Open Access
Feature Article

Part 5. Practical steps in your practice

Open Access
Feature Article

Part 5. Practical steps in your practice

David Baker, ANNE BALCOMB, JOSS O’LOAN, Jessica Howell
Dr Baker is a GP at East Sydney Doctors; and Senior Lecturer at the University of Notre Dame Sydney, Sydney, NSW. Dr Balcomb is a GP in Orange; and Honorary Lecturer at The University of Sydney, NSW. Dr O’Loan is a GP at Medeco Medical Centre Inala; Director of the Kombi Clinic; and Senior Lecturer at the University of Queensland, Brisbane, Qld. Dr Howell is a Consultant Gastroenterologist at St Vincent’s Hospital; Postdoctoral Research Fellow in Disease Elimination, Burnet Institute; and Postdoctoral Research Fellow in the Department of Medicine, University of Melbourne, Melbourne, Vic.

Follow up

Follow up of patients is essential after DAA treatment, as described in Part 4 of this series.7 The key date for follow up is 12 weeks after completion of therapy.
A negative HCV RNA PCR result at this time indicates hepatitis C cure, termed a sustained virological response (SVR12). This is truly a ‘miracle of modern medicine’ and a delightful message to convey to a patient. 

Patients who are cured and have ­normal liver function test results and early liver disease need no further follow up, unless there is ongoing exposure to HCV, such as continuing injecting drug use. If liver function test results continue to be raised, indicating liver disease, or the patient has been diagnosed with cirrhosis then they need specialist review.

Patients with cirrhosis need lifelong monitoring with six-monthly liver ultrasound examinations because of the risk of hepatocellular carcinoma. Monitoring can be done by the GP or specialist. Built-in recall systems in GP software are helpful for this.

HCV reinfection is possible as past infection does not provide any immunity to reinfection. Patients with an ongoing risk of HCV infection (e.g. continuing injecting drug use) need regular HCV RNA PCR tests at least once a year as long as they remain at risk. Note that the HCV antibody test will most likely give positive results for life, and this test is thus not useful for monitoring for reinfection and does not need to be repeated. 

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Complete patient care

Most people living with hepatitis C have comorbidities.12 These can be: 

  • hepatitis C-related, such as cirrhosis, liver failure and type 2 diabetes
  • associated with hepatitis C acquisition, such as injecting drug use and imprisonment
  • associated with marginalisation and poverty, such as smoking, alcohol abuse and mental illness. 

These problems require ongoing GP care and sometimes referral to other healthcare workers. 

Some health problems that are more common in people living with hepatitis C are listed in Box 5. These health problems will probably persist after curative treatment of hepatitis C and impact on quality of life. Patient engagement in ­hepatitis C care can provide an opportunity to consider other health problems. Patients should be offered appropriate health screening according to the guidelines of the Royal Australian College of General Practitioners.13

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Preventing reinfection is important. This may include offering opioid sub­stitution therapy and encouraging safer injecting (e.g. needle and syringe exchange). It is also helpful to encourage patients to support their partner and friends to access hepatitis C treatment, which will also reduce the likelihood of reinfection. 

Treating hepatitis C around Australia

GP referral to a specialist is a longstanding model, and referral is appropriate for patients with advanced liver disease or major comorbidities, such as chronic hepatitis B or HIV infection. However, treatment of chronic hepatitis C for most people is now simple and can be easily incorporated into primary care. Less experienced GPs can obtain specialist support and advice on a treatment plan by contacting a specialist by telephone, by email using the Reach-C proforma or by fax using the GESA proforma.