Presentation on theme: "Hepatitis C Treatment in Corrections: New Medicine, New Challenges"— Presentation transcript:
1 Hepatitis C Treatment in Corrections: New Medicine, New Challenges Spencer Epps, MD, MBA,Medical DirectorDelaware Department of CorrectionJames Welch, RN, HNB-BCChief, Bureau of Healthcare ServicesDelaware Department of Correction
2 Objectives Discuss Hep C Infection & Current Treatment Describe Hep C Treatment in CorrectionsExplain New Medications for Hep COutline Challenges Presented by New MedicationsPropose Strategies to Address these Challenges
3 Hepatitis CHepatitis C (HCV) is a flavivirus related to Yellow Fever and West Nile VirusMost common chronic bloodborne infection in the USContagious liver disease causing mild illness to serious, lifelong illness or death
4 Hep C Transmission Spread by blood to blood contact: IV drug useMother to child transmissionCan be sexually transmitted but less commonSince 1992, screening has limited spread through transfusions and transplantsFor most, acute infection leads to chronic infectionThere is no vaccine for Hepatitis C
6 Hep C Statistics 3.2 million persons chronically infected 1.8% prevalence in the free worldOf every 100 people with Hep C75–85 people will develop chronic Hepatitis C infection60–70 people will go on to develop chronic liver disease5–20 people will go on to develop cirrhosis over 20–30 years1–5 people will die from cirrhosis or liver cancer8000 to 10,000 deaths each year in USMajority unaware of infection- not clinically illHepatitis C. Centers for Disease Control & Prevention, 2011.
8 Hepatitis C. Centers for Disease Control & Prevention, 2011.
9 Hepatitis C Progression Fibrosis & Disease Progression in Hepatitis C. Marcellin, et al. Hepatology, 2002
10 Hepatitis C Progression Mechanisms associated with progression of fibrosis are poorly understoodRate of progression variable but slow in generalOlder age, male gender, excessive alcohol consumption, overweight, and immune deficiency associated with more rapid progressionAlcohol consumption controlled in correctional environmentTreatment of overweight & HIV is criticalFibrosis & Disease Progression in Hepatitis C. Marcellin, et al. Hepatology, 2002
11 Hepatitis C. Centers for Disease Control & Prevention, 2011.
12 Hepatitis C TrendsMost patients infected years ago before virus identification and screeningIncidence decreasing but number of patients developing cirrhosis, cancer & end stage liver disease increasing (peak 2020 to 2030)Total cost of care for untreated Hep C will continue to increase over next 20 yearsConsensus on when and how Hep C will be treated in Corrections is needed now
13 Current Hepatitis C Treatment PEG-InterferonIncreases expression of proteins that interfere with Hep C viral replicationRibavirinEnhances the antiviral effect of interferonPrecise mechanism of action uncertainTreatment lasts for one year; if successful, induces cure
14 Hepatitis Treatment and Management. Mukherjee, et al Hepatitis Treatment and Management. Mukherjee, et al. Medscape Reference, 2011
15 Side Effects Current Hep C Treatment INTERFERON - Hematologic complications (i.e., neutropenia, thrombocytopenia), neuropsychiatric complications (i.e., memory and concentration disturbances, visual disturbances, headaches, depression, irritability), flulike symptoms, metabolic complications (i.e., hypothyroidism, hyperthyroidism, low-grade fever), gastrointestinal complications (i.e., nausea, vomiting, weight loss), dermatologic complications (i.e., alopecia), and pulmonary complications (i.e., interstitial fibrosis)RIBAVIRIN - Hematologic complications (i.e., hemolytic anemia), reproductive complications (i.e., birth defects), and metabolic complications (i.e., gout)
16 New Hepatitis C Treatment FDA recently approved two new protease inhibitors for treatment of Hep CBoceprevirTelaprevirAre added to, do not replace, original therapyIndications:treatment of chronic Hep C genotype 1with compensated liver disease, including cirrhosispreviously untreated or who have failed previous interferon and ribavirin therapy.
17 New Hepatitis C Treatment In previously untreated patients, 79% of those receiving telaprevir experienced a sustained virologic response (SVR) compared with less than 50% with peginterferon alfa and ribavirin treatment alone.Cure rate for patients treated with telaprevir across all studies, and across all patient groups, was between 20-45% higher than current regimen.Course of treatment decreased from 48 weeks to 24 weeks.US Food and Drug Administration (FDA). FDA approves Incivek for hepatitis C. May 23, 2011.
18 Challenges of New Treatment Cannot be given alone or resistance will developSame side effects plus additional side effectsAnemiaNeutropeniaThrombocytopeniaSevere RashLogistical Challenges in the correctional environment:Must be given at same time every dayMust be given with fatty food (e.g., ice cream)
19 Cost of New TreatmentBoth boceprevir and telaprevir are priced for cure$45,000 to $75,000 per patientPrevalence of Hep C higher in correctional patient populationIn Delaware, 800/7000 patients with Hep CTreatment of entire population with new regimen would cost up to $60,000,000.Entire healthcare budget = $55,000,000.
20 Strategies for Hep C Treatment The Federal Bureau of Prisons uses the following criteria for limiting Hep C treatmentPEG-interferon contraindicatedIncarceration period insufficient for treatmentInmate has unstable medical or mental health conditionPatient refuses treatment
21 Strategies for Hep C Treatment Monitoring early stages of Hep C rather than treatment acceptable and occurs in free worldTreatment based on progression:Liver function testsLiver biopsyOther factors: age, co-infection with HIV, etc.Monitor patients with earlier stages of fibrosis & sentences under 5 years & coordinate with community providers for potential treatment
22 Consensus on Use of New Medications If fibrosis progression indicates treatment, patients are tried on current therapy firstIf therapy found to be futile at 12 weeks, patients are tried on new medical regimen, provided there are no contraindicationsAs with current practice, patients should be involved in the decision to treat whether using old or new regimen
23 Conclusion Discussed Hep C Infection & Current Treatment Described Hep C Treatment in CorrectionsExplained New Medications for Hep COutlined Challenges Presented by New MedicationsProposed Strategies to Address these Challenges
25 Hepatitis C Treatment in Corrections: New Medicine, New Challenges Spencer Epps, MD, MBA,Medical DirectorDelaware Department of CorrectionJames Welch, RNChief, Bureau of Healthcare ServicesDelaware Department of Correction