Take- home messages for GPs with patients with HCV
1. There are much more effective Hep C drug regimes becoming available that produce high cure rates.
- in general terms the newer drug regimes, called Interferon-free Direct acting antivirals (DAAs), are achieving >95% cure rates in HCV genotype 1, and not much less in HIV co-infected patients.They are daily oral tablets as opposed to previous injections, better tolerated and require much shorter durations of treatment (usually 12wks) than previous regimes.
- HCV genotype 3 requires a different drug regime to Genotype 1. More recently treatment has changed from Pegylated Interferon and Ribavirin (PEG/INF/RBV) regimes to Sofosbuvir and Ribavirin for 24wks.
- in HIV co- infected patients on cART( combination anti-retroviral treatment) some regimes increase risk of renal toxicity and renal impairment and so regular renal monitoring, including serum Creat, eGFR, Phosphate and urine Protein/ Creat Ratio, usually on a 2-4 wkly basis is suggested in early treatment.
- remember to consider cART and HCV drug-drug interactions.
2. Diagnostic testing- "if you can't identify who your patient's are you can't treat them"
- in at risk patients test antibody to Hep C (Anti-HCV) and if positive then do HCV RNA , understanding that in early infection there is a sero-negative window where HCV RNA won't be present and hence you should repeat the test again a few weeks later.
- early diagnosis is even more important in order to enable early treatment with a view to preventing progression to cirrhosis, liver failure and cancer in those who develop chronic hepatitis but also importantly to prevent virus transmission to others ( treatment as prevention).
- remember that upto 50% of patients spontaneously clear the virus, most of those within 2-6 months.
3. In HCV/ HIV Co- infection liver disease is accelerated. There is a 3x risk of progression, which is also more rapid, to cirrhosis and decompensated liver disease.
4. Clinicians, including GPs should determine the severity of liver disease using clinical examination, laboratory tests- including Bilirubin, PT, INR, Albumin. In addition, other specialist investigations are used to determine hepatic fibrosis, include non- invasive imaging such as Fibroscan and direct serum biomarkers such as Fibrospect II. Liver biopsy is usually preserved for instances where there is discordance in the other results. Tools such as the Child- Pugh- Turcotte Score ( CTP) and the Model for End stage Liver disease (MELD) help to determine disease severity and to guide management decisions
5. Be aware that 5-7% of Child's A ( mild) cirrhotics progress to decompensated liver disease each year and hence regular review, at least 6 monthly, is recommended.
6. Screen for Hepatocarcinoma. Remember that in those with chronic disease and liver fibrosis cure does not remove the risk of hepatocarcinoma.
7. Consider organising Gastroscopy to screen for oesophageal varices.