Diagnosis and Management of Hepatitis C Infection in Primary Care Settings
J Gen Intern Med
Diagnosis and Management of Hepatitis C Infection in Primary Care Settings
Debra Guss
ANP-C 1
Jagannath Sherigar 1
Paul Rosen 0
Smruti R. Mohanty
MS FACP 1
0 Department of Family Medicine, Brooklyn Hospital , Brooklyn , USA
1 Division of Gastroenterology and Hepatobiliary Diseases , New York-Presbyterian Brooklyn Methodist Hospital , Brooklyn , USA
Hepatitis C virus (HCV) infection is a significant health problem worldwide, and is the leading cause of cirrhosis, hepatocellular carcinoma, and liver transplantation in the United States. The management of HCV has changed significantly over the last 5 years, as treatments have become simpler and more efficacious. Medication efficacy is now greater than 90%, with a high barrier to resistance and few side effects. This review is a collaboration between primary care and hepatology providers to explore all aspects of HCV management: acute versus chronic HCV infection, transmission and testing, and diagnosis and treatment. Specific medications for the treatment of HCV infection are considered, and patient and medication factors including genotype, liver disease status, and comorbidities affecting medication choice are discussed. This is a new era for the management of HCV infection, and interested primary care physicians, family doctors, and general internists can be at the forefront of diagnosis, management, and treatment of HCV.
hepatitis C; primary care management; direct-acting antivirals (DAA)
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H wide health problem, representing an economic burden
epatitis C virus (HCV) infection is a significant
worldof over $6.5 billion in the United States alone,1 and a leading
cause of cirrhosis, hepatocellular carcinoma (HCC), and liver
transplantation. While the prevalence of HCV infection
peaked in 1994, the Centers for Disease Control and
Prevention (CDC) estimates that there are currently 2.7–3.9 million
persons in the United States with chronic HCV infection.2 A
disturbing trend of increased infections was observed from
2006 to 2012 among those less than 30 years of age, mostly
due to increased injection drug use.3 A significant number of
these patients with HCV are seen in the primary care setting,
but have not been adequately tested, and therefore not
diagnosed. A larger number of patients have been identified as
having HCV and were referred to a gastroenterologist or
hepatologist but lost to follow-up, had treatment deferred at
the time of referral, or failed prior treatments and have not
reengaged in care. With the development of simpler and more
efficacious drug regimens, a greater opportunity exists to
successfully manage chronically infected HCV patients at
the primary care level and to cure patients of HCV infection.
The door has opened for primary care physicians, family
doctors, and general internists to diagnose, treat, and cure
HCV.
Treatment of HCV infection has changed dramatically
since 1991 when the U.S. Food and Drug Administration
(FDA) approved the first treatment for HCV infection. The
standard of care at the time, interferon-alpha (subsequently
pegylated interferon) and ribavirin, had poor cure rates of
less than 50%, with treatment requiring self-injection and
risk of several severe adverse reactions4. The first oral
medications, boceprevir and telaprevir (NS3/4a protease
inhibitors), were approved in 2011 and were the first
direct-acting antivirals (DAAs) to target HCV viral
replication and clearance of infection.5 These NS3/4a protease
inhibitors demonstrated 70–80% efficacy in curing HCV
infections.6,7 However, while the duration, efficacy, and
side effects of these early oral medications were better than
previous regimens, they still required the concomitant use of
pegylated interferon injections and had significant side
effects. Treatments continued to be improved and simplified,
and in 2013, the first all-oral regimen sofosbuvir plus
ribavirin was approved by the FDA.5 This combination of
medications changed the face of HCV treatment, with easy
dosing, few side effects, and high efficacy. More recently,
DAAs with greater potency have been introduced, and HCV
treatments continue to evolve. The new DAAs have efficacy
rates greater than 90%, a higher barrier to resistance, and
fewer side effects.8,9 A new era in HCV treatment has
arrived, and for treatment-naïve patients without severe
liver damage or significant comorbidities, treatment of
HCV has been dramatically simplified, thus enabling
primary care providers (PCPs) to diagnose, treat, and cure
HCV without referral to specialists.
ACUTE HCV INFECTION
A complete understanding of the natural history of HCV
infection is difficult, as acute HCV infection is not always
recognized. Indeed, it is asymptomatic in most patients,
though many present with vague flu-like symptoms. Acute
hepatitis can occur 2–12 weeks after exposure (mean 7 weeks)
and can last 2–12 weeks, with a range of symptoms, from
complete absence of symptoms, to fatigue, myalgia, low-grade
fever, dark (...truncated)