Hepatitis C

Question 1

Test for HepC in…

Answer 1

Adults born 1945-65, IV Drug Use (at ALL), Intranasal illicit drug use, suspected exposure, HIV inf, clotting factors before 1987, hemodialysis (ever), tattoo in an unregulated setting, persistently abnormal ALT or unexplained liver disease, incarceration (ever) organ transplant or blood recipient prior to 1992, recognized exposure

Question 2

Testing

Answer 2

1. HCV antibody

2. If reactive: HCV RNA, if + have a current inf

Question 3

HepC Antibody…

Answer 3

NOT effective in preventing subsequent infection

Question 4

HepC Infection Progression Time Course

Answer 4

Slower: F
Faster: older, EtOH use, M, Coinfection (HIV/HBV), Obesity, Genotype 3

Question 5

HepC Treatment Goal

Answer 5

SUSTAINED VIROLOGIC RESPONSE (SVR): undetectable RNA 12w post treatment

• reduce all cause mortality and liver related health adverse consequences
• prevent transmission

Question 6

Who should be treated?

Answer 6

All w/ chronic HepC inf (except those w/ short life expectancies), IMMEDIATE treatment for adv fibrosis (stage F3)/compensated cirrhosis (F4)/liver transplant recipients/severe extrahepatic HepC

Question 7

HepC Counseling points

Answer 7

it’s slowly progressive, can’t donate, use barrier contraception, CAN breastfeed, don’t share razors/toothbrushes, avoid IVDA/Alcohol

Question 8

Interferon (P/C)

Answer 8

P: effective, durable response
C: injectable, sig AEs, required duration w/ ribavirin, differing effects based on genotype, use in decomp liver disease

Question 9

Ribavirin (P/C)

Answer 9

P: PO, inexpensive, effective combo w/ interferon/protease inhib/NSSB inhib
C: AEs, kinetics in renal disease, not monotherapy, no fixed dosing, required duration w/ interferon

Question 10

Direct-Acting Antiviral (P/C)

Answer 10

P: PO, high efficacy, safety profile
C: expense, access, emerging resistance

Question 11

HepC Treatment Duration

Answer 11

Mostly 12w, If have cirrhosis ext to 24w

Question 12

HepC Treatment Monitoring

Answer 12

4w: CBC, SCr, LFTs, HCV RNA
6w: HVC RNA (if +)
12w: TSH (if PEF-INF), HCV (?)
24w: HCV RNA

Question 13

Sofosbuvir (Solvaldi) General Info

Answer 13

Nucleotide NS5B Polymerase Inhib, Prodrug, treats all genotypes (backbone of treatment)

Question 14

Sofosbuvir Dosing

Answer 14

400 mg tab qd; CrCl >30, AEs: bradycardia (when used w/ amiodarone/other DAAs), fatigue, HA, N
*has a hole in gen3 ut much more favorable than PEG/RBV alone

Question 15

Sofosbuvir/Ledipasvir (Harvoni) General Info

Answer 15

Treats Gen1, approved for 12/24w cirrhosis treatment

Question 16

Sofosbuvir/Ledipasvir (Harvoni) Dosing

Answer 16

1t qd (90mg L/400mg S), CrCl>30

Question 17

Velpatasir General Info (used w/ SOF)

Answer 17

NS5A Protease Inhibitor, use for Gen1-6 in combo w/ SOF/naive or prior relapse/compensated cirrhosis w/ SOF, when used w/ Amiodarone watch bradycardia, DDI’s w/ P-gp, CYP2B6/2C8/3A4 inducers,, AEs (HA, fatigue)

Question 18

Velpatasir Dosing

Answer 18

1c qd (100mg V/400mg S) for 12w, CrCl>30

Question 19

Glecaprevir/Pibrentasvir (Mavyret) General Info

Answer 19

Use for Gen1-6 w/ or w/o comp cirrhosis, G (Ns3/4A PI) and P (NS5A Inhib), AEs (fatigue, HA), Don’t use w/ HepB react/CYP Induc (carbamazepine, efavirens/st john’s)/INR monitoring w/ warfarin use, CI in Severe HepImpair (CP C)/CoAdmin w/ atazanavir and Rifampin

Question 20

Glecaprevir/Pibrentasvir (Mavyret) Dosing

Answer 20

1t qd (100 mg G/40 mg P) for 8w (no cirrhosis) or 12w (w/ cirrhosis)

Question 21

Elbasvir/Grazoprevir (Zepatier) General Info

Answer 21

Use Gen1 (if have NS5A resistance)/Gen4 (IIa/B)/NS5A Polymorphisms (w/ ribavirin x16); G (NS3/4A PI) and E (NS5A Inh); CIs mod/sev HepImpair (CP B/C)/OAT1B1/3 Inhib, CYP3A Ind, efavirenz/ribavirin, AEs (fatigue, HA, N), DIs (Hep B react, CYP3A ind/inhib, Freq INR w/ Warfarin

Question 22

Elbasvir/Grazoprevir (Zepatier) Dosing

Answer 22

G 100mg/E 50mg