Download - MANAGEMENT HEPATITIS C · 2019-08-26 · DIAGNOSIS OF HEPATITIS C •Commonly asymptomatic •Not specific symptoms: fatigue, myalgia, abdomen pain, anorexia, nausea, vomiting, fever

MANAGEMENT HEPATITIS C

DR. Dr. Andri Sanityoso Sulaiman, Sp.PD-KGEHHepatobiliary Division, Department of Internal Medicine, Cipto Mangunkusumo National General

Hospital, Faculty of Medicine, Universitas Indonesia

Pertemuan Ilmiah Tahunan Ilmu IDI Jakarta UtaraJakarta, 25 Agustus 2019

HEPATITIS C

GLOBAL PREVALENCE OF HEPATITIS C INFECTION

Petruzziello A, Marigliano S, Loquercio G, Cozzolino A, Cacciapuoti C. Global epidemiology of hepatitis C virus infection: an up-date of the distribution and circulation of hepatitis C virus genotypes. World J Gastroenterol. 2016;22(34):7824-7840

Asia is the continent with highest prevalence of Hepatitis C infection

PREVALENCE OF ANTI-HCV IN ASIA

Prevalence anti-HCV : Indonesia (0.8%) – Thailand (2.7%)Petruzziello A, Marigliano S, Loquercio G, Cozzolino A, Cacciapuoti C. Global epidemiology of hepatitis C virus infection: an up-date of the distribution and circulation of hepatitis C virus genotypes. World J

Gastroenterol. 2016;22(34):7824-7840

GENOTYPE OF HCV IN ASIA

G1 and G6 covers 60% from all genotype in AsiaPetruzziello A, Marigliano S, Loquercio G, Cozzolino A, Cacciapuoti C. Global epidemiology of hepatitis C virus infection: an up-date of the distribution and circulation of hepatitis C virus genotypes. World J

Gastroenterol. 2016;22(34):7824-7840

PREVALENCE OF HCV INFECTION (ANTI-HCV) IN INDONESIA, RISKESDAS 2013

Riset Kesehatan Dasar. 2013.

TRANSMISSION OF HCV

Host Resipien

Transmisi Horizontal Transmisi Vertikal

Ibu

Bayi

Injection drug use and tattoo (60%)

§ Pengguna jarum suntik

§ Tato dan tindik

Sexual (15%)

§ Multiple sexual partners

§ Men who sex with men (MSM)

Transfusi darah (10%)

Others (5%)

§ Hemodialisis jangka panjang

§ Tenaga kesehatan

Unknown (10%) Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017

Centers for Disease Control and Prevention (CDC), 2012

RISK FACTOR OF HEPATITIS C INFECTION

Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017

NATURAL HISTORY OF HEPATITIS C

75-85% kasus akut akan menjadi kronik 10-20 %

1-4 %

Chen SL, Morgan TR. The natural history of hepatitis C virus (HCV) infection. Int J Med Sci. 2006;3(2):47-52

DIAGNOSIS OF HEPATITIS C

• Commonly asymptomatic• Not specific symptoms: fatigue, myalgia,

abdomen pain, anorexia, nausea, vomiting, fever

Anamnesis

• Can found subfebrile fever, icteric, hepatomegaly

• If already become cirrhosis à stigmata cirrhsosis

Physical examination

• Laboratory: anti-HCV, HCV RNA, ALT, AST• Examination of liver stiffness: USG,

Fibroscan, biopsy

Supported examination


SEROLOGY FEATURE OF HEPATITIS C INFECTION

HVC-RNA detected 7-10

days after exposure

Anti-HCV detected 2-8 weeks after

exposure


LABORATORY INTERPRETATIONAnti-HCV VHC-RNA Interpretation

Positive Positive Acute or chronic depend on symptoms

Positive Negative HVC resolution, infection status cannot determined (intermittent viremia)

Negative Positive Early acute HCV infection; chronic infection in immunosuppression patient

Negative Negative Not infected with HCV


DIAGNOSIS OF CHRONIC HEPATITIS C INFECTIONAnti-HCV and HCV-RNA still detected > 6 months since infected

with or without symptoms of chronic liver disease

DIAGNOSIS RECOMMENDATION OF HEPATITIS C INFECTION

Anti HCV

Positive Negative

HCV RNA

Not infectedInfection HCV if positive

High suspicion

EIA / CLIARapid Diagnostic Test


THERAPY INDICATION OF CHRONIC HEPATITIS C

TARGET THERAPY OF HEPATITIS C

Eradication of HCV


DEVELOPMENT THERAPY OF HCV INFECTION

PHARMACOLOGY PROFILE OF DAA


MECHANISMS OF HEPATITIS C DRUGS

DAFTAR DAA YANG RENCANA MASUK KE INDONESIA

Nama Obat Status Masuk ke Indonesia

Sofosbuvir Terdaftar 2015

Simeprevir Terdaftar 2016

Daclatasvir Terdaftar 2016

Sofosbuvir + Ledipasvir Terdaftar 2017

Elbasvir + grazoprevir Belum terdaftar 2018

Velpatasvir Belum terdaftar Rencana masuk ?


TERAPI HEPATITIS C (DAA): TANPA SIROSIS


Sofosbuvir + daclatasvir dan sofosbuvir + velpatasvir dapat digunakan untuk seluruh genotipe

TERAPI HEPATITIS C (DAA): SIROSIS KOMPENSATA


Sofosbuvir + daclatasvir dan sofosbuvir + velpatasvir dapat digunakan untuk seluruh genotipe pada pasien sirosis kompensata

PERHATIAN KHUSUS PADA SIROSIS DEKOMPENSATA !!

EASL Recommendations on Treatment of Hepatitis C 2018. J Hepatol.

REKOMENDASI PPHI PEMILIHAN REGIMEN TERAPI PADA SIROSIS DEKOMPENSATA

Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. 2017.

Sofosbuvir + daclatasvir dan sofosbuvir + velpatasvir dapat digunakan untuk seluruh genotipe pada pasien sirosis dekompensata

PEMBERIAN OBAT ANTI VIRUS HEP C PADA PAN-GENOTIPIK

Rekomendasi berbagai organisasi internasional: Regimen Sofosbuvir dan Daclatasvir Regimen Sofosbuvir dan Velpatasvir Regimen Sofosbuvir, Peg-IFN, dan Ribavirin

Jika dicurigai mengalami resistensi atau gagal terapi à periksa resistensigenotipik.


PEMANTAUAN DAN PENYESUAIAN TERAPI

Obat/Pemantauan

MingguUlangan

Jenispemeriksaan1 2 4 8 12

Peg-IFN √ √ √ 4-8 minggu

Leukosit, trombosit, tes fungsi hati

RBV √ √ √ 4-8 minggu

Hb, retikulosit

Sofosbuvir Berkala Fungsi ginjal

Grazoprevir/elbasvir

√ √Fungsi hati

• Rekomendasi: jika terjadi efek samping pada terapi kombinasi DAA dengan Peg-IFN atau RBV à modifikasi dosisdilakukan pada selain DAA.


PEMANTAUAN EFEK SAMPING TERAPI

Apa yang dimonitor?Sofosbuvir Fungsi ginjal

Simeprevir RuamBilirubin

Elbasvir/grazoprevir Fungsi hati


Initial Screening with RDT/ELISA Antibody Test No further HCV screening

Confirmation of active HCV infection

Pre-treatment Assessment including staging of liver disease using non-

invasive test

No further HCV screening

Refer to liver specialist

Negativeresult

Positive result

Negativeresult

Decompensated Cirrhosis

Positive result

Treatment with pan-genotypic DAA regimen (for example sofosbuvir/daclatasvir)

Post-Treatment Assessment with HCV RNA test

Patient Cured

SVR

F0 – F4

No SVR Refer to specialist for genotyping and re-

treatment

1

2

3

4

HCV Diagnostic Summary with DAAs

THANK YOU