 2014;9:e101554.
HCV in the US: Gaps in Practice
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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.
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Talking to Patients About Hepatitis C Testing
CDC. Guide to Comprehensive Hepatitis C Counseling and Testing.
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Current All-Oral Therapies Highly
Effective
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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
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Counseling for HCV-Infected Individuals
AASLDIDSA. HCV Guidelines 2017.
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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)
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Back to Our Case
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FIB-4 Index = (54 × 64) ÷ (155 × √68) = 2.70 (F2-3)
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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.
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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
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HCV Therapy Regimens
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Maverit
Vosevi
Epclusa
Zepatier
Harvoni
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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
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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
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Recommended Follow-up After Hepatitis C
Treatment
AASLD/IDSA. HCV Guidelines 2017.
Virologic cure does not protect against reinfection
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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
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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
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Questions or Comments
Send me an email if
you are interested in
becoming HCV treater