Serena
Welcome to tonight's webinar, hepatitis C in general practice. We are joined tonight by speakers, Dr Scott Davison and Dr Nada Andric. My name is Serena, your RACGP representative for this evening. Before we get started, I would like to make an acknowledgment of country. We recognise the traditional custodian of the land and sea on which we live and work, and we pay our respects to elders, past, present, and emerging. I will also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening.
To introduce to our presenter for this eve evening, Dr Davison is a star specialist at the Liverpool Hospital and a conjoint lecturer at the UNSW. Dr Davison is dedicated to provision on high quality medical care to a board population of the community with a focus on liver health, cancer prevention and management, and viral hepatitis. He has extensive clinical experience in chronicle viral hepatitis B and C and contributes to clinical research in the management of these conditions. He has been an educator and speaker in various capacity in relation to these topics with a particular interest in chronic viral hepatitis in indigenous Australians.
Dr Andric is a general practitioner at Earlwood General Practice in Sydney and a head of vocational education at GP Synergy. Apart from medical education, her special interests are in the health of marginalising population and viral hepatitis management. She has also interested in providing holistic care of people with severe and enduring mental illness. Her research interests are in primary care professional of hepatitis C treatments. I will now hand it to Nada.
Dr Nada Andric
Thank you. Now I might see if I can share my screen, see if that works. Perfect.
Thanks so much for the introduction, and thanks everyone for joining us this evening. I might just go through our learning objectives for the evening. The first being to increase GP confidence in identifying patients for testing, including how to initiate a testing discussion, understanding hepatitis C testing options and how to interpret results, learning about hep C treatment options and how we can prescribe treatment, and also understanding which patients need referral to specialist care and how we get them to see our specialist colleagues. We will just start up by a quick introduction. Most of you already know, a bit about chronic hepatitis C. Hepatitis C is a blood borne RNA virus, and it affects the liver, and it is curable, certainly more curable since the introduction of the DAA therapies in 2016. 58 million people globally have chronic hep C, so it is quite a common illness, and the transmission mode is blood to blood contact. People with hep C often do not have symptoms, but when you do treat hep C, people who have had hep C and no longer have hep C feel lots better. They may be less fatigued and they may feel more engaged with the world, less brain fog is what a lot of people say, so even though there are no specific symptoms with hep C, people do feel better when they do not have it. Highly effective, well tolerated oral therapies have been available since 2016 on the PBS, and that has been a huge change in how we have approached chronic hepatitis C treatment and care, and, in fact, I think now it is not even as big a deal in Australia as it used to be. We have done such a fantastic job in treating so many people with this illness. Untreated hepatitis C can cause liver disease, cancer, fibrosis and cirrhosis, much like any of the other illnesses that do affect the liver, and the New South Wales and Australian hepatitis C strategy, is on track to eliminate hep C as a public health threat by 2030, and I think this education, that we are doing tonight is part of ensuring that we can engage as many people into testing and to treatment as we can.
Scott, I think you are next on board, if that is alright, just to identify people for testing.
Dr Scott Davison
I just want to flow into this by saying that identifying is probably the biggest challenge, that we have in hepatitis C now. The drugs work wonderfully well, and they are really easy for in almost 99% of cases, but looking across the desk from you and thinking, could this patient be someone who will benefit from a discussion about hepatitis C, and how do I get this in in trying. This is really the big challenge. I am not typically look in front of patients that I am going to describe now in the first instance than you are, and that is why general practice is really the forum for us to have these discussions. We are looking at a group that not may be easily identified according to their previous injecting drug use or exposure to blood borne viral infections. Now that might be people who self identifies as injectors, people who have been incarcerated previously, but also, if you were born in Egypt in the 50s and 60s, the program of schistosomiasis vaccination involved needles going out of one arm into another, and as a consequence, 15% of Egyptians, I think it might be even be more, will have the particular viral strain, the genotype that is endemic to that area, and that is all part of that program of vaccination. There are patterns of epidemiology throughout the world that are based around iatrogenic exposure to the virus as well. In the indigenous population in Australia, we know that there are higher rates and that probably relates to some of the cultural practices or perhaps some of the ways that health is managed in those communities, but, predominantly, where I would like to put emphasis tonight is that we are under testing patients who might be going to Bali for a tattoo or to other Asian countries where the Vaseline pot is a great transmission spot for blood before the needle goes into the skin, and that can be a spot for transmission of the virus. Needle stinging injuries at the occupational place of work, coinfection with other viral infections, patients where you are not really sure why they have got liver inflammation or cirrhosis, mothers born to hepatitis C positive, mothers with babies, health care workers, and people engaged in sex work may be at higher risk of that as well, and I am not sure if we are going to talk about gay men and HIV, but that is another forum for infection as well. We might move on there.
Broader screening outside of just is this person an injector, is really warranted now. We are going to have difficulty reaching the elimination by 2030 unless we look at a broader group to make sure that we are covering all of the population with testing. Now if you do not identify these infections, there is a whole host of things that swing into effect, and we think about 20 years is the lifespan, from the start of the infection to the time when the consequences are really felt. An acute hepatitis C infection goes into a phase where a lot of people actually develop a chronic infection. Only really 20% will spontaneously clear the virus. They will be left with hepatitis C antibody that identifies them as someone who has had the infection previously. So majority, 80% will develop chronic hepatitis C at about 20 years, 10% of those patients will be developing cirrhosis, and a lot of them will have chronic inflammation or elevated ALT and AST as their markers that that go on for many years. Of those, cirrhotic patients, 4 to 5% will develop a decompensation event that might be a variceal haemorrhage or peripheral oedema or jaundice. Quite a substantial portion will develop a cancer, so that is about 3%, so it is a very preventable cancer if we can address the root cause that is the infection, and, unfortunately, deaths from hepatitis C is still going on even though we have done quite a fabulous job in the last 10 years of identifying and treating a lot of patients. We will just move on there.
Looking at the way that this 20-year flow, you go from a healthy liver that looks red and has a predictable small size to being something that is enlarged and full of fat. That is one of the hallmarks of the hepatitis C infection in many instances is a fatty liver. It can start to develop some fibrosis before it develops a nodular contour, and that is the cirrhosis that 20% to 30% of patients are experiencing at 20 to 30 years, and then liver cancer or solid lesions that appear out of the cirrhotic liver or in many instances that they develop at a rate of 1% to 3% a year in these patients.
Now this is getting into the specialist territory. This is not very common, and in the early part of my career when hepatitis C was not treated exactly the same way we did struggle with a few patients here, but lymphomas, glomerulonephritis, and other autoimmune conditions including vasculitis, they do flow out of this infection. One of the ones that was really I used to think was really fascinating was cryoglobulinemia. I used to elderly women with very awful looking legs from this terrible vasculitis that was easily cured by treating the hepatitis C, but by that stage, a lot of people were up for the treatment of the day, which was interferon. Thank goodness we do not do that anymore. It was a terrible treatment, but it is very much in the rear vision mirror now. Diabetes mellitus can occur as well, and there are some other unusual dermatological conditions that I have not really had much to do with in my career.
Dr Nada Andric
I guess your points are really valid, Scott. I think, we have done a very good job at treating some of the people who are already engaged in care, and who have had testing and who are quite engaged in their communities and engaged in their health, but there are definitely people across Australia that have been told 20 years ago that it is Hep C, do not worry, you will never get rid of it, and those people are still living in the community and potentially still at risk of fibrosis, cirrhosis, and hepatocellular carcinoma for something which is now, like, actually curable. They are the clients that I think that we are trying to target for testing.
When we think of testing, it is fairly straightforward. Testing sequence is really testing someone who may be in a priority population or someone who has just come in and asked for a blood borne virus screen starting with a hepatitis C antibody. Basically, we screen people, like we might even screen for blood borne viruses in general, hep C, HIV, hep B antibodies. We might add a syphilis. If we are just doing a general BBV STI screen, that might be part of our entire screening profile, and I know a lot of AMSs have already incorporated hepatitis C into their care plans and into their normal structure of care and their standard of care for their clients, but we start with a hepatitis C antibody test and if we have a positive antibody then we go on to a hepatitis C RNA test. If we have a negative hepatitis C antibody test, we stop testing at that time because we know that our patient has not been exposed to hepatitis C and it is a nonreactive test. If they have been exposed to hepatitis C, what we want with a hepatitis C RNA test is to figure out, do they still have hepatitis C or have they been treated and just have a positive antibody or have they cleared the virus like 20 or so percent that Scott went through earlier. What we are want to figure out is does this person currently have hepatitis C infection and the only way to do that is to test for the Hepatitis C RNA in someone who has a positive antibody test.
If we have a positive test result for a Hepatitis C RNA, we know that that person does have Hepatitis C and they have a current infection, and that is our chance to have that discussion with that patient around, talking about engaging them into care, talking about treatment, and to the fact that it can happen very quickly with over-the-counter medications that are quite easily accessible and quite well tolerated. What we do often get wrong in general practice is the understanding of the hepatitis C antibody test. I think a lot of people can stop and at the antibody and think, oh, we have got a positive antibody. That person has got hepatitis C, but we really do need to proceed to the RNA test to ensure that the blood actually has the RNA in it. That then that way we can tell the patient, yes, we definitely have tested for hepatitis C and you do have the virus. It does need a second dedicated tube. I have been caught short before with only taking one of the serum tubes. It is useful if you are taking blood in clinic to take two of the yellow tops and an INR as well as one of the purple tops, if that is what you are doing, just to make sure that you have enough blood when testing because some of our clients definitely have veins that are a little bit more difficult than normal, and you do not particularly want to rescreen, so that is where we, on the form, would write hepatitis C antibody test. If positive, please proceed to RNA testing. It does say here that some private labs already do that, and they do, but it is a little bit hit and miss, so I would continue to write if positive reflex testing, request on all of my pathology forms anyway.
Gone a bit too far. There is some really good information out there. ASHM has some fantastic information. The decision-making tool for hepatitis C is just an easy two pager, and it will go through, who the client group we are looking at for testing and very simple decision making and what we need to do from that point onward. For a little bit more in-depth information, the consensus statement in chronic hepatitis C is available, and that is a GESA, Gastroenterological Society of Australia document, and there has been a little bit of movement in when to test for cure and so forth, so it is a really good statement to read, every so often if you are interested, but most of the information that you need in general practice is really available on that decision making tool from ASHM. I think we have got the link going out, with these the slide deck, but if you just google decision making tool in hepatitis C, it will come up and you will be able to see it, and all the links in the tool are also live links. I might just continue on if that is alright.
We have got other ways of picking up hepatitis C. They are available not just your stock standard blood draw in general practice or from a pathology test. We definitely have clients that do not have easy venous access, and that is actually incredibly stigmatising, and I think that is why we have not been super successful in treating chronic hepatitis C in this country. It is not like your stock standard urinary tract infection where you can go into the GP and just say, look, I have got urinary frequency and get the treatment, there is a whole bunch of stigma that comes with having this infection, and I think getting treatment and seeking health care and that is mostly because of its transmission, the risk factors associated with transmission and people that have previously injected drugs or people that have acquired the infection many years ago may still carry that stigma and may not even want to speak to you about their hepatitis C status. So that is something that I think that we need to be aware of, but also that is why so many of these other ways of detecting hep C are so important. Point of care test is something that they do use quite a lot of now, particularly in people who are in prison and being able to reliably take just a finger prick sample of someone's blood and have a positive PCR result at the end of that is pretty amazing, particularly because in the past, we used to wait for a couple of weeks sometimes to get a genotype and a viral load from some of our blood draws, so now having something that is available in less than 60 minutes and then being able to actually prescribe treatment at the time is pretty incredible. This is through a national point of care screening program that has been funded by the federal government and is available through sites across Australia, pretty much run by local health districts and people associated with local health district testing teams. It may not be as readily available to our regional colleagues, but if it is available and if it is coming your way, I think it is really something to look out for. In New South Wales, we are really lucky. We have access to the DBS tests, so we can refer our clients who may not be super keen to engage at the moment to having a DBS test, a dry blood spot test that can be sent out to them to their PO Box or to their home, after answering a few questions online that look at risk factors, so DBS is available for both HIV as well as for hepatitis C and a PCR test is also done on the dry blood spot samples. If you are in New South Wales and you do have some clients that might have incredibly difficult veins, do not really want to engage at the moment, but might be interested in getting the test in the future, I think referring them to the DBS test is really fabulous. Have you had much to do with that, Scott?
Dr Scott Davison
No. Dried blood had a vogue in public hospitals where I work some years ago, and it does get used in our injecting site, but in hospital, we have such great facilities for pathology collection that we just got use that as our mode. It is very effective though. The only weakness in the model that concerns people like myself is that linkage to care is still something that is important, and I guess there is an extension out in a practice like mine, we do B and HIV concurrently, and this is just one little slice of the blood borne viral thing, and I am not diminishing that in any way, but it is a fabulous start if needed.
Dr Nada Andric
Excellent. Thanks. Alright. We will click onto the next slide, and that is just on pretreatment assessment.
Just moving on with after we do our initial discussion with the client around risk factors or even figuring out whether or not the patient is interested in getting testing or if they are worried about anything or if you as a GP is worried about an increased liver function test or something just a general blood borne virus screen. We do need to do a comprehensive assessment before we embark on treatment if somebody does have the positive PCR test. In times past, very early in the piece when the DAAs were available, we did need a quantitative RNA result as well as a genotype to assist us in managing people with hepatitis C because different medications are available for the different genotypes, but now we are really lucky and both of the main medications we use for hepatitis C work on all genotypes equally and they are equally efficacious and they are very effective. I have not asked for a genotype in a very long time, and, in fact, I think that would also take quite a long time to come back from the lab.
In our pretreatment assessment, we also do ask about previous treatment and I think delineating between previous treatment with interferon versus previous treatment with our current DAAs is important. I think we need to figure out if someone has had a discreet infection that has been diagnosed, cured, and they have a new infection or whether or not somebody might not have a completely treated illness or infection, and that is where we might need to refer them to the specialists in that instance. Figuring out if someone has been treated previously and if they have been given a cure, a result, an SVR result is important. I think it is also important to figure out how good people are with their tablets if it is a good time in their life to take tablets every day for a couple of months, or if it is something that they need to hold off for a couple of weeks or a little while until things are a little bit easier. Obviously, having the patient in front of you makes it a little bit easier to really engage with them and try and put into place some strategies for adherence. Obviously, with OTP, people can pick up the same time they might pick up their methadone or Subutex or they might be able to pick up weekly if they are on weekly buvidal, but really trying to make a plan in case nonadherence becomes a problem is important. Because hepatitis affects liver, it is important to talk about alcohol intake, and sometimes very heavy alcohol intake can really influence how good people are with taking their medications as well, so not only does the liver get impaired with heavy alcohol intake, which like a double whammy, I guess, but also some people who are really quite heavy into the alcohol may not be as reliable with taking their medication, so it is important to ask.
It is important to know which medicine someone is on just because there may be some drug interactions, and Scott will talk about that a little bit later. Treatment in pregnancy is not something that is indicated at the moment. I think it is being studied and I do not think it is hugely bad, but it certainly is not a category, like a safe category of medications at this stage, the DAA, so we often hold off until after breastfeeding has been completed until we can actually treat women who are currently pregnant. Pregnancy is a fantastic time to pick up hep B, hep C, and really have women engaged in care, so I think it is a really good opportunity to have those discussions, and really keep people engaged until they are so ready to embark on treatment.
Weight and BMI are important. Obviously, there are lots of things that may continue to impair the liver function even after treatment, so what we do like to have is a bit of a baseline weight and BMI for those clients, and obviously, a quick physical examination, signs of chronic liver disease is important, and your stock standard medic blood test, FBE, EUC, LFTs, and INR.
A cirrhosis assessment is probably the most important thing, and I think when you do call up for the authority prescription, you are asked by the person on the authority's line if the patient is cirrhotic, and you should be able to answer that question. We will talk about cirrhosis assessment next, and that is either through an APRI score or a FibroScan. The APRI score is the most accessible, and the beauty of the APRI score is it does not really matter where you live. You can use it. If you can order an AST on a client and you can order a platelet count on a client, then you can do an APRI score, and that gives you a pretty gross marker of fibrosis, and certainly, the AST to platelet ratio is something that we continue to use to assist us in figuring out if the person is at risk of cirrhosis or severe fibrosis, and, we will use the calculator in a little bit of time as well just as we are going through the assessment. A low APRI is a good thing. Any APRI over 1 is something that we assume someone may have high risk of cirrhosis with. The other tool we often do use for a fibrosis assessment is a FibroScan, and a FibroScan is an elastography investigation. There used to be a fantastic slide about this that talked about assessing the thickness and fibrosis of a liver, and it was based on a machine that used to test for how thick and how thick brie cheese was, so, the machine is actually based on an aging of cheddar cheese kind of machine or brie cheese machine, but it is really like, I like to explain to my patients, we are really lucky we have got one. I like to explain to my patients that it is trying to figure out if your liver is still a bit like jelly or if your liver is a little bit harder or more like a brick, AND really what we want is a nice jelly-like liver. I do not know if you have anything you want to talk about with respect to the FibroScan, Scott.
Dr Scott Davison
We could talk about FibroScan for quite a while, but, essentially, your analogies are really important that sound will travel differently through these organs of different density. If you have got a lot of human between where the probe sits and where the liver is, the reliability of this type of scan may be altered. If people have really, really kind of big wastes that could make it a little harder to use, but, essentially, when it comes to my assessment of cirrhosis, I will use this and other bits of information including abdominal imaging and what the liver looks like to put together an opinion. It is rare that we biopsy is kind of where I am going with that.
Dr Nada Andric
I guess what would you do if you were in like a regional or rural area and really did not have this access? What other tools might you use to figure out if someone is at risk of cirrhosis?
Dr Scott Davison
I would certainly be looking at things like platelet count and other aspects of the way that the liver functions, the hepatic synthetic markers of INR, bilirubin, and albumin, but probably the thing that I would find most reliable is to get a service that you respect to do an ultrasound and try to look for features of a nodular contour of the liver. Now if everything looks normal and if all the markers that you are collecting in your serum are normal and the organ looks normal and there are no signs of portal hypertension, it is very unlikely that cirrhosis is present, so that is a bit rough and ready, but that is a way to go around this really quick and easy tool to come up with an assessment that is pretty reliable as well.
Dr Nada Andric
I think Serena is going to share from now on. Thanks so much, Scott.
Dr Scott Davison
I think we are up to my bit about treatment now, and the direct acting antivirals were a revolution that occurred in the middle of the last decade that has really changed my practice at work. They are all oral and quite easy to take. They really do not have side effects that I would care to prioritise as a factor here. They either last for 8 or 12 weeks, and between 93-99% of patients are achieving what is called sustained virological response by using these medications. It is pretty rare that we come across infections that are not treated.
The SVR is now considered to be a cure, and there are thousands of Australians who live in sustained virological response and their rate of recurrence of these infections, I am not sure I have ever seen one. We do not suggest that anybody, even if they have just been infected, waits for clearance. We always just get started. The two therapies we use now, Epclusa and Maviret, they are pan-genotypic. They are supplied through authority prescription, S85, and any GP is able to just get going on these scripts. I am not actually sure where we are up to with the referral to some sort of external body, but I think that those days are over. Is that right, Nada?
Dr Nada Andric
I was going to ask you about that because I think some of our very straightforward patients might actually, just this education and us speaking about some of these cases is probably enough for us to be able to prescribe this with some confidence, but I think some of our more complicated patients, we may still need to go through the process of a remote request form. That will really depend.
Dr Scott Davison
I am not sure if the remote request form is in this presentation, but it is essentially, just a bit of data that goes through that initial data collection table that Nada has already spoken to. It allows you to prioritise within the information that has been made available to you during your time with your client to make sure that it is a safe thing to do. It is the right therapy to apply for this particular patient and that there are no issues that are going to get in the way of it. I wanted to emphasise something within what Nada said. I actually personally believe that the most important part of the therapy is will the tablet leave the box and get in the mouth? By that, I mean, is your patient distracted by something else that is going on in their life? Are they going to not take these tablets over 8 or 12 weeks? People who are homeless, people who are currently going through some other substance use issue, or who have other big things going on in their life. It is probably just not the right time to start, and that is the issue to really focus on there. You are all sensible enough to see your patients going through big deals that might be the priority rather than hepatitis C. Minor side effects, nausea, headache, fatigue. I have not actually met many patients who have reported those, but most of the time, it is my nurses who do the treatment. I am a bit removed from the side effects side of things.
The six genotypes that we have got, 1-6, they are treated by both. There is a slight difference if you have got cirrhosis and you are on Maviret, you do not get a short course, the 8-week course. You get a 12-week course. The only other difference with those two therapies is that Epclusa or sofosbuvir and velpatasvir, it is a one tablet a day versus Maviret is three pills a day.
What is really important to deliver back to a specialist? You see someone who has got cirrhosis. It is not so much even that the infection is difficult to treat. It is more that after a patient is cured or goes through an SVR and they are at the other side, what happens to your patient then? Now, there is a type of patients who would take it as a green light for alcohol use or everything else that they wanted to do with their liver. They are going to get going on it right now, and those patients are on a steady path to cirrhosis from a different etiology, and they may already have preloaded themselves with quite a severe liver injury from hepatitis C. We do not want to do that. If someone has got obvious skin manifestations, they have got renal disease, or some other condition that you cannot tease out as being clearly not related to their viral infection, then obviously, send on to me. The really complex patients I have had to deal with have actually been cardiac patients on amiodarone as those therapies are really difficult to discontinue, and some of these therapies I am going to describe how we cannot really mix these drugs together. For that reason, you need to really work with a cardiologist to get the program for heart care going in the right direction. Kidney impairment was already spoken about. If you have got somebody who is HIV or hep B co-infected, the therapy still actually runs pretty similar to a standard therapy, but there is definitely some nuance to it that would benefit from the specialist to be involved. If somebody has already failed the DAA, it is not the end of the world. We can definitely retreat using a another therapy. There is actually a line of therapy called Vercedi, which has got three antiviral agents in it. I am not going to describe that here, but that is up our sleeve if we need it. Somebody with acute hepatitis C, really, really rarely these people end up on ventilators for severe liver failure. You do not really want to muck around with somebody who is circling the drain with hepatitis C in its acute phase, and juniors, I do not actually look after paeds myself, but I have certainly been involved in their care before, and they would be better off in a specialist practice for sure. We have already spoken a little bit about forms that are used in remote request and point to the GESA remote consultation request form. It is an online site that allows you to move step by step through the collection of information. The REACH-C, I am actually not really familiar with that form right now because it has been a while since I had a look at this presentation. REACH-C through ASHM would be very similar and would help you to make your own decisions and also move towards specialist referral if needs be. They are available on those websites there.
You have got your patient. You have decided to treat, and you want to know about what do you do on treatment. Monitoring on treatment is not thought to be something that is essential. If you have got a patient who is unwell with nausea or headache, they will probably turn up and want to talk about it. We would not ordinarily change that therapy, if the adverse effects are mild, but you can definitely take them off if you are worried and send them to a specialist. Interruptions are discouraged very strongly, but there is this weird data that comes out particularly in injecting drug users where they looked at the length of time that it took to complete the 8-week or the 12-week program, and the length of time that it took did not actually really correlate so much with the outcome, the SVR. These therapies are quite durable. Even if tablets do not go in at the right time, we certainly are encouraging patients to not interrupt if possible. As you finish therapy, there is really good data to say that if you do a Qual, I have already put this in the chat that rather than count the RNA virus particles, just the presence of the virus in the serum at 4 weeks or 12 weeks is a reliable indicator of sustained virological response. If you are only able to get a 4-week post treatment blood test, then that is pretty good, but our standard of care is for a 12-week test. You can see there that the ASHM guide has got the box for monitoring and follow-up. I am going to talk about follow-up now a little bit. I would do LFTs at the end of therapy as well. I think that is really important. You may find that your patient gets rid of one component of their liver injury and you see that they you have sliced some of their ALT and AST elevation off, but they have remained in liver inflammation, and there is a reason that there is something else going on. That is really where I earn my money through State Health. I spend a lot of time with trying to work out what is going down with this sort of patient.
We are going to go onto a case study now and pull it all together.
Dr Nada Andric
We will start with Mark. Mark is a 42-year-old unemployed male who is new to your practice. He has just been released from custody. In his background history, he has been injecting methamphetamine since 2005, and he is still injecting only occasionally. He rarely drinks alcohol, has a past medical history of reflux, which he is on esomeprazole for. He has a thin body type with a BMI of 20, no stigmata of liver disease, and does not identify as Aboriginal or Torres Strait Islander. Would you offer Mark a hepatitis C test?
I guess we would. Nice thumbs up. That is right. When we look at this scenario, we look through the hepatitis C ASHM tool, and the decision making tool will assist us in ordering the right tests. We will order the FBE, EUC, LFTs, hepatitis C antibody, HIV test, hepatitis A and B testing, as well as an INR. We get a result that Mark has a positive hepatitis C antibody, and so we do a reflex test and that shows that he has active hepatitis C. He is suitable for treatment just by having that active hepatitis C result. Is that correct? If you have got a positive PCR, Scott, is there any kind of timeframe? There used to be a 6-month timeframe to say somebody was chronic. I am just wondering if there is a timeframe now for when you treat.
Dr Scott Davison
Nada, I do not see very many acute hep C, maybe one a year, and I do not really think about this. I just give them treatment. If I meet somebody who has got an exposure and acute infection, I would just get them started on treatment right away rather than think about where they are up to in the infection.
Dr Nada Andric
Excellent. I think that is very reasonable because how often are you going to get someone back in six months' time exactly to check for whether or not they still have the virus? Interestingly, for this particular scenario, Mark has had a genotype test done and he is genotype 3a. Would you say that is a common genotype?
Dr Scott Davison
In Australia, 3 was not the most common, 1 was the most common, but 3 was up there. 1 and 3 were around about.
Dr Nada Andric
But often, we would not actually get this result at all unless we specifically ask for it.
We are going to do a pre-treatment assessment for Mark, and you can see that his AST level was 45 and his platelet count was 419. We are trying to calculate an APRI score with the AST of 45, upper limit of normal for the AST is 40, and then his platelet count is 419, so his APPRI score is well less than 1. That is kind of in the range that suggests that he is not overtly fibrotic or at risk of cirrhosis. You could see that if the platelet count was really low, so say if it was only like 80, you could see that the APPRI score would really push above 1, and so we would be more concerned about cirrhosis, and then we would probably make a decision about what to do next. If the APPRI score is above 1, we do want to do some further testing. We want to either do some more imaging, so ultrasound, FibroScan, elastography, whatever we have got available.
Dr Scott Davison
I would not recommend that this patient be referred for any further testing on the basis of what I see right now. I am not sure if I am answering that.
Dr Nada Andric
I think that is great. Somehow, we have managed to get Mark a FibroScan, which is wonderful. These are the results and the good news is that I know what both of them are, but could you explain how important it is having a CAP as well as a fibrosis assessment for Mark?
Dr Scott Davison
I do FibroScan in clinics where I get patients referred in for opinions based upon their FibroScan, and I find the use of both of these measures extremely helpful. I just want to draw attention to the colours on the fibrosis arrow there. You see a green F0-F1 where our patient Mark is sitting, and that is a very reassuring result. It is really quite solid that cirrhosis is excluded when you get a number like 6.2. You may even see his FibroScan result go down after treatment, which is, again, really reassuring. I also just want to point out, I do quite a lot of this and see patients walking off the street with FibroScans of 15 or 20, and I can be certain that cirrhosis is their diagnosis. That is really helpful. In the middle there, when you have got somebody with 7 to 12 zone, it is quite difficult to be really settled on the fibrosis level. In particular, you may, in fact, have somebody with cirrhosis who has a FibroScan that is less than 12. One of the parameters that I use to think about this, though is steatosis or the CAP, which is another way that sound is used going through liver tissue like if you can imagine a pool of lipid speeding up the flow of sound and then it suddenly stops again. What you have got is this staccato signal coming back at the at the probe that is measuring something that is interrupted. The CAP is quite a reliable measure of steatosis. In chronic hepatitis C, you can see there is a band above 250 where the fat content of the liver is significant. Now, fat just by itself is able to promote the stiffness of the liver. There are times when I meet somebody who has got a FibroScan of 10 and a CAP of 350, and I think you have got a fatty liver, and it is really hard to tell what is going on with the stiffness there. Suffice to say, I am able to give quite a good opinion there to say, I think that whatever you came in with, you have got your hepatitis B or your hepatitis C, I think that steatosis is a cofactor, and it may in fact be the dominant factor. We are going to work on both of these things, and that is how I might shape an opinion out of the information from liver stiffness and steatosis. What is important here is that the dynamic process of doing more than one FibroScan is able to tell me whether treatments have happened successfully or whether we are on the right track of rehabilitating the liver. Sorry, long answer there.
Dr Nada Andric
The next question, and maybe this is a teeny tiny question, is what do you do when you have a CAP of 350 and you know you have got a patient who has got significant steatosis? Do you want to see that patient or are we meant to do something about it in general practice?
Dr Scott Davison
I am just a hepatologist and within hepatology, I have developed a really big focus on making sure that people are aware of their metabolic health and that we are doing something about it. I have clinical trials for drugs that are going to revolutionise the face of hepatic steatosis. Let us move on. I am really into your patients if you have got them.
Dr Nada Andric
Just going back to Mark, we know that he has got chronic hepatitis C. We think that the date of infection was 2005, but we are not exactly sure because he has been injecting drugs intermittently since that time. We have a genotype of 3a, and we do have a 2.3 million copy viral load. We know that he has no fibrosis, no comorbidities, normal renal function, just is on some esomeprazole really, and we know that he has not been on any treatment before. What do we do next? Treat.
Can we go to the next slide, please? Can he be treated in a primary care setting? Is ongoing injecting drug use going to be a barrier to his treatment? Yes, exactly. He can be treated in a primary care setting, but will ongoing injecting drug use be a barrier? That is right, Steven. No. It will not. The beautiful thing about these medications is that they should be offered to everybody, no matter what their risk factors of ongoing injecting drug use are, really having people engaged in care and minimising their risk of ongoing liver harm, but also the harm of other people is really important.
There is a fabulous NSP outlet map available, if you do want to know where your local needle and syringe program outlet is or vending machine is, you can just Google NSP Outlets New South Wales Health, and you will come up with that particular map.
Scott, this one is for you, I think.
Dr Scott Davison
I have sort of talked about this a little bit. Epclusa and Maviret are both the right treatments to be thinking through. They are quite similar. Some patients would hate the idea of putting three tablets in their mouth and would be honest. Some people would say, I do not want to go for 12 weeks. I want to go for 8 weeks. If you have got a simple patient like Mark, you can give them either. The outcome of the treatment is equivalent, and I can say that with great confidence. If you want help, if you would like someone to support you in your decision making or whatever bit of the care, there is really good services available through ASHM or through GESA. This is our bread and butter. We are right into answering questions with general practitioners who maybe are varying levels of exposure to hepatitis C treatment or even the patient cohort involved in hepatitis C. We have got good connections. If you are wanting to get somebody into a specific drug and alcohol harm minimisation type of frame, we have got quite good connections there as well.
Drug-drug interactions. There is this amazing website that has run through the University of Liverpool, not Liverpool Hospital where I am from. Liverpool University in UK have the ability to throw one of these two drugs or both of them alongside esomeprazole, and you see that there is a weak potential interaction with esomeprazole and a stronger one, the potential interaction for Epclusa that we think "Oh my gosh. I cannot use this." Actually, if you dig down a bit, there is quite a text alongside there to say that if you give these therapies, you may decrease the effective antiviral therapy in some instances. This is overcome by just not co-administering them within three or four hours. These sorts of interactions are typically able to be overcome. If you were at all wanting advice or if something looked more complex, then you could dig out from the hep-druginteractions.org website. If you really want some help, going through the specialist program would be fine. If you have got somebody who is on a real shopping list of drugs and it is really hard to work it all through, that is probably somebody that I would not waste your time there because it can be very tricky, and I do not do them myself. I give them to my pharmacist, and that is very nice because I get to spend a bit of time doing all this technical work that is fun for them.
If there are drug-drug interactions, what are other options? If you really wanted to exclude the chance of the interaction, the H2 receptor antagonists, I use nizatidine and famotidine that is something that could be used with Epclusa. You could put them onto Maviret, which has this lower chance of interaction, and that is really how we do measure it. Sometimes I give advice to patients that your therapy, your beta-blocker may change its effect, and you might need to stand up more slowly. That is because there is a potential interaction, and the interaction has been talked about before, but it is not a very well-established interaction, and in particular, the nursing team that I work with are great at giving really clear advice about that.
Post treatment and monitoring. Mark gets treated with Maviret, and at the end of that, does he need further testing? Yes. We are going to do a PCR at the end, just a qualitative one, and we are going to do his liver enzymes. Now someone asked in the chat, do I do 4 or do I do 12? I personally do 12. I like 12 weeks after because by that time, if your liver is going to settle down, it really definitely will have settled down from HCV, so you have really got a good chance of looking at the liver tests and getting meaningful data there. If someone really wants to be through with it and you are not clear on whether they are going to turn up again, four weeks is an acceptable time point to measure Qual.
Does he need ongoing specialist care? Not at all. He is done. You do not need to have him referred back to us at all. If he has got cirrhosis, it is a different kettle of fish. Even somebody with advanced fibrosis. We are really not sure just how to treat these patients. If you want to run them by a specialist at the conclusion of the therapy, we would be happy to have a think about that and come up with some strategies for management there. Mark is cured.
I am not sure who does this, but I can do it. Mark is occasionally injecting, and he has got an ongoing reinfection risk, and what do you do there? Well, essentially, you just want to really give clear advice about how injecting exposes individuals to infections and harms and provided on a practical level, including someone having access to a needle and syringe program. You do not have to keep going with antiviral testing. I would ordinarily do liver enzymes. You do not do antibody because it will always be positive. The RNA for somebody who is injecting is a worthwhile test even though not a lot of them do.
Dr Nada Andric
Fabulous. Thanks so much, Scott. That is tops. We have got one question I could not really answer in a diplomatic way. If a patient is already on a DAA, goes into prison, would Justice Health continue the treatment? Is it available in all prisons?
Dr Scott Davison
The answer is no, and that is an indictment of justice. Justice in my coarse opinion is indifferent to the health of the individuals who arrive in the service. The fact that they have got a bottle of tablets with a really clear indication and a good management strategy ready to go, it will not be adhered to, and you probably will lose that therapy. That is not the end of the world. Thankfully, I have got some really, really dear colleagues who work tirelessly to try to provide high quality care to patients in prisons. I have received patients from prisons who are on therapy and received cirrhotic patients post therapy for ongoing management. That can work quite well, but I am sorry to be pessimistic because it is unlikely. What do you think about it, Nada?
Dr Nada Andric
I think it is getting better. I think there is a real push, but I think it is quite difficult to actually continue medicines that were in community in prison, but also the same continue medicines that started in prison in the community. I think that is about it.
I think we have got two plugs left. I think one is a plug for your awesome Project ECHO.
Dr Scott Davison
Telementoring is kind of an instant handholding experience. You are able to put the data into the remote access page, send it to us, and then once every two months at the moment, we will talk about viral hepatitis, and in particular, we will talk about cases like this with general practitioners and try to make sure that your support needs are met. It is really quite interesting. Most of the people who turn up do not get tired of me talking for 45 minutes even though I am surprised. I have got a great panel. I have got a social worker, and I have got drug and alcohol people and sexual health people who are part of the panel. The diversity of information that is generated out of Project ECHO is fabulous. I have got another hepatologist who helps with it as well. If any of you wanted to get involved, please do. We really do appreciate getting cases from the community, and you do not have to, I know you are all busy workers. You have got practices to attend to. We are not trying to make this onerous in any way, but we will try to meet your support needs through Project ECHO.
Dr Nada Andric
Awesome. Just a plug for the project that I am involved with called MotivateC. It is a project to look at whether or not cash will assist anyone that is a little bit reluctant living with chronic hepatitis in the community, engage in treatment. There is some fantastic potential cash rewards on offer. Googling MotivateC will get you to the project page, and you might be able to navigate through that with your patient. Also, we have remote online GPs that will be able to prescribe treatment for your patients as well. It has been really great in regional and rural communities.
Thanks so much. Thanks, Serena.
Serena
Thank you. I would like to extend my thanks to Scott and Nada for presenting and also everyone who joined us online. We do hope you enjoyed the session and that you also enjoy the rest of your evening.