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Treatment of HCV in Cirrhotic Patient Mark Thursz.

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Presentation on theme: "Treatment of HCV in Cirrhotic Patient Mark Thursz."— Presentation transcript:

1 Treatment of HCV in Cirrhotic Patient Mark Thursz

2 Mrs LG - Presentation 48 year old Latvian woman HCV diagnosed 2007 – symptoms of fatigue Source of HCV unknown No alcohol No current medications No significant past medical history

3 Examination Generally well Palmar erythema and spider naevi 4cm hepatomegaly No splenomegaly No ascites No oedema No encephalopathy

4 Initial investigations Hb – 12.2 WBC – 4.5 (Neutrophil 1.2) Platelets – 75 AFP – 18.3 INR – 1.4 Albumin – 32 ALT – 73 Bilirubin 18 HCV RNA – 1,230,000 iu/ml HCV Gt 1

5 Ultrasound Irregular liver margin Portal vein patent, diameter 17mm No focal lesion Spleen – 17.5 cm

6 Biopsy or not?

7 Fibroscan 38.5 kPa

8 OGD Small varices Propranolol 40mg tds Not tolerated Carvidolol 25 mg od

9 Summary 48 year old woman HCV cirrhosis (Child-Pugh A) Portal hypertension Low platelets and neutrophils Treat now?

10 Treatment Pegylated interferon  2a 180 ug o.w. Ribavirin 600 mg b.d

11 Progress

12 Case Review 49 year old woman HCV Gt 1 Relapse Responder Portal hypertension Low platelets Low neutrophils Options Triple therapy Await transplantation

13 Option 2 Telaprevir Pegasys Ribavirin SinusitisTransfusion

14 Follow-up USS every 6 Months ? Biopsy in 5 years

15 Issues Prognosis with decompensated cirrhosis – HCV Impact of intervention with HCV Potential drawbacks of HCV treatment Benefits of treatment before transplant

16 Progression of Disease in HCV 7.7% 6.3% 8.1 – 54.5% 9.9 – 20% 3.7% Alazawi. APT %

17 Survival in Decompensated HCV Cirrhosis Fattovich Gastro yr Survival - 50%

18 Issues Prognosis with decompensated cirrhosis Impact of intervention with HCV Potential drawbacks of HCV treatment Benefits of treatment before transplant

19 Treatment of HCV Cirrhosis Prevents Decompensation Bruno Hepatology 2007

20 Treatment of HCV Cirrhosis Reduces the Risk of HCC Bruno Hepatology 2007

21 HCV Decompensated Cirrhosis Trials StudyDesignExclusionsNoDiscontinueSVR Crippin 2002 RCTCytopaenias Renal impairment 15100%0% Thomas 2003 Prospective observational Cytopaenias20060% Forns 2003 Prospective observational Cytopaenias Renal impairment Encephalopathy 3020%30% EversonProspective observational Ascites Renal impairment Non-responders 12413%GT1 – 13% GT2/3 – 46% Iacobellis 2007 Prospective controlled Rapid deterioration6620%GT1/4 – 7% GT3/4 44% Iacobellis 2009 Prospective observational Rapid deterioration Renal impairment 9419%GT1/4 – 16% GT3/4 57%

22 Treatment of Decompensated HCV Cirrhosis Everson Hepatology 2005

23 Virological Outcomes According to Child’s Pugh Grade ABC EOTR Gt 135%28%21% EOTR Gt non-175%77%52% SVR Gt113%16%7% SVR Gt non-156%38%56% Everson Hepatology 2005

24 Issues Prognosis with decompensated cirrhosis Impact of intervention with HBV Potential drawbacks of HBV treatment Impact of intervention with HCV Potential drawbacks of HCV treatment Benefits of treatment before transplant

25 Adverse Events in HCV Treatment Groups Adverse effect / Treatment discontinuation Non-CirrhoticsCompensated Cirrhotics Decompensated Cirrhotics Fatigue55%34%59% Headache50%54%45% Impaired concentration 17%6%2% Infection2%0%4% Anaemia15%35%50% Neutropaenia6%38%53% Thrombocytopaeni a 17%24%50% Dose reductions27%30%42% Discontinuation13%12%20%

26 Issues Prognosis with decompensated cirrhosis Impact of intervention with HCV Potential drawbacks of HCV treatment Benefits of treatment before transplant

27 Everson Hepatology 2005 Reinfection post transplant

28 Gane NEJM 1996 Outcome of HCV Post-Transplant

29 Summary Decompensated viral-cirrhosis has a poor prognosis In HBV infection decompensation can be reversed with minimal side effects In HCV infection treatment is challenging but the rewards are worth the effort Decompensated cirrhotics cannot wait for IFN-free regimens Eliminating HCV prior to transplantation will improve the prognosis

30 HCV Therapy Post-Transplant Vezali Clinical Therapeutics 2010


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