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DECISION-MAKING IN HCV
HEPATITIS C – Testing
STEP 1 Could it be hepatitis C?
STEP 2 Review results
STEP 3 Check Hep C PCR
STEP 4 Follow up and referral
Hep C Ab -ve
LFT normal
Abnormal liver function test (LFT)
(means hepatitis C
unlikely, PCR
if recent (possible not needed)
Presence of risk factors
Hep C Ab -ve
• Injecting drug use PCR –ve
• Sharing of snorting equipment Hep C antibody (Ab) means hepatitis C unlikely • Birth in high prevalence countries Hep C Ab -ve
• Blood transfusions and blood LFT abnormal
products before 1990 in Australia or possible
• Unsterile tattooing and body piercing acute hepatitis C
Hep C Ab -ve
• Unsterile medical and dental procedures Refer ALL PCR +ve
and blood transfusions in high means acute hep C prevalence countries • Time in prison Hep C Ab +ve
• Needle stick injuries Step 5 Further assessment
• Mother to child transmission is around 5% means chronic hepatitis C • Household transmission is very rare (chronic if > 6 months) • Sexual transmission is rare but can occur in Hep C Ab +ve
certain populations, such as men who have acute hepatitis, sex with men (MSM) or those who are Human Hep C polymerase Hep C Ab +ve
Immunodeficiency Virus (HIV) positive. chain reaction (PCR)* plus repeated PCR –ve
(to detect HCV RNA) means cleared hepatitis C if on-going risk Jaundice or acute hepatitis
Convey test result
If positive, results should always be provided in person and explain: Gain informed consent in a culturally appropriate manner
• Natural history • Modes of transmission and risk reduction • Reason for test • Availability of treatment • Need for ongoing, potentially lifelong monitoring • Meaning of a positive antibody test • Life style factors e.g. alcohol minimisation, diet * Check Medicare schedule rebates • Availability of treatment if HCV PCR positive • Availability of peer support services, information and support services for hepatitis C PCR testing • Mechanism for communicating test results • Refer to Hepatitis Australia National Infoline 1300 437 222 For further details on testing, see the National HCV Testing Policy 2012, available at http://testingportal.ashm.org.au/hcv
DECISION-MAKING IN HCV
HEPATITIS C – Fur
ther assessment, advice and referral STEP 5 Further assessment
STEP 6 Monitoring and lifestyle issues
STEP 7 Treatment assessment and referral
Baseline screening to exclude other
Regular monitoring if no active treatment:
Contraindications to current treatment
conditions that may influence treatment: • FBC and LFT every 6 months Address possible contraindications to therapy with pegylated interferon and ribavirin: • Full Blood Count (FBC) • Consider referral for annual Fibroscan as • Decompensated cirrhosis - refer to specialist • Electrolytes, urea, creatinine part of specialist review • Alcohol abuse • Coagulation studies • Provide information about current • Unstable social/accommodation/work situation • Fasting blood sugar level and lipids treatment options • Major untreated psychiatric illness • Thyroid function tests • Refer if ready for treatment • Autoimmune disease • Liver ultrasound • Major concurrent medical disease • Pregnant or unwilling to comply with adequate contraception Evaluate risk factors for liver
Detect other causes of liver disease:
Note: injecting drug use does not exclude people from treatment, but unstable injecting drug use is a contraindication disease progression:
• Hepatitis A – check hep A IgG, • Heavy alcohol intake vaccinate if -ve Specialist referral:
(> 4 standard drinks per day) • Hepatitis B – check anti-HBs, • Patients ready for treatment anti-HBc, HBsAg, vaccinate if all -ve • Long duration of infection • Signs of advanced liver disease / cirrhosis (>20 years since exposure) • Other liver disease needing assessment • Iron studies (haemochromatosis) • Older age at infection • Complex patients • Autoimmune screen • Coinfection with HIV or HBV • Major adverse events of therapy • Alpha–1 – antitrypsin (deficiency) • Obesity/insulin resistance/diabetes • Assessment of liver fibrosis by Fibroscan or biopsy • Copper, caeruloplasmin • Elevated ALT Support before and during treatment
(Wilson's disease) • Referral to nurse, social worker, psychologist, dietician, peer support worker as needed Note: patients with risk factors have an • Drug and alcohol counseling and treatment Detect possible cirrhosis
increased risk of disease progression and • Consider shared care during treatment Symptoms: jaundice, encephalopathy, need specialist assessment.
bleeding varices Hepatitis C treatment, response and duration
Signs: ascites, spider naevi, palmar Genotype 1
Genotypes 2 / 3
Genotype 4
Provide lifestyle advice to reduce
erythema, oedema BOC + PEG IFN + RBV TPV + PEG IFN + RBV PEG IFN + RBV PEG IFN + RBV liver disease progression:
Duration of therapy Lead in period:
No lead-in period Investigations: aspartate 4 wks PEG IFN/RBV (if no cirrhosis) • Minimal alcohol aminotransferase (AST) > alanine Then PEG IFN/RBV 12 wks PEG IFN/RBV + TVR • Healthy weight transaminase (ALT), prolonged + BOC for 24 - 44 weeks Then 12-36 weeks prothrombin time (PT),  bilirubin, • Minimal cannabis  platelets,  albumin Treatment naïve Hepatocellular carcinoma (HCC) screening
Previously treated Determine hepatitis C genotype
For all those with cirrhosis: 6 monthly and quantitative PCR (viral load)
– Partial responder upper abdominal ultrasound and – Null responder Influences length of treatment and alpha-foetoprotein (AFP) PEG IFN = Pegylated Interferon, RBV= Ribavirin, BOC= Boceprevir, TVR =Telaprevir response to treatment Sustained Virological Response (SVR) is considered a cure (-ve HCV RNA six months after completion of therapy) *from Product Information for Genotype 1 Additional copies and electronic version available at: http://www.ashm.org.au/publications
FUNDED BY THE
Department of Health and Ageing*
ASHM 2013. Produced March 2013
* Disclaimer: Whilst the Australian Department of Health and Ageing provides financial assistance to ASHM, the material contained in this resource produced by ASHM should not be ISBN: 978-1-920773-17-5 taken to represent the views of the Australian Department of Health and Ageing. The content of this resource is the sole responsibility of ASHM.

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