Hepatitis C

Characteristics of Viral Hepatitis

Hepatitis virus A

Hepatitis virus B

Hepatitis virus C

Hepatitis virus D

Hepatitis virus E

Incubation (days)

15–50 30–180 15–160 30–180 10–60

Transmission F/Ofecal/oral

BBFblood and body fluids

BBF BBF F/O

Onset Abrupt Insidious Insidious Insidious Abrupt

Chronichepatitis

Rare Possible Possible Possible Unlikely

Chief Complaint

“My family doctor told me that my liver function tests were

abnormal. I’ve been a little more tired than usual, but I thought that was because of menopause. I’ve also been retaining more fluid in my legs, been dizzy and lightheaded at times, and having more headaches than I did last year. I’ve lost some weight lately, too, but that’s good, isn’t it?”

HPI

Linda Lane is a 49-year-old woman who has been referred by her family physician to the liver clinic for assessment of her abnormal liver enzymes. She reports remote use of recreational drugs in high school, including marijuana, alcohol, occasional amphetamines, and IV cocaine. She still drinks alcohol occasionally (2–4 glasses of wine once or twice a week), but otherwise has been “drug free” since her mid-twenties when she was married.

She states that she feels fine much of the time, but sometimes has fatigue, fluid retention, headaches, and difficulty sleeping. She tends to get dizzy on exertion at times. She has lost about 10 pounds in the last 2 months, which she attributes to reduced appetite, since her activity level has diminished. She is perimenopausal and has isolated episodes of hot flashes and flushes but still menstruates on a regular 25-day cycle. She has no past history of liver problems.

PMH IV drug abuse in high school HTN GERD Early menopause FH

No known family history of liver disease. Both parents are alive, still

living independently, and doing reasonably well considering they are in their early 80’s. Her father has HTN, her mother has hypothyroidism and a chronic “bathroom problem.” One older brother with DM Type 2, HTN, and GERD.

SHMarried for 24 years; two children in college. Non-smoker;

denies illicit drug or inhalant use; drinks two to four glasses of wine once or twice weekly.

ROSDenies any signs or symptoms of liver diseases except for

nonspecific constitutional symptoms such as fatigue and headaches. No changes in urine color. Recalls having icteric sclerae and a period of severe fatigue and nausea in high school.

Meds MVI 1 tablet po daily × 1 year Calcium citrate with vitamin D 1 tablet po BID × 1 year Protonix 40 mg po once daily × 2 years Norvasc 10 mg po once daily × 5 years Acetaminophen 500 mg 1–2 tablets up to 3 times daily

PRN for headaches and other body aches (averages 3–4 tablets per day)

Physical Examination

Gen

Well-nourished woman VS

BP 100/63, P 72, RR 17, T 37.0°C; Wt 61 kg, Ht 5'4'' Skin

No jaundice; no spider angiomata or palmar erythema HEENT

PERRLA; EOMI; sclerae anicteric; funduscopic exam normal

Lungs

Normal breath sounds CV

RRR, S1, S2 normal; no S3 or S4 Abd

Liver span 11 cm; spleen not palpable; no evidence

Labs

Hgb 13.0 g/dL AST 177 IU/L HbsAg (–) ALT 198 IU/L Anti-HAV (–) Alk phos 86 IU/L Anti-

HCV (+) T. bili 1.5 mg/dL HCV RNA (bDNA assay) 4.4 million

copies / ml BUN 11 mg/dL Alb 3.5 g/dL SCr 1.0 mg/dL HCV genotype 1 Glu 111 mg/dL HIV (–)

Liver Biopsy (Performed after Liver Clinic Visit)

Moderate degree of fibrosis and inflammation consistent with

chronic hepatitis

Diagnosis

Chronic hepatitis C

What physical findings, laboratory values, and medical history information suggest the presence of chronic hepatitis C virus (HCV) infection?

First exam at the doctor's office Your doctor will: Ask questions about your medical history. Do a physical exam. Check your livere nzymes to see if they are high. This may

be the first sign that you have the virus.

Tests for the hepatitis C virus If your doctor thinks that you may have hepatitis C, he or she may

order: A hepatitis C virus test. This is a blood test that looks for antibodies

against the hepatitis C virus. It shows whether you have been exposed to the virus. A rapid test is available that gives results in 20 minutes.

A blood test that looks for the genetic material (RNA) of the hepatitis C virus. This test shows whether you are infected with the virus now.

A blood test to find out the kind of hepatitis C virus (genotype) you have. Knowing your genotype will help you and your doctor decide if and how you should be treated.

Tests for liver problems To check how well your liver is working, you may have: Liver function tests. These are blood tests that can help

your doctor find out if you have liver damage. A liver biopsy. The doctor puts a needle in the liver to find

out whether the virus has caused scarring or damage to your liver.

Imaging tests such as a CT scan, an MRI, or an ultrasound to make sure that you don't have liver cancer.

What are the goals of treatment for chronic HCV infection?

To eradicate HCV infection, which prevents the development of chronic HCV infection and sequelae

What non-pharmacologic measures should be considered for this patient?

You should get plenty of bed rest, drink plenty of fluids, and eat healthy foods

Avoid alcohol. DO NOT share needles Check with your provider before taking any over-the-

counter medications or herbal supplements. This includes medicines such as acetaminophen, aspirin, or ibuprofen.

What pharmacotherapeutic alternatives are available for treatment of this patient?

The latest drug to get approved for hepatitis C is called Harvoni. It's a once-daily pill that combines Sovaldi (sofosbuvir) and ledipasvir. It cures the disease in most people in 8-12 weeks. Other options include taking a combination of Sovaldi, Olysio (simeprevir), interferon and/or ribavirin. Talk with your doctor about what's right for you, based on your medical needs and insurance coverage, since the newer hepatitis C drugs are very expensive.

Design a pharmacotherapeutic plan for this patient.

Treatment options include: Daclatasvir (Daklinza) Ledipasvir and sofosbuvir (Harvoni) Ombitasvir-paritaprevir-ritonavir (Technivie) Ombitasvir-paritaprevir-ritonavir plus dasabuvir (Viekira Pak) Simeprevir (Olysio) Sofosbuvir (Sovaldi)

These medications are, in general, well tolerated. The FDA has issued a warning that Technivie and Viekira Pak can cause severe liver injury especially if you already have severe liver disease.  

Interferon and ribavirin used to be the main treatments for hepatitis C and are now used less frequently. They can have severe side effects including fatigue, flu-like symptoms, anemia, skin rash, mild anxiety,depression, nausea, and diarrhea.

Does this patient have any medical conditions that are considered contraindications to receiving the treatments discussed in the previous question?

Contraindications to treatment include: autoimmune hepatitis, decompensated liver disease, women who are pregnant or patients whose female partners are pregnant, hemoglobinopathies, creatinine clearance <50 mL/ min, hemodialysis, or ischemic cardiovascular or cerebrovascular disease

Monitoring Chronic Hepatitis

To manage chronic hepatitis B or C, your doctor will order regular blood tests to check how well your liver is working.

Ultrasounds and CT scans can also reveal signs of damage. If the virus is not causing any liver problems, you may not need treatment. But it's important to have regular tests to watch for changes. Complications are easiest to treat when found early.

Outcome Evaluation

How should the therapy you recommended for HCV infection be monitored for efficacy and adverse effects?

You can know the efficacy adverse effects of the therapy by 2 ways

1- Clinical Parameters like signs and symptoms

2- Laboratory data

Which baseline parameters of this patient have been suggested as predictors of poor response to the treatment you recommended?

AST 177 IU/L

ALT 198 IU/L

HCV RNA (bDNA assay) 4.4 million copies / ml

What are the complications of hepatitis

Hepatitis can lead to cirrhosis, liver cancer, and liver failure.

Common side effects of peginterferon and ribavirin

Common side effects of ribavirin are fatigue, flu-like symptoms, neutropenia, thrombocytopenia, and anemia

Common side effects of peginterferon are* : Fatigue , Arthralgia , Fever , Musculoskeletal pain , Headache,

Insomnia , Nausea , Depression , Anorexia , Anxiety/emotional

lability , Rigors, Alopecia , Myalgia , Injection site reactions

* Experienced by > 20 % of patients