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HEPATITIS C CLINICAL TRAINING
Simplified Algorithm for Management of Hepatitis C Infection for Primary Care ProvidersPaul Gaglio, MDDirector: Hepatology OutreachProfessor of Medicine (in Surgery)Columbia University College of Physicians and SurgeonsCenter for Liver Disease and TransplantationNY Presbyterian Hospital-Columbia University Medical Center
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Disclosures
Learning Objectives
By the end of this presentation, participants will be able to:• Identify patients appropriate for hepatitis C (HCV) screening• Recall the simplified algorithm for assessing patients for and
initiating HCV therapy• Assess patient's risk for HBV reactivation• Explain the role of fibrosis testing in HCV treatment• Recognize potential drug-drug interactions of HCV therapies
Increase in Acute HCV Incidence – USA
Centers for Disease Control. Viral Hepatitis Surveillance United States, 2015. Available at: https://www.cdc.gov/hepatitis/statistics/2015surveillance/pdfs/2015HepSurveillanceRpt.pdf (accessed June 2018);Suryaprasad AG. Clin Infect Dis 2014:15;59:1411–9; Zibbell JE, et al. MMWR Morb Mortal Wkly Rep 2015;64:453–8; Centers for Disease Control unpublished data
Year2000 2003 2006 2009 2012 2015
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0
Rat
e pe
r 100
,000 Male
Female
• ~33,900 new HCV infections in 2015• 1:1 male: female ratio, predominantly white race• Highest incidence: 20–29 years, non-metropolitan areas
Age Distribution of Reported Chronic HCV Infections in the NYC, 2008 and 2018
www1.nyc.gov. Accessed March 28, 2020
0
10 0
20 0
30 0
40 0
50 0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
2005
Female Male
0
50
10 0
15 0
20 0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
2012
Female Male
0
50
10 0
15 0
20 0
0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 97
2015
Female Male
0
50
10 0
15 0
20 0
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97
2016
Female Male
Slide courtesy of NYS DOH Bureau of Viral Hepatitis.
Total HCV by Age, Sex, and Year, New York State (Excluding NYC)
1. Zibbell JE, et al. Am J Public Health. 2018;108(2):175-181. 2. CDC. https://www.cdc.gov/nchhstp/newsroom/2017/hepatitis-c-and-opioid-injection-press-release.html. December 21, 2017. Accessed August 9, 2019.
0
5
10
15
20
25
30
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Dru
g Tr
eatm
ent A
dmis
sion
s R
epor
ting
Inje
ctio
n of
any
Opi
oid
(%)
2.5
2
1.5
1
0.5
0A
nnua
l Rat
e of
Acu
te H
epat
itis
C
(per
100
,000
per
sons
)
Any opioid injection (18-29)Any opioid injection (30-39)HCV rate (18-29)HCV rate (30-39)
The national increase in acute HCV infection is associated with the nation’s opioid epidemic.1
Among people aged 30-39 years1:
Among people aged 18-29 years1:
400%622%
Rate of acute HCV
Admission for opioid injection
325%83%
Rate of acute HCV
Admission for opioid injection
CDC, Centers for Disease Control and Prevention.
From 2004-2014, HCV and Opioid Injection Drug Use Increased Significantly Among People Aged 18-39 Years1,2
HCV Screening Recommendations
2020 CDC Recommendations HCV ScreeningAmong Adults in the US
1. Universal ScreeningScreen at least once in a lifetime for all adults ≥18 years(except in settings where HCV RNA-positivity is <0.1%)
2. Pregnancy Screening all pregnant women during each pregnancy(except in settings where HCV RNA-positivity is <0.1%)
3. ExposureOne-time testing among people with recognized conditions or exposures (more info on https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm), regardless of age or setting prevalence
4. Periodic testingRoutine periodic testing for people with on-going risk factors
2020 USPSTF HCV Screening Recommendations
• Screen all adults (including pregnant persons) aged 18 to 79 years• One-time screening for most adults
– Periodically screen persons with continuous risk (history of or current injection drug use)
JAMA. Published online March 02, 2020. doi:10.1001/jama.2020.1123
Read the full recommendations at https://jamanetwork.com/journals/jama/fullarticle/2762186
Recommendations For HCV Screening In Persons Less Than 18 Years Of Age
• One-time testing should be performed for all persons less than 18 years of age with behaviors, exposures or risk factors or circumstances associated with an increased risk of HCV exposure
Hcvguidelines.org. Accessed March 28, 2020
Re-testing for Patients at Risk for HCV
• Periodic repeat HCV testing should be offered to all persons with behaviors, exposures or risk factors associated with HCV
• Annual HCV testing is recommended for all persons who inject drugs and for HIV-infected men who have unprotected sex with men
AASLD, IDSA, IAS-USA. Recommendations for testing, managing, and treating hepatitis C. http://www.hcvguidelines.org. Accessed March 28, 2020.
Summary: 2020 HCV Screening Recommendations
Adults Under 18 years
One-time HCV screening
• All adults 18 to 79 years of age• All pregnant women during each
pregnancy
(CDC, USPSTF)
• All children born to women infected with HCV
• People under 18 with HCV risk factors
(AASLD, IDSA, IAS-USA)
Repeat HCV testing (e.g. annual)
Adults with HCV risk factors, including:• People with a history of or active
injection drug use• HIV-positive men who have
unprotected sex with men
(CDC, USPSTF, AASLD, IDSA, IAS-USA)
Inner coat
Outer coat
Virus genes
Significant Progress Has Been Made In HCV Understanding And Management
Adapted from Sahoo SS. Epidemiology of hepatitis B and C. Available at: https://www.slideshare.net/drswaroopsoumya/epidemiology-of-hepatitis-b-and-c (accessed June 2018);Yau AHL, Yoshida EM. Can J Gastroenterol Hepatol 2014;288:445–51; Seifert LL, et al. World J Hepatol 2015;7:2829–33 PEG-IFN: pegylated interferon; RBV: ribavirin
Hepatitis C virus
1960 20051965 1980 1990 201020001995 20151970 1975 1985 2020
1975: Description of non-A, non-B hepatitis
1989: HCV identified
1993: HCV genomedelineation
1996: 3D structure of HCV enzymes: HCV protease
1997: Infectious clone of HCV constructed
1999: Replicon system established
2005: Recombinant infectious HCV
1998: IFN + RBV
2003: PIs developed
2011: First all-oral DAA data presented
2014: Launch of first all-oral DAA regimen
2001: PEG-IFN + RBV
Rapid Therapeutic Advances In HCV
Gilead Sciences Ltd. SOVALDI▼ (sofosbuvir), SmPC, September 2017; WHO. Patent situation of key products for treatment of hepatitis C: Simeprevir Working Paper; June 2016; Bristol-Myers Squibb Pharmaceuticals Ltd. DAKLINZA▼ (daclatasvir), SmPC, January 2018; Gilead Sciences Ltd. HARVONI▼ (ledipasvir/sofosbuvir), SmPC, December 2017; AbbVie Ltd. VIEKIRAX▼ (ombitasvir//paritaprevir/ritonavir), SmPC, January 2018; Gilead Sciences Ltd. EPCLUSA▼ (sofosbuvir/velpatasvir), SmPC, March 2018; Merck Sharp & Dohme Ltd. ZEPATIER▼
(elbasvir/grazoprevir), SmPC, July 2017; Gilead Sciences Ltd. VOSEVI▼ (sofosbuvir/velpatasvir/voxilaprevir), SmPC, August 2017; AbbVie Ltd. MAVIRET▼ (glecaprevir/pibrentasvir), SmPC, May 2018
Not all regimens are approved in all patient populations and/or in all countries. Please refer to your local country authorisation. The addition of RBV is recommended in some patient
populations; HCPs should refer to the respective SmPCs.DCV: daclatasvir; DSV: dasabuvir; EBR: elbasvir; GLE: glecaprevir; GZR: grazoprevir;
HCP: healthcare professional; LDV: ledipasvir; OBV: ombitasvir; PIB: pibrentasvir; PTV: paritaprevir; RTV: ritonavir; SMV: simeprevir; SOF: sofosbuvir;
VEL: velpatasvir; VOX: voxilaprevir
SOF + RBV
SOF + SMV ±RBV
LDV/SOF ± RBV
SOF + DCV ±RBV
OBV/PTV/RTV ±DSV ± RBV
SOF/VEL ±RBV
EBR/GZR ± RBV GLE/PIB
SOF/VEL/VOX
Jan 2014 Nov 2014 Aug 2014 Nov 2014 Jan 2015 July 2016 July 2017
OO N
NH
O
O
PO
HN
O
O
OH3C
H3C
CH3HO F
CH3
SOF VELLDV
SMV DCV
VOX
PIB
PTV DSV
OBV
O
O
NN
FF
O
OOO
O O OS
NH
FF
HN
NNH
PIB
GLEGZR
EBR
HCV elimination?
Case Study 1
• 46 year-old African-American female diagnosed with HCV two months ago– Complains of fatigue– PMH: Hypertension– She has a history of intravenous drug use who last used 10 years ago– ALT 45, AST 56, total bilirubin 1.1, platelet count 165,000– HCV RNA 6,680,056, genotype 1a– Transient elastography with F2, S2
Think about what you would do next. We will review at end of presentation.
A Simplified Algorithm for Management of HCV Infection
Simplified Algorithm: Background
• WHO objective: HCV elimination by 2030
• Treatment access limited by availability of specialists
• Current guidelines are comprehensive and most appropriate for experienced treaters, but non-specialists may consider them too complex
• A simplified treatment algorithm targeting non-traditional HCV treaters to drive HCV elimination is needed
20Dieterich et al, Gastroenterology & Hepatology; volume 15, issue 5, supplement 3, May 2019HCV guidance: recommendations for testing, managing, and treating hepatitis C. Available at: http://www.hcvguidelines.org/ (accessed March 2020)
HCVGuidelines.org: Treatment is recommended for ALL patients with chronic HCV infection
Simplified Algorithm: Method of Development
• Authors participated in a consensus meeting in September 2018 to develop a simplified HCV treatment algorithm
• A committee of 13 expert members from various settings was formed, including FQHCs and ID practices
• Meeting and manuscript funded by Gilead Sciences– Funder’s role limited to attendance at meeting and review of the
manuscript for medical accuracy
21Dieterich et al, Gastroenterology & Hepatology; volume 15, issue 5, supplement 3, May 2019
Test for HBV Before Initiating HCV DAA Therapy
ESAL: Patients commencing DAA-based treatment for hepatitis C should be tested for HBs antigen, anti-HBc antibodies and anti-HBs antibodies (B1)
Anti-HBc test resultNegative Positive
HBsAgtest result
Negative No risk of HBV reactivation Very low risk of HBV reactivation
Positive Moderate risk of HBV reactivation(depending on HBV DNA)
AASLD: All patients initiating HCV DAA therapy should be assessed for HBV coinfection with HBsAg, anti-HBs, and anti-HBc (B1)
Boxed Warning: Risk Of HBV Reactivation with DAA Use in HCV/HBV Coinfected Patients1
1. Test all patients for HBV before initiating treatment with any HCV DAA therapy• HBV reactivation has been reported in HCV/HBV coinfected patients undergoing or completed
HCV DAA treatment and not receiving HBV antiviral therapy
• Some cases have resulted in fulminant hepatitis, hepatic failure, and death
• Cases have been reported in patients who:• Are HBsAg positive • Have serologic evidence of resolved HBV• Receive certain immunosuppressant or chemotherapeutic agents
2. Monitor HCV/HBV coinfected patients for hepatitis flare or HBV reactivation during HCV treatment and post-treatment follow-up
3. Initiate appropriate patient management for HBV infection as clinically indicated
231. https://www.hcvguidelines.org. accessed April 20, 2020
How Simple Can Treatment Be For Most Patients?
Assess for cirrhosis with platelets (>150x109/L)
SOF/VEL 1 tab daily w/ or w/o food for 12 weeks
GLE/PIB 3 tabs daily w/ food for 8 or 12 weeks
History, exam, labs* *Assessment Labs: CBC, AST, ALT, bilirubin, albumin, creatinine, HBV, HIV, HAV; eGFR
HCV viremia
Assess for DDI
Dieterich et al, Gastroenterology & Hepatology; volume 15, issue 5, supplement 3, May 2019
Simplified Algorithm for Management of HCV Infection
HCV antibody test with reflex to PCR
2. Pretreatment assessment and testing
3. Treatment and monitoring
Positive (+) PCR
Active HCV infection
Initial assessment: physical exam, stigmata of cirrhosis,
clinical and prior treatment history, extrahepatic manifestations
Blood testsCBC, AST, ALT, bilirubin, albumin,
creatinine; HBV, HIV, HAV; eGFR
Platelets >150x109/L
Assess for potential DDI
Treatment with pan-genotypic therapy: GLE/PIB or SOF/VEL
Assessment of cure (SVR12)HCV RNA, ALT
Negative (-) HCV RNA
Cured
1. Screening and diagnosis
Universal screening optimalor
Risk factors/age screening
Refer to post-cure managementPlatelets <150 refer to specialist
Dieterich et al, Gastroenterology & Hepatology; volume 15, issue 5, supplement 3, May 2019
High SVR Rates Achieved Across Patient Types
*Safety and efficacy of SOF/VEL has not been assessed in patients with CTP class C cirrhosis; †As approved in the Canadian Product Monograph. These are not head-to-head studies and direct comparisons cannot be made;CTP: Child–Turcotte–Pugh; GLE/PIB: glecaprevir/pibrentasvir; GT: genotype; RBV: ribavirin; SOF/VEL: sofosbuvir/velpatasvir;
Agarwal K, et al. ILC 2016 Poster #SAT-195; Gane E, et al. AASLD 2017; Oral #74; Puoti M, et al. ILC 2017 Poster #SAT-233; AbbVie Corporation. MAVIRET (glecaprevir/pibrentasvir) Product Monograph, August 2017; Gilead Sciences Canada Inc. EPCLUSA (sofosbuvir/velpatasvir) Product Monograph, April 2018
GT 1 GT 2 GT 3 GT 4 GT 5 GT 6
GLE/PIB8, 12 or
16 weeks†
SOF/VEL 12 weeks
98%323/328
99%237/238
95%264/277
100%116/116
97%34/35
100%41/41
98%502/513
98%228/232
96%289/302
96%65/68
100%4/4
94%16/17
F0–F4 & CTP A CTP B–C*
GT1–6
94%82/87
X
+ RBV
Liver Disease Stage Considerations
DAA-naïve patientsAbbVie Corporation. MAVIRET (glecaprevir/pibrentasvir) Product Monograph, August 2017; Gilead Sciences Canada Inc. EPCLUSA (sofosbuvir/velpatasvir) Product Monograph, April 2018
GLE/PIB
SOF/VEL 12 weeks
8 weeks 8 weeks
F 0 F 1 F 2 F 3 F 4 CTP A CTP B CTP C
Fibrosis stage CTP score
12 weeks + RBV
Contraindicated Contra-indicated
XX
Why Is Fibrosis Staging Still Important?
• Uncover undiagnosed cirrhosis• In some states, there are still fibrosis requirements to treat• Most importantly any stage 3 or 4 fibrosis requires (for now)
lifelong screening for HCC • Protease inhibitors should not be used in Childs B or C patients
Assess Cirrhosis and HCC Risk with Platelet Count
• Thrombocytopenia is a surrogate for cirrhosis and a marker for the identification of patients at high-risk for hepatocellular carcinoma (HCC)
• The best cutoff platelet count was 150,000/mm for a diagnosis of cirrhosis.
• The proportion of thrombocytopenia was significantly greater in patients with HCV-related HCC(63%) than in patients with HBV-related HCC (42%).
Cancer Volume107, Issue91 November 2006
Does This Patient With Liver Disease Have Cirrhosis?
• Meta-analysis of 86 studies of adequate quality that evaluated the accuracy of clinical findings for identifying histologically proven cirrhosis
• 19,533 patients were included in this meta-analysis, among whom 4,725 had biopsy-proven cirrhosis
• a platelet count <160 x 103/μL (LR, 6.3; 95% CI, 4.3-8.3)
JAMA. 2012 Feb 22;307(8):832-842. doi: 10.1001/jama.2012.186
FDA Drug Safety Communication on the Use of PI-Containing DAA Regimens for HCV
• On August 28, 2019, the FDA issued a safety announcement about the rare occurrence of serious liver injury with the use of protease-inhibitor (PI)-containing regimens for HCV, including glecaprevir/pibrenasvir, elbasvir/grazoprevir and ledipasvir/velpatasvir/voxilaprevir
Using these drugs to treat chronic hepatitis C in patients with moderate to severe liver impairment has resulted in rare cases of worsening liver function or liver failure.
These medicines are not indicated for use in patients with moderate to severe liver impairment.
https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-rare-occurrence-serious-liver-injury-use-hepatitis-c-medicines-mavyret-zepatier-andAccessed on August 28, 2019
FDA Drug Safety Communication: Serious Liver Injury with PI-Containing DAA Regimens
• FDA received reports of 63 cases of worsening liver function, including liver failure and 8 deaths, in HCV patients treated with PI-containing DAA regimens:
https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-rare-occurrence-serious-liver-injury-use-hepatitis-c-medicines-mavyret-zepatier-andAccessed on August 28, 2019
46
143
Mavyret Zepatier Vosevi
Serious Liver Injury per PI-Containing Regimen (n)
21
29 33
17
No Cirrhosis CC DC Unknown
Baseline Liver Function (%)
1363
1163
1863
2163
• More than half of the cases with no cirrhosis or compensated cirrhosis (CC) were misclassified and had evidence of advanced liver disease or risk factors for decompensation (low platelets, portal hypertension, alcohol abuse, other liver comorbidities)
Glecaprevir/Pibrenasvir
Elbasvir/Grazoprevir
Ledipasvir/Velpatasvir/Voxilaprevir
FDA Drug Safety Communication Recommendations
• Perform liver chemistries at baseline and as clinically indicated
• Monitor for clinical signs and symptoms of hepatic decompensation (e.g. jaundice, ascites, hepatic encephalopathy, and variceal hemorrhage
• Encourage patients to read the prescribing information
• Discontinue glecaprevir/pibrenasvir, elbasvir/grazoprevir, ledipasvir/velpatasvir/voxilaprevir in patients who develop hepatic decompensation or as clinically indicated
• Report adverse events involving glecaprevir/pibrenasvir, elbasvir/grazoprevir, ledipasvir/velpatasvir/voxilaprevir or other medicines to the FDA MedWatch program: call 1-800-332-1088 or access https://www.accessdata.fda.gov/scripts/medwatch/
https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-rare-occurrence-serious-liver-injury-use-hepatitis-c-medicines-mavyret-zepatier-andAccessed on August 28, 2019
Assess for Potential Drug-Drug Interactions
35
SOF/VEL GLE/PIB
Key DDI
anticonvulsants, rifampicin, efavirenz, St. John’s wort§ amiodarone§ proton pump inhibitors § statins
§ dabigatran§ ethinyl estradiol-containing contraceptives§ atazanavir§ darunavir§ ritonavir§ statins§ cyclosporine
Common drugs without interactions
ARBs, methadone, buprenorphine, calcium channel blockers, lamotrigine, omeprazole, progestin-only contraceptives
HCPs should consult prescribing information, their local pharmacist and/or online tools (eg, HEP Drug Interactions; http://www.hep-druginteractions.org) to confirm interaction or lack of interaction for specific drugs within a class, as exceptions may exist.
Dieterich et al, Gastroenterology & Hepatology; volume 15, issue 5, supplement 3, May 2019
†Treatment duration of SOF/VEL for treatment-experienced patients is 12 weeks.‡GLE/PIB is also indicated for patients with HCV GT 1 infection with no cirrhosis or compensated cirrhosis (Child-Pugh A) who have been treated with a regimen containing an HCV NS5A inhibitor or NS3/4A protease inhibitor, but not both. Duration of treatment for patients with prior NS5A inhibitor experience or NS3/4A protease inhibitor experience is 16 weeks or 12 weeks, respectively. §Prescribing information in the EU, but not the US, states that addition of RBV may be considered for patients with HCV GT 3 and compensated cirrhosis. ¶For patients with decompensated cirrhosis, SOF/VEL is indicated in combination with ribavirin.
Treatment Options
36
SOF/VEL† GLE/PIB‡
Treatment duration, wkNo cirrhosisCompensated cirrhosisDecomp. cirrhosis
1212§
12¶
88
Contraindicated
Dosage
1 tablet (400 mg SOF + 100 mg VEL)
Once daily With or without food
3 tablets (100 mg GLE + 40 mg PIB per tablet)
Once dailyFood required
Common side effects (≥ 5%)
Headache, fatigue, nausea, asthenia, insomnia Headache, fatigue, nausea
Dieterich et al, Gastroenterology & Hepatology; volume 15, issue 5, supplement 3, May 2019
sofosbuvir/velpatasvir/voxilaprevirPrescribing Information
Indicated for treatment of adults with chronic HCV without cirrhosis or with compensated cirrhosis (Child-Pugh A) who have:• Genotype 1, 2, 3, 4, 5, or 6 infection and
previously treated with an HCV regimen containing an NS5A inhibitor
• Genotype 1a or 3 infection and previously been treated with HCV regimen containing sofosbuvir without an NS5A inhibitor
Additional benefit of sofosbuvir/velpatasvir/voxilaprevir over sofosbuvir/velpatasvir was not shown in adults with genotype 1b, 2, 4, 5, or 6 infection previously treated with sofosbuvir without an NS5A inhibitor.
• Take once daily with food for 12 weeks• Safety and efficacy unknown for patients
with eGFR <30 mL/min/1.73 m2 or ESRD requiring hemodialysis due to higher exposures (up to 20-fold) of the predominant sofosbuvir metabolite
• Not recommended in patients with moderate or severe hepatic impairment (Child-Pugh B or C) due to higher exposures of voxilaprevir (up to 6-fold in non-HCV infected subjects)
37VOSEVI US Full Prescribing Information, Gilead Sciences Inc, Foster City CA. November 2017.
Monitoring Recommendations
• Advise patients, particularly those with prior HBV infection, to contact their HCP if they experience unexpected or severe symptoms
• At least 12 weeks after treatment completion, confirm cure by assessing HCV RNA by PCR– Refer patients with detectable HCV RNA to a specialist
• At least 12 weeks after treatment completion, obtain ALT level– If ALT remains abnormal on repeated measure, refer the patient to a specialist
Dieterich et al, Gastroenterology & Hepatology; volume 15, issue 5, supplement 3, May 2019
Case Study 1
• 46 year-old African-American female diagnosed with HCV 2 months ago– Complains of fatigue– PMH: Hypertension– She has a history of intravenous drug use who last used 10 years ago– ALT 45, AST 56, total bilirubin 1.1, platelet count 165,000– HCV RNA 6,680,056, genotype 1a– Transient elastography with F2, S2
• What would you do for this patient?
Case Study 1
• Screen for hepatitis B• Review for drug-drug interactions• Inquire about OTC’s and herbal products• Start DAA therapy
– Either• GLE/PIB for 8 weeks
• SOF/VEL for 12 weeks
Post-Cure Recommendations
• Inform patients who are cured that they are susceptible to reinfection
• Provide patients with appropriate HCV harm-reduction resources such as buprenorphine and a prescription for naloxone to help patients stay safe and to minimize the possibility of reinfection
41Dieterich et al, Gastroenterology & Hepatology; volume 15, issue 5, supplement 3, May 2019
Renal Impairment Labeling Updates for Sofosbuvir-Based HCV Therapies 11/20/2019
• FDA has approved updated labeling for in renal disease for: – sofosbuvir/velpatasvir– ledipasvir/sofosbuvir – sofosbuvir/velpatasvir/voxilaprevir
• Prescribing information now states that no dosage adjustment is recommended in patients with any renal impairment including patients on dialysis – Results showed the pharmacokinetics of sofosbuvir, GS-331007 (the predominant
circulating metabolite of sofosbuvir), velpatasvir, and ledipasvir were consistent with those observed in HCV-negative patients with ESRD requiring dialysis
– While not studied in ESRD patients, voxilaprevir exposure is not expected to be meaningfully altered in HCV patients with ESRD requiring dialysis
42
Things to Remember when Treating HCV
• Screen for HBV: HBsAg, HBsAb, HBcAb– Treat if HBsAg+ or DNA +
• Vaccinate for HAV and HBV where indicated• Platelet count < 150,000 concerning for advanced fibrosis • Stage fibrosis: Fibroscan most convenient > 9.5 kPA =HCC screen for life
(F3)– >12.5 kPA needs screening for varices (or platelets < 125,000) (F4)– >12.5 kPA needs CT or MRI screening. US often not adequate
• DO NOT use Protease Inhibitors in Child’s B or C patients
Conclusions
• HCV is curable with readily available combination therapies• Elimination will require a multifactorial approach to diagnose, link to care,
treat and cure HCV • The Simplified Algorithm provides a roadmap for non-specialists to treat
HCV• Costs of treatments have come down drastically • Risk of HCC in cured patients with cirrhosis is decreased but patients still
need to be screened for life• The biggest issue we have now is getting people tested and treated • To eliminate HCV, we need to broaden our treater base• Patients with advanced disease should be referred to a liver specialist
Resources
• NYS HCV Clinical Consultation Hotline: (866) 637-2342
• HCV referrals: www.nyc.gov/health/hepc– Free or low-cost care – Programs with supportive services
• www.HepFree.NYC– CME HCV Training – NYC Hep C Task Force and HepCX
Contact Us
For CMEs or educational opportunities, contact:
Meg Chappell, MPHProgram Manager
Empire Liver [email protected]
www.empireliverfoundation.org
For questions about resources, contact:
Nirah Johnson, LCSWDirector, Capacity Building
Viral Hepatitis ProgramNew York City Health Department
HCV Provider Training Series
• May 7, 2020:
• May 14, 2020:
• May 21, 2020:
• May 28, 2020:
Hepatitis C : Epidemiology, Natural History and Diagnosis with Dr. Arun Jesudian
Simplified Algorithm for Management of Hepatitis C Infection for Primary Care Providers with Dr. Gaglio
Management of Hepatitis C Complications with Dr. Wolf
Hepatitis C Treatment in Persons Who Inject Drugs (PWID) with Dr. Taki
Hepatitis clinical care can continue during COVID-19 via telemedicine
• New NYC Health Department Weekly telehealth implementation support webinars
• New Hep Free NYC Telehealth Capacity Building Webpage
• Rapid Implementation of Telemedicine in response to COVID-19 with Su Wang, MD - May 13 (4:30 - 5:30 PM)