1. The changing landscape of hepatitis infection
Michael E. Herman D.O.

2. What’s New? For Primary Care Providers For HCV Treaters For everyone
Importance of diagnosing HCV
For HCV Treaters
How can we improve current therapies?
For everyone
What’s in the horizon

3. Hepatitis C Infection is CURABLE!
We can cure the majority of treated patients
75% of infected individuals have not been diagnosed
Largely asymptomatic in first 2-4 decades
Most diagnosed patients have not been treated (~75% - 80%)
Toxicity of current medications

4. Who is Infected? Moorman AC, et al. JCI 2013;56:40-50
Pyenson B, et al. Milliman Inc, 2009

5. Who Cares? Most common indication for liver transplantation
33% undiagnosed baby-boomers have advanced fibrosis/cirrhosis
Most common indication for liver transplantation
Accounts for ½ of the 3-fold increase in hepatocellular carcinoma
McGarry LJ, et al. Hepatology 2012;55:
Davis G, et al. Gastroenterology. 2010;138(2):

6. USPSTF* Birth Cohort Screening Recommendations
One-time screening of ALL adults born between
Screening of people at high risk including:
Intranasal drug use
Current or past IVDU
Born to a mother with HCV
Incarceration
Getting an unregulated tattoo
*US Preventive Services Task Force
Moyer VA and USPSTF. Ann Intern Med 2013

7. Public Awareness Campaign

8. Benefits of Diagnosis Risk for progression, need for monitoring
Lifestyle modifications
Alcohol abstinence
Risk to others
Opportunity for treatment
Possible cure
Modification of natural history of the disease

9. HCV Cure Improves Prognosis
International study, n=530, median age 48, HCV with advanced fibrosis
SVR = cure
Van der Meer AJ, et al. JAMA 2012;308:

10. HCV Therapy Saves Lives
VA Study, n=16,864, all genotypes, all stages.
Backus LI et al. Clin Gastroenterolo Hepatol 2011;9:

11. You Can Make a Difference!
Screen and diagnose HCV infection

12. What can we offer today? “Triple Therapy” Telaprevir or Boceprevir
Pegylated interferon
Ribavirin
1st Generation protease inhibitor
Telaprevir or
Boceprevir

13. What can we offer today? PEG + ribavirin + sofosbuvir
Genotypes 1, 4, 5 & 6, naïve
Non responders ???
12 weeks, weeks??
Interferon free sofosbuvir + ribavirin
Genotypes 2 & 3
PEG + ribavirin + simeprevir
Genotype 1, naïve and non-responders
24/48 weeks response guided therapy

14. Interferon-free Regimens
96-97% SVR
Harvoni (ledipasvir (NS5A inhibitor) / sofosbuvir (nucleotide analog NS5B polymerase inhibitor) or Viekira Pak (protease inhibitor ABT-450, a 100 mg boosting dose of ritonavir, and the NS5A inhibitor ombitasvir) for treatment.

15. Predicting the Future

16. Many Unknowns Remain….. Cost? Regimen approved? Payor “interference”
4, 6, 8, 12, 16, 24 weeks?
Payor “interference”
Step up therapy?
Restricted access?
Excessive copays?
Ability to mix and match?

17. How Long Are You Going to Wait?
There will always be something better coming down the pipeline….

18. Take Home Points HCV Therapy has “taken off”
We can cure most patients if
They are diagnosed
They can afford and tolerate the drugs
Research is advancing rapidly