Hep C Flashcards
Hepatitis C
Transmission?
Potential for chronic infection?
Curable?
Transmission?
- Percutaneous, sexual MSM in HIV+
Potential for chronic infection?
- Yes
Curable?
- Yes
What is the most frequent mode of transmission in north America?
Which provinces in Canada are the highest risk
Sharing IV equipment
Manitoba and Saskatchewan
Who should get tested for Hep C
- Every adult should be screened at least once in their lifetime
- Every pregnant patient: at each pregnancy
- Everyone with risk factors: screen regularly
T/F you can acquire HCV from contaminated objects
True
- HCV can remain infectious for up to 6 weeks ex-vivo
How do we test for HCV?
- Anti-HCV test. (antibody)
- Negative = no infection
- Positive = have or had HCV - HCV RNA test (if positive)
- Positive: current infection
- Negative: past infection
T/F We have to test for genotypes in HCV to guide treatment
False
- only do it for patients with Hep C who have tried treatment before
OR have cirrhosis
Who qualifies for HCV treatment
Everyone with acute or chronic infection unless palliative or do not want
What are treatment goals for Hep C
- Prevent cirrhosis
- Prevent HCC (Hepatocellular Carcinoma)
- Achieve SVR (sustained virologic response = cure) (done 12 weeks after treatment)
What do the 3 following HCV treatment class target/ responsible for?
What suffix is their drugs?
N53/4A protease
NS5B polymerase
NS5A
N53/4A protease
- target HCV protein processing
- responsible for translation and polyprotein
-PREVIR
NS5B
- target HCV replication
- interacts with several cellular proteins and may be involved in RNA binding
-BUVIR
NS5A
- target HCV replication
- responsible for RNA synthesis
-ASVIR
What is the treatment duration of HCV
8-24 weeks
- Duration depends on presence of cirrhosis, HCV genotype, HCV RNA level
if patient has baseline resistance-associated substitutions or cirrhosis
- include weight-based ribavirin or
- extend DAA Tx duration, urgency increases
What pre-treatment workup do you have to do for Hep C management
- CBC count
- Basic metabolic panel (lytes, creatinine)
- Hepatic function panel
- INR
- HCV RNA
- HCV test
- Fibrosis test (fibroscan)
- HIV, HAV, HBV test
- Physical exam (ascites)
When do we provide ON treatment monitoring?
What do we do?
For patients with decompensated cirrhosis
- CBC
- Hepatic function panel
- HCV RNA PCR
repeat yearly for on-going patients with risk factors for HCV re-infection
or
if they have elevated ALT, AST, or bilirubin
What 3 non-invasive tests do we use for liver fibrosis
- Aspartate transaminase to platelet ratio
(AST: platelet) (APRI) - Fibrosis index (FIB-4)
- Fibroscan (ultrasound)
What do the fibroscan results mean?
F0- F4
F0: No scarring
F1: MILD fibrosis
F2: MODERATE fibrosis
F3: SEVERE fibrosis
F4: Cirrhosis or advanced fibrosis
Why is baseline Hep B testing screening necessary
Hep C treatment can cause Hep B flare up
What is are the 2 treatments available for Hep C?
Drug composition
Duration
Food?
DDI?
Contraindication?
Maviret
(GlecaPREVIR 300mg/ pibrentASVIR 120mg)
(NS3+4a protease inhibitor/NS5A)
3 tabs daily for 8 weeks
Take with Food
DDI: Ethinyl estradiol (increases ALT), phenytoin, st johns wart, warfarin, statins, etc..
Contraindication: AVOID in decompensated cirrhosis
Epclusa
(SofosBUVIR 400mg/velpatASVIR 100mg)
(NS5B polymerase/NS5A)
1 tab daily for 12 weeks
DDI: PPI, Amiodarone
What is the treatment of HEP C after they have had previous treatment and failed?
Vosevi
(VoxilaPREVIR/ sofosBUVIR / velpatASVIR )
Presence of resistance mutations did not affect SVR12
SE Diarrhea, headache, fatigue
What to look for in cirrhotic HCV patients (3)
Determine if current/past decompensation
Calculate child-pugh score (watch for 7+)
Calculate MELD (watch for 19+)
What is the treatment for COMPENSATED cirrhosis
Same as 1st line options
(Maviret)
If considering Epclusa
- want to check for genotype 3. Causes more complexity
What is the treatment for DECOMPENSATED cirrhosis
Dose?
Duration?
ADR?
What is used in Canada?
ADD Ribavirin to Epclusa FOR 12 WEEKS
Weight-based dosing:
- <75kg: 1000mg/day
- 75+ kg: 1200mg/day
ADR
- ANEMIA,
- fatigue, neutropenia, insomnia, headache, nausea
PREGNANCY TEST (May cause fetal death & abnormalities in animals)
Do NOT use PIs. (cannot use maviret)
In Canada
- EXTEND EPCLUSA duration to 24 WEEKS.
Note: Ribavirin is discontinued in Canada
When do you consider postponing antiviral therapy after liver transplat
MELD 25+
- If you treat patients and they improve - they will get bumped down the liver transplant list
