1 / 36

Challenges of Treatment of Hepatitis C in the Incarcerated US Population

Challenges of Treatment of Hepatitis C in the Incarcerated US Population. Federal Medical Center Carswell 2011 Dr William Resto-Rivera MD, USPHS Kiesha Resto Pharm D, USPHS. Objectives.

Download Presentation

Challenges of Treatment of Hepatitis C in the Incarcerated US Population

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Challenges of Treatment of Hepatitis C in the Incarcerated US Population Federal Medical Center Carswell 2011 Dr William Resto-Rivera MD, USPHS Kiesha Resto Pharm D, USPHS

  2. Objectives #1) Examine Hepatitis C Virus (HCV) infections in prison population versus the regular population. #2) Analyze the challenges of identifying and treating prison population. #3) Review common & rare side effects that are related to Hepatitis C therapy. #4) Discuss challenges in treating patients with co-morbid conditions. #5) Review recent FDA approved medications for HCV.

  3. US Hepatitis Statistics Reference #4

  4. Population • Baby boomers account for 2 out of 3 cases of HCV patients. • Peak prevalence men born in early 1950’s • HCV is over-represented in African Americans. Reference #5

  5. Center of Disease Control & National Institutes of Health Convention January 2003 identified 5 optimal approaches to Screening & treating HCV in US prisons • #1 Testing of HCV in Prisons would identify many Infected Americans • #2 Prison Substance Abuse programs would decrease HCV infections & future prisons cost • #3 Patients can be Selected using Published Guidelines • #4 Prisons Treatment Reflects Community Standards and Require Sufficient Medical Workforce • #5 Collaboration Between Correctional & Public Health Systems is Needed Reference #14

  6. Factors for Treatment • Screening • Screening and Diagnosis of Hepatitis C individuals. • Screening for candidates for treatment • Safety , Efficacy & Cost • Monitoring Laboratories and ADR • Patient Tolerate treatment • Viral Response to treatment • EVR/SVR • Source of funding

  7. Hepatitis C Not a Routine Universal Screening Routine screening based on 4 criteria: • Amenable to treatment • Interfere with activities of daily living • Progress without treatment during time of incarceration • Risk of transmission Reference # 14

  8. To Screen or to Not Screen Rhode Island State Corrections Wisconsin State Corrections 91% HCV infected inmates identified through testing 27% of population with risk factor IVDA Indiana State Corrections Universal testing found 13% of population HCV (+) Screened all incoming inmate • 4263 Males – 23% + HCV • 499 Females – 40% HCV Out of inmates who tested + HCV 66% did not report high risk behaviors Reference #16 Reference #14

  9. USA and territories Incarcerated population 2008 Reference #3

  10. Break down of 2,424,279

  11. Summary of Assumptions of Paid Cost per Patient Per Month (PPPM) as of 2008 Reference #5

  12. Missed Opportunity Benefits for treatment during Incarceration • Lower cost in long run for HCV treatment • Stable living environment • Accessible medical care • High Risk Population • Direct Observed Medication • Abstinence from Substance abuse • Coordination between Rehabilitation programs and treatment

  13. Hepatitis C • Multiple Genotypes • 1 Most common (US) Approx. 80% • 2/3 US Approx 20% • 4 Egypt • RNA Virus • Family Flavovirus ( Denque, yellow fever)

  14. US Hepatitis C Statistics • Genotype 1 40-50% Successful SVR at 12 months • Genotype 2/3 70-80% Successful SVR at 12 months

  15. Contraindications to Ribavirin • Thalassemias (sickle cell anemia) or other hemoglobinopathy. • Significant cardiac disease (arrhythmias, angina, CABG, MI) in the past 12 months. • Renal dialysis or creatinine clearance < 50 mL/min. • Hypersensitivity to ribavirin • Pregnancy Reference #1

  16. Ribavirin Side Effects Black Box Warnings: • Hemolytic Anemia Warning (primarily in the first two weeks of therapy) • Pregnancy Warning. Negative pregnancy test is required pre-therapy & at every evaluation • Respiratory Warning for patients requiring assisted ventilation Reference #1

  17. Contraindication Peg-Interferon • Serious concurrent medical diseases; severe hypertension, heart failure, coronary heart disease, COPD , autoimmune disorders, uncontrolled endocrine disorder • Decompensate cirrhosis, History of solid organ transplant • Platelet count <75,000/mm3 or ANC <1,500 cells/mm3 • Ongoing injection drug use or alcohol use • Severe uncontrolled psychiatric disease Reference #1

  18. Reference # 6 & #7

  19. Management of Side Effects • Headaches/ Body aches • Tylenol • FLUIDS, FLUIDS, FLUIDS • NSAIDS!!!??? • Nausea & Vomiting • Promethazine

  20. Hemoglobin adjustment Reference #1

  21. Absolute Neutrophil Count (ANC) Adjustment Granulocyte Colony Stimulating Factor (G-CSF): If the patient is responding to treatment and neutropenia persists despite reduced peginterferon dose, consider G-CSFDosage: Filgrastim 300 microgram subcu. daily. Goal: ANC >1500 Reference #1

  22. Platelet Adjustment Reference #1

  23. Serious Adverse Reaction • Auto immune • Arrhythmias • Depression / Psychosis • CHF • Permanent thyroid dysfunction

  24. Patients with Co-morbid conditions • Pre-exiting Cardiac Condition • Renal Disease • Autoimmune Disease • Depression

  25. Case Studies Reference # 8-#10

  26. New Treatment Options

  27. Telaprevir (Incivek) Reference #20

  28. Boceprevir (Victrelis) Reference #21

  29. Adverse Effects

  30. Summary • Prison are an ideal setting to treat a large population of HCV (+) people. • Screening for HCV need to be examined cost/benefit per institution. • Treating patient while incarcerated can be a cost saving to society • HCV treatment is associated with multiple side effects that need an educated multidiscipline approach to manage

  31. Summary • Guidelines are established for screening and to help guide management of adverse events. • Patient with co-morbidies are an increase challenge to treat but can be treated safely and effectively with proper monitoring. • New Antiviral medications just approved will improve overall outcomes in the future.

  32. QUESTIONS ??

  33. References • Federal Bureau of Prisons Clinical Guideline Prevention of Hepatitis C and Cirrhosis June 2009 • Raison. Depression During Pegylated Interferon-Alpha Plus Ribavirin Therapy: Prevalence and Prediction. J Clin Psychiatry. 2005 January ; 66(1): 41–48.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615913/pdf/nihms3152.pdf ( Accessed 4/11) • http://en.wikipedia.org/wiki/Incarceration_in_the_United_States (Accessed 9/24/10) • Jennifer A. Tan, Tom A. Joseph, Sammy Saab, Treating hepatitis C in the prison population is cost-saving ,Hematology . 2008; 48: 1387-1395 • Suzanne M. Kirchhoff, Economic Impacts of Prison Growth, Congressional Research Service, April 13, 2010. http://assets.opencrs.com/rpts/R41177_20100413.pdf (Accessed 9/24/10 ) • Hadziyannis, S. Peginterferon-2a and Ribaviriin Combination Therapy in Chronic Hepaitits C. Annals of Internal Medicine. 2004 ;140: 346-357 • Fried, M. Side Effects of Therapy of Hepaptitis C and Their Management. Hepatology. 2002: 36.

  34. References 8 . Bruchfeld, A. Lindahl, K. Interferon and Ribavirin treatment in patients with hepatitis C-associated renal disease and renal insufficiency. Nephrology Dialysis Transplantation, 2002;18, 1573-1580. http://ndt.oxfordjournals.org/content/18/8/1573.short ( Accessed 4/2011) 9. EL-Atrebi, K. El-Bassyouni, H. Management of rare side effects of peginterferon and ribavirin therapy during hepatitis C treatment: a case report. Case Journal 2009:2 : 7429 10. Lovy M.R, Starkemaum G. Hepatitis C Infection Presenting with Rheumatic Manifestations: Mimic of Rheumatoid. Journal of Rheumatology 1996; 23;979-983 11. Center of Disease Control Morbidity and Mortality Weekly Report. Prevention and Control of Infections with Hepatitis Viruses in Correctional Settings. January 24, 2003 / Vol. 52 / No. RR-1 12. Durante-Mangoni E, Iossa D. Safey and efficacy of peginterferon alpha plus ribavirin in patients with chronic hepatitis C and coexisting heart disease. Dig Liver Dis 2011 [ pub ahead of print]. 13. Ghany M, Strader B. Diagnosis, Management, and Treatment of Hepatitis C: An Update. HEPATOLOGY 2009; 49: 1335-74

  35. References 14. Spaulding A, Weinbaum C. A Framework for Management of Hepatitis C in Prisons. Annals of Internal Medicine 2006; 144: 762-769 15. Kim R. The Burden of Hepatitis C in the United States. Hepatology 2002;36:S30-S34 16. Macalino G. A Missed Opportunity: Hepatitis C Screening of Prisoners. AM J Public Health. 2005;95: 1739-1740 17. Sutton A, Edmund J. Estamating the cost-effectiveness of detecting cases of chronic hepatitis C infection on reception into prison. BMC Public Health 2006;6;170 18. Mc Hutchinson J, Brunce B. Chronic Hepatitis C: An Age Wave of Disease Burden. Am J Manag Care 2005;11:S286-S295 19. Wong J, McQuillan G. Estimating Future Hepatitis C Morbidity Mortality, and Cost in the United States. Am J Public Health. 2000;90:1562-1569 20. http://www.hivandhepatitis.com/hep_c/news/2011/0524_2011_a.html ( Accessed 6/2/11) 21. http://www.hivandhepatitis.com/hep_c/news/2011/0517_2011_a.html ( Accessed 6/2/11)

More Related