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HCV - Coggle Diagram
HCV
Risk Factors for Routine Screening
Anyone born between 1945-1965
Patients who have been on hemodialysis
Percutaneous/Parenteral exposure in unregulated setting
Blood transfusion or organ transplant before July 1992
Unexplained elevated ALT levels or evidence of liver disease
History of Injection or intranasal drug use
Healthcare worker after needle-stick
Persons who were ever incarcerated
Coinfection with HIV
Sexually active about to start PrEP
Solid organ donors
Pharm Treatment
Sofosbuvir (Sovaldi)
Approved for GTS 1-4
Bradycardia observed when used with amiodarone
T1t (400mg) PO Qd
Ledipasvir/Sofosbuvir (Harvoni)
Treats Genotypes 1, 4, 5, 6
Take 1 tablet PO daily with or without food
Treatment Duration: 1. Treatment Naive, non-cirrhotic, or cirrhotic - 12 weeks 2. Non-cirhottic, Non-HIV, HCV PCR < 6 milliion - 8 weeks
AE: Nausea, headache, fatigue, asthenia
DDIS: PPI max omeprazole 20 mg daily administered at same time as Harvoni, H2RA max famotidine 40 mg BID taken at same time or 12 hours apart from Harvoni, No amiodarone , decrease statin dose by 1/2
Sofosbuvir/Velpatasvir (Epclusa)
Pan-genotypic
Can use in decompensated cirrhosis
Treatment Duration: 1. Treatment Naive or experienced, non-cirrhotic or cirrhotic - 12 weeks 2. Decompensated cirrhosis - 12 weeks with ribaviron
Take 1 tablet daily with or without food
ADR: headache, fatigue, nausea
DDI: PPI max omperazole 20 mg daily take epclusa with food 4 hours before PPI, H2RA max famotidine 40 mg q12h taken at same time or 12 hours apart from epclusa, no amiodarone
Elbasvir/Grazoprevir (Zepatier)
Pan-Genotypic
Treatment- Duration : 1. Treatment Naive, non-cirrhotic - 8 weeks, 2. Treatment naive, cirrhotic - 12 weeks 3. HCV-recipient of HCV + organs - 12 weeks
Take 1 tablet PO daily with or without food
DDI: CPY3A4 inducers, stain decrease dose 1/2
AE: headache, fatigue, nausea
Glecaprevir/Pibrentasvir (Mavyret)
Pan-Genotypic
Can be used in renal insufficiency and hemodialysis
CI'd in ethinyl estradiol containing products
AE: Nausea, headache, fatigue
DDIs: Carbamazepine, efavirenz, SJW, estradiol, decrease statin dose 1/2
Take 3 tablets PO with food once daily
Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi)
Pan-Genotypic
Cannot be used in decompensated cirrhosis (Child Pugh B/C)
Treatment Duration: With or without cirrhosis previously treated with NS5A inhibitor - 12 weeks
Take 1 tablet PO daily
DDIs: PgP inducers, inducers of CYP2B6, 2C8, 3A4, PPI max dose omeprazole 20 mg, decrease statin dose 1/2
Ribavirin
Add-on therapy for decompensated cirrhosis patients
Causes hemolytic anemia
Teratogenic, requires 2 forms of contraception during therapy and for 6 months after
Non-Pharm Treatment
All patients with chronic HCV should be vaccinated against Hep A and Hep B
Lifestyle modifications are important factor in reducing health consequences from HCV
Alcohol use can result in disease progression
Weight loss - normal weight can help to reduce fibrosis progression
Discontinue herbal therapy due to high risk of DDIs
Harm reduction strategies to prevent spread of HCV
General Approach to Treatment
all patients with HCV should be treated
Screen all patients for HCB
No clearly identified contraindications to treatments
Perform quantitative HCV testing prior to initiation, genotyping, and underlying liver disease
Assess for cirrhosis to determine Child Pugh Score
Epidemiology
Most common blood-borne pathogen with incidence on the rise
Difficult to diagnose
45-85% of people may not be identified until severe liver damage due to delay in diagnosis
6 genotypes: Genotype 1 (USA, hardest to treat), Genotype 2 and 3 (USA, East Asia, Japan), Genotype 4 (North Africa), Genotype 5 (South Africa), Genotype 6 (Asia)
Goals of Treatment
Primary Goal: Eradicate HC Infection - virology cure or sustained virology response (non detectable HCV RNA at least 12 weeks after completing HCV therapy)
Resolving patients ESLD, HCC and death
Cure also reduces transmission rate
Pathophysiology
Acute infection leads to chronic infection which leads to cirrhosis and HCC
Progression typically occurs over 30 years
If patient is immunosuppressed, coinfected with HIV, obese or high alcohol intake there is risk for rapid progression
Diagnosis
HCV Antibody Negative
No prior HCV exposure
If recent HCV infection suspected, test for HCV RNA
HCV Antibody Positive - requires HCV RNA Testing
HCV RNA + indicates current active infection
Could indicate prior HCV infection with prior successful resolution or prior HCV infection with prior successful treatment
Symptoms
Acute infection - commonly asymptomatic , N/V, fatigue, abdominal pain, AST/ALT may be elevated
Chronic infection - often asymptomatic, fatigue, porphyria, LFT elevations