Hepatitis C (HCV)

Question 1

Features

Answer 1

Mainly acquired from IV drug use & tattooing

Minimal clinical symptoms—often asymptomatic

About 70% can progress to chronic hepatitis (see Fig. H11)

Treatment decisions based on the HCV genotype which should be tested

Good cure rates now esp. with types 2 & 3

Question 2

Time course of active Hepatitis C infection

Answer 2

Question 3

Serology

Answer 3

HCVAb (anti-HCV) +ve = exposure (current or past)

HCV RNA (a PCR test) +ve = chronic viraemia

–ve = spontaneous clearance

CD4/HCV = viral load

ALTs in LFTs → indicates disease activity (tested 3 times over next 6 mths)

• –ALT persistently normal = good prognosis
• –ALT ↑↑ = treatment required; refer

If PCR +ve + significant viral load +↑ ALT, perform genotyping (to determine treatment)

HCV genotyping—to determine duration of anti-HCV therapy

HCV RNA is present when the ALT becomes abnormal while the anti-HCV rises more slowly and may not be detectable for several weeks.

Follow progress with LFTs and αFP screening. Also check for HBV and HIV (informed consent).

Monitor severity of hepatic fibrosis by FibroScan® imaging.

Question 4

Treatment

Answer 4

The current standard Rx for chronic hepatitis C is direct-acting antivirals (DAAs) taken daily by mouth.

These agents are now supplanting interferon-based therapy.

The determination of genotype and viral load,

• as well as hepatic status,
• will identify those most likely to respond to therapy

Question 5

Examples of DAAs are:

Answer 5

• protease inhibitors, e.g. simeprevir
• nucleotide polymerase inhibitors, e.g. sofosbuvir
• non-nucleotide inhibitors, e.g. dasabuvir
• NS5A inhibitors, e.g. daclatasvir, ledipasvir

These agents are given in combination according to the genotype, e.g. Epclusa, Harvoni.

Cure rates are in the order of 95%.

Rx can be managed within general practice,

• in collaboration with a specialist gastroenterologist.

Question 6

The recommended steps for pretreatment assessment are:

Answer 6

1. Confirm the diagnosis of chronic HCV infection.
2. Test for hepatitis C virus genotype and viral load.
3. Document the HCV treatment history.
4. Evaluate comorbidity and liver status,

• especially cirrhosis by fibroscan (refer if present)
• and renal function (eGFR > 30).

5. Discuss contraception and pregnancy (if applicable).
6. Consider concomitant medication.
7. Assess adherence to treatment.
8. Select treatment regimen (8 or 12 weeks)
   * and review potential drug interactions.
9. Consult with a specialist.
10. Treat and monitor (compliance).

Side-effects of Rx;

• These can be quite distressing.
• Monitor carefully.