Screening and Management of Hepatitis C in the Wake of New Guidelines and Treatments

With state-of-the-art treatment regimens for hepatitis C becoming more effective and easier to administer and monitor, care delivery will shift away from specialists to include more involvement by prima ry care physicians.

“The disease is moving swiftly into the arena of internists,” said Norah A. Terrault, MD, MPH, FACP, a professor of medicine and director of the Viral Hepatitis Center at the University of California, San Francisco, during a presentation at the American College of Physicians Internal Medicine 2014 annual meeting held in Orlando, FL.

About 65 percent of people infected with the hepatitis B and 75 percent of those infected with hepatitis C virus do not know it. Screening guidelines recently changed for both diseases. For hepatitis B, all people born in countries with a high prevalence of the disease (a HBsAg prevalence of equal to or greater than 2 percent) should be screened, as should anyone born in the United States who was not vaccinated as an infant with a parent born in regions with a HBV endemicity of equal to or greater than 8 percent.

“You need to understand where it is prevalent in the world,” in order to guide your screening decisions, Terrault said.

Additional people screened include injection-drug users, men who have sex with men, immunosuppressed people, those with elevated liver function tests, hemodialysis patients, organ donors, and partners of patients with the disease.

Screening guidelines for hepatitis C changed from only those with risk factors to include all people born between 1945 and 1965. They may have been infected years ago due to lifestyle experimentation, meaning they may have been infected for nearly 40 years, she said.

“If we identify 800,000 infected people and treat, we will prevent liver cancer and cirrhosis,” Terrault said. “We need to find them now to get them care to prevent downstream complications. Timing is critical.”

Goals are to reduce the risk of chronic infection and transmission to others. The hepatitis B vaccine is the most important intervention in the prevention of hepatitis B, but no vaccine for hepatitis C exists, she said. With the hepatitis B vaccine, pre-vaccination testing is recommended. Post-vaccination testing is indicated only for high-risk patients at one to two months after the last dose. If the desired titer is not reached, a second course can be given. Booster shots are not recommended

Whether treating hepatitis B or C, prevention of the progression to cirrhosis involves reducing risk with abstinence from alcohol and cannabis and maintaining an ideal body weight.

Terrault emphasized the importance of staging cirrhosis, because patients remain at risk of liver decompensation. Staging provides guidance for when to treat the infected patient. Noninvasive tests are the first step. “We can make the diagnosis short of a biopsy,” she said.

A platelet count of less than 140,000 platelets per microliter of blood indicates the patient may have cirrhosis. Other tests include the Fibrotest (or FibroScore) and the APRI or F1B4, which are two markers for fibrosis that can be calculated at the bedside.

“The tests perform best at the extremes and are not perfect,” she said. “They give an estimate.”

If the blood testing indicates cirrhosis, do more testing to confirm or eliminate the diagnosis, she recommended. That may include transient elastography, which uses sound waves to assess liver stiffness.

Patients with chronic hepatitis B are more difficult to manage and need ongoing monitoring, Terrault said. Patients who are immune inactive or immune tolerant do not require treatment, only those who are immune active, with an increased ALT and HBVDNA. Peginterferon, tenofovir, and entecavir are first-line drugs. Patients are not cured only controlled.

Hepatitis C, on the other hand, can be cured in most people. The goal is to suppress the virus long term, which will lead to improved liver enzymes and a seroconversion.

Treatment regimens depend on genotype. Some genotypes still require interferon as part of the drug regimen, but interferon-free combinations have shown great promise in clinical trials and are expected to be available within a year.

“Our options for treatment continue to improve,” Terrault concluded. “It’s only going to get better.”