Hepatitis CUpdate on New Treatments

Kevork M. Peltekian, MD, FRCPC

44th Annual Dalhousie Spring Refresher Course - Therapeutics

April 5 - April 7, 2018

Halifax Convention Centre

Disclosures

Conflicts of Interest

Neither I, nor any

immediate family

member has any

financial relationship

with, or interest in, any

commercial interest

connected with this

presentation.

Off-Label Drug Use

The of material in this CPD activity will not include discussion of unapproved or investigational uses of products or devices.

Why Do We Need To Engage You?

Modelled Prevalence is 1.0%

(Plausibility Range 0.6 - 1.3%)

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When Do We Need To Engage You?

4

How Do We Need To Engage You?

5

The Canadian Liver Foundation

recommends that all adults

(baby-boomers) born between

1945 and 1975 be tested for

hepatitis C once.

Is There Another Reason To

Engage You?

6

1. Yehia BR, et al. PLoS One. 2014;9:e101554.

HCV in the US: Gaps in Practice

Questions I Will Try Answer…

• What is new regarding HCV treatment?

• Who is eligible for treatment of HCV?

• Why should every primary care providor

be diligent in identifying HCV cases and

treating them?

7

Case: 56-Yr-Old Woman Presenting to Primary Care

• A 56-yr-old woman visits your office

• She has recently moved to the area following a promotion and is

looking for a primary care clinician

• She is not aware of having been tested for hepatitis C virus

infection previously

The Canadian Liver Foundation

recommends that all adults

(baby-boomers) born between

1945 and 1975 be tested for

hepatitis C once.

Talking to Patients About Hepatitis C Testing

CDC. Guide to Comprehensive Hepatitis C Counseling and Testing.

Current All-Oral Therapies Highly

Effective

Back to Our Case

• A 56-yr-old woman visits your office

• She has recently moved to the area following a promotion and is

looking for a primary care clinician

• Routine hepatitis C antibody test: reactive (positive) and her HCV

RNA by PCR is detectable with HCV viral load reported in Log10

is 5.78 IU/L or 600,000 IU/L

Counseling for HCV-Infected Individuals

AASLDIDSA. HCV Guidelines 2017.

Recommendations for Additional Follow-up of

Initial HCV Testing

• Testing for hepatitis C

genotype—all genotypes can

be treated, but genotype will

guide choice of antiviral

therapy

• Ultrasound to look for signs

of portal hypertension

(advanced cirrhosis) and

identify fatty liver disease

• Testing for HBsAg and HIV

• Testing for CBC, renal (Cr) +

liver functions (INR,

Bilirubin, Albumin) and

enzymes (ALT, AST, ALP)

• Assess presence of cirrhosis

by:

Clinical or Laboratory Testing

• Liver Biopsy (invasive)

• FIB-4 Index (simple)

Imaging by Elastography

• VCTE Fibroscan (long wait

list)

• MR Elastography (limited and

expensive)

Back to Our Case

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FIB-4 Index = (54 × 64) ÷ (155 × √68) = 2.70 (F2-3)

Recommendations for When and in Whom to

Initiate HCV Treatment

• Treatment for all: Unless pts already have short life expectancy,

treatment is recommended for all pts with chronic HCV

infection, regardless of genotype and fibrosis level[1]

• Treatment even at lower-stage fibrosis (F0-F1) improves

survival[1]

• Barriers to access: Contrary to these recommendations, some

insurers including provincial pharmacare restrict coverage to pts

with F2-F4 (moderate fibrosis or cirrhosis)[2]

1. AASLD/IDSA. HCV Guidelines. April 2017. 2. DHHS National Viral Hepatitis Action Plan 2017-2020.

Potential Future Scenario “When to Refer to an

Experienced Hepatitis C Treater”

• Treatment naïve

HCV infection

• Re-infection (not

relapse) with HCV

• No advanced

fibrosis

• Renal impairment

• Active substance use

• Prior treatment with

pegylated

interferon/ribavirin

• HIV or HBV co-

infection

• Compensated or

decompensated (ascites,

encephalopathy or

bleeding varices)

cirrhosis

• Recurrent HCV after liver

transplantation

• Liver mass

HCV Therapy Regimens

17

Maverit

Vosevi

Epclusa

Zepatier

Harvoni

Recommendations for First Line

Therapy for HCV

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Adverse Events

• Newer hepatitis C medications do not have same adverse events

as interferon and are generally well tolerated

• Most common adverse events and management strategies in

pre-education session

• Headaches: nonpharmacologic management strategies, limits of

OTC pain relievers and liver disease

• Anemia: still a concern when ribavirin needed (not used as first

line therapy anymore)

• Other common adverse events: fatigue, nausea, diarrhea

• Encourage pts to report bothersome or unusual adverse events

Pretreatment: Look for Potential

Drug–Drug Interactions

• Review all herbals/supplements, prescription and OTC

medications, including contraceptives and proton pump inhibitors

• Ask about PRN usage of other drugs

Consult with clinical pharmacist when possible

Key resource: www.hep-druginteractions.org

Recommended Follow-up After Hepatitis C

Treatment

AASLD/IDSA. HCV Guidelines 2017.

Virologic cure does not protect against reinfection

Benefits of Curing HCV Extend Beyond the Liver

1. Smith-Palmer J, et al. BMC Infect Dis. 2015;15:19. 2. Negro F, et al. Gastroenterology.

2015;149:1345-1360. 3. George SL, et al. Hepatology. 2009;49:729-738.

SVR 12 weeks after completing Rx

Key Points

• All pts born 1945-1975 should be screened for

hepatitis C virus infection

• Virtually all pts with hepatitis C virus infection

should be treated, regardless of genotype and

fibrosis

Prevents morbidity, progression of fibrosis, hepatocellular carcinoma

• Many pts can be treated in primary care setting

Refer pts with decompensation (ie, ascites)

• Current treatments include pangenotypic and

ribavirin-free options

More than 95% rate of cure for most genotypes

Most therapies are 8-12 wks, ribavirin free, all oral, once daily

Questions or Comments

Send me an email if

you are interested in

becoming HCV treater

kevork.peltekian@nshealth.ca