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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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Common Hepatitis C exam questions for medical students, finals, OSCEs and MRCP PACES

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Perfect revision for medical students, finals, OSCEs and MRCP PACES