Penny R.

Thayer, FNP, BC
Gastro/Hepatology NP
James H. Quillen, VAMC
OBJECTIVES
PREVALENCE
IDENTIFY RISK FACTORS
TREATMENT OPTIONS
COMMON SIDE EFFECTS OF
ANTIVIRAL THERAPY
APPROPRIATE CODING
FACES OF THE DISEASE
PREVALENCE
NHANES IV (1999-2002)1
1.6% anti-HCV positive (95% CI 1.3-1.9%) =
4.1 million persons (95% CI 3.4-4.9 million)
1.3% chronic infection = 3.2 million persons
Peak prevalence age 40-49 (4.3%)
Three characteristics identified 85.1% all
infections: abnormal serum ALT, ever IVDU,
transfusion <1992
Most persons born 1945-1964

Armstrong GL, Wasley A, Simard E, et al. Ann Intern Med 2006; 144: 705-14.
TESTING FOR HCV AB
Recent/past injection drug
userseven if only used
once
Groups with high HCV
prevalence
HIV-infected individuals
Hemophiliacs treated
with clotting factor
concentrates before
1987
Hemodialysis recipients
Patients with
unexplained
aminotransferase
abnormalities
Recipients of transfusion
or transplantation before
July 1992
Children born to women
infected with HCV
Healthcare, public safety,
and emergency medical
personnel following needle
injury or mucosal exposure
to HCV-infected blood
Current sexual partners of
individuals infected with
HCV
Persons who have used
illicit drugs by noninjection
routes
DIAGNOSIS
Positive Hepatitis C antibody-exposure
Positive Hepatitis C RNA (PCR)
RIBA
Generally asymptomatic
Acute Hepatitis C
PROGRESSION
ACUTE HEPATITIS C
15-40% will spontaneously resolve, generally
within the first 6-18 months after acute onset.
60-85% will progress to chronic infection
CHRONIC
85-90% stable
10-15% progress to cirrhosis
PROGRESSION
CIRRHOSIS
75% slowly progressive
25% progress to HCC
2-4% liver failure
HCC
Risk increases for every year for a patient
with chronic hepatitis C.
Patients without signs of cirrhosis can
develop HCC
PREDICTIONS BY 2019
193,000 HCV deaths
720,700 million years of advanced liver disease
1.83 million years of life lost

$11 billion in direct medical care costs

$21.3 and $54 billion societal costs from

premature disability and mortality
RISK FACTORS
IVDU-Even ONCE
ETOH ABUSE-includes binge drinking
Multiple sex partners
Tattoos
Snorting cocaine-Even ONCE
Blood transfusions before 1991
Dialysis
INITIAL WORKUP
CBC
CMP
TSH
HCV PCR (VIRAL LOAD)
HCV GENOTYPE
Hepatitis A and Hepatitis B vaccine panel
HIV
AFP
Liver Ultrasound
MELD SCORE

http://www.mayoclinic.org/meld/mayomo
del6.html
survival probability of a patient with end-
stage liver disease is estimated based
on the following variables.
INR, Bilirubin, Creatinine, on dialysis
twice per week
Score greater 11
GENOTYPES
Genotype 1
Treatment nave
Relapse, partial response, null responder
Genotype 2 & 3
Treatment nave, usually 24 weeks
Relapse, partial response, null response
Genotype 4
Treatment nave, 48 weeks
Relapse, partial response, null responder

*Those not treatment nave, treated on a case

by case basis.
TREATMENT
Monitoring
Ultrasound every 6 months
CBC, CMP, PT/INR, AFP every 6 months
EGD or ESO cam to check for varices at least
once
Education
Liver biopsy?
Every patient gets treatment, not every patient is
a candidate for antiviral treatment
TREATMENT
Antiviral Treatment
Goal is achieving SVR
Ask when not if a candidate for treatment
No marijuana or other illicit drug use
Abstinence from ETOH for at least 3 months
HCV PCR (viral load)
Depression screening before and during
treatment
Liver biopsy if not already done for GT 1
Education class to review expectations of
frequent visits, labs and possible side effects.
STANDARD ANTIVIRAL THERAPY
Pegylated interferon therapy (PegIFN)
Pegasys
PegIntron
Injections one time per week, duration based on
genotype and response
Must be kept cool (in the fridge!)
Can be taken alone, although sustained viral
response is diminished.
Ribavirin
Tablets taken every day, dose based on genotype
Not used as monotherapy
DIRECT ACTING ANTIVIRAL/
PROTEASE INHIBITOR
ONLY GT 1 PATIENTS ARE
CANDIDATES
NO PRESCRIPTIONS TO BE FILLED
WITHOUT FIRST CHECKING WITH
PROVIDER WHO IS TREATING THE
HEPATITIS C.
MULTIPLE SIDE EFFECTS AND DRUG
INTERACTIONS.
DIRECT ACTING ANTIVIRAL/
PROTEASE INHIBITOR
BOCEPREVIR/VICTRELIS
Treatment nave
Lead in phase 4 weeks, response guided therapy,
generally 28 weeks of triple therapy
Relapse, partial responder, null responder
Lead in phase 4 weeks, response guided therapy,
36-48 weeks of triple therapy
DIRECT ACTING ANTIVIRAL/
PROTEASE INHIBITOR
TELAPREVIR/INCIVEK
Treatment nave
No lead in phase
Triple therapy for 12 weeks
RGTgenerally done in 24 weeks
Relapse, partial responder, null responder
No lead in phase
Triple therapy for 12 weeks
RGT-completed in 36-48 weeks
SIDE EFFECTS
Multiple side effects that can be mild to
severe
Flu like symptoms, depression, dry skin,
insomnia, hair loss, increased pain
Flu like symptoms most common
Will make autoimmune disorders worse
i.e. Psoriasisneeds Derm monitoring
Depression: increased risk for suicidal
ideation, worsening anxiety etc
ADDITIONAL SIDE EFFECTS WITH
USE OF DAA/PI
Profound anemia
Increased risk of neutropenia
Increased risk of significant rash
Ano-rectal pain
Dysguesia

**this is NOT intended to be a complete

list, see prescribing information for these
medications.
APPROPRIATE CODING
EIA PCR RIBA HEP C ICD-9 CODE
RESULT RESULT RESULT STATUS
NEG NEG NEG Negative, NONE
(w/o Tx) not exposed
to HCV
NEG NEG POS Previously V01.79
(w/o Tx) exposed to
Hep C, at
time of
testing, not
chronically
infected
POS NEG NEG False NONE
(w/o Tx) positive
Ab-not
exposed
APPROPRIATE CODING
EIA PCR RIBA HEP C ICD-9
RESULT RESULT RESULT STATUS CODE
POS NEG POS Previously V01.9
exposed to
(w/o Tx) hepatitis C, at
time of testing,
not chronically
infected
ANY NEG ANY Cleared 070 series
WITH TX virus in
response to
treatment
ANY POS ANY Chronic 070 series
Hepatitis C
NONE NONE NONE UNKNOWN If test
ordered:
V73.9
Counseling:
V65.49
RESOURCES
Several websites
www.hepatitis.va.gov
www.hepatitiscnewdrugs.blogspot.com
www.aasld.org
Hepatitis C Resource Centers (HCRC)
www.hepatitis.va.gov
Support Groups
CASE STUDY # 1
48 yo african american male with Hepatitis
C type 1a, previously treated with
peginterfon and ribavirin in 2009, relapsed
within 3 months of stopping therapy, HCV
PCR 500,000, PLT count 120, Albumin 3.2.
Previous history of IVDU, marijuana, and
ETOH use. Has been clean and sober for
the last 5 years.
CASE STUDY #1 cont.
What treatment options would you
discuss with him?
A. Noneit is more likely he would not
respond to treatment and the risks/benefits
are too great.
B. Liver biopsy and consider treatment to
include a direct acting antiviral.
C. Retreatment with standard therapy and
continue for 72 weeks
??QUESTIONS??