PlayPlay Podcast downloadDownload Podcast Take Post TestTake Post Test

Transcription:

UAB MedCast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Melanie Cole (Host): Hepatitis has been recognized as a global health problem. Our topic today is hepatitis C and here to tell us about that are my guests Dr. Brendan McGuire, he’s the Medical Director of Liver Transplant and Dr. Michael Saag, he’s the Associate Dean for Global Health, both at UAB medicine. Gentlemen, welcome to the show. Dr. Saag, I’d like to start with you. Explain a little bit about hepatitis C.

Michael Saag, MD (Guest): Yeah, thanks a lot. Those of us who trained before 1989 would have known hepatitis C as non-A, non-B hepatitis and then in 1989 a flavivirus which is similar to dengue and at least in that family or a Zika virus even was discovered. It’s an RNA virus. It’s one that’s transmitted sort of in the same realm as HIV in that it’s transmitted through blood products, through sexual activity and rarely but a lot less frequently from mom to baby when mom’s infected with the virus. The virus itself has a varied natural history in that the virus once it infects about 15-20% of people will clear the infection without any problem and they will just be rid of it and you will know that because an antibody test will be positive but there won’t be any virus detected in the bloodstream. For the other 80% of people, they have a chronic infection and you would detect that by testing for antibody and then seeing a fairly high level of HCV RNA in the realm of usually 100,000 to millions of copies of virus and that would indicate that the person has chronic infection. And then just to round out the natural history, once somebody has chronic infection somewhere between 40-50% of people will go on to progress with liver scarring, sometimes up to the stage of cirrhosis and that would be approaching end-stage liver disease and that’s when the real complications of hepatitis C start. That occurs over a period of about 30 years.

Melanie: Dr. McGuire how many people in the United States have hepatitis C and who really is at risk of acquiring it? Tell us a little bit about the pathophysiology of it.

Brendan McGuire, MD (Guest): The prevalence of chronic hepatitis C in the United States is estimated to be about 3.5 million people. As Dr. Saag said, it is primarily a blood to blood transmission. Anyone who is a current or former injection drug users are at risk. Anyone who received blood products really prior to 1992 is also at risk. Patients also in the past on chronic hemodialysis, patients who have been exposed, hospital workers to needle sticks involving patients that are hepatitis C positive, people with HIV infection are also at risk and also as Dr. Saag said, children born to hepatitis C positive mothers.

Melanie: Dr. Saag as you have also already told us about transmission and exposure how important is early diagnosis as being crucial to improve the outcome prediction and what are the diagnostic criteria? Who should get tested?

Dr. Saag: Well the earlier the better for almost any kind of infectious disease and so I would recommend routine screening of really virtually anyone. When screening started, it was an antibody test and it was recommended first and foremost for what was called the baby boomers. That’s the individuals born between 1945 and 1965 in the United States and they had what was felt to be the highest prevalence of infection, but we are learning now that there’s another spike of people with infection that’s occurring in people aged 20 to 30 years of age perhaps a combination with the opioid epidemic that’s sweeping the country right now. But from my perspective, since we will get to treatment in a minute, but since treatment has become relatively easy, in the form or oral therapy for 8-12 weeks for most people; I would argue that anyone should be tested at least once. That would be anybody from I would say the age of 13 through the rest of life, at least tested once and if they go into higher risk groups that Dr. McGuire described then perhaps more frequently. But everyone should be tested at least once.

Melanie: Dr. McGuire are there genotypes? Are they important for treating patients? Tell us about some of the treatments available. Are you still using interferon or ribavirin? Tell the listeners, other physicians what you are doing right now in the current standard of care.

Dr. McGuire: It has actually been fun to treat hepatitis C and like Dr. Saag and I we both started treating it back in the early 1990’s with at that point we just used interferon and unfortunately it had a lot of side effects and about 20% of patients actually could not tolerate the side effects. But we have gotten a lot better. Now we have newer agents. They are oral pills. The pills, they are direct acting antiviral agents or DAA agents. These agents are a pill or a couple of pills once a day that you take for 8-12 weeks. Side effects are pretty minimal. Discontinuation rate is less than one percent and when you take these medications, success rate in terms of clearing virus is over 95%. There are six different genotypes in the US, primarily genotype 1 makes up 80% of the patients, genotype 2 makes up about 15% and the remaining five percent are genotype 3. With the current DAA’s some of them are so broad that they are successful against all six different genotypes. Some of them are more specific to genotype 1, but there are medications out there that are so easy to take, so easy to treat and so easy to clear virus. I agree with Dr. Saag, everyone really should be treated.

Melanie: Dr. Saag do you have any predictors of treatment response or and is there anyone who should not be treated? Are the clinical indications or contraindications for institution of these treatments?

Dr. Saag: Well back in the days of interferon treatment, sometimes we added ribavirin and oral antiviral to that. The side effect profile was pretty horrible and so the people that were referred or recommended for therapy were those who really had more advanced infection and we sort of didn’t treat everyone. Now with the direct acting agents available; we are really recommending treating most everyone. The exception would be those who have a short life expectancy, those who for example might have another underlying disease in which they are unlikely by the probability to live for another year or two. But most everybody else unless there are extenuating circumstances, drug-drug interactions or things that preclude the availability of the drugs to the individual or the provider; then I think most everyone should be treated. The biggest hurdle we are having right now isn’t really the testing or the indications for therapy; it’s really gaining access through the payors working out deals with the pharmaceutical companies to get the prices low enough to where they are affordable for all people to be treated.

Melanie: Dr. McGuire you get the fun question of promising new therapies, looking forward to the next ten years in the field; what do you feel will be some of the most important areas of research?

Dr. McGuire: Well the research for hep C has really been done since the drugs are there. The hardest part is just finding everyone who has it and that’s why we need primary care people to start screening individuals out there. We think that we have probably treated about half the people in the US, but there is still another half that we don’t even know that even have it. And for a lot of these people, their symptoms are just slowly progressing. They can have this for over twenty years and 20% of those will go on to develop cirrhosis, but it’s such a slow progressive disease. Most patients don’t have any specific symptoms for it. So, it really takes primary care doctors identifying these patients to get them all treated.

Dr. Saag: And if I could add to that, I think the treatment has become so straightforward that is somebody in practice is in internal medicine or primary care, they may want to learn about how to treat hepatitis C on their own. If they are not comfortable with that, then referral to either a GI specialist or infectious disease specialist can get it done. But the treatments really are pretty straightforward and the prerequisites of knowledge to treat would be obviously learning about the natural history of hepatitis C, learning especially how to stage the degree of liver fibrosis and historically we use liver biopsy. I think we have other means now that are less invasive especially elastography which is a special sound wave test that’s done on the liver that can estimate the degree of fibrosis to the point of perhaps cirrhosis and understanding which genotypes respond to which drugs. One very important caveat that I think Dr. McGuire would underscore is that if you are following somebody and you want to treat them, and you discover that they have cirrhosis; that’s something that should be managed in conjunction with a hepatologist. Otherwise, if the fibrosis scores are lower, the range usually goes from F0 to F4 by METAVIR criteria. Anybody who is F0 to F2 for sure I think can be readily managed by primary care. When you start getting F3, F4 degrees of fibrosis then that’s something you may want to reach out and talk to a hepatologist or share the care with them.

Dr. McGuire: And I would like to add just one additional comment. Hepatitis C is currently the number one indication for liver transplants, but with current treatments and the current drugs available; we think in two years it will not be and we think nonalcoholic steatohepatitis progressive cirrhosis will be the number one indication for liver transplant. But I have a lot of patients in my clinic with cirrhosis, we cleared their virus and their liver disease is stable and they are not progressing and it’s actually fun to see. I have them come back once a year just to screen them because they are at risk for developing cancer down the road; so, I will screen them for that. They are at risk for having varices from bleeding and I will screen them for that. But otherwise though, they are living a normal life and they have a very functioning liver. The cells work well even though they have cirrhosis.

Melanie: Isn’t that amazing gentlemen? So, Dr. Saag first last word to you. Are we using the word cure for hepatitis C when you talk about these standards of care and these treatments; and wrap it up for us. What would you like the listeners to take away from this segment about hep C, testing and when to refer.

Dr. Saag: Well to answer your fist question, absolutely. It is a cure. CURE. Cure. If you treat someone, their virus goes undetectable, where you can’t detect to target at all after their 8-12 weeks of therapy, you bring them back somewhere between four and six months later and if they are still undetectable; which 99% are; then you can look them in the eye and say, your hepatitis C has been eradicated, you are cured of your hepatitis C infection. And that is a joyful experience for the patient, but it is also for the provider. I guess my final take home point is hepatitis C which was unknown just thirty years ago has reached a point where we can cure 98% of people and the trick for us now is to test everyone, find out those who are infected, get them treated either you can treat them yourself with some training or you can refer them to the people that take this on everyday and you will find that your patients are cured and we can begin to think about eliminating hepatitis C from the United States. Dr. McGuire any other final comments?

Dr. McGuire: Oh, it’s a fun time. And I’m like you Mike, I never dreamed we would get this far, this quickly. And we have. And your comment is the patient is so excited when you tell them cured; but trust me, I think I’m just as excited if not more excited than they are. It is a great…

Dr. Saag: Me too.

Melanie: Thank you gentlemen so much for being with us today. What amazing times we live in for things like this and thank you so much for all the great work that you both are doing. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB MedCast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.