Recommendations 8/14/2014. Hepatitis C Clinical Approach Primary Care. Purpose of Presentation. HCV Prevalence Year of Birth

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1 Hepatitis C Clinical Approach Primary Care Dr. Vicki L. MIt McIntyre, FNP Tucson Gastroenterology Specialists Tucson, Arizona University of Phoenix Lead Faculty, Department of Nursing Tucson, Arizona Purpose of Presentation Establish competence in screening and diagnosing of persons with hepatitis C (HCV) infection. Summarize HCV testing sequence for identifying current infection. Recognize and diagnose persons with chronic HCV infection. Summarize the natural history of persons with chronic HCV infection. Provide appropriate counseling to patients for preventing further liver insults. Conduct hepatocellular carcinoma surveillance when indicated. Provide management strategies for person with chronic HCV infection Increase awareness of future therapies available for treatment of HCV. HCV Prevalence Estimate in U.S. Source: Chak e, et al, Liver Inst 2011;31: HCV Prevalence Year of Birth CDC HCV Testing CDC HCV Testing Recommendations Source: Armstrong GL, et al. Ann Intern Med. 2006;

2 CDC HCV Testing CDC HCV Testing Recommendations 2012 CDC Birth Cohort HCV Testing Recommendations Source: CDC and Prevention. MMWR RR61:1 32. Estimated Prevalence Chronic HCV in U.S. Rationale for Birth Cohort HCV Testing Recommendations Source: Armstrong GL, et al. Ann Intern Med. 2006; Chak e, et al, Liver Inst 2011;31: Age Adjusted Mortality Rates from HBV, HCV, & HIV U.S Forecasted Annual HCV Related Deaths U.S. Chronic HCV and no Cirrhosis in 2005 Source: Ly KN, et al. Ann Intern Med.2012:156: Source: Rein DR, et al. Dig Liver Dis.2011:43:

3 Forecasted Annual HCV Related Deaths U.S. Chronic HCV and no Cirrhosis in 2005 Burden of Disease Related to HCV Expected to triple in next years Source: Rein DR, et al. Dig Liver Dis.2011:43: Source: WHO Hepatitis C Fact Sheet HCV Treatment: Historical Milestones HCV Treatment Cure Rates HCV Testing Birth Cohort Projected Benefit of One Time Testing Goals for Birth Cohort HCV Testing in U.S. Source: Rein DB, et al. Ann Intern Med.2012:156:

4 Testing Sequence HCV Testing Sequence Testing Sequence Testing Sequence Testing Sequence Testing Sequence 4

5 Testing Sequence CDC Recommendations for Post Test Counseling HCV Infection: Post Test Counseling Messages HCV Survival in Syringes HCV survives for up to 63 days in syringes Lower survival in insulin syringes than tuberculin syringes Source: Paintsil E, et al, J Infect Dise.2010:202: HCV Survival in Bottled Water Heterosexual Transmission of HCV Monogamous Serodiscordant Couples HCV survives for up to 3 weeks in bottled water Source: Doerrbecker J, et al. J Infect Dis, 2013:207: Source: Vandelli C, et al. Am J Gastroenterol.2004;99:

6 Heterosexual Transmission of HCV Monogamous Serodiscordant Couples HCV Survival Outside the Body Source: Vandelli C, et al. Am J Gastroenterol.2004;99: Source: Ciesek S et al. J Infect Dis.2010;201: Preventing Household Transmission HCV Mother to Child Transmission HVC Annual births with HCV infected mothers: estimated at 40,000 Risk of Transmission i from mother to child: 3 10% Source: CDC and Prevention, Division of Viral Hepatitis Source: CDC and Prevention, Division of Viral Hepatitis Alcohol Alcohol Use >48 g/day associated: increased risk of cirrhosis, liver cancer, mortality Alcohol Use and HCV Synergistic effect >50 g/day or > 5 drinks/day: increased fibrosis Light and moderate also with an effect Degree of fibrosis correlates with degree of use <31 g/day probability of increased fibrosis Cannabis Biologic Effects Cannabinoid receptor types 1 and 2 regulate progression of experimental liver fibrosis Use is associated with liver disease Daily cannabis use associated: higher risk of moderate to severe liver fibrosis Combination moderate/heavy ETOH use associated with even greater risk of fibrosis Should be discouraged in HCV infection 6

7 OTC, Complementary, Alternative Medications CDC Additional Messages Over the counter Limit acetaminophen to 2 g/day, 1g/day in cirrhosis Avoid NSAIDs in cirrhosis Avoid Fe supplementation (unless Fe deficiency anemia present) Complementary and alternative medicines Insufficient evidence to support their use Source: CDC and Prevention, Division of Viral Hepatitis Physical Exam Findings in Chronic Liver Disease Initial Evaluation Chronic Hepatitis C Physical Examination Laboratory Studies After Initial Diagnosis General Hepatic profile CBC/diff CMP Disease related Imaging Determine liver damage Liver biopsy Noninvasive markers FibroSure, etc. 7

8 Laboratory Studies Liver Tests Laboratory Studies After Initial Diagnosis Liver Enzymes AST ALT Alkaline Phosphatase GGT Liver Synthetic Tests TRUE LIVER FUNCTION TESTS Bilirubin Albumin Protime/INR Platelets Immunizations Assessment: Alcohol Use Disorder Assessment: Alcohol Use Disorder HCV Infection Natural History 8

9 Natural History of Hepatitis C Infection Natural History of Hepatitis C Infection Progression of HCV is Variable GROSS IMAGE: NORMAL AND A CIRRHOTIC LIVER Normal Liver Cirrhotic Liver Irregular surface Evaluation and Staging of Liver Fibrosis Nodules 9

10 Staging of Liver Disease Scoring: Histologic Stage (Fibrosis) Abbreviation: International Association for Study of the Liver (IASL) Clinical Outcomes of Cirrhosis Evaluation and Prognosis HCV Cirrhosis Survival: Compensated vs Decompensated Cirrhosis Cirrhosis Classification System 10

11 Natural History of End Stage Liver Disease (ESLD) Natural History of ESLD Transition to decompensated cirrhosis 5% to 7% patients per year Hepatocellular carcinoma Can trigger decompensation Predictor of death in decompensated cirrhosis Tools: Predicting disease severity/death (decompensated cirrhosis) Child Turcotte Pugh (CTP) score Model for End Stage Liver Disease (MELD) score Variceal Surveillance Endoscopic View Esophageal Varices Prophylaxis Variceal Bleeding Variceal 11

12 Variceal Hemmorhage ESLD AND HCV ALL patients with cirrhosis require monitoring for Varices with EGD HCC surveillance: imaging and alpha fetoprotein Ascites and infection Jaundice Surveillance for Hepatocellular Carcinoma Hepatocellular Carcinoma Surveillance Hepatocellular Carcinoma Risk All patients with cirrhosis require monitoring Ultrasound first line CT or MRI if lesion found Alpha fetoprotein (AFP).. Many treatment modalities depending upon size and number of lesions 12

13 2008 Global Cancer Deaths Hepatocellular Carcinoma (HCC) HCV Extra hepatic Manifestations HCV Extra hepatic Manifestations Hematologic Mixed cryoglobulinemia Aplastic anemia Thrombocytopenia Non-Hodgkin s -cell lymphoma Dermatologic Porphyria cutanea tarda Lichen planus Cutaneous necrotizing vasculitis Renal Glomerulonephritis Nephrotic syndrome Endocrine Anti-thyroid antibodies Diabetes mellitus Hadziyannis SJ. J Eur Acad Dermatol Venereol. 1998;10: Ocular Corneal ulcer Uveitis Vascular Necrotizing vasculitis Polyarteritis nodosa Neuromuscular Weakness/myalgia Peripheral neuropathy Arthritis/arthralgia Autoimmune Phenomena CREST syndrome Salivary Sialadenitis HCV Extra hepatic Manifestations Ascites 13

14 Management of Ascites Ascites Hepatic Encephalopathy (HE) Hepatic Encephalopathy Source: Bajaj JS. Aliment Pharmaco Ther. 2010; Hepatic Encephalopathy Mental State Grading West Haven Criteria 14

15 Goals for Liver Transplantation Referral for Liver Transplantation Cirrhosis and Liver Transplantation Liver Transplants Source: Smith BD et al. MMWR Recomm. Rep.2012:61(RR 4):1 32. Rationale and Goals for Treatment Chronic HCV is a progressive disease HCV Treatment Can produce significant morbidity and mortality if left untreated 15

16 Treatment Reduces Liver Related Complications HCV Treatment Cure of HCV achievable Sustained Virological Response (SVR) SVR associated with significant clinical benefit Slows or reverse disease progression Reduces hepatic and all cause mortality Improves extra hepatic manifestations Projected New HCV Treatment Agents Five Clinical Practice Points Screen for HCV infection Identify and Educate person with HCV infection Assessment of HCV disease progression Rf Referral lfor appropriate it care Cirrhosis decompensated and decompensated Treatment cure Clinical Management Cirrhosis semi yearly for HHC surveillance/disease progression Non cirrhosis yearly for disease progression Thank you!. Questions? 16

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