The most complex part of pretreatment investigation is assessing for advanced liver disease. Patients with cirrhosis need specialist referral and may require changes to the treatment regimen. Most patients do not have cirrhosis and can be treated easily in general practice.
Steps in patient assessment for advanced liver disease are shown in the Flowchart.9 A simple assessment that can be performed with the results of a full blood count and liver function testing is the aspartate aminotransferase to platelet ratio index (APRI). APRI calculators are available online (e.g. www.hepatitisc.uw.edu/page/clinical-calculators/apri). If the APRI score is less than 1.0 then cirrhosis is unlikely, and the patient can be treated without further investigation (see the case study in Box 4). If the APRI score is 1.0 or more then the patient needs further assessment.
The most useful next investigation is transient elastography, such as FibroScan. In many parts of Australia, this investigation can be performed by a specialist nurse at the GP clinic or local hospital (Figure 2).
Treat with DAAs
Hepatitis C treatment is straightforward, as described in Part 3 of this series.6 DAA therapy for hepatitis C became available in March 2016 and has continued to evolve. Treatment options are based on the national guidelines, Australian recommendations for the management of hepatitis C virus infection: a consensus statement (September 2018).3
The choice of DAA medication depends on:
- HCV genotype
- presence of cirrhosis
- presence of hepatitis B or HIV coinfection
- patient’s renal function
- potential drug interactions and
- patient or provider preference.
Potential drug interactions can be checked using the University of Liverpool’s online interaction checker (www.hep-druginteractions.org/checker).
There are two regimens that can be used for any HCV genotype (pangenotypic). Their characteristics are summarised in the Table.
Minimal monitoring is required during treatment. Many medical practitioners see the patient after four weeks to check on adherence and side effects, but pathology testing is no longer generally needed.
GPs who are not experienced in hepatitis C treatment need to have the treatment plan signed off by a specialist (gastroenterologist, hepatologist or infectious diseases physician). They can communicate with the specialist by telephone, email or fax. A proforma can be used, such as:
- Remote consultation request for initiation of hepatitis C treatment form from the Gastroenterological Society of Australia (http://cart.gesa.org.au/membes/files/Resources/Hepatitis%20C/
- Reach-C interactive webpage (https://reach-c.ashm.org.au ).