Hepatitis B and C What’s new

2. Hepatitis B and CWhat’s new Thomas C. Mahl, MD Professor, Medicine University at Buffalo Chief, Gastroenterology VA Western New York

3. Disclosure • No financial conflicts to disclose • No off label uses will be discussed

4. Does this patient have hepatitis C? • 56 y/o man with a history of needle sharing about 30 years ago. He has no complaints suggestive of hepatitis and his liver feels normal on exam. He has elevated aminotransferases.

5. What is the most common chronic viral hepatitis? • Hepatitis A • Hepatitis B • Hepatitis C • Hepatitis D • Hepatitis E

6. What is the most common chronic viral hepatitis? • Hepatitis A • Hepatitis B • Hepatitis C • Hepatitis D • Hepatitis E

7. Hepatitis C - The Plague • 0.6-2.4 % of US population • 3.8 million Americans infected • 15-20 thousand in Western New York • 7.5% of US Veterans • 18% of Viet Nam era Veterans • “Dr. Mahl’s retirement plan” • 3% world wide!!!!

8. How could you confirm he has hepatitis C? • Hepatitis C Antibody by EIA • Hepatitis C Antibody by RIBA • Hepatitis C RNA by PCR or branched chain assay • Measure HBcAb

9. How could you confirm he has hepatitis C? • Hepatitis C Antibody by EIA • Hepatitis C Antibody by RIBA • Hepatitis C RNA by PCR or branched chain assay • Measure HBcAb

10. Who Should You Screen for HCV? • Anyone with elevated liver tests • Anyone with risk factors • Everyone born 1945-1965 (Baby-boomers)

11. Does he Also Have Hepatitis B? • His serology notes: • HBsAg – negative • Anti-HBs –positive • Anti-HBc - positive

12. Does he Also Have Hepatitis B? • No! • HBsAg – negative • Anti-HBs –positive • Ant-HBc - positive

13. Diagnosis of Hepatitis B • Hepatitis B surface antigen –HBsAg • Indicates infection • No HBsAg? Not infected • Hepatitis B surface antibody – anti-HBs • Protective • Anti-HBs? Can’t have HBsAg • Follows natural infection and vaccination

14. Diagnosis of Hepatitis B, con’t. • Hepatitis B core antibody –anti-HBc • Not protective • Infected or resolved infection • Hepatitis B viral DNA • Gold standard • Quantifiable • Followed during treatment

16. Case 2 • 59 y/o Irish woman is noted to have elevated liver enzymes during a routine blood draw. She recalls no episodes of jaundice but did receive an injection of contaminated RhoGAM after her daughters delivery in 1973. Her liver is enlarged and slightly firm.

17. What is the most common risk factor for becoming infected with HCV? • Transfusion? • Needle sharing? • Sexual congress? • Tattoos? • Occupational exposure (HCW)?

18. What is the most common risk factor for becoming infected with HCV? • Transfusion • Needle sharing • Sexual congress • Tattoos • Occupational exposure (HCW)

19. What is the most common risk factor for becoming infected with HBV? • Transfusion? • Needle sharing? • Sexual congress? • Tattoos? • Occupational exposure (HCW)?

20. What is the most common risk factor for becoming infected with HBV? • Transfusion? • Needle sharing? • Sexual congress? • Tattoos? • Occupational exposure (HCW)?

21. What is this Woman’s Prognosis? • Good? • Bad? • Ugly?

22. What is this Woman’s Prognosis? • Good? • Bad? • Ugly?

26. Predictors of Poor Prognosis • Alcohol: use - abuse • Acquisition via transfusion • Male gender

28. HCV Prognosis: Bottom Line • HCV is a very slowly progressive disorder in many patients • Significant numbers of patients develop cirrhosis • However, only about 10% patients will ever develop symptoms or will die of liver disease

29. Case 3 • 37 y/o developed HCV after experimenting with IVDA about 20 yrs ago. He feels well and is in good health. Liver enzymes are elevated and bilirubin is slightly elevated.

30. What further information would be helpful before considering treatment? • HCV RNA • HCV Genotype • Liver biopsy • His net worth and health insurance plan

31. What further information would be helpful before considering treatment? • HCV RNA • HCV Genotype • Liver biopsy • His net worth and health insurance plan

32. Molecular Tests • HCV genotype • 6 different genotypes • Very predictive of response to treatment • ‘Non-one’ genotype’s do best • ‘Non-one’ genotypes – uncommon in US! Genotypes in USA

33. Liver biopsy - Chronic HCV

34. Normal Chronic inflammation Cirrhosis

36. Case 3 - further information • HCV RNA 567,345 IU/ml • Genotype 1a • Liver biopsy • Grade – moderate inflammation • Stage – moderate fibrosis • Very wealthy!!!

37. What is the optimal treatment for this man? • Interferon alpha • Pegylated interferon alpha • Pegylated interferon, ribavirin • Pegylated interferon, ribavirin and telaprevir or boceprevir • Milk thistle

38. What is the optimal treatment for this man? • Interferon alpha • Pegylated interferon alpha • Pegylated interferon, ribavirin • Pegylated interferon, ribavirin and telaprevir or boceprevir • Milk thistle

40. Treatment of Hepatitis C10 Years of Progress >50% ‘Cure’! Sustained Virologic Response (SVR) = Cure

41. Telaprevir

42. $50,000!!!! Telaprevir

43. Telaprevir • Oral inhibitor of HCV serine protease • Used in combination with PEG/riba • Sustained response – 67% overall • 89% in those who completed treatment • FDA approved

45. Telaprevir Associated Rash Diffuse rash with some superficial skin peeling, pruritus, mucosa involvement but no ulceration. Localized rash with or without pruritus. Ulcer, vesicles, bullae or systemic symptoms Monitor Closely STOP Telaprevir Try oral antihistamines, good skin care, topical corticosteroids Data extracted from Vertex Presentation to FDA Advisory Committee

46. Boceprevir

49. Interferon –Adverse Effects • Depression/suicide • Psychosis • Thrombocytopenia • Leukopenia • Hair loss

50. So… Not a terrible disease in most Treatments difficult and expensive Who should you refer for treatment? • Everybody except those not able to be treated • Substantial mental illness • Ongoing substance abuse • Significant medical comorbidities • Unreliable patient