Hepatitis C Toolkit

Hepatitis C in Primary Care: A Toolkit for the Clinician

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Introduction

Is Hepatitis C the “HIV of the 21st century”? The Centers for Disease Control (CDC) reports that infection with hepatitis C virus (HCV) is the most common blood borne infection in the United States, with chronic infection affecting about 3.2 million people and causing more deaths than HIV.[1] The CDC has recommended that all baby boomers (people born between 1945 and 1965) be screened for hepatitis C infection, and in the first decade of 2012, 75% of deaths from HCV infection occurred in adults age 45 to 64.[2]

Clinicians in primary care face a challenge to recognize, diagnose, monitor, and assist in treatment decisions for a large population of patients, many of whom may be asymptomatic but at risk for chronic liver disease and primary liver cancer.

Questions clinicians ask:

  • Which patients are most likely to benefit from screening?
  • What tests are recommended for screening?
  • What tests are used to confirm a positive hepatitis screen?
  • How can we help infected patients make informed treatment decisions?
  • Where can we easily access up to date treatment and monitoring guidelines?

Recommendations from the CDC and the Veterans Administration are the foundation of the following toolkit for clinicians who want to offer screening and advice to patients known to be infected or at risk for infection with hepatitis C.

Screening Population

The CDC recommends screening the following populations for chronic infection with hepatitis C:[3-4]

  • Adults born between 1945 and 1965.
  • HIV-infected patients.
  • Persons who ever injected illegal drugs.
  • Persons who received clotting factor concentrates before 1987.
  • Persons who were ever on chronic hemodialysis.
  • Persons with consistently abnormal aminotransferase levels.
  • Prior recipients of transfusions, blood components, or organ transplants. At risk are those who received these before 1992 and/or those persons notified they had received blood or tissue from a donor later identified as infected with hepatitis C.
  • Workers who suffer needle stick injury, sharps injury, or mucosal exposure to HCV- positive blood.
  • Children born to HCV-positive women.

Screening Tests for HCV infection
To screen:

  1. Start with Anti HCV, a qualitative measure of antibody to hepatitis C virus. If negative, no other screening test for hepatitis C infection is needed.
  2. If Anti HCV is positive, proceed to a confirmatory test. This can be recombinant immunoblot assay (RIBA) or viral load (HCV RNA). Confirmation is needed to detect false positive Anti HCV initial screen.

For interpretation of results and suggested actions for follow-up, see Chart 1. For a screening algorithm, see Chart 2.

HCV Lab Test Interpretation
Chart 1: Reference for Interpretation of Hepatitis C Virus (HCV) Test Results. Source: US Department of Health and Human Services Centers for Disease Control Division of Viral Hepatitis.

HCV Testing
Chart 2: Hepatitis C Virus (HCV) Infection Testing for Diagnosis. Source: US Department of Health and Human Services Centers for Disease Control Division of Viral Hepatitis.

Post-Test Counseling and Treatment Decision Making
After diagnosing a patient with hepatitis C infection, we want to counsel the patient about minimizing further insult to general health, avoiding liver toxins, and protecting the health of others.

This discussion may include:

  • The importance of regular contact with primary care or liver specialist.
  • The need to check with a physician or other health care provider before taking any new medication or supplement.
  • Checking for co-infection with hepatitis A or B and HIV, and offering immunization against hepatitis A and B in susceptible patients.
  • Avoidance of alcohol.
  • Maintaining a normal weight.
  • Refraining from donating blood, semen, or tissue, or sharing objects that may come in contact with blood.[4]

As clinicians in primary care, we want to offer patients chronic hepatitis C infection management options, from watchful waiting to potentially complex regimens that involve multiple drugs.

Our challenge is to identify the best candidates for treatment and who might benefit from close monitoring without drug therapy.

The United States Department of Veterans Affairs Hepatitis C Resource Center guidelines for management of patients infected with hepatitis C include pretreatment assessment, recommendations for therapy, and treatment monitoring, summarized for clinicians on the VA website: Summary of Recommendations.

Recommendation highlights[5]

1) Prescreening

Necessary Tests

  • Medical history, including psychiatric and substance abuse histories, and any prior treatment for hepatitis C and response.
  • Laboratory evaluation including liver function tests, prothrombin time, CBC, metabolic profile, serum ferritin, iron saturation, ANA, HIV serology, hepatitis C genotype and viral load, evaluation for hepatitis A and B infection/immunity, and EKG for patients with known cardiac disease.

Recommended Tests

  • Liver biopsy (if results influence management) Note: Biopsy is invasive and subject to sampling error. Alternatives: liver imaging, serum fibrosis markers
  • IL28B genotype (if results will influence management)
  • Eye exam for retinopathy (for patients with diabetes and/or hypertension)
  • Urine toxicology

2) Recommendations for treatment after prescreening

VA guidelines recommend consideration of treatment for patients with more than portal fibrosis (greater than stage 1). Counseling patients on their likelihood of achieving sustained viral response (SVR), based on individual factors such as body mass index, genotype, viral load, and liver fibrosis stage.

Treatment and Monitoring

Once we have identified and counseled patients who are appropriate for treatment of hepatitis C infection, we can initiate therapy based on viral genotype, and patient treatment naïve or treatment experienced status.

Algorithms for treatment and monitoring are available at the VA website[6].

Conclusion

Patients infected with hepatitis C often are asymptomatic in the early stages of chronic infection. Identifying and counseling patients who may benefit from watchful waiting or treatment of their infection is within the scope of primary care practice. Screening can be accomplished in the primary care office, and we can readily access treatment and monitoring protocols at the point of care, and offer them to patients in discussions of treatment options.

 

Andrea Brand, MD
Published on December 11, 2012


Biosketch

Andrea Brand has produced numerous articles, has presented, and has written a personal memoir. Since 2008, she has been a clinical assistant professor of Family Medicine at the Florida State University School of Medicine.

References

  1. MMWR 2012; 61 (RR-4); 1-18. Aug.12, 2012
  2. Ly, KN, Xing J The increasing burden of mortality from viral hepatitis in the US 1999-2007 Annals of Internal Medicine Feb. 21,2012 156 (4): 271-8.
  3. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents MMWR 2009;58 (No.RR-4).
  4. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945-1965 MMWR 61, No. 4 August 17, 2012
  5. Pretreatment assessments update on the management and treatment of Hepatitis C virus infection: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Office. May 2012.  http://www.hepatitis.va.gov/pdf/2012HCV-guidelines.pdf
  6. U.S. Department of Veterans Affairs. Therapy against Hepatitis C in Patients with Genotype 1 Infection. Update on the Management and Treatment of Hepatitis C Virus Infection. http://www.hepatitis.va.gov/pdf/2012HCV-guidelines.pdf