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Chronic Viral Hepatitis C Treatment

Hcv Testing And Management In Pregnant Adults

CAR-T therapy, a novel promising treatment option for chronic hepatitis B and HBV-associated HCC

Reviewed and updated: David E. Bernstein, MD, with the HCV Guideline Committee October 6, 2022

RECOMMENDATIONS
HCV Testing and Management in Pregnant Adults
  • Clinicians should perform HCV testing in all patients who are planning to get pregnant or are currently pregnant , and screening should be repeated with each pregnancy .
  • See the CDC: Hepatitis C, Perinatal Infection 2018 Case Definition and the IDSA/AASLD: HCV in Pregnancy.
  • Contraceptive Use With HCV Treatment Containing RBV
    • Before initiating RBV as part of an HCV treatment regimen in a patient of childbearing potential, clinicians should confirm a negative pregnancy test and advise patients to use 2 methods of birth control for the duration of DAA therapy and 6 months after completion.
    • If a patient becomes pregnant while taking RBV, the clinician should discontinue the RBV.
    • Contraindication: Clinicians should not prescribe RBV for any patient planning pregnancy within 6 months of the last RBV dose or any male patient with a pregnant partner.

    Abbreviations: AASLD, American Association for the Study of Liver Diseases CDC, Centers for Disease Control and Prevention DAA, direct-acting antiviral HCV, hepatitis C virus IDSA, Infectious Diseases Society of America RBV, ribavirin.

    If an individual with HCV becomes pregnant while taking an HCV treatment regimen containing RBV, RBV should be discontinued.

    References

    Floreani A. Hepatitis C and pregnancy. World J Gastroenterol 2013 19:6714-6720.

    Overview Of Hcv Treatment

    For genotype 3, first-line treatments include

    • Fixed-dose combination of sofosbuvir 400 mg/velpatasvir 100 mg once a day for 12 weeks

    • Fixed-dose combination of glecaprevir 300 mg/pibrentasvir 120 mg once a day for 8 to 16 weeks, depending on history of prior treatment and degree of liver fibrosis

    For genotype 4, first-line treatments include

    • Fixed-dose combination of ledipasvir 90 mg/sofosbuvir 400 mg orally once a day for 12 weeks

    • Fixed-dose combination of elbasvir 50 mg/grazoprevir 100 mg orally once a day for 12 weeks

    • Fixed-dose combination of velpatasvir 100 mg/sofosbuvir 400 mg once a day for 12 weeks

    • Fixed-dose combination of glecaprevir 300 mg/pibrentasvir 120 mg once a day for 8 to 12 weeks, depending on degree of liver fibrosis

    For genotypes 5 and 6, first-line treatments include

    • Fixed-dose combination of ledipasvir 90 mg/sofosbuvir 400 mg orally once a day for 12 weeks

    • Fixed-dose combination of velpatasvir 100 mg/sofosbuvir 400 mg once a day for 12 weeks

    • Fixed-dose combination of glecaprevir 300 mg/pibrentasvir 120 mg once a day for 8 to 12 weeks, depending on degree of liver fibrosis

    Causes And Risk Factors

    HCV causes hepatitis C. People contract the virus through blood-to-blood contact with contaminated blood. For transmission to occur, blood containing HCV must enter the body of a person without HCV.

    A speck of blood, invisible to the naked eye, can carry hundreds of hepatitis C virus particles, and the virus is not easy to kill.

    The report the following risk factors for developing hepatitis C:

    • using or having used injectable drugs, which is currently the most common route in the U.S.
    • receiving transfusions or organ transplants before 1992, which is before blood screening became available
    • having exposure to a needle stick, which is most common in people who work in healthcare
    • being born to a mother who has hepatitis C

    The CDC offer advice on cleaning syringes if it is not possible to use clean and sterile ones. Although bleach can kill the HCV in syringes, it may not have the same effect on other equipment. Boiling, burning and using alcohol, peroxide, or other common cleaning fluids to wash equipment can reduce the amount of HCV but might not stop a person from contracting the infection.

    It is extremely dangerous to inject bleach, disinfectant, or other cleaning products, so people should make sure they rinse the syringe thoroughly. A person should only ever use bleach to clean equipment if new, sterile syringes and equipment are not available.

    People who are at risk due to these factors can have screening to rule out HCV.

    • peginterferon alfa-2a

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    Detection Of Hepatocellular Carcinoma During The Treatment With Pegylated Interferon Alfa

    2006, Digestive and Liver Disease

    Background and aim: To determine the postoperative mortality and morbidity after a total gastrectomy with a D2 lymphadenectomy for gastric adenocarcinoma perfomed on patients of more than 70 years of age. Material and methods: Betweeu 1987 aud 2005 we observed 432 pz with gastric and cardia cancer. The cases of 52 pz > 70 years and 136 pz < 70 years-old who underwent to total gastrectomy with a D2 lymphadenectomy for gastric adenocarcinoma were rewiewed. Results: No differences were observed with respect to patients of a younger age at diagnosis regarding the site of the tumor, extension of the disease, or Lauren’s histologic type. The elderly group had a higher ASA risk . All of them had a RO resection. We observed complications in 5/52 pz in the elderly group, in 20/136 in the younger group , . Mortality < 30 days occurred in 5/52 pz in the elderly group (3 with a pregress IMA,…

    What Are The Treatments For Hepatitis C

    How Can You Get Hepatitis

    Treatment for hepatitis C is with antiviral medicines. They can cure the disease in most cases.

    If you have acute hepatitis C, your health care provider may wait to see if your infection becomes chronic before starting treatment.

    If your hepatitis C causes cirrhosis, you should see a doctor who specializes in liver diseases. Treatments for health problems related to cirrhosis include medicines, surgery, and other medical procedures. If your hepatitis C leads to liver failure or liver cancer, you may need a liver transplant.

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    Patients With Persistent Liver Disease

    Cessation of fibrosis progression and histological improvement are among the benefits of treating chronic HCV infection. However, patients should still be monitored for potential post-treatment decompensation . Individuals cured of HCV infection remain at risk of liver disease progression if they have advanced baseline fibrosis, other chronic liver conditions , comorbidities , or at risk of liver injury from drugs or dietary supplements .

    There is wide individual variation in the time needed for fibrosis progression in patients with chronic liver disease. It is important to maintain an elevated suspicion for progression and the complications associated with hepatic decompensation, particularly in individuals with bridging fibrosis or cirrhosis before the initiation of DAA therapy and HCV cure.

    In patients with bridging fibrosis or cirrhosis, an ultrasound and alpha-fetoprotein testing should be performed every 6 months, regardless of SVR, to screen for HCC . The risk of HCC for patients with stage 3 or higher fibrosis is 1.5% to 5% per year, but it is not known whether the histologic improvement after successful treatment mitigates this risk .

    References

    AASLD/IDSA. Hepatitis C guidance: AASLD-IDSA recommendations for testing, managing, and treating adults infected with hepatitis C virus. 2021 Oct.

    Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology 2011 53:1020-1022.

    Importance Of Adhering To Your Treatment Plan

    Once you begin treatment for your Hepatitis C infection, youll want to do everything you can to make it a success. Adherence to your Hepatitis C medication regimen is an important predictor of successful treatment. When it comes to medications, this means that you want to adhere to taking them as prescribed meaning taking the right dose, the right way, at the right time, for as long as prescribed.

    The goal of using medications to treat Hepatitis C is to:

    • Clear the Hepatitis C virus from your body
    • Prevent or slow down scarring of your liver
    • Reduce your chance of developing cirrhosis and liver cancer

    Proper adherence to Hepatitis C therapy will increase your chance of being cured and decrease the long-term complications of Hepatitis C.

    Adhering to other aspects of your treatment plan is also important. Keeping your medical appointments and getting the necessary lab tests will help to maximize your chance of treatment success and minimize potential problems.

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    How Do Doctors Treat Hepatitis C

    Doctors treat hepatitis C with antiviral medicines that attack the virus and can cure the disease in most cases.

    Several newer medicines, called direct-acting antiviral medicines, have been approved to treat hepatitis C since 2013. Studies show that these medicines can cure chronic hepatitis C in most people with this disease. These medicines can also cure acute hepatitis C. In some cases, doctors recommend waiting to see if an acute infection becomes chronic before starting treatment.

    Your doctor may prescribe one or more of these newer, direct-acting antiviral medicines to treat hepatitis C:

    You may need to take medicines for 8 to 24 weeks to cure hepatitis C. Your doctor will prescribe medicines and recommend a length of treatment based on

    • which hepatitis C genotype you have
    • how much liver damage you have
    • whether you have been treated for hepatitis C in the past

    Your doctor may order blood tests during and after your treatment. Blood tests can show whether the treatment is working. Hepatitis C medicines cure the infection in most people who complete treatment.

    Hepatitis C medicines may cause side effects. Talk with your doctor about the side effects of treatment. Check with your doctor before taking any other prescription or over-the-counter medicines.

    For safety reasons, talk with your doctor before using dietary supplements, such as vitamins, or any complementary or alternative medicines or medical practices.

    Interferons And Pegylated Interferons

    Screening and Treating Hepatitis C at the Penn Center for Viral Hepatitis

    The two most frequently used recombinant interferon preparations in clinical trials have been IFN alfa-2b and IFN alfa-2a , which differ from each other by only a single amino acid residue. IFN alfacon-1 , or consensus IFN, is a genetically engineered compound synthesized by combining the most common amino acid sequences from all 12 naturally occurring IFNs. Roferon-A was discontinued from the market in 2007 and Infergen was discontinued from the market in 2013.

    The addition of propylene glycol molecules to IFN has led to the development of long-lasting IFNs that have better sustained absorption, a slower rate of clearance, and a longer half-life than unmodified IFN, which permits more convenient once-weekly dosing. The FDA has approved PEG-IFNs for the treatment of chronic hepatitis C.

    Two PEG-IFN preparations are available for the treatment of chronic hepatitis C. PEG-IFN alfa-2b consists of IFN alfa-2b attached to a single 12-kd PEG chain it is excreted by the kidneys. PEG-IFN alfa-2a consists of IFN alfa-2a attached to a 40-kd branched PEG molecule it is metabolized predominantly by the liver.

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    Can Hepatitis C Be Prevented

    There is no vaccine for hepatitis C. But you can help protect yourself from hepatitis C infection by:

    • Not sharing drug needles or other drug materials
    • Wearing gloves if you have to touch another person’s blood or open sores
    • Making sure your tattoo artist or body piercer uses sterile tools and unopened ink
    • Not sharing personal items such toothbrushes, razors, or nail clippers
    • Using a latex condom during sex. If your or your partner is allergic to latex, you can use polyurethane condoms.

    NIH: National Institute of Diabetes and Digestive and Kidney Diseases

    Monitoring During Daa Treatment

    Reviewed and updated: David E. Bernstein, MD, with the HCV Guideline Committee October 6, 2022

    RECOMMENDATIONS
    Monitoring of Patients Taking RBV
    • While patients are taking RBV, clinicians should perform hemoglobin testing at weeks 2 and 4 of treatment and every 4 weeks thereafter until therapy is complete.
    Monitoring for HBV Reactivation
    • In patients who are HBsAg-positive and have no detectable HBV DNA, clinicians should monitor for HBV reactivation by performing AST, ALT, and HBV DNA tests every 4 weeks during HCV treatment.
    • Clinicians new to HCV treatment should consult a liver disease or experienced viral hepatitis specialist for further evaluation of patients who develop detectable HBV DNA.

    Abbreviations: ALT, alanine transaminase AST, aspartate aminotransferase HBsAg, HBV surface antigen HBV, hepatitis B virus HCV, hepatitis C virus RBV, ribavirin.

    The adverse events associated with direct-acting antiviral treatment are listed in Table 8, below, and most are manageable. Patients who are taking RBV and experience insomnia may need to adjust the timing of the dose to earlier in the afternoon to avoid any sleep disruption.

    KEY POINT
    • HCV RNA testing is needed only at baseline and at least 12 weeks after treatment is finished HCV RNA testing is not necessary during or at the completion of treatment.
    Table 8: Adverse Events Associated with Direct-Acting Antivirals
    Drug or Combination
    Headache, fatigue, diarrhea, and nausea
    References

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    Acute Hepatitis C Vs Chronic Hepatitis C

    Acute and chronic hepatitis C are caused by the same virus.

    Acute hepatitis C develops after initial infection with the HCV. This stage can last up to 6 months. Many people have no symptoms during the acute stage and never find out that they have the infection.

    According to the CDC, of people with acute hepatitis C develop chronic hepatitis C.

    The World Health Organization states that 15 to 45 percent of people with acute hepatitis C spontaneously clear the virus within 6 months. This means that the virus goes away even though it hasnt been treated.

    The 55 to 85 percent of people who dont clear the virus will develop a chronic HCV infection.

    Chronic hepatitis C can be managed with medications and even cured, but its still a serious condition. According to the CDC,

    Potential Outcomes Of Treatment

    HCV New Drugs: Treatment of chronic hepatitis C: The new standard of ...

    In order to adequately monitor your response to treatment, youll need to visit your healthcare provider so he or she can examine you in person and discuss how youre feeling. The level of Hepatitis C virus in your bloodstream will be checked to monitor your response to treatment. The potential outcomes of treatment are the following:

    • Sustained virologic response : You are considered cured if the Hepatitis C virus is not detected when measured with a blood test three months after youve completed treatment. This is called a sustained virologic response and data suggest that you will stay virus free indefinitely.
    • Nonresponse: The Hepatitis C virus does not become undetectable as a result of treatment. This can be further categorized as partial response, when the viral levels become lower but not undetectable, or null-response which is when the viral level never drops significantly.
    • Relapse: The Hepatitis C virus becomes undetectable on treatment, but then is detectable again, either during treatment or after treatment is stopped.
    • Incomplete treatment: Treatment ended earlier that the prescribed duration.

    The goal of treatment is to have an SVR. This is when you are considered cured. Taking your medication as prescribed will increase your chance of being cured and decrease the long-term complications of Hepatitis C.

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    How Effective Is Treatment

    Direct-acting antivirals cure 9 out of 10 patients with hepatitis C.

    Successful treatment does not give you any protection against another hepatitis C infection. You can still catch it again.

    There’s no vaccine for hepatitis C.

    If treatment does not work, it may be repeated, extended, or a different combination of medicines may be tried.

    Your doctor or nurse will be able to advise you.

    Managing Your Health While On Treatment

    There are many things you can do to improve your health and feel better while on treatment for your Hepatitis C infection. And by taking good care of yourself, you will increase your chances of be able to take your medication as prescribed.

    IMPORTANCE OF DIET AND NUTRITION

    Contrary to some claims you might read on the Internet, there is no special Hepatitis C diet. However, a healthy diet can improve liver health in a person with Hepatitis C.

    A well-balanced diet can lead to better liver functioning and lowered risk of cirrhosis of the liver. It can also help your immune system fight off illness. People with Hepatitis C tend to have higher rates of diabetes, but a good diet can help control blood sugar and reduce body fat, thereby lowering your risk for becoming diabetic.

    Multiple studies have now demonstrated the benefit of drinking coffee to improve liver health in Hepatitis C. Studies suggest you need to drink more than two cups per day to gain this benefit. However, the research is not strong enough to make a recommendation to start drinking coffee and some people do not tolerate it well. But for those who currently do drink coffee enjoy!

    General dietary recommendations include the following:

    BE CAUTIOUS ABOUT DIETARY SUPPLEMENTS

    Certain vitamins and minerals like vitamins A and D, iron and niacin can be harmful to your liver in high doses. Before taking a vitamin or supplement, its best to talk with your doctor, dietician or nutritionist.

    ALCOHOL

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    Hcv Treatment Goals And Considerations

    Reviewed and updated: David E. Bernstein, MD, with the HCV Guideline Committee October 6, 2022

    RECOMMENDATIONS
    Considerations in HCV Treatment
    • Before initiating antiviral therapy, clinicians should assess CrCl, HIV and HBV status, and the degree of fibrosis, among other factors.
  • Clinicians new to HCV treatment should consult a specialist in treatment of liver disease or viral hepatitis when treating patients who:
  • Have severe renal impairment and/or are undergoing hemodialysis.
  • Require retreatment after treatment failure of any DAA regimen.
  • Clinicians should prescribe RBV with caution for patients with a CrCl < 50 mL/min.
  • If prescribed, a reduced dose of 200 mg per day is required.
  • Non-RBV-containing regimens can be prescribed without dose adjustments for patients with CrCl 30 mL/min.
  • Contraindications
    • Clinicians should not prescribe RBV for treatment of the following patients:
    • Female or male patients planning conception within 6 months of the last dose of RBV.
    • Male patients who have pregnant partners.

    Abbreviations: CrCl, creatinine clearance DAA, direct-acting antiviral HBV, hepatitis B virus HCV, hepatitis C virus RBV, ribavirin.

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