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Hepatitis C Case Presentations “One & Done” Arriving But Which One? Alan Glombicki, MD October 12, 2013.

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Presentation on theme: "Hepatitis C Case Presentations “One & Done” Arriving But Which One? Alan Glombicki, MD October 12, 2013."— Presentation transcript:

1 Hepatitis C Case Presentations “One & Done” Arriving But Which One? Alan Glombicki, MD October 12, 2013

2 Disclaimer for General Counsel No patients were harmed in the fabrication of these treatment scenarios Napoleon reminds us that: “History is a myth agreed upon”, therefore no affirmative claims of veracity are implied or explicit The photos are real, as are the construed clinical dilemmas, only the embarrassment is muted to protect the “not so innocent”

3 38 year old Hispanic American man referred with chronic hepatitis C Diagnosed 2 months ago after complaints of fatigue and discovery of abnormal liver enzymes Treatment naïve Traumatic chronic arthritis BMI 29 Biopsy showed grade 2 inflammation and stage 3 fibrosis. Lab values ALT: 89 AST: 94 Total bilirubin: 0.8 Albumin: 4.1 INR: 0.9 WBC: 5.1 Hgb: 13.0 Platelets: 201k Anti-HCV Ab: Positive HCV RNA: 1.5 million IU/mL Genotype: 1a Case # 1 - HCV What treatment would you recommend?

4 A. Peg-IFN/RBV for 48 weeks B. Peg-IFN/RBV for 72 weeks (standard dose) plus baseball bat supplied by MLB Commissioner, Bud Selig & NY fans C. Duration of therapy to be determined by response at week 4 or 12 D. PEG-IFN, RBV, DAA (Boceprevir or Telaprevir) Response guided E. No treatment at this time / Await future therapies 15

5 Treatment initiated with PEG-IFN, RBV, & DAA At week # 12 of triple therapy, he remains virus positive, with a 2.5 log IU drop in HCV RNA Tolerating therapy with few side effects (Seriously?, inquire about self- medication with “clear vitamins”) Case # 1 How would you proceed?

6 A. Complete Peg-IFN/RBV with a goal of 48 weeks (as long as virus negative by week # 24) B. Complete Peg-IFN/RBV/DAA with a goal of 24 weeks triple (as long as virus negative by week # 24) C. Add/exchange newest 12/2013 oral possible agents (if FDA is not still disabled by government shut down in December) D. DAA Mutation analysis using line probe assay 30

7 20 year old Caucasian woman/ girl? referred with a diagnosis of chronic hepatitis C, genotype 1a Past year received numerous tattoos Overprotective father Billy Ray is also infected Found to have many close Facebook followers hitting the “like this” button after the VMA Cat Show There were no prior antiviral treatments (the one time Niave seems less pejorative) She has manic depression which she reports was managed with an antidepressant & plethora of natural herbs only legal in Colorado & Washington (state, not DC so…….…no excuse for equally erratic Congress!) Unlike many of her friends, she is afraid of needles You perform a liver biopsy which reveals grade 2 inflammation and stage 2 fibrosis Case # 2 - HCV Lab values ALT: 60 AST: 45 Total bilirubin: 0.6 Albumin: 3.9 INR: 1.0 WBC: 8.4 Hgb: 12.3 Platelets: 320k HCV RNA: 3,200 IU/mL Genotype: 1a What treatment would you recommend?

8 A. Trial of PEG-IFN, RBV DAA for 48 weeks. B. PEG-IFN, RBV with DAA response guided therapy C. Strict Detox prior to any Rx. D. Silimarin (Silly Mare (all) In) Homeopathy +/- Noni Juice E. No treatment at this time. Await future therapies. 30

9 ALT: 107 AST: 99 Total bilirubin: 2.4 Albumin: 3.1 INR: 0.9 WBC: 4.8 Transvestite on a stable HAART regimen found to be co-infected with HCV Resident of SuperMax Fort Leavenworth, where needles are discouraged Abandoned original name Bradley so not to be confused with the Bradley Fighting Vehicle namesake, adopted new name Chelesea in honor of the Clintons’ only known daughter. Given below labs, what would you do? Case # 3 Hgb: 13.0 Platelets: 157k Anti-HCV Ab: Positive HCV RNA: 1.5mil IU/mL Genotype: 1a

10 How would you proceed? A. Start Peg-IFN/RBV/off label DAA with a goal of 48 weeks (as long as virus negative by week # 24) B. Continue Peg-IFN/RBV with a goal of 72 weeks (as long as virus negative by week # 24) C. Non-invasive fibrosis staging using Fibroscan Ultrasound Elastography D. MRE Magnetic Resonance Elastography E. Serologic Fibrosis Assay 30

11 42 year old Australian man referred with a diagnosis of chronic hepatitis C, genotype 1b Treated last year with PEG-IFN/RBV for a total of 48 weeks Cleared virus by week #14 and remained negative at the end of treatment Found to have relapsed 7 months after completion of therapy There were many treatment interruptions and dose reductions Compliance was in part hindered by frequent embassy relocation seeking asylum You perform a liver biopsy which reveals grade 2 inflammation and stage 2 fibrosis Case # 4 - HCV Lab values ALT: 60 AST: 45 Total bilirubin: 0.6 Albumin: 3.9 INR: 1.0 WBC: 8.4 Hgb: 10.3 Platelets: 32k HCV RNA: 3,200 IU/mL Genotype: 1a What treatment would you recommend?

12 A. Repeat another PEG-IFN with RBV for 48 weeks with Promacta / Procrit B. Consensus interferon with Ribavirin C. PEG-IFN with RBV for 72 weeks. D. Maintenance treatment with half dose PEG-IFN. E. No treatment at this time. Await future therapies. 10

13 31 year old Viet -Singaporean- American Houston raised MTV star stage-named after Mexican liquor referred with CAH-C Diagnosed after complaints of fatigue and discovery of abnormal LFT in rehab Treatment naïve Fibromyalgia Opiate-controlled BMI 16 Biopsy showed grade 2 inflammation and stage 3 fibrosis. Lab values ALT: 129 AST: 94 Total bilirubin: 0.8 Albumin: 4.1 INR: 0.9 WBC: 7.1 Hgb: 12.9 Platelets: 231k Anti-HCV Ab: Positive HCV RNA: 2.3 million IU/mL Genotype: 6 Case # 5 - HCV What treatment would you recommend?

14 A. Peg-IFN/RBV for 48 weeks (standard dose) B. Peg-IFN/RBV for 72 weeks (standard dose) C. Duration of therapy to be determined by response at week 4 or 12 D. Pre-treatment clearance by Dr. Sanjay Gupta/Dr. Conrad Murray E. No treatment at this time / Await future therapies 15

15 43 year old Child Literature Celebrity noted to have hyper-bilirubinemia and subjective jaundice incidentally diagnosed with CAH-C, Nome de Plume: Grant Oiseau Marfans Syndrome body habitus with Chronic laryngitis following Asian travel Treatment naïve, but balked on an offer to enter all oral antiviral protocol fearing biochemical side effects Biopsy showed grade 3 inflammation and stage 3 fibrosis, no ductal proliferation MRCP suggests unremarkable ductular systems. Lab values ALT: 129 AST: 94 Total bilirubin: 2.9 Albumin: 4.1 INR: 0.9 WBC: 7.1 Hgb: 12.9 Platelets: 231k Anti-HCV Ab: Positive HCV RNA: 2.3 million IU/mL Genotype: 1b Case # 6 - HCV What treatment would you recommend?

16 A. Peg-IFN/RBV for 48 weeks (standard dose) B. Advise the patient about reversibility of transport hyper- bilirubinemia & benign natural history of Gilberts C. UN-WHO Protocol usage of Alinia (Nitazoxanide) for avian flu & HCV Active per Egyptian Abstract D. No treatment at this time / Await future therapies 15


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