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Treatment of HCV in Cirrhotic Patient

Treatment of HCV in Cirrhotic Patient. Mark Thursz. Mrs LG - Presentation. 48 year old Latvian woman HCV diagnosed 2007 – symptoms of fatigue Source of HCV unknown No alcohol No current medications No significant past medical history. Examination. Generally well

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Treatment of HCV in Cirrhotic Patient

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  1. Treatment of HCV in Cirrhotic Patient Mark Thursz

  2. Mrs LG - Presentation 48 year old Latvian woman HCV diagnosed 2007 – symptoms of fatigue Source of HCV unknown No alcohol No current medications No significant past medical history

  3. Examination • Generally well • Palmarerythema and spider naevi • 4cm hepatomegaly • No splenomegaly • No ascites • No oedema • No encephalopathy

  4. Initial investigations • Hb – 12.2 • WBC – 4.5 (Neutrophil 1.2) • Platelets – 75 • AFP – 18.3 • INR – 1.4 • Albumin – 32 • ALT – 73 • Bilirubin 18 • HCV RNA – 1,230,000 iu/ml • HCV Gt 1

  5. Ultrasound • Irregular liver margin • Portal vein patent, diameter 17mm • No focal lesion • Spleen – 17.5 cm

  6. Biopsy or not?

  7. Biopsy or not? • Fibroscan 38.5 kPa

  8. OGD • Small varices • Propranolol 40mg tds • Not tolerated • Carvidolol 25 mg od

  9. Summary • 48 year old woman • HCV cirrhosis (Child-Pugh A) • Portal hypertension • Low platelets and neutrophils • Treat now?

  10. Treatment • Pegylated interferon a2a 180 ugo.w. • Ribavirin 600 mg b.d

  11. Progress

  12. Case Review • 49 year old woman • HCV Gt 1 • Relapse Responder • Portal hypertension • Low platelets • Low neutrophils • Options • Triple therapy • Await transplantation

  13. Option 2 Telaprevir Pegasys Ribavirin Sinusitis Transfusion

  14. Follow-up • USS every 6 Months • ? Biopsy in 5 years

  15. Issues • Prognosis with decompensated cirrhosis – HCV • Impact of intervention with HCV • Potential drawbacks of HCV treatment • Benefits of treatment before transplant

  16. Progression of Disease in HCV 7.7% 6.3% 3.7% 4.6% 9.9 – 20% 8.1 – 54.5% Alazawi. APT 2010

  17. Survival in Decompensated HCV Cirrhosis 5 yr Survival - 50% Fattovich Gastro 1997

  18. Issues • Prognosis with decompensated cirrhosis • Impact of intervention with HCV • Potential drawbacks of HCV treatment • Benefits of treatment before transplant

  19. Treatment of HCV Cirrhosis Prevents Decompensation Bruno Hepatology 2007

  20. Treatment of HCV Cirrhosis Reduces the Risk of HCC Bruno Hepatology 2007

  21. HCV Decompensated Cirrhosis Trials

  22. Treatment of Decompensated HCV Cirrhosis Everson Hepatology 2005

  23. Virological Outcomes According to Child’s Pugh Grade Everson Hepatology 2005

  24. Issues • Prognosis with decompensated cirrhosis • Impact of intervention with HBV • Potential drawbacks of HBV treatment • Impact of intervention with HCV • Potential drawbacks of HCV treatment • Benefits of treatment before transplant

  25. Adverse Events in HCV Treatment Groups

  26. Issues • Prognosis with decompensated cirrhosis • Impact of intervention with HCV • Potential drawbacks of HCV treatment • Benefits of treatment before transplant

  27. Reinfection post transplant Everson Hepatology 2005

  28. Outcome of HCV Post-Transplant Gane NEJM 1996

  29. Summary • Decompensated viral-cirrhosis has a poor prognosis • In HBV infection decompensation can be reversed with minimal side effects • In HCV infection treatment is challenging but the rewards are worth the effort • Decompensated cirrhotics cannot wait for IFN-free regimens • Eliminating HCV prior to transplantation will improve the prognosis

  30. HCV Therapy Post-Transplant Vezali Clinical Therapeutics 2010

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