HEPATITIS 2014 BC

CHRONIC HEPATITIS B THE PROBLEM 350,000,000 PEOPLE HAVE IT IT IS TRANSMITTED MOTHER TO CHILD WHERE IT IS ENDEMIC IT CAN BE TRANSMITTED VIA BODY FLUIDS IT OFTEN PROGRESSES TO CIRRHOSIS IT CAUSES HEPATOCELLULAR CARCINOMA

CHRONIC HEPATITIS B VIRAL PHASE VIRAL LOADHISTOLOGY IMMUNE TOLERANT VERY HIGHNORMAL IMMUNE ACTIVE LOW ACTIVE HEPATITIS IMMUNE INACTIVE VERY LOW MILD OR INACTIVE IMMUNE CLEARANCE NONENORMAL

CHRONIC HEPATITIS B THE PROBLEM IT IS QUICKLY TRANSMITTED TO THE INFANT OF AN INFECTED MOTHER IT CAN BE REACTIVATED EVEN WHEN APPARENTLY “CLEARED” BY CHEMOTX OR PERHAPS TNF INHIBITORS

CHRONIC HEP B WHO TO TX? ALL PATIENTS WITH CIRRHOSIS AND DETECTABLE VIRUS ALL PATIENTS WITH IMMUNE ACTIVE PHASE DISEASE ASYMPTOMATIC PREGNANT WOMEN WHO HAVE > 1,000,000 COPIES/ML BEGINNING IN THE THIRD TRIMESTER PATIENTS WITH DETECTABLE HBsAg ABOUT TO UNDERGO IMMUNOSUPPRESSION

CHRONIC HEPATITIS B WHAT TO USE? ENTECAVIR TENOFOVIR TELBIVUDINE LAMIVUDINE

HEPATITIS C NOW A DISEASE FOR PRIMARY CARE THERAPY

THE SHORT VERSION ONE OR TWO SIDE-EFFECT- FREE PILLS DAILY FOR 3 TO 6 MONTHS CURES >90% OF PEOPLE WITH CHRONIC HEPATITIS C

HEPATITIS C-THE PROBLEM 3.8 MILLION AMERICANS HAVE IT 170 MILLION PEOPLE WORLDWIDE HAVE IT IT PROGRESSES TO CIRRHOSIS IN AT LEAST 25% IT CAUSES HEPATOCELLULAR CARCINOMA WE CAN’T PREDICT WHO WILL PROGRESS

HEPATITIS C-THE PROBLEM- EXTRAHEPATIC MANIFESTATIONS ARTHRITISVASCULITISCRYOIMMUNOGLOBULINEMIA RENAL DISEASE INSULIN RESISTANCE AND TYPE II DIABETES MELLITUS LYMPHOMATHYROIDITIS LICHEN PLANUS ETC

HEPATITIS C-THE PAST TREATMENT WAS DIFFICULT AND OFTEN INEFFECTIVE IT REQUIRED CLOSE MONITORING AND A CLEAR WORKING KNOWLEDGE OF THE NUANCES OF THE MEDICATIONS USED SIDE EFFECTS WERE UNIVERSAL AND OFTEN TERRIBLE PATIENTS HAD FREQUENT PHYSICIAN VISITS OVER 6 TO 12 MONTHS MOST PATIENTS UNDERGOING TREATMENT HAD TO MISS SOME WORK AND OFTEN COULD NOT WORK AT ALL WE COULDN’T TREAT THE SICKEST PATIENTS

HEPATITIS C-THE PAST WE EMPLOYED VERY SELECTIVE CRITERIA FOR TREATMENT: ILLNESS FROM THE INFECTION--RARE UNTIL CIRRHOSIS ENSUED, WHEN TREATMENTS WERE LESS EFFECTIVE HISTOLOGIC EVIDENCE SUGGESTING PROGRESSIVE FIBROSIS NOT TOO SICK TO TREAT

HEPATITIS C THE PAST THE BEST RECENT TREATMENT WAS EFFECTIVE IN ABOUT: 1/2 OF GENOTYPE 1b 2/3 OF GENOTYPE 1a 3/4 OF GENOTYPE 2 AND 3 EXCEPT IF YOU WERE OF MAINLY SUBSAHARAN AFRICAN ORIGIN THEN IT WAS < 1/2 THE ABOVE

HEPATITIS C THE PAST THE TREATMENT WAS EXPENSIVE $25,000-$30,000 WITH PEGI/RIBA >$80,OOO IF YOU ADDED TELAPREVIR OR BOCEPREVIR YOU LOST WORK USUALLY TOO

HEPATITIS C THE FUTURE NUMEROUS MEDS ARE COMING THEY WILL ATTACK THE VIRUS AT DIFFERENT SITES THEY HAVE MINIMAL SIDE EFFECTS TREATMENT WILL BE WEEKS FOR MOST PATIENTS

HEPATITIS C THE FUTURE THE MEDS WILL BE GIVEN IN TWO DRUG COMBINATIONS FOR MOST NO RIBAVIRIN WILL BE NEEDED WHEN AND IN WHAT COMBINATIONS WILL BE DETERMINED BY THE FDA

SO HOW GOOD ARE THE NEW TREATMENTS? VERY, VERY GOOD

CLASSDRUGSMECHANISM NS3/NS4/NS5B PROTEASE INHIBITORS SIMEPREVIR* FALDAPREVIR ASUNAPREVIR VIRAL SERINE PROTEASE INHIBITOR NS5A INHIBITOR DACLATASVIR LEDIPASVIR REGULATOR OF RNA POLYMERASE AND INTERFERON RESPONSE INHIBITOR NS5B INHIBITOR SOFOSBUVIR* SETROBUVIR FILBUVIR VIRAL RNA POLYMERASE INHIBITOR * AVAILABLE NOW

SOFOSBUVIR AND DACLATASVIR FOR 24 WEEKS GENOTYPE 1a/1b TX NAIVE SVR 100% GENOTYPE 1a/1b TX FAILURE SVR 100% GENOTYPE 2/3 TX NAIVE SVR 100% THESE WERE ALL NON CIRRHOTIC

SOFOSBUVIR, LEDIPASVIR, RIBAVIRIN IN GENOTYPE 1a AND 1b TREATMENTSVR RESULTS NAIVE S+L X 8 WKS 95% NAIVE S+L+R X 8 WKS 100% NAIVE S+L X 12 WKS 95% TX FAILURE S+L X 12 WKS 95%* TX FAILURE S+L+R X 12 WKS 100%* *40% HAD CIRRHOSIS

HEPATITIS C THE FUTURE SOME RESULTS WILL VARY GENOTYPE 3 WILL BE SLOWEST TO TX CIRRHOTICS WILL LIKELY HAVE SLOWER RESPONSES BUT LIKELY JUST NEED LONGER TX VIRAL RESISTANCE CAN OCCUR WE KNOW LITTLE ABOUT NON 1,2,3 GENOTYPES

HEPATITIS C THE FUTURE COST: $160,000! TIME INVOLVED IN GETTING THE DRUG IS 2 HOURS BRIGHT GETTING BRIGHTER

HEPATITIS C THE FUTURE CURRENTLY THE DRUG COMPANIES ARE VERY, VERY HELPFUL AT GETTING A GOOD DEAL FOR THE PATIENTS

WHO SHOULD THE NON HEPATOLOGIST/GASTROENTEROLOGIST REFER? CIRRHOTICS ANYONE YOU ARE NOT COMFORTABLE TREATING TREATMENT FAILURES ANYONE NEEDING TREATMENT UNTIL THESE NEW AGENTS AND COMBINATIONS ARE READY ANYONE WHO NEEDS A COLONOSCOPY--JUST KIDDING

HEPATITIS C THE FUTURE WHEN WILL THE DRUGS BE HERE THEY’RE HERE NOW--BUT ARE NOT APPROVED BY THE FDA IN COMBINATION SO INSURANCE WON’T BUY THEM MORE WILL COME LATER THIS YEAR AND FOR THE NEXT FEW YEARS

HEPATITIS C SUMMARY HEPATITIS C SUMMARY IT IS A COMMON DISEASE, WATCH FOR IT IT IS A CAUSE OF REMARKABLE MORBIDITY AND MORTALITY IT CAN BE CURED YOU CAN CURE IT IF WE CAN PAY FOR IT IF YOU HAVE THE TIME TO PRESCRIBE THE MEDS