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Managing Hepatitis C in General Practice

There is now encouragement by the Government and many gastroenterologists to have GPs diagnose and treat patients with Hepatitis C. It is important that GPs be aware of the new oral treatment options for this condition and that face-to-face referral of the patient to a specialist who is experienced in treating Hepatitis C is no longer necessary for straight-forward cases. All that is needed for uncomplicated patients is for the GP to discuss the genotype, liver function, assessment and management of the patient with a specialist who has experience in treating Hepatitis C (this specialist may be a general physician, infectious disease physician or gastroenterologist).

The most important test in the management of Hepatitis C is no longer the RNA viral load measured on PCR (unlike the assessment for Hepatitis B) but the Hepatitis C PCR genotype. This will determine the prognosis and type of treatment and whether the patient requires referral. The commonest is genotype 1A and 1B. Genotype 3 is next most common and then type 2 and then type 4 (this is most commonly found in Egypt). Type 5 and 6 are least common. Genotypes 4, 5 and 6 are more difficult to treat and early diagnosis increases treatment success.

Patients whose presentation is suitable for management by General Practitioners will have    Hepatitis C genotypes 1A, 1B and genotype 3. They will not have significant and especially not decompensated cirrhosis on ultrasound, and their liver function tests are not significantly deranged (ensure the patient has not been drinking significant amounts of alcohol in the weeks prior to testing).  These patients should have no other co-existent relevant infections (Hepatitis B, or HIV) or problems with abstaining from alcohol. Patients who do not fulfil these criteria should be referred.

Hepatitis C genotypes 2, 4, 5 and 6 should also be referred.  Genotypes 4, 5 and 6 may need interferon and this has an increased risk of side-effects (such as fatigue, headache, depression).  If the initial treatment by GPs fail the patient should be referred (this may be due to reinfection or viral reactivation).

Fibres canning the liver is the most appropriate non-invasive investigation for cirrhosis, but this is only available through the tertiary hospitals, not usually the general radiologists. This is a specialised ultrasound that measures the speed at which the ultrasound wave passes through the liver to assess fibrosis. Other investigations that are relevant include general bloods, STD screen. Alpha fetoprotein is no longer routinely recommended unless there is a suspicion of hepatocellular carcinoma. Liver biopsy is also not usually performed and is not a requirement of treatment.

Type 1A has a 98% cure if there are mild liver abnormalities and a 96% cure if the condition is more advanced. It is treated by a combination of two medications taken as one tablet daily (ledipasvir and sofosbuvir). Type 1B has a greater success than 1A but requires ledipasvir and sofosbuvir combination or the use of ombitasvir, paritaprevir, ritonavir and dasabuvir. It is also important to vaccinate these patients for Hepatitis B and C if they are not immune already.

Treatment requires combination medication for a total of twelve weeks. After this time the Hepatitis C viral RNA PCR is repeated and should be negative; this is repeated at six months. It is thereafter unnecessary for further viral RNA PCR testing unless reinfection is suspected. It is important to note that the Hepatitis C antibody will always remain positive and this does not equate to active hepatitis C nor chronic infection if the PCR test is negative six months after treatment.

 

Thompson A, Holmes J. Treating hepatitis C – what’s new? Aust Prescr: 2015 Sep; 38: 191-718. DOI: 10.18773/austprescr.2015.068
https://www.nps.org.au/australian-prescriber/articles/treating-hepatitis-c-what-s-new