Screening Baby Boomers: Implementing New Recommendations for Hepatitis C

Course Director

Robert G. Gish, MD

Robert G. Gish, MD
University of California, San Diego
San Diego, California


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Dr. Gish provides expert feedback to the questions submitted by your peers during a recent survey on this topic.

Overview

Effective treatment of hepatitis C virus (HCV) infection, with the goal of achieving sustained virologic response, is associated with a reduced risk of mortality, liver cancer, and other complications related to HCV infection. Therefore, expanding access to HCV testing and treatment is crucial. In August 2012, the Centers for Disease Control and Prevention (CDC) issued new recommendations calling for the screening of individuals born between 1945 and 1965 who have not previously been tested for HCV. This new screening strategy, based on the higher prevalence of HCV in this age cohort and the reality that many of these people remain unaware of their status, augments previous recommendations for screening of individuals with known risk factors such as injection drug use, HIV infection, and in healthcare workers and others with a high risk for exposure.

In this activity, Dr. Robert Gish offers practical guidance on screening patients for HCV and how to effectively counsel and manage individuals who test positive.


Disclosures

This activity is supported by an educational grant from Genentech. Additional support provided by Penn State College of Medicine and Answers in CME.

Course Director
Robert G. Gish, MD, has a financial interest/relationship or affiliation in the form of:
Consultant for Abbott Laboratories; Arrowhead; Bayer AG; Bristol-Myers Squibb; Celula, Inc.; Genentech, Inc.; Gilead; HepaHope, Inc.; Hoffmann-La Roche Inc.; Isis Pharmaceuticals, Inc.; Merck & Co., Inc.; and Onyx.
Grant/Research Support from Bristol-Myers Squibb; F. Hoffmann-La Roche Ltd.; Genentech, Inc./Roche; and Gilead.
Speakers Bureau participant with Bayer AG; Bristol-Myers Squibb; Genentech, Inc.; Gilead; GlaxoSmithKline; Hoffmann-La Roche Inc.; Merck & Co., Inc.; Onyx; Salix Pharmaceuticals, Inc.; Schering; and Vertex Pharmaceuticals Incorporated.
Major Shareholder in HepaHope, Inc.
Shareholder in Arrowhead and Kinex Pharmaceuticals.
Advisory Board for Applied Immunogenetics. Chair Clinical Advisory Board for Arrowhead; Chair of CAB.
Other Financial or Material Support from Expert Testimony for Bristol-Myers Squibb and ICN. Dr. Gish is a member of the data safety monitoring board for Tekmira Pharmaceuticals Corp.
Medical Director
Annette Wiggins
Answers in CME, Inc.
Annette Wiggins has no financial interests/relationships or affiliations in relation to this activity.

Answers in CME staff who may potentially review content for this activity have disclosed no relevant financial relationships.

Penn State College of Medicine staff and faculty involved in the development and review of this activity have disclosed no relevant financial relationships.

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Which patients should I be screening for hepatitis C? There is a significant gap between the percentage of patients in my practice who are hepatitis C positive and the national average.

Dr. Gish: We need to think about who to screen for hepatitis C in two distinct groups. The first group is the risk group, where you're going to take a risk history for blood exposure [and] intimate exposure. That risk factor list is available through the CDC [Centers for Disease Control and Prevention] MMWR [Morbidity and Mortality Weekly Report] [and] a lot of different national and international guidelines. But of course some patients don't remember or don't want to admit to their risk events. So another strategy recently is what's called the birth cohort screening, and that has to do with people born between 1945 and 1965.1 This birth cohort represents close to 70% of the individuals infected with hepatitis C today. And look how simple this is. You look at their date of birth and you order a hepatitis C antibody test.

This all came about through a collaboration of the CDC and the U.S. Public Health Service's Preventive Task Force, backed up by lots of data saying, one, hepatitis C is curable; two, with treatment and cure, we decrease mortality due to cancer, cirrhosis, [and] we decrease transplant.2 These are very important points.

Testing is inexpensive. The risks in terms of adverse events from testing are very low. False positive rates for testing, especially with confirmatory testing with PCR, are extremely low. So a whole package has now been put together. Take a risk history, look at the date of birth, order hepatitis C antibody tests. If positive, do confirmatory testing, and link those people to care.

Narrator: One-time testing should be done for those persons born between 1945 and 1965 regardless of risks.

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Many of my patients with hepatitis C are asymptomatic and do not want to take medications. Is waiting to begin therapy a good idea?

Dr. Gish: When you're talking to your patients about hepatitis C, remind yourself and the patients that asymptomatic does not necessarily mean they have a good or a bad prognosis. Although hepatitis C is a systemic disease, we know that hepatitis C increases all-cause mortality.

It's linked not just to liver disease and cirrhosis and cancer and transplant and death, but it's linked to kidney disease through nephritis. All-cause mortality through other disease states, including lymphoma, are related to hepatitis C infection. So hepatitis C [is both a] systemic disease and a liver disease.

Now, historically we've had medications that were interferon-based. Patients have heard horror stories about interferon, and a number of patients have contraindications to interferon therapy. And that has to be taken into account to time the timing of treatment correctly.

It's almost never an emergency to treat hepatitis C. This is a 20- to 30- to 40-year disease before it's fatal. And with all the new all-oral therapies that are evolving and will be available in the next 6 to 24 months, it is okay to wait to treat the majority of your patients.

The rationale of antiviral therapy is clearly cure. We would like the least adverse events and the best possible outcome, and that's going to evolve extensively in the next 1.5 to 2 years. As the adverse event profile of treatment drops, the criteria for starting therapy will also decrease in parallel.

So we're being much more selective about who we treat today. The only people that we're treating with interferon-based therapies today are individuals with advanced fibrosis and early cirrhosis that are highly motivated, maybe because they have hepatitis C damaging their kidneys. Maybe they're heading towards a liver transplant. Maybe they have liver cancer or want to decrease the cancer risk recurrence rate by treating and curing their hepatitis C.

There are a number of patients who do fall off therapy during treatment because of the adverse event profile. Those patients, of course, can be retreated with our new medication armamentarium.

So we are thinking that interferon-free regimens for genotype 2 and 3 will be available by December of 2013. And then what we call pan-genotypic treatment will become available between 2014 and 2016.

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How can I help my patients manage their hepatitis C infection effectively, including keeping clinic appointments and adhering to therapy?

Dr. Gish: You can best help your patients manage their hepatitis C infection effectively first by behavior modification—no alcohol, no marijuana, and lose weight if they have an elevated BMI, especially if they have metabolic syndrome.

Narrator: Elevated BMI has been linked to increased disease progression in patients with hepatitis C.

Dr. Gish: Number two, your hepatitis C patients should come back to their clinic appointments on a regular basis. You're not just going to be monitoring for more advanced liver disease or advanced cirrhosis or doing cancer surveillance, but talking about lifestyle issues, making sure individuals that they may have intimate contact with are tested for hepatitis C.

Narrator: Clinicians can also help protect a patient’s liver from further harm by providing hepatitis A and B vaccination if the patient is susceptible. In addition, new medicines, including over-the-counter and herbal medicines, should be evaluated carefully for liver safety and avoided if possible.

Dr. Gish: And then finally, adhering to therapy. This has been a big task with interferon-based therapy due to the side effects of interferon, or interferon plus ribavirin, or interferon plus one of the protease first-generation inhibitors. And then you want to bring those patients back frequently to respond quickly to any side effects, especially those that are interferon- or ribavirin-based. That's going to markedly increase the chances of your patient continuing therapy, and markedly lessen the rate that patients might come off therapy due to lack of support, adverse events, lack of monitoring, noncompliance.

So that tight provider-patient education and motivation network is very important to continuing therapy and keeping our cure rates high.

We like to have in place, as support for all of our patients on hepatitis C treatment, at least one individual that can come to clinic and help monitor, help with activities of daily living. Another important part of the team is the pharmacist. The pharmacist can help a lot with getting authorizations, education, managing adverse events, watching for drug-drug interactions. Our nursing team—and that may include PAs or NPs—are essential for this compliance/adherence issue, as gastroenterologists are typically extremely busy, and they can help with education, managing side effects, recommending specific treatments for specific symptoms, getting the right compounded therapies. These physician extender teams are really doing the dominance of treatment in lots of practices.

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References

  1. Centers for Disease Control and Prevention. MMWR. 2012;61:1-18.
  2. Ghany MG et al.; American Association for the Study of Liver Diseases. Hepatology. 2009;49:1335-1374.

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These materials do not necessarily reflect the views of Answers in CME or any of its supporters.

This activity is supported by an educational grant from Genentech.
Additional support provided by Penn State College of Medicine and Answers in CME.

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