Hepatitis C Care: It's Cookbook Medicine, Expert Tells Physicians

Internal medicine physicians may encounter patients in their practice who could benefit from the expertise of a gastroenterologist.

Speaking today at the American College of Physicians Internal Medicine Meeting (ACP 2017) in San Diego, California, Hashem El-Serag, MD, MPH, (photo) of Baylor College of Medicine in Houston, a professor of gastroenterology and hepatology gave a standing-room only audience a quick course in his specialties so they could treat many of these patients. El-Serag is a well-known expert on hepatocellular carcinoma, and has published over 350 papers on the topic.

Among his subjects today was whether a non-specialist can competently care for patients with hepatitis C infection.

Due to the success of direct-acting antivirals (DAAs), El-Serag said, the answer is usually yes.

“Hepatitis C care is cookbook medicine now,” he said. With a long and growing list of effective DAAs, there are few patients who are beyond the expertise of an internal medicine or primary care physician, he said.

There are exceptions, including patients with cirrhosis, fibrosis, drug addiction, or signs of complications like low platelets. Patients who have failed treatment with DAAs should also be referred to a specialist and patients with genotype 3 infections may also require specialty care, he said.

But the DAAs that revolutionized hepatitis C care and disease prognosis a few years ago are household words now, he said.

“Everyone knows Harvoni, especially if they watch professional football—those ads come on right after the Viagra commercials,” he said.

El-Serag went through a list of approved DAAs and said that for most non-specialists the best approach is to pick one that covers multiple genotypes of the virus.

One problem that remains though is that even after the hepatitis infection is cured, “the presence of cirrhosis means the patient is still at risk of cancer and they have to be plugged in for surveillance,” he cautioned.

The unaddressed need in hepatitis C care now is getting more people tested, he said, since many who have the virus are unaware they have been infected. Since past drug use is a risk factor, it might seem logical for physicians to ask patients if they have ever used injection drugs. El-Serag advised against it.

“I have a fool-proof rule,” he said, make hepatitis C testing part of a panel, based on a patient’s age.

“What does work is asking grandpa about drug use some years ago—he’ll never tell you,” he said.

In answer to an audience question about biosimilar drugs and their availability, El-Serag said that any physician who gets email is likely to have gotten queries “from someone from India or Russia or Bangladesh trying to sell you one.”

Though the major DAA manufacturers did decide to give away their formulas to countries where it was unlikely many people or their governments would pay the prices of DAAs sold in the Western world, that is not true for the newest DAAs, he said.

“There are biosimilars in India, for example, but they haven’t caught up with the newer one,” El-Serag said. “But it is true, some countries are selling deeply discounted drugs.”