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Hepatitis C Case Presentations

Hepatitis C Case Presentations. “One & Done” Arriving But Which One? Alan Glombicki, MD October 12, 2013. Disclaimer for General Counsel. No patients were harmed in the fabrication of these treatment scenarios

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Hepatitis C Case Presentations

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  1. Hepatitis C Case Presentations “One & Done” Arriving But Which One? Alan Glombicki, MD October 12, 2013

  2. Disclaimer for General Counsel • No patients were harmed in the fabrication of these treatment scenarios • Napoleon reminds us that: “History is a myth agreed upon”, therefore no affirmative claims of veracity are implied or explicit • The photos are real, as are the construed clinical dilemmas, only the embarrassment is muted to protect the “not so innocent”

  3. Case # 1 - HCV Lab values • 38 year old Hispanic American man referred with chronic hepatitis C • Diagnosed 2 months ago after complaints of fatigue and discovery of abnormal liver enzymes • Treatment naïve • Traumatic chronic arthritis • BMI 29 • ALT: 89 • AST: 94 • Total bilirubin: 0.8 • Albumin: 4.1 • INR: 0.9 • WBC: 5.1 • Hgb: 13.0 • Platelets: 201k • Anti-HCV Ab: Positive • HCV RNA: 1.5 million IU/mL • Genotype: 1a • Biopsy showed grade 2 inflammation and stage 3 fibrosis. What treatment would you recommend?

  4. What treatment would you recommend? • Peg-IFN/RBV for 48 weeks • Peg-IFN/RBV for 72 weeks (standard dose) plus baseball bat supplied by MLB Commissioner, Bud Selig & NY fans • Duration of therapy to be determined by response at week 4 or 12 • PEG-IFN, RBV, DAA (Boceprevir or Telaprevir) Response guided • No treatment at this time / Await future therapies 15

  5. Case # 1 • Treatment initiated with PEG-IFN, RBV, & DAA • At week # 12 of triple therapy, he remains virus positive, with a 2.5 log IU drop in HCV RNA • Tolerating therapy with few side effects (Seriously?, inquire about self-medication with “clear vitamins”) How would you proceed?

  6. How would you proceed? • Complete Peg-IFN/RBV with a goal of 48 weeks (as long as virus negative by week # 24) • Complete Peg-IFN/RBV/DAA with a goal of 24 weeks triple (as long as virus negative by week # 24) • Add/exchange newest 12/2013 oral possible agents (if FDA is not still disabled by government shut down in December) • DAA Mutation analysis using line probe assay 30

  7. Case # 2 - HCV • 20 year old Caucasian woman/ girl? referred with a diagnosis of chronic hepatitis C, genotype 1a • Past year received numerous tattoos • Overprotective father Billy Ray is also infected • Found to have many close Facebook followers hitting the “like this” button after the VMA Cat Show Lab values • ALT: 60 • AST: 45 • Total bilirubin: 0.6 • Albumin: 3.9 • INR: 1.0 • WBC: 8.4 • Hgb: 12.3 • Platelets: 320k • HCV RNA: 3,200 IU/mL • Genotype: 1a • There were no prior antiviral treatments (the one time Niave seems less pejorative) • She has manic depression which she reports was managed with an antidepressant & plethora of natural herbs only legal in Colorado & Washington (state, not DC so…….…no excuse for equally erratic Congress!) • Unlike many of her friends, she is afraid of needles • You perform a liver biopsy which reveals grade 2 inflammation and stage 2 fibrosis What treatment would you recommend?

  8. What treatment would you recommend? • Trial of PEG-IFN, RBV DAA for 48 weeks. • PEG-IFN, RBV with DAA response guided therapy • Strict Detox prior to any Rx. • Silimarin (Silly Mare (all) In) Homeopathy +/- Noni Juice • No treatment at this time. Await future therapies. 30

  9. Case # 3 • Transvestite on a stable HAART regimen found to be co-infected with HCV • Resident of SuperMax Fort Leavenworth, where needles are discouraged • Abandoned original name Bradley so not to be confused with the Bradley Fighting Vehicle namesake, • adopted new name Chelesea in honor of the Clintons’ only known daughter. • Given below labs, what would you do? • ALT: 107 • AST: 99 • Total bilirubin: 2.4 • Albumin: 3.1 • INR: 0.9 • WBC: 4.8 • Hgb: 13.0 • Platelets: 157k • Anti-HCV Ab: Positive • HCV RNA: 1.5mil IU/mL • Genotype: 1a

  10. How would you proceed? • Start Peg-IFN/RBV/off label DAA with a goal of 48 weeks (as long as virus negative by week # 24) • Continue Peg-IFN/RBV with a goal of 72 weeks (as long as virus negative by week # 24) • Non-invasive fibrosis staging using Fibroscan Ultrasound Elastography • MRE Magnetic Resonance Elastography • Serologic Fibrosis Assay 30

  11. Case # 4 - HCV • 42 year old Australian man referred with a diagnosis of chronic hepatitis C, genotype 1b • Treated last year with PEG-IFN/RBV for a total of 48 weeks • Cleared virus by week #14 and remained negative at the end of treatment • Found to have relapsed 7 months after completion of therapy Lab values • ALT: 60 • AST: 45 • Total bilirubin: 0.6 • Albumin: 3.9 • INR: 1.0 • WBC: 8.4 • Hgb: 10.3 • Platelets: 32k • HCV RNA: 3,200 IU/mL • Genotype: 1a • There were many treatment interruptions and dose reductions • Compliance was in part hindered by frequent embassy relocation seeking asylum • You perform a liver biopsy which reveals grade 2 inflammation and stage 2 fibrosis What treatment would you recommend?

  12. What treatment would you recommend? • Repeat another PEG-IFN with RBV for 48 weeks with Promacta / Procrit • Consensus interferon with Ribavirin • PEG-IFN with RBV for 72 weeks. • Maintenance treatment with half dose PEG-IFN. • No treatment at this time. Await future therapies. 10

  13. Case # 5 - HCV Lab values • 31 year old Viet -Singaporean- American Houston raised MTV star stage-named after Mexican liquor referred with CAH-C • Diagnosed after complaints of fatigue and discovery of abnormal LFT in rehab • Treatment naïve • Fibromyalgia Opiate-controlled • BMI 16 • ALT: 129 • AST: 94 • Total bilirubin: 0.8 • Albumin: 4.1 • INR: 0.9 • WBC: 7.1 • Hgb: 12.9 • Platelets: 231k • Anti-HCV Ab: Positive • HCV RNA: 2.3 million IU/mL • Genotype: 6 • Biopsy showed grade 2 inflammation and stage 3 fibrosis. What treatment would you recommend?

  14. What treatment would you recommend? • Peg-IFN/RBV for 48 weeks (standard dose) • Peg-IFN/RBV for 72 weeks (standard dose) • Duration of therapy to be determined by response at week 4 or 12 • Pre-treatment clearance by Dr. Sanjay Gupta/Dr. Conrad Murray • No treatment at this time / Await future therapies 15

  15. Case # 6 - HCV Lab values • 43 year old Child Literature Celebrity noted to have hyper-bilirubinemia and subjective jaundice incidentally diagnosed with CAH-C, • Nome de Plume: Grant Oiseau • Marfans Syndrome body habitus with • Chronic laryngitis following Asian travel • Treatment naïve, but balked on an offer to enter all oral antiviral protocol fearing biochemical side effects • ALT: 129 • AST: 94 • Total bilirubin: 2.9 • Albumin: 4.1 • INR: 0.9 • WBC: 7.1 • Hgb: 12.9 • Platelets: 231k • Anti-HCV Ab: Positive • HCV RNA: 2.3 million IU/mL • Genotype: 1b • Biopsy showed grade 3 inflammation and stage 3 fibrosis, no ductal proliferation • MRCP suggests unremarkable ductular systems. What treatment would you recommend?

  16. What treatment would you recommend? • Peg-IFN/RBV for 48 weeks (standard dose) • Advise the patient about reversibility of transport hyper-bilirubinemia & benign natural history of Gilberts • UN-WHO Protocol usage of Alinia (Nitazoxanide) for avian flu& HCV Active per Egyptian Abstract • No treatment at this time / Await future therapies 15

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