Hep C

Question 1

Hep C background

Answer 1

• RNA virus
• 6 major genotypes
• Type 1 is the most common

Question 2

Hep C epidemiology

Answer 2

• Speed and progression is affected by co-infection with HIV and alcohol use
• 5x as wide spread as HIV

Question 3

Risk factors for Hep C

Answer 3

• Being a baby boomer (1945 to 1965)
• IDU
• Transplant patient
• Birth from HCV mother

Question 4

First HCV epidemic

Answer 4

• 1960s to 1980s
• Peak deaths between 2030 and 2035
• Most likely due to iatrogenic causes (health care)
• NOT drug use

Question 5

Second HCV epidemic

Answer 5

-Due to rise in injection drug use

Question 6

Diagnosis of HCV

Answer 6

• Antibody test to identify exposure
• HCV RNA needed to determine if chronic infection
• HCV Ab positivity does not confer immunity

Question 7

Evolution of HCV therapy

Answer 7

1) Interferon based
- Long treatment (up to 1yr)
- Major toxicities
- Many patients are scared of this therapy
2) Direct acting antivirals (DAAs) first appearance in 2011
- Standard of care

Question 8

DAA treatment guidlines

Answer 8

• 8 to 12 weeks of therapy for all patients with OUT cirrhosis
• 12 weeks for patients WITH cirrhosis

Question 9

DAA ending and site of action

Answer 9

1) NS3/4A -previr
2) NS5A -asvir
3) NS5B -buvir

Question 10

Do you use DAAs as monotherapy?

Answer 10

• NO, must be used in combination
• Monotherapy will cause treatment failure/ resistance
• All DAAs have warning for HBV reactivation

Question 11

Glecaprevir/ Pibrentasvir (GLE/PIB)

Answer 11

• Mavyref
• Duration 8 to 16 weeks (dependent on pt)
• Can be used in renally insufficient pts
• Don’t use in decompensated cirrhosis
• Will mess up your oral birth control

Question 12

Ledipasvir/Sofosbuvir (LDV/SOF)

Answer 12

• Harvoni
• One tablet, once a day
• Duration is usually 12 weeks
• Cirrhosis (24 weeks or 12 weeks with ribavirin)
• Can be used in ages 12 years and up
• Do not use in pts with CrCl<30ml/min
• Needs acidic enviorment

Question 13

Sofosbuvir/Velpatasvir (SOF/VEL)

Answer 13

• Epclusa
• 12 week therapy
• 1 pill once daily
• Needs acidic enviorment
• Avoid PPIs and H2 blockers (12 hrs of separation)

Question 14

Sofosbuvir/Velpatasvir/Voxilaprevir (SOF/VEL/VOX)

Answer 14

• Vosevi
• Used when previous DAA therapy failed
• 1 pill once a day
• Diarrhea = main side effect

Question 15

Elbasvir/Grazoprevir (ELB/GZR)

Answer 15

• Zepatier
• 1 tablet once a day
• Need to test for resistance first (GT1a)
• No resistance use for 12weeks
• Yes resistance use for 16weeks with ribavirin

Question 16

Ribavirin

Answer 16

• MoA not well understood
• Has synergistic effects
• Inhibits viral replication
• Not effective as monotherapy
• Weight base dosing

Question 17

Side effects of Ribavirin

Answer 17

• Anemia
• Twice daily dosing to help decrease nausea
• Teratogen = avoid in pregnancy (don’t get pregnant for 6mo after therapy)

Question 18

General lab abnormalities with all DAAs

Answer 18

• Very few lab abnormalities
• Headache is most common side effect
• Fatigue is second

Question 19

Key points for drug interactions

Answer 19

• Use hepdruginteractions.org
• Amiodarone = bradycardia
• Acid suppressive therapy (LDV and VEL)
• Avoid ethinyl estradiol in GLE/PIB
• Avoid all herbals
• Avoid major CYP inducers (rifampin)

Question 20

General management of all viral hepatitis patients

Answer 20

• Minimize further liver damage
• Vaccinate for Hep A, B, yearly flu, and pneumococcal vaccine
• Avoid alcohol
• Minimize smoking
• Loose weight (if over weight)

Question 21

How to take care of Hep pts with cirrhosis

Answer 21

• Screen for liver cancer q6mo
• Evaluate esophageal varices
• Avoid hepatotoxic drugs
• Avoid all NSAIDs (aspirin, ibuprofen, naproxen) due to increased risk of bleed
• Impaired response to diuretics