1. Hepatitis C (and Aging) Martine Stomp RN Hepatitis C Treatment Nurse Sanguen Health Centre

3. Hepatitis C: History 1940’s –Occurrence of hepatitis after transfusion of prison-sourced blood. 1950’s –Named “non-A non-B”hepatitis. 1989 –Hep C virus identified. Specific antibody tests for Hep C developed. 1990 –Screening of blood supply in Canada introduced. 1995 –Hep C virus is first seen using electron microscope.

4. U.S. A. 4 M SOUTH AMERICA 10 M AFRICA 32 M EAST MEDITERRANEAN 20M SOUTH EAST ASIA 30 M AUSTRALIA 0.2 M SOURCE, WHO 1999 WEST EUROPE 9 M FAR EAST ASIA 60 M 170 Million Carriers Worldwide, 3 - 4 MM new cases/year 3% of World Population HCV: A Global Health Problem CANADA 300,000

5. Hepatitis C in Canada Estimated 300,000 HCV infections in Canada 110,000 in Ontario (1 in 170 people) 5,000 in Waterloo/Wellington

7. Risk Factors for HCV IDU Travel to/residence in endemic countries Sharing equipment for inhalation drug use Tattooing/ body piercing Sharing personal hygiene items Street involvement Incarceration Sexual/perinatal transmission Occupational blood exposure Contaminated blood products

8. Distribution of mutually exclusive risk factors for newly-acquired HCV infection among cases with known risk factor information in EHSSS, 2004-2008 PHAC. Epidemiology of Hepatitis C Infection in Canada. Results from the EHSSS. 2008

9. Natural History of Hep C Adapted from Lauer and Walker, NEJM 2001 Healthy Liver Acute Infection Chronic Infection 20% Clear the Virus 80% Virus Continues to Damage Liver Only 20% will show symptoms Initially !

10. Natural History Con’t Chronic Hepatitis Cirrhosis 20-30% Liver Cancer 1-4%/year Most symptoms begin to show only when liver is more severely damaged

11. Signs and Symptoms Individuals may have one or more of the following symptoms, while others experience no symptoms: –Tiredness –Nausea –Muscle or joint pain –Trouble sleeping –Loss of appetite –Weight loss –Abdominal pain –Itchiness –Depression –Dark urine

12. Hep C Treatment

13. Goals of Therapy Primary objective = cure No virus 1 Stop progression (necrosis/fibrosis) No symptoms Secondary objective = delay/prevent Reduce progression of fibrosis 1 Reduce progression to cirrhosis 2 Prevent decompensation Prevent HCC 2 1. Worman. Hepatitis C: Sourcebook 2002. 2. Peters et al. Medscape HIV/AIDS eJournal. 2002;8(1).

14. Therapy for Chronic Hepatitis C before November 2011 Best results with combination Pegylated IFN plus Ribavirin Two pegylated IFN products available:  Peginterferon alfa-2a (Pegasys©)  Peginterferon alfa-2b (Pegetron©) Hep C treatment can be problematic for former users because of the possibly triggering effect of the injections.

15. Treatment duration varied according to genotype and mono- or co-infection 24 weeks HCV mono-infected, genotype 2 or 3 48 weeks HCV mono-infected, genotype 1 or 4 48 weeks HIV/HCV co-infected (regardless of genotype)

16. Cure Rates before November 2011 HCV Genotype 1: 40-50% HCV Genotype 2: 80-90% HCV Genotype 3: 70-80% HCV Genotype 4: 60-70%

17. Since November 2011 Triple therapy for genotype 1: Pegylated Interferon, Ribavirin and a protease inhibitor (Boceprevir/Telaprevir) Treatment length depends on the following factors: Previously treated or never treated before Previous response to treatment ( if previously treated) Response to current treatment Amount of liver damage

18. Protease Inhibitors BoceprevirTelaprevir

19. Treatment with PI’s Pros More effective Shorter treatment duration possible Cons High pill burden Additional side- effects

20. Additional Issues Limited coverage Not straight forward (Regimen differences/Algorithms) Drug/Drug Interactions Timing of medications Adherence/Resistance

21. Side-effects Fever/Chills Muscle & Body Aches Headaches Fatigue Depression Anxiety Irritability Insomnia Dry Mouth/Ulcers Bad Taste in Mouth Poor appetite Nausea/Vomiting Diarrhea Cough Dry Skin/Rashes Injection Site Reactions Ano-rectal discomfort Anaemia

22. Factors Affecting Treatment Response HCV genotype 1 High viral load Increasing fibrosis Being male Black race Age > 40 years Insulin resistance Steatosis Renal failure High BMI

24. The Aging HCV Patient Most of the older adults with chronic hepatitis C virus infection acquired the disease earlier in life They often present with complications of liver disease like cirrhosis and HCC Chronic infection is prevalent and may be more severe in the elderly population Persons 50 years, fibrosis progression is rapid.

25. The Aging HCV Patient Cont’d The burden of chronic hepatitis C virus infection in elderly persons is expected to increase significantly during the next 2 decades The management of chronic HCV infection in older adults is complex in terms of comorbidities and quality of life. Hepatitis C is the leading cause of both liver transplantation and hepatocellular carcinoma (HCC, liver cancer)

26. Cognitive Impairment Chronic HCV infection is associated with cognitive impairment, which is reported in patients aged 28–69 years with mild liver disease. The prevalence of cognitive impairment among older patients may be higher as they might have a higher susceptibility to this complication. Because depression, fatigue, and cognitive impairment are common among the general elderly population, they may be overlooked in those with HCV infection or may not attributed to the disease.

27. Healthy Aging with HCV Cultivate a positive attitude See your doctor for regular check-ups Get protection from the flu, pneumonia and hepatitis A and B. Talk to your doctor or nurse about immunization for these conditions Be careful about mixing any drugs especially with alcohol Eat a healthy and well-balanced diet Talk to your doctor or nurse about whether you need to be treated for hepatitis C

28. Healthy Aging with HCV Cont’d Keep physically fit. Ask your doctor about an exercise program that is right for you. Maintain a healthy diet. Eat a low fat, low cholesterol, low sodium high-fiber diet with lots of fruits and vegetables. Try to lose weight sensibly if it’s advised Aim for 7 to 9 hours of sleep every night Learn to manage stress Drink generous amounts of water – 6 to 8 glasses a day Seek support. Join a support group. Maintain friendships and social contacts Engage in activities that actively stimulate your brain Maintain a sense of humor

29. Questions?

30. Thank You! Martine Stomp RN Sanguen Health Centre mstomp@sanguen.com www.sanguen.com