Treating Hep C with Novel Agents

Hepatitis C Background Hepatitis C is a viral infection spread mostly through blood to blood contact that affects the liver and can progress to cirrhosis and liver cancer. The infection may be asymptomatic for decades, leaving many unaware they are infected. 20% of patients will clear a hepatitis C infection on their own with no medical intervention.

Hepatitis C Incidence: 1.0 per 100,000 Prevalence: 3.5 million Who’s at risk? Injection drug users, including those who may have used drugs once many years ago. Infants born to HCV-infected mothers. People who had blood transfusions, blood products, or organ donations before June, 1992. Health care workers who suffer needle-stick accidents. How to screen Use an HCV antibody test to screen for past exposure and current infection. If ab+ follow up with HCV RNA test to confirm an active infection.

Common Novel Medications: (DAAs) Insurance Coverage: Mavyret is covered under Gold Coast Health Plan. Please check with the other payors for individual plan coverage. These are very effective oral medications that have significantly less side effects when compared to older interferon based treatments. Common Novel Medications: (DAAs)

Hep C Initial Visit First, order a Viral load if antibody positive. If Viral load present then proceed with labs and workup below. All of this information and more can be found at http://venturafamilymed.org/HepC Order the following labs (within 12 weeks of initiating treatment): Fibrotest Order via Quest Flexitest Name: FibroTest-ActiTest Panel CBC Test code: 92688 Coags 3.5 mL FROZEN CMP AFP HIV (within 30 days) Hep C Genotype Hep A/B antibody (within 30 days) or start Hepatitis Vaccination Within the last 6 months: Abd U/S or CT

Risk Assessment Tool (RAT) This tool will help you determine if you should treat the patient or refer them to GI. http://venturafamilymed.org/HepC/RAT

Hep C Treatment Visit Use DOT phrase at http://venturafamilymed.org/HepC There are 2 treatment regimens. Fibrosis score of 0-3 (non-cirrhotic): Mavyret x 8 Weeks. Fibrosis score of 4 w/ compensated cirrhosis (Child Pugh A): Mavyret x 12 weeks.

Labs and Follow up 8 Week Regimen 12 Week Regimen At week 4 of treatment: CBC, CMP, Viral Load, Coags At week 5 of treatment: PCP Visit At week 6 of treatment: Viral load only if no response at week 4 At week 8 of treatment: AST/ALT At week 9 of treatment: PCP Visit At week 20 of treatment: Viral load At week 21: PCP Visit At week 4 of treatment: CBC, CMP, Viral Load, Coags At week 5 of treatment: PCP Visit At week 6 of treatment: Viral load only if no response at week 4 At week 8 of treatment: AST/ALT At week 9 of treatment: PCP Visit At week 12 of treatment: Viral load At week 13: PCP Visit At week 24: Viral load At week 25: PCP Visit

Follow Up and Surveillance At 20 or 24 weeks (dependent on treatment regimen) post completion of therapy, order a viral load test to verify the patient has achieved a sustained virologic response (SVR). If viral load is undetectable, congratulations your patient is cleared of their hepatitis C infection.

Sample Patient 46 YOM with history of IVDU with GCHCP Viral Load: 816,000 IU/L HIV: Negative Hep B: Negative Previous Treatment: Yes, Interferon only Immune Modulating Medications: None Fibrosis Score: 2 Cirrhosis: Yes, compensated Child Pugh: A

RISK ASSESSMENT TOOL

Treatment Compensated Cirrhotic 12 weeks of Mavyret Rx sent to Caremark CVS utilizing a care manager Follow labs as outlined above Cured at 24 weeks with a SVR

Resources Everything you need to start can be found here: http://venturafamilymed.org/HepC Tipu V. Khan, MD, FAAFP Principal Investigator Faculty, Family Medicine Residency Program, Ventura County Medical Center Phone: (805) 652-5906 Pager: (805) 652-8021 Email: Tipu.Khan@ventura.org or TigerText Dr. Scott Underwood Medical Director, Specialty Care Services Email: Scott.Underwood@ventura.org