Hepatitis C Eliot Godofsky, MD University Hepatitis Center Bradenton, FL
Recent Advances in Hepatitis C Appreciation that many patients are undiagnosed Improved screening to identify infected persons Assessment of liver damage noninvasively Genetic testing (IL28B)to identify individual responsiveness to standard therapy (Interferon) Improvements in the treatment standard of care Blood tests that identify drug resistance Many promising new drugs in development 2
What is Hepatitis C The hepatitis C viral particle proteins bind to receptors on the surface of liver cells Virus? HCV is primarily a blood-borne infection. Sexual transmission occurs at a low rate. Approximately 170 million persons are infected with HCV worldwide. Global HIV cases estimated at 40 million. Each year, an estimated 3 to 4 million persons are infected with chronic HCV worldwide. HCV infection can lead to liver fibrosis, cirrhosis, liver cancer, and liver failure. 3
Hepatitis C in the United States Over 5 million living with chronic HCV 50-75% may be unaware 19,000 new cases in 2007 15,000 deaths due to HCV in 2007 HCV infects 30% of persons with HIV HCV cirrhosis and liver cancer projected to increase over the next 20 years Leading indication for liver transplant Direct and indirect medical costs estimated at 5-10 billion dollars yearly 4
Rate per 100,000 Persons Deaths from Hepatitis C Surpasses HIV in the United States 7 6 5 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Hepatitis B Hepatitis C HIV Source CDC 5
Persons Who Need to be Tested for Hepatitis C Higher Risk Persons who have injected illicit drugs (former and present, even if only once) Persons with HIV or HBV Blood transfusion or organ transplant before 1992 Blood products before 1987 Hemodialysis patients Persons with unexplained liver enzyme elevations Lower Risk Children born to infected mother Healthcare workers with exposure to HCVcontaminated blood Persons with multiple sex partners, MSM, history of STD Current sexual partners of HCV-infected persons Tattoos or body piercing 6
Awareness of HCV Infection Among HCV-Infected Persons Aware 25% Unaware 75% Colvin HM, Mitchell AE, eds. Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C. Institute of Medicine. Washington, DC: The National Academies Press, 2009. 7
Identifying HCV Infection Chronic HCV is often a silent disease A simple blood test is used to diagnose HCV 65% of persons infected with HCV were born between 1945 and 1965 In this group, the HCV prevalence is 4% overall, higher in men, blacks, and military veterans Testing everyone born from 1945-1965 is expected to identify nearly 1 million undiagnosed persons CDC recommendations updated by Summer 2012 8
Current Hepatitis C Treatment Therapy can prevent complications and death from HCV and is considered curative Not all infected persons require treatment Treatment can be difficult, lengthy, and expensive Patients with cirrhosis, blacks, HIV infection, and previous therapy failures are the hardest to treat Recently approved Protease Inhibitor pills when added to standard treatment greatly improve the success rate and decrease the treatment time 9
Response (%) Protease Inhibitor Triple Therapy: Success Rate by Patient Type 100 80 75-83 [1,2] 68-75 [3,4] 60 53-62 [3-4] 52-59 [1,2] 40 29-38 [1,6] 20 14 [5] * 0 Relapser Naive White/ Nonblack Naive Black Partial Responder Null Responder Cirrhotic Null Responder 1. Zeuzem S, et al. N Engl J Med. 2011;364:2417-2428. 2. Bacon BR, et al. N Engl J Med. 2011;364:1207-1217. 3. Jacobson IM, et al. N Engl J Med. 2011;364:2405-2416. 4. Poordad F, et al. N Engl J Med. 2011;364:1195-1206. 5. Zeuzem S, et al. EASL 2011. Abstract 5. 6. Vierling JM, et al. AASLD 2011. Abstract 931. 10
HCV Therapy Continues to Improve HCV Patients HIV/HCV Patients 90% 94% 75% 65% 40% 30% Standard Therapy Approved Triple Therapy Investigational Triple Therapy Short Course Investigational Quad Therapy 11
Hepatitis C Drugs in Development Dosed Daily ABT-072 ABT-267 ABT 450* ACH-1625 BI 201335 Daclatasvir GS 5885 GS 9451 IDX 184 INX-189 MK-5172 Narlaprevir* PSI-7977 PSI-938 TMC435 Dosed Twice Daily ABT-333 Asunaprevir BI 201335 BI 207127 BMS 791325 Danoprevir* Filibuvir GS9256 Mericitabine Setrobuvir Tegobuvir Vaniprevir VX-222 Multiple Doses BI 207127 Danoprevir 12
Vaccines for Hepatitis C Preventative Vaccines Probably more than 10 years away due to the extreme complexity and variability of the Hepatitis C virus Therapeutic Vaccines Recombinant vaccines containing specific HCV proteins under development may improve response to current therapy Vaccines Recommended for Persons with Hepatitis C Hepatitis A Hepatitis B 13
Hepatitis C Moving Forward More patients identified with improved screening practices Better access to care and treatment Newer therapies that work in all patient types, are easier to take, have less side-effects, and are affordable Decrease complications from Hepatitis C Vaccination to prevent spread of the disease 14