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Open Access
Feature Article

Part 3. Curing hepatitis C in general practice

TARA PURCELL, AMANDA WADE, LISA ACCADIA, Simone Strasser, Phillip Read, NICOLE ALLARD, David Baker, ALISA PEDRANA, JOSEPH DOYLE
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Abstract

Most patients with hepatitis C are treated with pangenotypic direct-acting antivirals (DAAs) such as sofosbuvir/velpatasvir and glecaprevir/pibrentasvir. GPs experienced in the management of hepatitis C can prescribe DAAs independently. Others must consult with a specialist before prescribing; online resources can streamline this process. Important considerations before prescribing include barriers to adherence and drug interactions.

Key Points

  • Most people with hepatitis C can be treated with direct acting antiviral (DAA) therapy in primary care.
  • Pangenotypic DAA regimens that are well tolerated and effective against all hepatitis C genotypes include sofosbuvir/velpatasvir and glecaprevir/pibrentasvir.
  • GPs who are experienced in the management of hepatitis C can prescribe DAAs independently, whereas others must consult with a specialist by phone, fax or email before DAA prescribing; online resources are available to facilitate this process.
  • Considerations before prescribing DAAs include barriers to adherence and interactions between DAAs and prescribed medications and other drugs the patient takes.
  • Clinical support, tools and resources to help GPs treat hepatitis C are available online.

GPs can treat most people living with hepatitis C using direct-acting antivirals (DAAs). These medications are highly effective, with few side effects, and can cure more than 95% of individuals after a full course of DAA therapy. Curing an individual’s infection can significantly reduce their risk of developing liver disease and liver cancer, and reduce onward transmission, moving Australia towards the WHO goal of hepatitis C elimination. 

This is the third article in a series on eliminating hepatitis C. Previous articles discussed how to identify your patients with hepatitis C and how to assess them in preparation for DAA treatment.1,2 This article focuses on initiating treatment in general practice.

Why treat hepatitis C in general practice?

More than 70,000 people with hepatitis C in Australia have been treated and cured since DAAs became available in this country. However, an estimated 165,000 people in Australia are still ­living with hepatitis C (projections based on a published model and updated MBS and PBS data).3 Most of these ­people are considered suitable for ­treatment in ­primary care.4 To eliminate hepatitis C as a public health threat in Australia, it is crucial that GPs engage in hepatitis C management for all ­people living with hepatitis C, including people who inject drugs. ­Providing hepatitis C treatment in ­general practice promotes treatment uptake, especially among marginalised populations.5

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What treatments are available?

Although multiple DAAs are approved in Australia, 85% of all patients are now treated with pangenotypic DAA regimens that are effective against all hepatitis C genotypes.6 This article focuses on two pangenotypic DAA regimens: 

  • fixed-dose combination sofosbuvir/velpatasvir 
  • fixed-dose combination glecaprevir/pibrentasvir. 

Both sofosbuvir/velpatasvir and ­glecaprevir/pibrentasvir have cure rates higher than 95%.4 These two pangenotypic DAA treatment regimens are well tolerated. Side effects may include mild fatigue, headache or nausea.4 The two regimens are compared in the Table.4 

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Who can treat chronic hepatitis C? 

Any medical practitioner or authorised nurse practitioner can prescribe DAAs for treatment of chronic hepatitis C.7 However, there are some provisos: 

  • Medical practitioners who are not experienced in the management of hepatitis C must consult with a specialist (gastroenterologist, hepatologist or infectious diseases physician) before prescribing DAAs. 
  • Medical practitioners and authorised nurse practitioners experienced in the management of hepatitis C can prescribe DAAs independently.
  • Although most people with hepatitis C can be treated by nonspecialists, a selected minority need specialist treatment, as described below. 

How do you consult with a specialist?

If GPs are not experienced in hepatitis management then they are required to consult with an experienced specialist. GPs can do this directly by phone, fax or email. This consultation process is one of the ways GPs can gain enough experience to prescribe independently. 

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© kateryna_kon/stock.adobe.com
© kateryna_kon/stock.adobe.com
Dr Purcell is a Public Health Registrar, Burnet Institute, Melbourne. Dr Wade is an Infectious Diseases Physician at Barwon Health, Geelong, Vic; and Senior Research Fellow, Burnet Institute. Ms Accadia is a Research Nurse in the EC Partnership, Disease Elimination, Burnet Institute. Associate Professor Strasser is a Senior Staff Specialist in Gastroenterology and Hepatology at Royal Prince Alfred Hospital, Sydney; and Clinical Associate Professor at Sydney Medical School, University of Sydney. Dr Read is a Senior Staff Specialist and Director of the Kirketon Road Centre, South Eastern Sydney Local Health District, Sydney. Dr Allard is a GP and Postdoctoral Research Fellow at the WHO Collaborating Centre for Viral Hepatitis, Doherty Institute, Melbourne. Dr Baker is a GP at East Sydney Doctors; and Senior Lecturer at the University of Notre Dame Sydney, Sydney, NSW. Dr Pedrana is Senior Research Fellow in Disease Elimination, Burnet Institute; and Adjunct Research Fellow in the School of Population Health and Preventive Medicine, Monash University, 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.