Hepatitis Foundation International - Hepatitis Living and Learning Resources, Support and Answers

Andrew Angelino, MD - Perceptions on Hepatitis C Infections

Educational Objectives:

Analyze the connections between depression & HCV.
Review psychological impact of HCV treatment.
Identify 3 recommendations for improved patient psychological outcomes for management of HCV.

Hepatitis C infection has major epidemic implications due to the natural history of the infection. Unlike Hepatitis B infections, where a small proportion of cases go on to chronic infection and thus, infectious states, the majority of Hepatitis C infections progress to chronic states. HCV viral loads do not correlate well with disease progression in the liver, however. Of those chronically infected, progression to liver disease (fibrosis) usually occurs in about 10 years, with progression to cirrhosis after about 20 years (hepatocellular carcinoma generally develops in a small percentage after about 30 years). Although the mechanism is unclear, HCV disease is associated with elevations of screening tools used to find major depression. This depression appears to be unrelated to the degree of liver fibrosis. To date, there have been no studies showing lifetime prevalence of depression in patients before acquiring HCV to suggest a possible causal mechanism. However, McDermott et al found increased high risk behavior in depressed patients, suggesting a possible mechanism.

Ed Marino, PA-C - Managing Side Effects on HCV Treatment

Educational Objectives:

Current HCV Medications

- Interferon: alpha 2a, alpha 2b, concensus

AKA: Pegasys, PegIntron, Infergen

- Ribavirin: Branded or generic

Review Side Effects Profile
Discuss Side Effect Management

Treating side effects improves compliance with treatment and taking all meds improves outcomes. The psychosomatic complaints are common and are difficult to treat. Ruling out other causes of side effects is critical; talk to your providers!
The side effects are common & predictable. Hence it is important to address them before treating and seek them out at every visit. Encourage the patients to journal symptoms. It is helpful to involve family members & friends for support and missing lab visits may be detrimental to progress.

Ed Marino, PA-C - Sorting Out the Diagnostics- Interpreting Liver Tests

Educational Objectives:

Review the most common liver lab tests
Review labs for determining true liver synthetic function
Review the most common viral hepatitis labs and what they mean
Review the non-viral hepatitis labs and their meaning

Liver tests are numerous and somewhat confusing. Not all liver disease is associated with abnormal test results; some of the worst liver disease has relatively normal appearing LFT’s and can only be noticed with a look at synthetic functions. It is important to investigate all abnormal liver tests and referral to an expert is absolutely needed. The liver biopsy is the “Gold Standard” for diagnosis while family histories of liver disease should be noted: “…my grandmother died of cirrhosis, but she never drank….” Patient history is the most important data. No other field in medicine has grown as much in the past 20 yrs but we continue to learn every day.

Diana Sylvestre, MD - The Challenge of Addiction for Providers and Hepatitis Patients

No one wants to treat drug users for hepatitis C.

- Poor adherence
- Re-infection
- Interferon can exacerbate psychiatric symptoms
- Interferon is an injectable medication and may increase the risk
for relapse

Organization to Achieve Solutions in Substance-Abuse (OASIS) provides high quality medical care to drug users or whoever shows up. It is hypothesized that active, street-recruited heroin users can be safely and successfully treated for hepatitis C after 12-24 weeks of buprenorphine stabilization. “HCV therapy has been successful even when the patients have not abstained from continued drug or alcohol use... Thus, it is recommended that treatment of active injection drug use be considered on a case-by-case basis, and that active injection drug use in and of itself not be used to exclude such patients from antiviral therapy.” --NIH Consensus Statement on HCV, 2002

Raymond Koff, MD -Evaluation and Management of Hepatitis C

Educational Objectives:

Modes of transmission of Hepatitis C
The Typical HCV Patient in 2009

Approximately 3-4 million US patients are HCV RNA (+). Nearly all are
asymptomatic. The average age at diagnosis is 50 years with a higher
prevalence in African-Americans than Caucasians. Infected persons are
most likely to have acquired HCV: via injection drug use but not during
past year.
Goals of therapy

             -Primary - Eradicate HCV infection
        -Secondary - Slow disease progression, Improve histology, Reduce risk
         of hepatocellular carcinoma, and Improve health-related quality of life

Kenneth Sherman, MD - Management of HCV & HBV in HIV-Infected Patients

Educational Objectives:

Why should we discuss co-infection?

   People living with HIV are increasing in number. Liver disease is an
   IMPORTANT outcome that ID caregivers are often ill-prepared to evaluate
   and manage. Gastroenterologists are frequently uncomfortable with HIV
   management and with HIV-infected patients.

Who should be tested?

HIV-infected patients should be tested routinely for evidence of chronic HCV infection. The initial testing for HCV should be performed using the most sensitive immunoassays licensed for detection of antibody to HCV (anti-HCV).
HBV prevalence- Globally 2 billion people have been exposed with 350 million people with chronic HBV infection.

Raymond Koff, MD - Hepatitis B - Chronic? Carrier? When and How to Treat

Educational Objectives:

Factors associated with sexual transmission

       -Multiple sexual partners, unprotected sex
       -Injecting drug user as sexual partner
       -Duration of sexual activity
       -Male to female, male to male, female to male
       -History or serologic evidence of other sexually transmitted diseases

    Among solid tumors, we have 5^th highest incidence worldwide and 3^rd most
    common cause of cancer deaths. In the U.S. in 2007, 13^th most common
    cancer and increasing faster than all others from 1995 to 2004; 8^th most
    common cause of cancer deaths. Despite advancing technology and
    available treatments, 5-year survival rates are generally less than 5%

Chronic Hepatitis B Management Goals

-Suppression of viral replication
-Improvement in hepatic necroinflammatory disease
-Reduction in long-term sequelae: HBV-associated cirrhosis,
hepatocellular carcinoma
-Reduction of infectivity

Breaking News

FDA Approves Use Test for HIV, Hepatitis B Virus and
Hepatitis C Virus

Roche has announced that the United States Food & Drug Administration (FDA) approved an additional intended use for its licensed nucleic acid test, , called the cobas® TaqScreen MPX Test for the simultaneous, direct detection of the human immunodeficiency virus (HIV-1 Group M RNA, HIV-1 Group O RNA , HIV-2 RNA), hepatitis C virus RNA and hepatitis B virus DNA in human plasma. Many countries have implemented Nucleic Acid Technology (NAT) testing in order to further ensure the safety of blood and blood products. NAT testing can detect HIV-1 and HCV in the early stages of infection, reducing the risk of transfusion-transmitted HIV-1 and HCV infections to negligible levels. The importance of hepatitis B virus in transfusion-transmitted diseases is increasingly being recognized and NAT screening for HBV is being implemented in some countries.

http://www.prnewswire.com/news-releases/fda-approves-use-of-roche-test-to-screen-source-plasma-for-hiv-hepatitis-b-virus-and-hepatitis-c-virus-78303537.html

A recent report published by the Journal of the National Cancer Institute states that certain mutations in the DNA of the hepatitis B virus are associated with the development of liver cancer and may be able to help determine which HBV patients are at increased risk. The study, conducted by Guangwen Cao, M.D., Ph.D. of the Second Military Medical University in Shanghai, found that certain mutations were associated with the development of hepatocellular carcinoma (HCC), the most common form of liver cancer and these mutations were more prevalent as chronic HBV infection progressed from an asymptomatic state to liver cirrhosis or HCC. Frequent examinations of chronically infected HBV patients for these mutations could be useful for identifying patients who may require preventive antiviral treatment and for the prediction of HCC.