Managing hepatitis C in general practice

Jennifer:
 
Welcome everyone to this evening's webinar, Managing Hepatitis C in General Practice. My name is Jennifer, your RACGP representative for this evening. We are joined by our presenters, Dr Michael Burke and Associate Professor Martin Weltman.

Before we get started, I would just like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and I pay respects to Elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us this evening.
 
So I would just like to introduce our two presenters formally for this evening. So Michael works in general practice in Blacktown and also part time at the Sexual Health and HIV clinic at nearby Nepean Hospital. He is committed to increasing the capacities of general practitioners to deliver quality service in sexual health medicine in primary care settings. Welcome, Michael.

And Martin is a Senior Staff Specialist and Department Head at the Gastroenterology and Hepatology Department at Nepean Hospital. Welcome, Martin.
 
 
Martin:
 
Thank you.
 
 
Jennifer:

Before I hand over to Michael and Martin, I am just going to quickly run through our learning objectives for this evening. So by the end of this online CPD activity, you should be able to have an increased knowledge and confidence to identify patients for hepatitis C testing, discuss different hepatitis C testing options including traditional venepuncture as well as point of care testing, and discuss how to treat and prescribe Hepatitis C medications and identify when specialist referral is required. So I am going to hand over to Michael.
 
 
Michael:
 
Thank you, Jennifer. Welcome to everyone. Hepatitis C, HCV, is a blood-borne RNA virus that affects the liver. Hepatitis C can be cured. That is great news, and in general practice we are privileged to be able to participate in that. An estimated 58 million people across the globe have chronic hepatitis C. The most common mode of transmission is through blood to blood contact. People with HCV often do not have symptoms. Highly effective and well tolerated direct acting antiviral therapies were introduced in 2016 marking a very significant medical advance in hepatitis C treatment and care. And if left untreated, the hepatitis C virus can cause severe liver disease and cancer, including fibrosis and cirrhosis. Next slide please.

The World Health Organisation has a goal to eliminate HCV by 2030. New South Wales, aiming a little higher, has the goal to eliminate hepatitis C by 2028. So far in New South Wales we have currently treated 55% of people estimated to be living with hepatitis C and we are now on track to achieve elimination by 2028. It is only five years away. However, we need to sustain and even increase our efforts to stay on track. Next slide.
 
 
Martin:

Thank you for that. All people with risk factors for hepatitis C infection should be tested to make the point that most diagnoses result from screening of at risk populations. These priority populations importantly include people who have ever injected drugs, even, you know, decades ago, Aboriginal and Torres Strait Islander people, people born in high risk prevalence countries such as Egypt, Pakistan, Mediterranean, Eastern Europe, Southeast Asia and Africa, people have been incarcerated. And then in particular, there is certain under-tested groups there on the right hand side column, people with tattoos and body piercings, people with blood transfusion or organ transplants prior to 1990. Children born to HCV positive mothers, sexual partners of HCV positive individuals, healthcare workers who practice exposure prone procedures are supposed to have themselves checked, sex workers, people with a needle stick injury, people with HIV or hepatitis B co-infection and people with evidence of liver disease. It is important though to really test everyone if you get the correct opportunity because a lot of people do not talk about risk factors or will not identify risk factors. If I could have the next slide please.
 
Yes. So this is just to encourage you, even people who do not disclose behaviours, you should think about testing everyone really. Thank you. Next slide.

So most people we see, most people who have elevated ALT levels and where you can have a normal level and still have an active viral load, but people who have a viral load a positive PCR and elevated ALT usually have some clinical relevance. When the liver hepatocyte parenchymal cells are damaged, aminotransferases leak from the liver into the blood and hence the elevated enzymes that are detected on blood tests. It should be noted that up to half of untreated patients with chronic hepatitis C infection display normal or only minimally elevated serum ALT levels. So the normal has changed over the past few decades, and the normal is lower, and in general for men is regarded as less than 23, and for women, less than 18. Could I have the next slide please?

So why test and treat in general practice for HCV? Well, most people see GPs at least annually, so it provides a good opportunity for you as GPs to identify hepatitis C within the community. We only get the referrals. The treatment landscape has changed significantly, allowing the involvement of non-specialists in prescribing quite simple treatments today. And as general practitioners, you play an important role in achieving HCV elimination. So the PBS listing of direct acting antiviral medicines enables GPs to initiate HCV treatment in primary care. And increasingly more general practitioners are taking on that role, other than managing complex patients or patients who have underlying complex liver disease. If I could have the next slide please?

So this algorithm really goes through what if hepatitis C is not treated? So just to make the point that hepatitis C infection can cause both acute and chronic infection. Acute infections are not that common. Most people are have a subclinical or asymptomatic infection and present chronically. So if you follow this flow chart, patients who get the hepatitis C, acute hepatitis C, up to 25% maybe even a little bit more spontaneously clear that virus over a number of years. Interestingly, they generally have a genome called IL-23 B, and they have to be homozygous, so IL-23 BCC. It is not used as a test anymore because we do not need it, but it was identified from a laboratory at Westmead Hospital.

So the bulk of people get chronic hepatitis C and over the next 20 years, 5% to 10% of people will have cirrhosis. And progressively if they go out further from that timeline, more and more people will have cirrhosis. Once you have cirrhosis, the risk factors are of hepatic decompensation with ensuing liver failure, ascites, variceal bleeding, encephalopathy, jaundice. So that is about 5% of patients per year. Up to 3% of people per year present with liver cancer or hepatocellular cancer, and clearly because of these factors a proportion of people are going die each year, and that is put at 3% to 4%. Next slide please.
 
So if we look at this display of the pathology of the liver, it goes from a healthy liver to this scarred and enlarged liver, ultimately to this nodular cirrhosis, and then a potential addition of liver cancer. So over time, 1% to 3% per year with liver cancer, as the lesion on the lower right hand illustrates. The next slide please.
 
So how do we conduct risk based testing? So patients usually, if they have an HCV antibody test, and it is not reactive, or negative, you do not need to do anything further, they do not have hepatitis C. So the antibody identifies that you have been exposed to hepatitis C. When we treat patients or they spontaneously clear the virus, they will always have evidence of the antibody. Today we know it does not necessarily identify active infection, and that is an important point to remember. If they have a positive or reactive test, they will go on to an HCV RNA test. If it is not detected, there is no current HCV infection. If you are uncertain, your patient has abnormal liver tests and they have big risk factors then you may want to repeat that. I would wait for a period of time, maybe six months. That is what we usually advise, as that will exclude very low viral loads that may not be picked on the initial HCV RNA test. But effectively if it is negative that do not have active hepatitis C. If it is positive, they have current HCV infection and then we look to see if it is appropriate and the need to link and hook them into, I mean need to treat and hook them into a treatment program accordingly.

So the next slide, I think Michael is going to take over.
 
 
Michael:
 
Yes, thanks. Thanks, Martin. We have got some great tools. The ASHM decision making tool for hepatitis C. This resource produced by the Australasian Society for HIV, Blood-borne Viruses and Sexual Health Medicine provides a comprehensive overview of hepatitis C diagnosis, treatment and follow up to assist GPs and primary care providers in the management of hepatitis C. It is an A4 double sided page. On page one, and you can download this from the website, or you can get it printed out, it is very useful. Page one, we can see we look at one, when to test and two, how to interpret the results. We reviewed that. And on page two, we focus on treatment and management of patients as well as some indicators of when to speak with a specialist. Very good resource, great to get, easily found on the Internet.

We also have Australian Recommendations for the Management of Hepatitis C Virus Infection, a consensus statement from the Gastroenterological Society of Australia. An excellent group. This is a national guideline for all you need to know about managing hepatitis C, and it is updated regularly and all resources are available online. Next please.

So, we meet a patient, what do we do? What tests do we order? Well, here we have a list. So before commencing treatment we need to do a pre-treatment assessment including medical history of, we need to find out have they had a previous hepatitis C virus treatment history? We need to assess if they are likely to be able to take the medicines. If they are probably in a very chaotic time in their lives, it may not be the best time to start medicine, so that is important to assess. We are interested in alcohol intake. Other drug to drug interactions, pregnancy is a factor, body mass index is another factor, and we are looking for signs of chronic liver disease and also performing a cirrhosis assessment. The Australian Recommendations for the Management of Hepatitis C provide additional information about the clinical guidance for treating hepatitis C. So there we have it in card form. We have a list of the tests in front of us. Let's go to the next slide.



Jennifer:
 
Michael, before we move on, we have had a question come through.
 
 
Martin:
 
I will answer that. Basically the question is, can you comment on a window period for antibodies and RNA? So assuming that is from exposure. For RNA, pretty quick. Could probably get most of it within a week, but really if you allow six weeks for an RNA that is pretty much it. Antibody takes a bit longer, it will probably take up to 12 weeks for an antibody.  
 
 
Michael:
 
Yes, we are looking to do a full blood count, kidney function, liver function and INR and a cirrhosis assessment. So we stratify people into cirrhotic and non-cirrhotic, and then we do the APRI test and FibroScan. Let's go to the next slide.
 
So there are tools available for the pre-treatment assessment. The first of cirrhosis, the first, is the AST to platelet ratio index. That is the APRI test, known as the APRI. The APRI is a serum biomarker investigation calculator used to determine AST to platelet ratio. You download the little calculator from the internet, google APRI test, and you type in the results from the blood test and it will generate a score of predicted fibrosis. The calculator is available online. That is very useful and very accessible. A second mode of determining if a person has cirrhosis is the FibroScan test. This machine works similarly to an ultrasound and measures liver fibrosis and steatosis. So next slide.

Now we have also new technologies coming on board which will be developing as time goes on. We have point of care testing that has been introduced as a national research program led by the Kirby Institute at the University of New South Wales and Flinders University to scale up hepatitis C virus point of care testing. So they are there and you get the result very quickly. It is done by doing a capillary finger stick swab and analysed in a GeneXpert machine and it looks for antibody and or hepatitis C RNA. Patients who return a hepatitis C RNA result can be prescribed hepatitis C treatment. And point of care testing is now being trialled in various settings including drug treatment clinics, needle and syringe programs, prisons, mental health settings, homeless services and Aboriginal community controlled health organisations across New South Wales. So it is a new interesting innovation and we are looking forward to further news on that. Next slide.

Well, we have met the patient and we need to know how to construct our interaction with the patient so that we are respectful and sensitive and we can help the patient move forward in their decision making about whether or not to be treated for this virus. So let us look, we are going to introduce you to Maria. Maria is a 28-year-old married school teacher. She recently attended for a full check as she is planning to start a family. The physical examination was normal. She has a BMI of 23. She has mild asthma and uses salbutamol occasionally, but she is otherwise well and takes no regular medications apart from the contraceptive pill. She describes social alcohol intake of two to three drinks on a weekend, so minimal intake. She was born in Australia and does not identify as Aboriginal. Very much an everyday patient. Let us go to the next slide.

So we have taken a history. We have done an examination, we now do some tests. Maria has attended the practice to discuss blood test results. Her blood count, rubella serology, and iron studies were all normal. Basic biochemistry revealed mildly abnormal liver function tests. The GGT is slightly raised at 56 and transaminase as you can see, ALT 50 and AST 42. Bilirubin and albumin are normal. Let us go to the next slide.

So we are going to do a little role play. Just as a way of modelling one appropriate way of engaging with the patient. I am taking the role of the general practitioner. And I think we have a volunteer patient. Martin, I think that is yourself, well done.
 
 
Martin:
 
I will be Maria. Thank you.
 
 
Michael:
 
All right. So off we go.

Thanks for coming back, Maria. Your blood results were mostly normal, but there is a mild elevation in your liver enzymes. Are you aware of any liver issues you might have?



Martin:
 
I do not know of any anything wrong? I do not drink a lot. Is it serious, doctor? What does it mean?



Michael:
 
Maria, well, the abnormalities are only mild, but they could be significant. I would just like to ask, have you or your partner or anyone in your family ever had liver problems or a history of hepatitis?
 
 
Martin:
 
No, not that I know of.



Michael:
 
Well, in that case we normally look for causes of liver strain. This can involve taking another blood test for things like hepatitis B virus and hepatitis C virus. We also check for other liver conditions. Do you know if you have ever had hepatitis before?



Martin:
 
How would I know, doctor? I do not usually get sick or have blood tests.



Michael:
 
People can be exposed to hepatitis in a number of ways, like through blood transfusion several years ago, tattoos or body piercings, sexual activity and injecting drug use.
 
 
Martin:
 
Oh no. I did get a tattoo in Thailand when I was 19, but that was ages ago. Could that have given me something? I feel fine and never have felt unwell.



Michael:
 
Okay. Well, I think it is important to make sure you are healthy if you are going to be planning a family. It would be sensible to go ahead and check if you have been exposed to hepatitis B or C.



Martin:
 
I am really nervous now, doctor.



Michael:
 
Oh dear. Well, I can understand your anxiety. The test result will be back soon, so I can see you again in two days. I am glad you came in for your check-up. Pregnant women are checked for hepatitis anyway, so checking things out now could avoid a surprise later on.
 
 
Martin:
 
So what tests will I have today?



Michael:
 
Well, Maria, I am going to refer you for an antibody test for hepatitis B and hepatitis C. That will tell me if you had been exposed to those viruses in the past. I will see you back here in two days.

So we have done our little role play. I think we did fairly well. And now let us see, Martin, I think it is over to you.
 
 
Martin:
 
Okay, I just see there is a question. Whenever spontaneous clearance of the hepatitis C infection, does it affect the diagnosis of chronic hepatitis C, which needs treatment? Yes it does. If you spontaneously clear that, you do not have hepatitis C that needs treatment, so about 20% of people will spontaneously clear. They are usually Caucasian. They are usually female. And they will still have antibodies forever, but they will never be PCR positive and they do not need treatment. They have cleared the virus.

So we are going to talk a bit about direct acting antiviral treatment. If I could please have the next slide.

So there are new effective treatments we introduced already in 2016 called the direct acting antivirals or the DAAs. Treatment is short between eight and 12 weeks. There are two brands in the market. They are oral medications, very limited side effects, extremely effective at eradicating the virus, both of them. There are multiple benefits from treatment including improvement in quality of life, loss of infectivity, which is important, regression of liver fibrosis and cirrhosis, and a reduction in the risk of liver failure and cancer. The last bits a little bit controversial in genotype 1. So they are different genotypes, as you know.  The DAA medications target multiple steps in the viral replication cycle. So they disable the virus because it cannot replicate and kill the virus that way. They are highly effective and safe. Treatments are very short duration with minimal side effects. They are what we call pangenotypic today, so that they will cover all the genotypes. We do not even have to really worry about the genotypes. And these pangenotypic drugs for hepatitis C have really taken over the market. If I can have the next slide.

So these are just illustrations of the two drug regimens available. So the goal of treatment is a cure. Medications are taken daily and both of these drugs are approved by the TGA and are available on the PBS. They are pangenotypic and they are available on a general schedule section 85. So any GP can prescribe these drugs under that mechanism. So you have two brands available as you can see there, the sofosbuvir-velpatasvir combination which is taken for 12 weeks, whether you have cirrhosis or no cirrhosis. And then you have got the Maviret or the glecaprevir-pibrentasvir combination, which is three tablets a day. These tablets are all combined into one, by the way, but there are three of these tablets per day. If you do not have cirrhosis, you take it for eight weeks. If you do have cirrhosis, you take the medications for 12 weeks. Next slide please.

So you could really choose either of these drugs as we have reinforced here, and if for some reason one of these treatments do not work, which is really very unusual, we are talking about 99% plus in real world studies. That means there is a degree of viral resistance and they do need to see a specialist with an interest in this so they can work out how this patient should be treated. And at our particular department, we have the luxury of ordering viral resistance studies so we can work out what is needed. Next slide please.
 
Most patients as I have already stated can be managed in general practice. This is a little slide where we talk about when to consult or refer patients to a specialist. Clearly patients who have advanced fibrosis or cirrhosis, if you do that APRI score, send them for a FibroScan. If patients have extrahepatic manifestations of viral hepatitis, skin, renal, neurological, et cetera, then they should definitely be seeing a specialist. If there underlying complex comorbidities, I think it would be a good idea to at least consult the specialist. If there is renal impairment, as some of the drugs are excreted renally, if there is coinfection with other blood-borne viruses, if they have failed first line direct acting antiviral, so that is very few patients, acute hepatitis C because it is not funded for treatment, and patients under the age of 18, so children, should probably see or at least consult a specialist. If we could have the next slide please.

So with regard to making that decision, do you have experience in treating hepatitis C, yes or no? If yes, we go back to the paradigm of test, treat and monitor. So I think you need to educate your patient. You should be confident in supporting them and managing their hepatitis C as well as the treatment journey. And understand your local referral pathways and specialists if you need to call on them. I use a lot of these forms filled out that GESA and ASHM have that our local GPs often fill out these forms for treatment and what treatment they want to use. And we look at these forms when we go to our clinic and just counter sign them that we approve this treatment, and it is just about always appropriate when we get that piece of paperwork. We email it back to our GPs so that they can continue to look after their patient and we do not need to see them. If, on the other hand, you do not have experience in treating hepatitis C infection, you should consult with your interested gastroenterologist, liver specialist, disease physician, who has an interest in this, and you should refer your complex patients for that specialist to look after. Otherwise, you go ahead with treatment once it is approved and put your toe into the water if you have not done this, and you will find it is not so hard to do. It is quite easy really. We could probably have the next slide, please.

So there are these forms you can download. They are often sent to us. We mostly see the GESA one but we see the REACH one as well and they get emailed. Our liver nurse looks at these forms and makes sure that me or one of my specialist colleagues looks at them, signs them, and gets that returned to the GP promptly for approval of treatment. And so if you have any ambivalence or uncertainty, start using those forms and you will find it makes your life a lot easier if you are not experienced doing this. We probably should have the next slide please.

So when we used to use interferon and the first DAAs, there was a lot of intense monitoring mainly because of side effects and compliance, longer durations of treatment. The treatment is quite short and we would generally tell people if they coping people and do not need a lot of support, to come back at 12 weeks upon completion of treatment to test them for PCR, and see if they have eradicated the virus. So they should be PCR negative. So this just outlines what you do at the beginning. Their pre-treatment bloods would include the liver tests and the HCV PCR. They have got to obviously be PCR positive and that goes to the previous question. 12 weeks after treatment, we want to know if there is a sustained viral response, and today SVR which we used to use as post-treatment, people do not relapse then. They might get reinfected, they do not relapse. So we see that as a cure. And we do repeat the liver function tests in another qualitative, not quantitative, we do not need to measure the number of the virus or the amount of virus. We measure qualitative. And these tests, these PCR tests, if it is in the context of hepatitis C treatment, are paid for by Medicare. There is Medicare reimbursement. There are certain patients who may require more intensive treatment or more intensive follow up. So you may have someone who you think well, to reinforce compliance I would like to see them more often because they may not be coping people, they may be people with a bit more advanced liver disease and we want to make sure that we monitor them properly.
 
People who get the Maviret combination, sorry, the elbasvir-grazoprevir combination is hardly ever used. I would just leave that combination out, but there was there was occasionally some hepatotoxicity. That drug combination has really gone into obsolescence and we probably should not even mention that. I am happy to for the next slide.



Michael:
 
So, yes, well we are working together as a team. I am in general practice, Martin is a specialist in hepatitis C in the hospital, and we are going to present to you next slide, a case where we are going to introduce you to Mark. So Mark is a 42 year old unemployed male. He is a new patient in your practice, recently released from Justice Health. He has a history of injecting amphetamines starting in 1985, a long time ago, and still continuing up until this day. He rarely drinks alcohol. There is a past history of reflux, which is treated with Nexium. He has got a thin body type with the BMI of only 20. There is no obvious signs of fibrosis. He does not identify as an Aboriginal or Torres Strait Islander. Now, is there anything in this history which would make you think it would be a good idea to offer a hepatitis C test? Let us see what we have got. You all wrote yes, his history of injecting drug use. That is certainly one of the risk groups. So we progress on and we want to do an appropriate screen of tests, and here we have them listed. So you can see them there for blood count, kidney function, liver function, the various antibodies. And then we all just need to know as well as having an antibody of there is actually virus. We no longer really need to know genotype because the new medications are pangenotypic. And of course, yes, if the antibody is positive, we need to know the viral load.
 
And then we have another question. What other assessments are appropriate before commencing treatment? Well, we need to know if the person is: let us go to the next slide. Yes, we need to stratify the patient as to whether or not they are cirrhotic or non-cirrhotic, non-cirrhotic or cirrhotic. And as we heard earlier in the presentation, we can either do the APRI test, which is the AST to platelet ratio calculator, or we can do a FibroScan. So here we have Mark’s numbers put into the APRI calculator, from our blood tests. His AST 45. We use the nominal figure of 40 as the upper limit of normal based on the laboratory reporting back, we look at his platelet counts, we put the numbers into the calculator and we get a result of 0.268. The general rule of thumb, less than 1, non-cirrhotic, greater than 1 much more likely to be cirrhotic. This one is a long way less than one, so non-cirrhotic. So that is interesting. Let us see, what we have got? Next slide.

Another way of doing this. This is slightly more demanding on the patient's time, they have to attend and have a FibroScan. And he sits, we do his FibroScan test, and we see that his result is, if you look on the left hand side of the panel, 6.2. He sits just below the cut off at 7 for mild fibrosis, so this is quite early. You can see the different colours on the spectrum there. The cut off line is to the far right. This fellow mark is at the far left, so he is very unlikely to have cirrhosis. He has probably got some mild form of fibrosis. So that is very useful in stratifying what is appropriate. Next slide.

And then, yes, I am going along, I am learning more and more about his condition by doing these tests. Yes, his RNA test is positive. Date of infection? Well, often people who inject are infected early in their injecting history. Martin, I get these results back. Genotype and the viral load. Any comments on that?



Martin:
 
Yes. I actually do not even think we need to do a genotype anymore or a viral load, but you can. That is really a high viral load, 12345. It is 2 to the power of log of 6, so it is a high viral load, and genotype 3A has always been relatively easy to treat, even in the interferon days that responded well to treatment. So I would expect that any treatment would smash this. You do not even need to get a viral load. You could just get a qualitative PCR instead of a quantitative PCR.
 
 
Michael:
 
Yes. So the treatment for hepatitis C is getting more simplified, more straightforward, as time goes on. Now with the new pangenotypic drugs, the genotype, in a sense the viral load too, is becoming a little bit unnecessary. So what we have in this panel is a summary of key information that we would like to determine. It will guide our therapy and our follow up. We, yes, we need to confirm things including, have they got chronic hepatitis C? Yes, they have got viral RNA. Their fibrotic status. Yes, we have done that through the APRI. We have done that through the FibroScan. We need to know what medications they are on. His diagnosis is chronic hepatitis C infection without cirrhosis. His kidneys are working well and he has not got any significant coinfections. However, his medications will need to be checked for interactions. Next slide.

All right. Yes, Martin, I think later we are going to learn about doing the drug interactions.
 
 
Martin:
 
Yes.
 
 
Michael:
 
But just before we get to that, we have got some early questions. These are questions for all in our session tonight. So question one, can Mark be treated in a primary care setting?
 
 
Martin:
 
Let us know in the Q and A or the chat.
 
 
Michael:
 
So I will have a look at the Q and A.
 
 
Martin:
 
No takers?
 
 
Michael:

Yes, we have got Steven saying yes. Sivaraja, Dushianthi, that is good. Renee. Yes, we have we have got a consensus for yes, and I think that is actually very true. Mark can be well treated in a primary care setting. It is safe to treat him. If you are unsure, I would get on my phone and I would ring a friend. Phone a friend. I would ring Dr Martin Weltman, and I would ask, you know, these are the numbers, Martin. What is this telling me? What should I do?

So next question is, we have learned from Mark that he has got a history of ongoing injecting drug use. Is this a barrier to treatment? Please can you put the answers in the Q and A? We have got, let us see, we have got some yeses and we have got one or two nos. This is very interesting. Martin, can you help us solve this problem?
 
 
Martin:
 
Yes. So there is a number of studies in fact, we are co-authors on some of the studies that were done at our hospital, some of these studies, showing that there is really no barrier. The issue is patients who have really erratic behaviour, some major injecting, they are going to be chaotic and not take their medication, so you would exclude those patients. This is a patient who we said early on occasionally still injects. He would probably cope quite well with treatment and probably would not inject during treatment. That is usually what we see. We showed very high levels of compliance in this patient group with different drug regimens in fact, so they do cope. You have the option of bringing them back sooner to see if their behaviour is appropriate and to have that discussion with them. And a lot of patients are open to an intervention at that stage, Michael, they really say, you know, this is the time to fix me, let’s do away with the drugs. You are going to save my liver. I am getting a second lease on all of this. I did not know until now I could get rid of the hepatitis C. So it is an opportunity to actually intervene in the drug use. Those patients can get reinfected if they have risky behaviour like sharing needles afterwards. So that is what you have to discuss with them. They can get retreated, but I would not see this as a barrier to treatment.
 
 
Michael:
 
Thank you Martin, of course the patients are absolutely delighted. They tend to stigmatise a lot. They think, oh goodness, I have got this dreadful virus in my body, very unhappy about this. If they can be treated and cured, they are very grateful. Now I am a GP that has done all these particular tasks. I have looked at my ASHM double sided card. I might have done the email and the check questions and got my response from my local hospital. So I am feeling pretty confident that I have done well so far, but I am not really feeling that confident about prescribing treatment options. So in this situation, I would phone Dr Martin.
 
 
Martin:
 
Yes, I would say to you, you are probably fine to use both the treatment regimens, you know, and either way, whatever you want to treat with, it will work well. You have got to check for the drug-drug interactions and we are going to discuss that, I think on the next slide, aren't we? Yes, so either of these are suitable for first line. In this particular patient who does not have cirrhosis, the Maviret treatment you would use for eight weeks and the Epclusa you would use for 12 weeks. The advantage of Epclusa is 1 tablet a day. As Maviret is three tablets a day, but Maviret is a shorter duration of treatment. I do not think these are deal breakers for most patients in our experience. So they would take either of these really in reality, it is not a huge difference. If we see the next slide.

So this is something you should look up, there is this drug-drug interaction. So some drugs do react with for example, proton pump inhibitors, as patients who use esomeprazole. The Maviret combination has a potential weak interaction. The Epclusa combination has just a potential interaction, so you could carry on with either of them. If you are worried about a potential interaction, use the other one where there is weak interaction or no interaction. Either of these you could continue. If there is a drug interaction, you can either stop the drug if it is non-essential, like say a statin or esomeprazole if that were to be the case, and then reintroduce the other medication at the end of treatment or switch to the alternative prescription. But either of these are potential interaction or potential weak interaction, is not a big issue.

So this is Liverpool University in the UK, they have this website and it is fantastic for drug-drug interactions with antivirals. Very easy to use. Really, it is as easy as you can. So you could either, yes, if there was a drug-drug interaction, you could choose a simpler regimen. You could switch to an H2 receptor antagonist while they are on this treatment. But really, in this case, low interaction or low risk with either of them and you could use either of these regimens. Next slide.

So in this instance Mark was treated with the glecaprevir-pibrentasvir, so the Maviret combination for eight weeks, three tablets a day. Does he need further testing and when? Can you put that into your Q and A please? 12 weeks after treatment? Someone has written here, 12 weeks. He not need any test really until 12 weeks, so he completes his treatment at eight weeks, subsequently to that 12 weeks later, you check liver tests and an HCV PCR qualitative. You do not need to check before and there is a 99.9% chance that he has got rid of the virus.

Look, the next question should be, does Mark need to be referred for ongoing specialist care? So he has had his treatment. Not getting any bites, are we? No, Mark does not need it. He does not have significant liver disease. He had low FibroScan low APRI score. His liver tests are back to normal and presumably he is going to be SVR positive. So he does not have the virus anymore. It is gone. He does not need to see specialist. He does not need to actually see you for hepatitis C anymore. He is done. So, next slide please.

Mark still occasionally injects drugs, so he is at risk of reinfection. So you could check an RNA, HCV RNA, PCR every six to 12 months, and antibodies are going to stay there regardless whether you have eradicated it or not. So it is pretty useless in monitoring Mark. It is vitally important, as I have said previously, to intervene and educate Mark about the risks of sharing needles and getting the appropriate support from drug use support services and safe equipment. If he is misbehaving he can get reinfected, and the PBS allows him to be retreated if he is reinfected. Yes. So thanks for those answers, they are good answers. Thanks folks.
 
 
Michael:
 
All right. We have learned a lot. We have had great case studies, Maria and Mark. Now we have got some key take home messages. Every GP can test and prescribe treatment for hepatitis C virus. You play a critical role in hepatitis C virus elimination. It is very rewarding. People are delighted to be cured. It is great to be able to cure someone. Patients may not identify themselves at risk of hepatitis C, so keep asking questions and be willing to screen. Clinical tools and support is available to help guide hepatitis C virus testing and also to help with prescribing treatment and assist with different steps in management. And always specialist support is available. It is important to get to know your local team. Find out who you can talk to in your local hospital setting. And specialist support is available to boost confidence and answer the difficult questions in testing and treating hepatitis C virus. Next slide.
 
We have some clinical resources. We have been over some clinical resources tonight, but here are some more. And we have got the decision making tool in hepatitis C, the double sided card that was very good. We have got Australian Recommendations for the Management of Hepatitis C, that is the book. That is excellent. There is a national hepatitis C testing policy. There is guidance on how to test for hepatitis C in children. I think best to refer to a specialist in that one. There is the decision making tool for hepatitis C and children. Again probably you do need the support of a specialist in that area, and then also just how to avoid stigmatising language and how that makes people less likely to seek treatment. We want to normalise this engagement and recognise that this is a treatment that is available for all and people are more than almost certainly likely to be cured. Next slide.
 
 
Martin:

You can start writing down your questions if you want. I can see there is some coming up.
 
 
Jennifer:
 
So I will just read through the learning objectives again, and if anyone did have any questions, please feel free to send them through now. We still do have some time to answer those.

So by the end of this session, we should now all have an increased knowledge and confidence to identify patients for hepatitis C testing, discuss different hepatitis C testing options including traditional venepuncture as well as point of care testing and discuss how to treat and prescribe hepatitis C medications and identify when specialist referral is required.
 
So there has just been a comment that is come through just to provide specialist support links for when we need help, for which we will share all of the resources.
 
 
Martin:
 
I think you just need, your own link should be either your local hospital, closest local hospital or health service clinic or specialist in private practice. You know, that is going to vary depending on where you are and which part of the state or city you are in, you know that is going to vary a lot. You need to build your own linkages, as you would for other diseases I would think.
 
 
Jennifer:

Perfect. So did anyone have any other questions they would like to ask? I am just going to share the email address, so if you do have any questions after the webinar has ended, please feel free to send them through.
 
 
Michael:


I will just comment generally, for my patients in the Blacktown area, I am able to ring a group of gastroenterologists. They are all very supportive and encouraging, they are very keen to help, and I always learn something more. So I find it not a difficult task, and it is a task that I enjoy doing.
 
 
Martin:
 
Someone has asked, do we do hepatitis serology in the first trimester, should we do hepatitis serology when they plan for pregnancy? You could equally make a case for pregnancy planning. I am not, you know, looking after pregnant women directly, so I am not sure when you do all the tests, but you could easily do that pre-pregnancy planning, because they might want treatment before pregnancy, they might decide to delay till after pregnancy. But I think a lot of women, if they knew, would probably want it before pregnancy.
 
There is another question, do I need to wait for a FibroScan before starting treatment? You can use that APRI score, and if the APRI score is below 1, you can go ahead with treatment. If the APRI score is on the high side, I think those patients should get referred anyway, and it depends if you have to wait a long time for a FibroScan or not, or whether you can get access to a FibroScan, and I guess that is going to differ in different parts of the state and how available the equipment is. We make our FibroScan available to everyone with a FibroScan referral form whether we see them or do not get to see them. But that has become very popular and unfortunately giving that easy access has made it very busy.
 
 
Jennifer:
 
So I would just like to extend my thanks to Michael and Martin for presenting this evening. I would also like to thank everyone who has joined us online and for sending through your questions. So thank you very much. We do hope that you enjoyed this session and of course enjoy the rest of your evening.