hepatitis c treatment in corrections.ppt

8/11/2019 Hepatitis C Treatment in Corrections.ppt

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Hepatitis C Treatment in Corrections:

New Medicine, New Challenges

Spencer Epps, MD, MBA,Medical Director

Delaware Department of Correction

James Welch, RN, HNB-BCChief, Bureau of Healthcare Services



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Objectives

Discuss Hep C Infection & Current Treatment

Describe Hep C Treatment in Corrections

Explain New Medications for Hep C Outline Challenges Presented by New Medications

Propose Strategies to Address these Challenges


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Hepatitis C

Hepatitis C (HCV) is aflavivirus related toYellow Fever and WestNile Virus

Most common chronicbloodborne infection inthe US

Contagious liver diseasecausing mild illness toserious, lifelong illness ordeath


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Hep C Transmission

Spread by blood to blood contact:

IV drug use

Mother to child transmission

Can be sexually transmitted but less common Since 1992, screening has limited spread through

transfusions and transplants

For most, acute infection leads to chronicinfection

There is no vaccine for Hepatitis C


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Hep C Statistics

3.2 million persons chronically infected 1.8% prevalence in the free world

Of every 100 people with Hep C 7585 people will develop chronic Hepatitis C

infection 6070 people will go on to develop chronic liver

disease

520 people will go on to develop cirrhosis over 20

30 years 15 people will die from cirrhosis or liver cancer

8000 to 10,000 deaths each year in US

Majority unaware of infection- not clinically ill

Hepatitis C. Centers for Disease Control & Prevention, 2011.


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8/25Hepatitis C. Centers for Disease Control & Prevention, 2011.


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Fibrosis & Disease Progression in Hepatitis C. Marcellin, et al. Hepatology, 2002

Hepatitis C Progression


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Hepatitis C Progression

Mechanisms associated with progression offibrosis are poorly understood

Rate of progression variable but slow in general

Older age, male gender, excessive alcoholconsumption, overweight, and immunedeficiency associated with more rapidprogression

Alcohol consumption controlled in correctionalenvironment

Treatment of overweight & HIV is critical

Fibrosis & Disease Progression in Hepatitis C. Marcellin, et al. Hepatology, 2002


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Hepatitis C. Centers for Disease Control & Prevention, 2011.


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Hepatitis C Trends

Most patients infected 20-40 years ago beforevirus identification and screening

Incidence decreasing but number of patients

developing cirrhosis, cancer & end stage liverdisease increasing (peak 2020 to 2030)

Total cost of care for untreated Hep C will

continue to increase over next 20 years Consensus on when and how Hep C will be

treated in Corrections is needed now


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Current Hepatitis C Treatment

PEG-Interferon

Increases expression of proteins that interfere

with Hep C viral replication

Ribavirin

Enhances the antiviral effect of interferon

Precise mechanism of action uncertain

Treatment lasts for one year; if successful,

induces cure


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Hepatitis Treatment and Management. Mukherjee, et al. Medscape Reference, 2011


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Side Effects Current Hep C Treatment

INTERFERON- Hematologic complications (i.e.,neutropenia, thrombocytopenia), neuropsychiatriccomplications (i.e., memory and concentrationdisturbances, visual disturbances, headaches, depression,irritability), flulike symptoms, metabolic complications (i.e.,

hypothyroidism, hyperthyroidism, low-grade fever),gastrointestinal complications (i.e., nausea, vomiting,weight loss), dermatologic complications (i.e., alopecia),and pulmonary complications (i.e., interstitial fibrosis)

RIBAVIRIN - Hematologic complications (i.e., hemolyticanemia), reproductive complications (i.e., birth defects),and metabolic complications (i.e., gout)


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New Hepatitis C Treatment

FDA recently approved two new proteaseinhibitors for treatment of Hep C

Boceprevir

Telaprevir Are added to, do not replace, original therapy

Indications:

treatment of chronic Hep C genotype 1

with compensated liver disease, including cirrhosis

previously untreated or who have failed previousinterferon and ribavirin therapy.


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New Hepatitis C Treatment

In previously untreated patients, 79% of thosereceiving telaprevir experienced a sustainedvirologic response (SVR) compared with less than50% with peginterferon alfa and ribavirin

treatment alone. Cure rate for patients treated with telaprevir

across all studies, and across all patient groups,was between 20-45% higher than current

regimen. Course of treatment decreased from 48 weeks to

24 weeks.

US Food and Drug Administration (FDA). FDA approves Incivek for hepatitis C. May 23, 2011.


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Challenges of New Treatment

Cannot be given alone or resistance will develop

Same side effects plus additional side effects Anemia

Neutropenia

Thrombocytopenia

Severe Rash

Logistical Challenges in the correctional

environment: Must be given at same time every day Must be given with fatty food (e.g., ice cream)


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Cost of New Treatment

Both boceprevir and telaprevir are priced for

cure

$45,000 to $75,000 per patient

Prevalence of Hep C higher in correctional

patient population

In Delaware, 800/7000 patients with Hep C

Treatment of entire population with new

regimen would cost up to $60,000,000.

Entire healthcare budget = $55,000,000.


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Strategies for Hep C Treatment

The Federal Bureau of Prisons uses the

following criteria for limiting Hep C treatment

PEG-interferon contraindicated

Incarceration period insufficient for treatment

Inmate has unstable medical or mental health

condition

Patient refuses treatment


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Strategies for Hep C Treatment

Monitoring early stages of Hep C rather than

treatment acceptable and occurs in free world

Treatment based on progression:

Liver function tests

Liver biopsy

Other factors: age, co-infection with HIV, etc.

Monitor patients with earlier stages of fibrosis

& sentences under 5 years & coordinate with

community providers for potential treatment


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Consensus on Use of New Medications

If fibrosis progression indicates treatment,

patients are tried on current therapy first

If therapy found to be futile at 12 weeks,

patients are tried on new medical regimen,

provided there are no contraindications

As with current practice, patients should be

involved in the decision to treat whether using

old or new regimen


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Conclusion

Discussed Hep C Infection & Current Treatment

Described Hep C Treatment in Corrections

Explained New Medications for Hep C Outlined Challenges Presented by New Medication

Proposed Strategies to Address these Challenges


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Discussion


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Hepatitis C Treatment in Corrections:

New Medicine, New Challenges

Spencer Epps, MD, MBA,Medical Director


James Welch, RNChief, Bureau of Healthcare Services


hepatitis c treatment in corrections.ppt

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