1 / 25

Hepatitis C Update: A Primary Care Perspective

Hepatitis C Update: A Primary Care Perspective. Jay Fathi, M.D. February 2003. Overview—an epidemic. RNA virus; discovered by cloning in 1988 First serologic test 1990 Approximately 4 million Americans infected; most common liver disease in US, most common indication for transplantation

tyme
Télécharger la présentation

Hepatitis C Update: A Primary Care Perspective

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Hepatitis C Update: A Primary Care Perspective Jay Fathi, M.D. February 2003

  2. Overview—an epidemic • RNA virus; discovered by cloning in 1988 • First serologic test 1990 • Approximately 4 million Americans infected; most common liver disease in US, most common indication for transplantation • Roughly 30,000 new cases annually; only 30% diagnosed

  3. Overview (cont.) • 85% become chronically infected • 10,000 deaths annually • Incidence falling recently; prevalence increasing over last decade

  4. Natural Course • Acute infection: asymptomatic or mild illness • Virus detectable by PCR-RNA in 2-4 weeks after exposure usually • Roughly 15% spontaneously clear virus; remain Ab-positive but are PCR-RNA negative • 20% (3-30% depending on study) develop cirrhosis, usually over many years • Alcohol, co-morbid HIV, Hep B increase risk

  5. Natural Course (cont.) • 20% cirrhotic patients (5% of total) develop hepatocellular carcinoma; survival after Dx of HCC is 6 months-2 years • Clinic course varies greatly case by case

  6. Transmission • Contaminated blood most infectious (transfusions prior to 1992, now needle-sharing, intranasal cocaine) • Sexual transmission (less than 5%) • Perinatal transmission (approx. 5%); dependent on maternal viral load • Shared razors, toothbrushes, open cuts, etc.

  7. Transmission (cont.) • Occupational exposure (roughly 2% with needlesticks) • ALWAYS USE UNIVERSAL PRECAUTIONS

  8. Diagnosis • Enzyme immunoassays • PCR (viral load), qualitative vs. quantitative useful to follow treatment response • Viral load not correlated with disease progression • Genotyping (when considering treatment) • Complete Hep screen, HIV

  9. LFTs • LFTs are not well correlated with hepatic fibrosis • Fairly specific; poor sensitivity • Normal LFTs somewhat reassuring, but hepatic fibrosis can still exist • Biopsy-gold standard for assessing disease progression

  10. Patient Education • Avoid hepatotoxins (esp. ALCOHOL!!!) • General healthcare maintenance (diet, smoking cessation, exercise, etc.) • Weight loss—can help steatosis and may possibly alter course of disease • Immunizations (Hep A, B, pneumovax, Td, flu shot, etc.)

  11. Education (cont.) • Do not donate blood, share needles or inhalation devices for recreational drugs, cover wounds, discuss possible sexual/perinatal transmission • Support groups

  12. Treatment • 18-60 years old (**) • Persistently elevated LFTs (?) • PCR positive, biopsy positive • Studies currently ongoing in other populations (children, older adults, severe cirrhotics, etc.)

  13. Treatment (cont.) • No current substance abuse • Patient interested in therapy • *No current substance abuse, generally healthy, no unstable psychiatric disorders*

  14. Treatment (cont.) • Interferon plus oral ribavirin • Usually 12 months, 1-3 weekly injections, very costly ($15,000 for Ribavirin alone) • Side effects –flu-like symptoms, alopecia, bone marow suppression, cardiac and pulmonary impairment, thyroid/ocular abnormalities, seizures, exacerbation of any pre-existing psychiatric abnormalities

  15. Treatment (cont.) • Pegylated interferon: higher clearance rates, once-weekly injections, less psychiatric SE • Lasting (?) clearance of virus in 20-50% patients • Resposne to treatment somewhat dependent on genotype (1 most prevalent in US, likely most virulent also) • Genotype I, previous non-responders, African Americans less responsive to treatment

  16. Treatment (cont.) • Depression (‘emotional disturbances’) most common reason for discontinuation • 20% or more drop out of treatment before 48 week course completed • Protease Inhibitors: promising preliminary data • Milk thistle? Data shows no improvement

  17. Frequent Co-morbidities • HIV, Hep B, alcohol abuse, other substance abuse, psychiatric disorders (depression, bipolar), homelessness, etc.

  18. Suggested Management Plan • Check PCR; if negative, periodically screen with ALT and/or PCR (Q2-5 years?) to ensure patient has definitively cleared virus • If PCR positive, assess if patient is candidate for therapy and give thorough counselling about disease/treatment/etc. to see if they are interested

  19. Management plan (cont.) • If yes to both (PCR positive, interested in treatment), refer for liver biopsy • Primary care clinician must be able to competently counsel patients regarding the myriad of complicating issues • Each patient must be managed individually

  20. Hepatitis B • Double-stranded DNA virus • Global prevalence: 5% • Approximately 400 million people! • Mostly in SE Asia, Philippines, Middle East, Africa, parts of S. America • Lowest prevalence: US, Canada, N. Europe • US: 1 million chronically infected (chronic carriers)

  21. Transmission • Blood, body fluids (saliva, semen) • Most common mode of spread in US: sexual contact (heterosexual and homosexual) • Most common mode of spreas worldwide: VERTICAL TRANSMISSION

  22. Acute to chronic infection • After acute infection, 5-10% of adults become chronically infected • Up to 90% of neonates become chronically infected when vertical transmission occurs • HBcAB+ evidence of prior infection • HBsAg + chronically infected • HBcAB + and HBsAg negative: prior infection, have cleared virus

  23. Chronic Hep B • HBeAg—indicative of replication and infectivity • HBeAg + “Replicators,” more infections, poor prognosis • 15-20% progress to cirrhosis in 5 years • HBeAg negative---- “Non-replicators,” less infectious, better prognosis • Both should be referred to specialist for likely liver biopsy, treatment evaluation

  24. Treatment • Interferon, 3TC (lamivudine) • Fairly low numbers re: response rates • Hepsera (Adefovir)—new treatment • 50-60% ‘cure rate’ (?) in studies • Liver fibrosis improved on biopsy • SE: 25% can experience exacerbation of hepatitis

  25. Prevention • IMMUNIZATION !!!!!!!!!!!!!!!!!!!!!!!!! • ALL infants • High risk adults • All adults?

More Related