Progressive fibrosis may lead to debility and death from liver failure or cancer Advanced fibrosis (F3-4) means reduced response to Hepatitis C therapies Successful treatment of Hepatitis C infection will halt the progression of liver disease in these patients at high risk of symptomatic decompensation
Before the onset of advanced fibrosis Better response in early disease: F0-2 Treatment better tolerated if patient is healthier Fatigue and other symptoms Anemia No risk of decompensation from loss of functioning liver mass Best response to therapy: Younger age Less fibrosis Elevated ALT Female
Architectural description of the liver after long term injury and regeneration with replacement of functioning liver tissue by fibrosis. Is partially reversible if the noxious agent is removed and the liver is able to regenerate. Eventually leads to functional liver impairment.
History Alcohol excess Male sex Longer duration of infection (>20 years) Steatosis Physical exam Liver contour (enlarged left lobe, rounded, firm) Splenomegally, ascites, caput: portal HTN Spider angiomas, gynecomastia: estrogenic Jaundice Asterixis
Contraindications to treatment Pregnancy/contraception advice Auto-immune hepatitis Renal insufficiency Severe cardiopulmonary disease Uncontrolled affective disorder/psychosis Hepatocellular carcinoma Is there a history of liver decompensation? Potential drug interactions
Is there an opportunity for improvement? Alcohol/smoking cessation Other comorbidities to optimize? Diabetes, cardiac, pulmonary Relative contraindications to treatment Decompensated cirrhosis Ascites, encephalopathy, jaundice Albumin <35 Bilirubin >25 Platelets <75, 000 Anemia: Hg <130 male; <120 female
What about non medical factors? Housing Disability coverage/income replacement Drug coverage Preparing patient expectations for the experience on therapy
48 wks therapy for G1; 24 wks for G2/3 More likely to need medications tapered, more frequent measurement of hematology recommended. Less able to tolerate therapy: need closer follow up and reassessment Higher rate of drop out due to adverse effects, esp G1’s
Recent French report treating cirrhotics with triple therapy: 35-45%signficant adverse events (anemia, infection, renal failure, decompensation) 1% death from infection, bleeding 50% significant anemia and EPO use 5% significant neutropenia and thrombocytopenia Esp age>65, female, low initial Hg
Anticipate trouble! Identify the fragile cirrhotic: Thorough work up before treatment should identify those most at risk 4 week lead in may be illuminating…. How bad is a patient’s liver disease Compensated Previously decompensated: “Recompensated” Currently decompensated Abnormal liver functions: bilirubin, albumin, INR Abnormal hematology at baseline predicts cytopenias on therapy
Symptomatic decompensation Variceal bleeding, ascites, encephalopathy Treatment of symptoms Is there an identifiable precipitant? Alcohol, new medication, infection Does therapy need to be stopped? Infection Low threshold for antibiotic use with bacterial infection; patient are immune compromised Respiratory, urinary, skin
Treatment related issues Cytopenias: dose reductions; growth factors Symptoms: Fatigue, mucositis Other organ systems: cardiac, skin rash, diarrhea
54 yr old man; G1a, start Pegasys Sept 2010 Cirrhosis: ex-IVDU/Alcohol; compensated 2007 Thoracic aortic aneurysm repair 2009 Aortic valve endocarditis Baseline: WBC 3.8/Hg121/plt 68 INR 1.1, ALT 94, alb 40, bili 25 IFN 1000 mg/ IFN 180 mcg Week 5 Hg 95, plt 30 Hold riba a week, restart at 600
Week 12 Hg 80-95, plt 30-40; fatigue – off work Riba 400-600, IFN 2/3 – PCR 2 log drop Week 26 Riba stopped, had been interrupted and dose reduced IFN 2/3 dose Week 24 PCR negative Week 30 ascites, increased fatigue, 25 lb wt loss then 12 lb gain Stop all Rx
PCR negative at wk 30 = end treatment PCR relapsed 12 weeks later Ascites slow to resolve; issues with congestive failure and required urgent aortic valve replacement May 2011 Now wants to be retreated!