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Part 2. Assessing your patient for antiviral treatment

CHLOE LAYTON, JACQUI RICHMOND, David Baker, LOUISE OWEN, GAIL MATTHEWS, ERIN OLIVER-LANDRY, Jessica Howell, JOSEPH DOYLE
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© science source/monica schroeder/diomedia.com
© science source/monica schroeder/diomedia.com

Abstract

As soon as a patient is diagnosed with chronic hepatitis C, preparations can begin for treatment with direct-acting antivirals (DAAs). Most patients can receive DAA therapy in general practice. GPs are ideally placed to assess their patients in preparation for DAA therapy and to identify the minority who require specialist referral.

Key Points

  • Most patients with hepatitis C can be treated with direct acting antivirals (DAAs) in general practice.
  • GPs are ideally placed to assess patients in preparation for DAA therapy.
  • Pretreatment assessment includes a comprehensive medical and social history, medication review, physical examination and investigations.
  • Key questions to determine the safety of DAA therapy in primary care concern the presence of cirrhosis, hepatitis C virus (HCV) genotype, hepatitis B or HIV coinfection, potential drug interactions, previous HCV treatment and renal function.
  • Patients with cirrhosis, complex comorbidities or who have previously failed DAA therapy should be referred for specialist care.

With the introduction of direct-acting antivirals (DAAs) in Australia in 2016, most people with chronic hepatitis C can be cured of this infection. GPs and suitably qualified nurse practitioners working in all areas of primary care have a key role in identifying, testing and treating their patients with hepatitis C.

The previous article in this series discussed how to identify your patients with hepatitis C. This article provides practical advice on assessing a patient after diagnosis in preparation for DAA therapy. This includes determining whether they can be safely treated in general practice or require specialist referral. 

After diagnosis, what next?

All people diagnosed with hepatitis C should be considered for DAA therapy. DAAs have the potential to cure most people with hepatitis C and have few contraindications. As soon as a patient is diagnosed with hepatitis C, assessment for treatment can begin, in consultation with the patient. 

Pretreatment assessment

Patient assessment in preparation for treatment includes: 

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  • comprehensive medical and social histories
  • medication review
  • physical examination
  • investigations, including a liver fibrosis assessment. 

A full list of the required assessments and investigations appears in Box 1.1 

Six key questions need to be answered to help determine whether the patient can be treated safely in primary care or needs to be referred to a specialist, and the most appropriate treatment option. These ­questions regard the individual, the ­hepatitis C virus (HCV) and the liver. 

The key questions are:2

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  • Does the patient have cirrhosis? 
  • What is the genotype of the infecting HCV? (This requirement may be removed in the future owing to the availability of pangenotypic agents.)
  • Is the patient coinfected with HIV or hepatitis B virus (HBV)? 
  • Are there any potential drug interactions between the patient’s current medication and the DAAs? 
  • Has the patient previously been treated for hepatitis C?
  • What is the patient’s renal function? 

An important part of the pretreatment assessment is determining the presence of advanced liver disease. Patients with ­cirrhosis require specialist referral and may need changes to the standard treatment regimen. 

It is also important to address potential psychosocial barriers to treatment during the assessment process. Current active injecting drug use is not a contraindication to hepatitis C treatment. However, some patients may need support to stabilise drug and alcohol use or to establish adherence support services before treatment.

Vaccinations 

All susceptible patients with hepatitis C should be offered vaccinations against hepatitis A and B viruses. These vaccinations are subsidised for patients with liver disease and those who are at high risk of infection in some jurisdictions. 

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© science source/monica schroeder/diomedia.com
© science source/monica schroeder/diomedia.com
Ms Layton is the Nurse Co-Ordinator of the EC Partnership, Disease Elimination, Burnet Institute, Melbourne. Dr Richmond is the Program Manager, Workforce Development and Health Service Delivery, EC Australia, Disease Elimination, Burnet Institute. Dr Baker is a GP at East Sydney Doctors; and Senior Lecturer at the University of Notre Dame Sydney. Associate Professor Owen is a Sexual Health Physician in Hobart, Tas; and Director of the Sexual Health Service Tasmania. Associate Professor Matthews is an Infectious Diseases and HIV/Sexual Health Physician and Clinical Academic in the Viral Hepatitis Clinical Research Program at the Kirby Institute and in HIV/Infectious Diseases at St Vincent’s Hospital, Sydney, NSW. Dr Oliver-Landry is a GP at McIntyre Medical Centre and Streetlink Youth Health Service, Adelaide, SA. Dr Howell is a Consultant Gastroenterologist at St Vincent’s Hospital, Melbourne; Postdoctoral Research Fellow in Disease Elimination, Burnet Institute; and Postdoctoral Research Fellow in the Department of Medicine, University of Melbourne. Dr Doyle is Deputy Program Director of Disease Elimination, Burnet Institute; and Infectious Diseases Physician in the Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Vic.