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Hepatitis C When, how and which patients should be treated

Hepatitis C When, how and which patients should be treated. Graham R Foster Professor of Hepatology Queen Marys School of Medicine Barts and The London. JC. 34 year old man Infected with genotype 1 HCV (ALT 120) Refuses liver biopsy. JC. 34 year old man Infected with genotype 1 HCV

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Hepatitis C When, how and which patients should be treated

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  1. Hepatitis CWhen, how and which patients should be treated Graham R Foster Professor of Hepatology Queen Marys School of Medicine Barts and The London

  2. JC • 34 year old man • Infected with genotype 1 HCV (ALT 120) • Refuses liver biopsy

  3. JC • 34 year old man • Infected with genotype 1 HCV • Refuses liver biopsy • Single • Lives in a rented flat does not drink

  4. JC • 34 year old man • Infected with genotype 1 HCV • Refuses liver biopsy • Single • Lives in a rented flat does not drink • Methadone prescription – 80 mls/day

  5. JC • 34 year old man • Infected with genotype 1 HCV • Refuses liver biopsy • Single • Lives in a rented flat does not drink • Methadone prescription – 80 mls/day • Injects heroin x3 per week/ crack ‘ occasionally’

  6. JC Should we treat him ?

  7. HCV in 2006 • Not treating Jason • Good reasons/Bad reasons

  8. HCV in 2006 • Not treating Jason • Good reasons/ Bad reasons • He does not have bad disease

  9. HCV in East LondonPrevalence of cirrhosis in Pakistani/Bangladeshi patients presumably infected at birth D’Souza et al Clin Gastro Hep 2005

  10. HCV in East LondonPrevalence of cirrhosis in Pakistani/Bangladeshi patients presumably infected at birth D’Souza et al Clin Gastro Hep 2005

  11. HCV in East LondonPrevalence of cirrhosis in Pakistani/Bangladeshi patients presumably infected at birth D’Souza et al Clin Gastro Hep 2005

  12. HCV in East London

  13. Therapy for HCV:Who should receive therapy?

  14. Therapy for HCV:Who should receive therapy?

  15. Therapy for HCV:Who should receive therapy?

  16. HCV in 2006 () • I am seeing increasing numbers of patients from Bangladesh and Pakistan with advanced liver disease from HCV

  17. HCV in 2006 ()Are we missing something ? • The government tells us that this is a drug users disease • I am seeing non-drug users with liver cancer secondary to HCV • Are we missing something important ?

  18. HCV in 2006 • Not treating Jason • Good reasons/ Bad reasons • He does not have bad disease – but he will get it!

  19. HCV in 2006 • Not treating Jason • Good reasons/ Bad reasons • He does not have bad disease – but he will get it! • He is unlikely to respond

  20. Sustained Response Rates in HCVGenotype 1 – 40 KD PEG IFNα2a + Ribavirin 51% 41% 40% 29% SVR (%) n=101 n=118 n=250 n=271 PEG IFNRBV 800 PEG IFNRBV 1000/1200 PEG IFNRBV 800 PEG IFNRBV 1000/1200 24 weeks 48 weeks Hadziyannis et al Ann Intern Med 2004:140;346-355

  21. 90 80 70 60 Calculated SVR Rate (%) 50 40 30 20 60 55 50 45 40 35 30 25 20 Age (completed life-years) Effects of age and SVR(Data from patients treated with 40 KD PEG IFNα2a and Ribavirin) Foster et al AASLD 2003

  22. Sustained Response Rates in HCVGenotype non 1 – 40 KD PEG IFNα2a + Ribavirin 78% 78% 77% 73% SVR (%) n=106 n=162 n=111 n=165 PEG IFNRBV 800 PEG IFN RBV 1000/1200 PEG IFNRBV 800 PEG IFNRBV 1000/1200 24 weeks 48 weeks Hadziyannis et al Ann Intern Med 2004:140;346-355

  23. Treating the non-1 patientCan we use shorter durations of therapy ? • Pilot study of 14 weeks therapy in patients with an early virological response • Used Peg-Intron 1.5mg/kg + Normal dose ribavirin Dalgard et al Hepatology 2004:40:1260-1265

  24. Treating the non-1 patientCan we use shorter durations of therapy ? SVR (by per protocol analysis) of patients with an early virological response receiving 14 weeks therapy

  25. Peg-IFN and Ribavirin Today • The standard algorithms are being revised • Easy to treat patients may need shorter durations of therapy

  26. Peg-IFN and Ribavirin Today • The standard algorithms are being revised • Easy to treat patients may need shorter durations of therapy • Easy to treat patients are young with no fibrosis!

  27. HCV therapy tomorrow BILN 2061 New protease and polymerase inhibitors are on the way

  28. HCV in 2006 • Not treating Jason • Good reasons/ Bad reasons

  29. Therapy in difficult patient groups

  30. HCV – Who should we treat?(Opinion based medicine) We should NOT treat active drug users They will not comply They will get reinfected (They are not worth it)

  31. Treatment of chronic hepatitis C in injecting drug users: 5 years' follow-up.Dalgard O, Bjoro K, Hellum K, Myrvang B, Skaug K, Gutigard B, Bell H; The Construct Group.Eur Addict Res 2002 Jan;8(1):45-9 • Treatment of hepatitis C infection in injection drug users Markus Backmund, Kirsten Meyer, Michael Von Zielonka, Dieter Eichenlaub HepatologyJuly 2001 • Volume 34 • p188 to p193 HCV in drug users - evidence

  32. HCV in drug users • Drug users infect others ! • Not treating drug users encourages the spread of HCV

  33. Treating the untreatable 27 patients started therapy (13 Genotype 1) Early cessation = 2 Completed = 10 Completed 3 months = 11 ETR = 9 (SVR 3/3) 7 PCR -ve 4 PCR +ve i.e. by Intent to treat analysis 16/23 = 70% have an EVR

  34. Treating the untreatable 27 patients started therapy (13 Genotype 1) Early cessation = 2 Completed = 10 Completed 3 months = 11 ETR = 9 (SVR 3/3) 7 PCR -ve 4 PCR +ve ALL patients have benefited from the attention – two are looking for work!

  35. Therapy for HCV Summary (I) • The natural history of HCV is of glacial progression • Many patients will eventually develop cirrhosis • Delaying therapy may reduce response rates

  36. Therapy for HCV Summary (II) • We have effective therapies available and these can be given to ALL patients with chronic HCV

  37. Therapy for HCV • Who would treat Jason ?

  38. Therapy for HCV Post Script • JC was offered therapy • He agreed to undergo therapy and has completed 9 months treatment • He has not injected for 3 months • He has been offered a job in his brothers shop

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