Hepatitis C

Hep C diagnosis and management for doctors, medical students, finals and MRCP PACES

 

Definition of Hepatitis C

• Infection of hepatocytes caused by hepatitis C virus

 

Epidemiology of Hepatitis C

• Incidence 0.5% in UK
• Much higher in Africa, and IV drug users.

 

Causes of Hepatitis C

• Hepatitis C  virus – an RNA virus
• Predominantly blood-borne transmission but sexual and vertical transmission can occur.

 

Presentations of Hepatitis C

• Rarely presents acutely and then only as a mild flu-like illness
• 85% develop chronic infection
• Presents as chronic liver disease (see CLD page)

 

 

Differential diagnosis of Hepatitis C

•  Any cause of chronic liver disease (see CLD page)

 

Genotypes of Hepatitis C

• There are 11 distinct genotypes of hepatitis C virus and many different subtypes
• Genotypes 1-3 are the most common and have worldwide distribution
• Genotypes 1a and 1b account for 60% of all disease and traditionally were the most difficult subtypes to treat. This is now changing with the development of new direct acting antiviral agents.

 

Initial management of Hepatitis C

• Investigations as per any other cause of chronic liver disease (see CLD page)
• HCV RNA levels
• Anti-HCV IgM
• Ultrasound liver  and alphafetoprotein
  • Every 6 months in those patients with cirrhosis to monitor for HCC
• Liver biopsy

 

Treatment of Hepatitis C

• The development of highly effective protease inhibitors which have been available since 2011 has significantly altered the landscape of hepatitis C treatment.
• The aim of chronic hepatitis C treatment is now full viral load suppression with the intent to cure patients of this disease.
• Several new drugs have been approved in the last few years and many more are on the way.
• This information is correct at the time of publication but is likely to change as well as be subject to national and local policies with regard to funding and availability.
• The AASLD and EASL guidelines can provide thorough up to date information on which drugs are currently available for treatment.
• Treatment should be prioritised for those:
  • With significant fibrosis or cirrhosis
  • With HIV/HBV coinfection
  • Pre/post liver transplantation
  • At high risk of transmitting the virus
• There are a number of treatment regime options and the choice will be determined by the patient genotype, possible drug interactions and previous drug treatment.
• Genotype 1 treatment
  • Traditionally the most difficult genotype to treat – this has now changed with the advent of direct-acting antiviral agents.
  • Sofusbovir plus ribavirin and peg-interferon
    • Sustained viral response >90% cases
  • Ledipasvir-sofusbuvir
    • An 8-12 week course gives a sustained viral response (SVR) in >94% cases
  • Simeprevir plus sofusbovir
    • This is given for 12-24 weeks
  • Peg-interferon and ribavirin
    • The traditional agents used in genotype 1 which give viral suppression in only 40-50% cases
• Genotypes 2 & 3
  • Ribavirin + sofusbovir +/- peg-interferon

 

Complications of Hepatitis C

• Chronic infection which can lead to chronic liver disease, cirrhosis and its complications including HCC (see decompensated CLD page)

 

Prognosis of Hepatitis C

• It is estimated that approximately 350 million people die every year from hepatitis C and its complications
• With new treatments however, improved prognosis for chronic hepatitis C and potentially a cure looks very promising.
• However, these new drugs are currently prohibitively expensive and not therefore available to the vast majority of people in the world who are living with chronic hepatitis C.

 

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