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Hepatitis D: A Case Presentation

Hepatitis D: A Case Presentation. GI Research & Hepatitis Support. Daphne Meyer. Canadian Association of Hepatology Nurses March 1, 2013. Small defective RNA virus. Requires HBsAg to complete it’s life cycle, enter hepatocytes & propogate infection. Aggressive.

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Hepatitis D: A Case Presentation

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  1. Hepatitis D:A Case Presentation GI Research & Hepatitis Support Daphne Meyer Canadian Association of Hepatology Nurses March 1, 2013

  2. Small defective RNA virus Requires HBsAg to complete it’s life cycle, enter hepatocytes & propogate infection • Aggressive most severe form of viral hepatitis in humans  risk of cirrhosis + HCC • Co-Infection or super infection • 8 genotypes, geography, distinct clinical course

  3. Est. 15-20 million infected (~ 5% of B’s)

  4. Howdo we measure for Hepatitis D????? Antibody RNA

  5. CLINICAL CLUE: • HBV DNA  • ALT  • **Immigrant

  6. 53 yr-old married caucasian woman • Homemaker • What brought her to doctor? Diagnosis Hep B GP Diagnosed Hep D at Liver Centre Patient Profile From Afghanistan, Moved to Canada in 2006

  7. History, Etc. • Med Hx: Stable depression, hyperlipidemia, headaches, osteopenia, esophagitis, hysterectomy/oopherectomy), • Obese (BMI: 30.7) • Meds: Zoloft, simvastatin, omeprazole, risedronate • Øprevious hepatitis tx

  8. DIAGNOSTIC PROCEDURES Suggested Cirrhosis, echogenic nodule 0.29 mild fibrosis 6.1 KPamild disease A2, F2, no steatosis No HCC, tiny focal lesions

  9. Treatment ???

  10. Mental Status Hx depression during transition to Canada Hx insomnia, fatigue, anxiety (PTSD - conflict in Afghanistan) Pre tx: stable on anti-depressant • Anti-depressant dose increased • Monitor with PHQ-9 and GAD-7 • Monthly psych f/u x 12 wks then prn • Pt education re-self assessment of mood Referred to psychiatrist Depression in remission PTSD in remission Pre-Tx Considerations

  11. Drug Coverage Pegassist - Ontario doesn’t cover • Family Support Married 30 years Husband attends appointments 25 year old son at home • Language Barrier Speaks and understands Persian Attending English classes Husband interprets Other Pre-Tx Considerations • Willingness Patient wanted treatment

  12. Good Candidate

  13. Peg-IFN x 48 wks 20-30% sustained reduction in HDV RNA • 1° endpoint – get rid of Hep D, 2° endpoint – get rid of HBsAg • Other oral agents not effective • Ø difference in efficacy b/w Peg-IFN alone and Peg-IFN plus Adefovir • Some studies reveal comb. Therapy with Peg-IFN/Tenofovir reveal marked reduction in HBsAg which correlates with HDV RNA reduction Tx Guidelines

  14. Treatment Labs

  15. Hepatitis Labs During Tx

  16. Generally Tolerated Well • Mood Disturbance Treatment Side Effects

  17. POSTTREATMENT

  18. Post-TxLabs Flared after stopping tx

  19. Hepatitis Testing Post-Tx

  20. Abdominal Ultrasounds Jan 20/11: Stable, Fatty, No HCC Feb 23/12: Stable, NO HCC Aug 30/12: Stable, slightly nodular, NO HCC Fibroscans Post-Treatment

  21. Current Status • Patient Feels Well • Lost 3kg wt. in past year • Continue to Assess q 6 mths • ? Treat Hep B

  22. HBV DNA , ALT , immigrant ?? HEP D • Treat with Peg-IFN x 48 weeks • Drug Coverage • Success rate is low • Treatment generally tolerated well Key Points

  23. Coffin, C., et al. Management of Chronic Hepatitis B: CASL Consensus Guidelines, December, 2012. • Pascarella, S., et al. Hepatitis D Virus: An Update. Liver International. 2010. • Rizzetto, M. Current Management of Delta Hepatitis. Liver International. 2013. • Samiellah, S., et al. World Journal of Gastroenterology, October 28, 2012 References

  24. THANK YOU!

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