Diagnosis and Management of Hepatitis C Infection in Primary Care Settings

Journal of General Internal Medicine, Jan 2018

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.

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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) - 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)


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Debra Guss, Jagannath Sherigar, Paul Rosen, Smruti R. Mohanty. Diagnosis and Management of Hepatitis C Infection in Primary Care Settings, Journal of General Internal Medicine, 2018, pp. 551-557, Volume 33, Issue 4, DOI: 10.1007/s11606-017-4280-y