Open Access
Feature Article

Part 4. Ongoing care after hepatitis C treatment

Open Access
Feature Article

Part 4. Ongoing care after hepatitis C treatment

KICO CHAN, * MICHELLE GOOEY, * MARGARET HELLARD, BELINDA GREENWOOD-SMITH, RICHARD CHANEY, David Baker, ALISA PEDRANA, JOSEPH DOYLE, Jessica Howell
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© FilippOBaCCi/istOCKphOtO.COm mODEls UsED FOr illUstratiVE pUrpOsEs OnlY

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Ms Chan* is a Research Nurse in the EC Partnership, Disease Elimination, Burnet Institute, Melbourne. Dr Gooey* is a Public Health Registrar at the Burnet Institute. Professor Hellard is Deputy Director of the Burnet Institute; Consultant Physician in the Department of Infectious Diseases, Alfred Hospital; and Adjunct Professor in the School of Public Health and Preventive Medicine, Monash University, Doherty Institute and Melbourne School of Population and Global Health, University of Melbourne, Melbourne. Dr Greenwood-Smith is a Remote Medical Practitioner and Coordinator of the Centre for Disease Control, Alice Springs, NT. Dr Chaney is a GP Consultant in the Sexual Health Service of Royal Perth Hospital, the HepatitisWA Deen Clinic and General Practice in Perth, WA. 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. Dr Howell is a Consultant Gastroenterologist at St Vincent’s Hospital, Melbourne; Postdoctoral Research Fellow in Disease Elimination, Burnet Institute, and Department of Medicine, University of Melbourne, Melbourne, Vic. * Equal first authors.

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Liver cirrhosis is a significant complication that occurs in about two to three of every 10 people with chronic hepatitis C, generally after longstanding (20 to 30 years) infection.6 People with cirrhosis remain at risk of complications of liver disease such as hepatocellular carcinoma (HCC), even after being cured of hepatitis C. 

Follow up for patients with cirrhosis 

Patients with cirrhosis require lifelong follow up (Table).6,15,16 They should be referred to a gastroenterologist for specialist care. In particular, all patients with cirrhosis require HCC surveillance with six-monthly targeted liver ultrasound examinations. The GP should also provide hepatitis A and B, influenza and pneumococcal vaccinations to all patients with cirrhosis in accordance with Australian immunisation guidelines.10

Shared models of care with open lines of communication between the GP and specialist can facilitate safe and effective management of patients with cirrhosis. This includes timely adherence to screening programs, safe prescribing of medications when liver dysfunction is present and early identification of decompensating liver function. Shared models of care can be supported through initiation of chronic disease care plans, team care arrangements and case conferencing.

Rural and remote GPs 

Patients in a rural or remote area may not always be able to access a gastroenterologist. In this situation, the GP may need to take greater responsibility for co-ordinating care and may organise screening and monitor the patient’s liver function in collaboration with the specialist (Table).6,15,16 Co-ordination of care can be facilitated through a good relationship with a specialist in the regional centre, use of telemedicine and case conferencing.

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Conclusion

After hepatitis C treatment with DAAs, all patients need follow up by their GPs. Over 95% of patients are cured after a full course of DAA treatment and will not need further hepatitis C treatment (see the Case study in Box 1). A small proportion of patients will require further management, and GPs can play a valuable role in their ongoing care in partnership with specialists. Patients at risk of reinfection will also need support to reduce their risk as well as regular HCV RNA testing by PCR.  MT

 

COMPETING INTERESTS: Ms Chan, Dr Gooey, Dr Greenwood-Smith, Dr Chaney, Dr Howell: None. Professor Hellard receives funding support from Gilead Sciences, AbbVie and Bristol-Myers Squibb for investigator-initiated research. 
Dr Baker has received clinical trial funding and conference sponsorship and serves on the advisory board for AbbVie, Gilead and MSD.
​Dr Pedrana receives funding for investigator-initiated research from AbbVie, Gilead and MSD. Dr Doyle receives funding for investigator-initiated research or consulting from AbbVie, Bristol-Myers Squibb, Gilead and MSD.

 

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Acknowledgement

The authors gratefully acknowledge the contribution to this work of the Victorian Operational Infrastructure Support Program received by the Burnet Institute.

 

References

1.    Kirby Institute. Monitoring hepatitis C treatment uptake in Australia. Issue 10, June 2019. Sydney: Kirby Institute, UNSW Sydney; 2019. Available online at: https://kirby.unsw.edu.au/report/monitoring-hepatitis-c-treatment-uptake-australia-issue-10-june-2019 (accessed September 2019).
2.    Doyle JS, Scott N, Sacks‐Davis R, Pedrana AE, Thompson AJ, Hellard ME. Treatment access is only the first step to hepatitis C elimination: experience of universal anti‐viral treatment access in Australia. Aliment Pharmacol Ther 2019; 49: 1223-1229.
3.    Draper B, Layton C, Doyle J, et al. Eliminating hepatitis C: Part 1. Finding your patients with hepatitis C. Med Today 2019; 20(6): 34-40.
4.    Layton C, Richmond J, Baker D, et al. Eliminating hepatitis C: Part 2. Assessing your patient for antiviral treatment. Med Today 2019; 20(7): 24-32.
5.    Purcell T, Wade A, Accadia L, et al. Eliminating hepatitis C: Part 3. Curing hepatitis C in general practice. Med Today 2019; 20(8): 20-26.
6.    Hepatitis C Virus Infection Consensus Statement Working Group. Australian recom­mendations for the management of hepatitis C virus infection: a consensus statement. Melbourne: Gastroenterological Society of Australia; 2018.
7.    Department of Health. Hepatitis C MBS items table. Canberra: Department of Health; last updated August 2018. Available online at: www1.health.gov.au/internet/main/publishing.nsf/Content/path-comp-hep-table (accessed September 2019).
8.    Burnet Institute Eliminate Hepatitis C Partnership. Eliminate hepatitis C partnership practice support toolkit. Melbourne: Burnet Institute; 2018. Available online at: https://ecpartnership.org.au/toolkit (accessed September 2019).
9.    Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2018. Sydney: Kirby Institute; 2018. Available online at: https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance (accessed September 2019).
10.    Australian Technical Advisory Group on Immunisation (ATAGI). Australian immunisation handbook. Canberra: Australian Government Department of Health; 2018. Available online at: https://immunisationhandbook.health.gov.au (accessed September 2019).
11.    Papaluca T, Sinclair M, Gow P, et al. Retreatment with elbasvir, grazoprevir, sofosbuvir ± ribavirin is effective for GT3 and GT1/4/6 HCV infection after relapse. Liver Int 2019 Jul 29. doi: 10.1111/liv.14201. [Epub ahead of print] 
12.    Cornford C, Close H. The physical health of people who inject drugs: complexities, challenges, and continuity. Br J Gen Pract 2016; 66: 286-287. 
13.    Australian Injecting and Illicit Drug Users League (AIVL). ‘We live with it almost every day of our lives’: an AIVL report into experiences of stigma and discrimination. Canberra: AIVL; 2015.
14.    Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Removing barriers; it’s easy as 1, 2, 3. Available online at: http://removingbarriers.ashm.org.au/ (accessed September 2019).
15.    Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Decision making in HCV. Sydney: ASHM; 2019. Available online at: https://www.ashm.org.au/products/product/Decision-Making-in-HCV (accessed September 2019).
16. de Franchis R; Baveno VI Faculty. Expanding consensus in portal hypertension. Report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752.