management hepatitis c · 2019-08-26 · diagnosis of hepatitis c •commonly asymptomatic •not...
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MANAGEMENT HEPATITIS C
DR. Dr. Andri Sanityoso Sulaiman, Sp.PD-KGEHHepatobiliary Division, Department of Internal Medicine, Cipto Mangunkusumo National General
Hospital, Faculty of Medicine, Universitas Indonesia
Pertemuan Ilmiah Tahunan Ilmu IDI Jakarta UtaraJakarta, 25 Agustus 2019
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HEPATITIS C
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GLOBAL PREVALENCE OF HEPATITIS C INFECTION
Petruzziello A, Marigliano S, Loquercio G, Cozzolino A, Cacciapuoti C. Global epidemiology of hepatitis C virus infection: an up-date of the distribution and circulation of hepatitis C virus genotypes. World J Gastroenterol. 2016;22(34):7824-7840
Asia is the continent with highest prevalence of Hepatitis C infection
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PREVALENCE OF ANTI-HCV IN ASIA
Prevalence anti-HCV : Indonesia (0.8%) – Thailand (2.7%)Petruzziello A, Marigliano S, Loquercio G, Cozzolino A, Cacciapuoti C. Global epidemiology of hepatitis C virus infection: an up-date of the distribution and circulation of hepatitis C virus genotypes. World J
Gastroenterol. 2016;22(34):7824-7840
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GENOTYPE OF HCV IN ASIA
G1 and G6 covers 60% from all genotype in AsiaPetruzziello A, Marigliano S, Loquercio G, Cozzolino A, Cacciapuoti C. Global epidemiology of hepatitis C virus infection: an up-date of the distribution and circulation of hepatitis C virus genotypes. World J
Gastroenterol. 2016;22(34):7824-7840
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PREVALENCE OF HCV INFECTION (ANTI-HCV) IN INDONESIA, RISKESDAS 2013
Riset Kesehatan Dasar. 2013.
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TRANSMISSION OF HCV
Host Resipien
Transmisi Horizontal Transmisi Vertikal
Ibu
Bayi
Injection drug use and tattoo (60%)
§ Pengguna jarum suntik
§ Tato dan tindik
Sexual (15%)
§ Multiple sexual partners
§ Men who sex with men (MSM)
Transfusi darah (10%)
Others (5%)
§ Hemodialisis jangka panjang
§ Tenaga kesehatan
Unknown (10%) Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
Centers for Disease Control and Prevention (CDC), 2012
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RISK FACTOR OF HEPATITIS C INFECTION
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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NATURAL HISTORY OF HEPATITIS C
75-85% kasus akut akan menjadi kronik 10-20 %
1-4 %
Chen SL, Morgan TR. The natural history of hepatitis C virus (HCV) infection. Int J Med Sci. 2006;3(2):47-52
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DIAGNOSIS OF HEPATITIS C
• Commonly asymptomatic• Not specific symptoms: fatigue, myalgia,
abdomen pain, anorexia, nausea, vomiting, fever
Anamnesis
• Can found subfebrile fever, icteric, hepatomegaly
• If already become cirrhosis à stigmata cirrhsosis
Physical examination
• Laboratory: anti-HCV, HCV RNA, ALT, AST• Examination of liver stiffness: USG,
Fibroscan, biopsy
Supported examination
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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SEROLOGY FEATURE OF HEPATITIS C INFECTION
HVC-RNA detected 7-10
days after exposure
Anti-HCV detected 2-8 weeks after
exposure
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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LABORATORY INTERPRETATIONAnti-HCV VHC-RNA Interpretation
Positive Positive Acute or chronic depend on symptoms
Positive Negative HVC resolution, infection status cannot determined (intermittent viremia)
Negative Positive Early acute HCV infection; chronic infection in immunosuppression patient
Negative Negative Not infected with HCV
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
DIAGNOSIS OF CHRONIC HEPATITIS C INFECTIONAnti-HCV and HCV-RNA still detected > 6 months since infected
with or without symptoms of chronic liver disease
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DIAGNOSIS RECOMMENDATION OF HEPATITIS C INFECTION
Anti HCV
Positive Negative
HCV RNA
Not infectedInfection HCV if positive
High suspicion
EIA / CLIARapid Diagnostic Test
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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THERAPY INDICATION OF CHRONIC HEPATITIS C
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TARGET THERAPY OF HEPATITIS C
Eradication of HCV
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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DEVELOPMENT THERAPY OF HCV INFECTION
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PHARMACOLOGY PROFILE OF DAA
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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MECHANISMS OF HEPATITIS C DRUGS
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DAFTAR DAA YANG RENCANA MASUK KE INDONESIA
Nama Obat Status Masuk ke Indonesia
Sofosbuvir Terdaftar 2015
Simeprevir Terdaftar 2016
Daclatasvir Terdaftar 2016
Sofosbuvir + Ledipasvir Terdaftar 2017
Elbasvir + grazoprevir Belum terdaftar 2018
Velpatasvir Belum terdaftar Rencana masuk ?
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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TERAPI HEPATITIS C (DAA): TANPA SIROSIS
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
Sofosbuvir + daclatasvir dan sofosbuvir + velpatasvir dapat digunakan untuk seluruh genotipe
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TERAPI HEPATITIS C (DAA): SIROSIS KOMPENSATA
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
Sofosbuvir + daclatasvir dan sofosbuvir + velpatasvir dapat digunakan untuk seluruh genotipe pada pasien sirosis kompensata
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PERHATIAN KHUSUS PADA SIROSIS DEKOMPENSATA !!
EASL Recommendations on Treatment of Hepatitis C 2018. J Hepatol.
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REKOMENDASI PPHI PEMILIHAN REGIMEN TERAPI PADA SIROSIS DEKOMPENSATA
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. 2017.
Sofosbuvir + daclatasvir dan sofosbuvir + velpatasvir dapat digunakan untuk seluruh genotipe pada pasien sirosis dekompensata
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PEMBERIAN OBAT ANTI VIRUS HEP C PADA PAN-GENOTIPIK
Rekomendasi berbagai organisasi internasional: Regimen Sofosbuvir dan Daclatasvir Regimen Sofosbuvir dan Velpatasvir Regimen Sofosbuvir, Peg-IFN, dan Ribavirin
Jika dicurigai mengalami resistensi atau gagal terapi à periksa resistensigenotipik.
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. 2017.
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PEMANTAUAN DAN PENYESUAIAN TERAPI
Obat/Pemantauan
MingguUlangan
Jenispemeriksaan1 2 4 8 12
Peg-IFN √ √ √ 4-8 minggu
Leukosit, trombosit, tes fungsi hati
RBV √ √ √ 4-8 minggu
Hb, retikulosit
Sofosbuvir Berkala Fungsi ginjal
Grazoprevir/elbasvir
√ √Fungsi hati
• Rekomendasi: jika terjadi efek samping pada terapi kombinasi DAA dengan Peg-IFN atau RBV à modifikasi dosisdilakukan pada selain DAA.
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. 2017.
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PEMANTAUAN EFEK SAMPING TERAPI
Apa yang dimonitor?Sofosbuvir Fungsi ginjal
Simeprevir RuamBilirubin
Elbasvir/grazoprevir Fungsi hati
Perhimpunan Peneliti Hati Indonesia. Konsensus Nasional Penatalaksanaan Hepatitis C di Indonesia. Jakarta. 2017
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Initial Screening with RDT/ELISA Antibody Test No further HCV screening
Confirmation of active HCV infection
Pre-treatment Assessment including staging of liver disease using non-
invasive test
No further HCV screening
Refer to liver specialist
Negativeresult
Positive result
Negativeresult
Decompensated Cirrhosis
Positive result
Treatment with pan-genotypic DAA regimen (for example sofosbuvir/daclatasvir)
Post-Treatment Assessment with HCV RNA test
Patient Cured
SVR
F0 – F4
No SVR Refer to specialist for genotyping and re-
treatment
1
2
3
4
HCV Diagnostic Summary with DAAs
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