HEPATITIS 2014 BC. CHRONIC HEPATITIS B THE PROBLEM 350,000,000 PEOPLE HAVE IT IT IS TRANSMITTED MOTHER TO CHILD WHERE IT IS ENDEMIC IT CAN BE TRANSMITTED.

HEPATITIS2014 BC

CHRONIC HEPATITIS B

THE PROBLEM•350,000,000 PEOPLE HAVE IT

• IT IS TRANSMITTED MOTHER TO CHILD WHERE IT IS ENDEMIC

• IT CAN BE TRANSMITTED VIA BODY FLUIDS

• IT OFTEN PROGRESSES TO CIRRHOSIS

• IT CAUSES HEPATOCELLULAR CARCINOMA

CHRONIC HEPATITIS B

VIRAL PHASE

VIRAL LOAD HISTOLOGY

IMMUNETOLERANT

VERY HIGH NORMAL

IMMUNE ACTIVE

LOWACTIVE

HEPATITISIMMUNEINACTIVE

VERY LOWMILD ORINACTIVE

IMMUNECLEARANCE

NONE NORMAL

CHRONIC HEPATITIS B

THE PROBLEM•IT IS QUICKLY TRANSMITTED TO

THE INFANT OF AN INFECTED MOTHER

•IT CAN BE REACTIVATED EVEN WHEN APPARENTLY “CLEARED” BY CHEMOTX OR PERHAPS TNF INHIBITORS

CHRONIC HEP BWHO TO TX?

• ALL PATIENTS WITH CIRRHOSIS AND DETECTABLE VIRUS

• ALL PATIENTS WITH IMMUNE ACTIVE PHASE DISEASE

• ASYMPTOMATIC PREGNANT WOMEN WHO HAVE > 1,000,000 COPIES/ML BEGINNING IN THE THIRD TRIMESTER

• PATIENTS WITH DETECTABLE HBsAg ABOUT TO UNDERGO IMMUNOSUPPRESSION

CHRONIC HEPATITIS B

WHAT TO USE?

•ENTECAVIR

•TENOFOVIR

•TELBIVUDINE

•LAMIVUDINE

HEPATITIS C

NOW A DISEASE FOR PRIMARY CARE THERAPY

THE SHORT VERSIONTHE SHORT VERSIONTHE SHORT VERSIONTHE SHORT VERSION

ONE OR TWO SIDE-EFFECT-ONE OR TWO SIDE-EFFECT-

FREE PILLS DAILY FOR 3 TO FREE PILLS DAILY FOR 3 TO

6 MONTHS CURES >90% OF 6 MONTHS CURES >90% OF

PEOPLE WITH CHRONIC PEOPLE WITH CHRONIC

HEPATITIS CHEPATITIS C

HEPATITIS C-THE HEPATITIS C-THE PROBLEMPROBLEM

3.8 MILLION AMERICANS HAVE IT3.8 MILLION AMERICANS HAVE IT

170 MILLION PEOPLE WORLDWIDE HAVE IT170 MILLION PEOPLE WORLDWIDE HAVE IT

IT PROGRESSES TO CIRRHOSIS IN AT LEAST IT PROGRESSES TO CIRRHOSIS IN AT LEAST 25%25%

IT CAUSES HEPATOCELLULAR CARCINOMAIT CAUSES HEPATOCELLULAR CARCINOMA

WE CAN’T PREDICT WHO WILL PROGRESSWE CAN’T PREDICT WHO WILL PROGRESS

HEPATITIS C-THE PROBLEM-HEPATITIS C-THE PROBLEM-EXTRAHEPATIC EXTRAHEPATIC MANIFESTATIONSMANIFESTATIONS

ARTHRITISARTHRITIS

VASCULITISVASCULITIS

CRYOIMMUNOGLOBULINEMIACRYOIMMUNOGLOBULINEMIA

RENAL DISEASERENAL DISEASE

INSULIN RESISTANCE AND TYPE II DIABETES MELLITUSINSULIN RESISTANCE AND TYPE II DIABETES MELLITUS

LYMPHOMALYMPHOMA

THYROIDITISTHYROIDITIS

LICHEN PLANUSLICHEN PLANUS

ETCETC

HEPATITIS C-THE PASTHEPATITIS C-THE PAST

TREATMENT WAS DIFFICULT AND OFTEN INEFFECTIVETREATMENT WAS DIFFICULT AND OFTEN INEFFECTIVE

IT REQUIRED CLOSE MONITORING AND A CLEAR IT REQUIRED CLOSE MONITORING AND A CLEAR WORKING KNOWLEDGE OF THE NUANCES OF THE WORKING KNOWLEDGE OF THE NUANCES OF THE MEDICATIONS USEDMEDICATIONS USED

SIDE EFFECTS WERE UNIVERSAL AND OFTEN TERRIBLESIDE EFFECTS WERE UNIVERSAL AND OFTEN TERRIBLE

PATIENTS HAD FREQUENT PHYSICIAN VISITS OVER 6 TO PATIENTS HAD FREQUENT PHYSICIAN VISITS OVER 6 TO 12 MONTHS12 MONTHS

MOST PATIENTS UNDERGOING TREATMENT HAD TO MISS MOST PATIENTS UNDERGOING TREATMENT HAD TO MISS SOME WORK AND OFTEN COULD NOT WORK AT ALL SOME WORK AND OFTEN COULD NOT WORK AT ALL

WE COULDN’T TREAT THE SICKEST PATIENTSWE COULDN’T TREAT THE SICKEST PATIENTS

HEPATITIS C-THE PASTHEPATITIS C-THE PAST

WE EMPLOYED VERY SELECTIVE CRITERIA FOR WE EMPLOYED VERY SELECTIVE CRITERIA FOR TREATMENT:TREATMENT:

ILLNESS FROM THE INFECTION--RARE UNTIL ILLNESS FROM THE INFECTION--RARE UNTIL CIRRHOSIS ENSUED, WHEN TREATMENTS CIRRHOSIS ENSUED, WHEN TREATMENTS WERE LESS EFFECTIVEWERE LESS EFFECTIVE

HISTOLOGIC EVIDENCE SUGGESTING HISTOLOGIC EVIDENCE SUGGESTING PROGRESSIVE FIBROSISPROGRESSIVE FIBROSIS

NOT TOO SICK TO TREATNOT TOO SICK TO TREAT

HEPATITIS C THE PASTHEPATITIS C THE PAST

THE BEST RECENT TREATMENT WAS EFFECTIVE THE BEST RECENT TREATMENT WAS EFFECTIVE IN ABOUT:IN ABOUT:

1/2 OF GENOTYPE 1b1/2 OF GENOTYPE 1b

2/3 OF GENOTYPE 1a2/3 OF GENOTYPE 1a

3/4 OF GENOTYPE 2 AND 33/4 OF GENOTYPE 2 AND 3

EXCEPT IF YOU WERE OF MAINLY EXCEPT IF YOU WERE OF MAINLY SUBSAHARAN AFRICAN ORIGIN THEN IT WAS SUBSAHARAN AFRICAN ORIGIN THEN IT WAS < 1/2 THE ABOVE< 1/2 THE ABOVE

HEPATITIS C THE PASTHEPATITIS C THE PAST

THE TREATMENT WAS EXPENSIVETHE TREATMENT WAS EXPENSIVE

$25,000-$30,000 WITH PEGI/RIBA$25,000-$30,000 WITH PEGI/RIBA

>$80,OOO IF YOU ADDED TELAPREVIR OR >$80,OOO IF YOU ADDED TELAPREVIR OR BOCEPREVIRBOCEPREVIR

YOU LOST WORK USUALLY TOOYOU LOST WORK USUALLY TOO

HEPATITIS C THE FUTURE

• NUMEROUS MEDS ARE COMING

• THEY WILL ATTACK THE VIRUS AT DIFFERENT SITES

• THEY HAVE MINIMAL SIDE EFFECTS

• TREATMENT WILL BE 12-24 WEEKS FOR MOST PATIENTS

HEPATITIS C THE FUTURE

• THE MEDS WILL BE GIVEN IN TWO DRUG COMBINATIONS FOR MOST

• NO RIBAVIRIN WILL BE NEEDED

• WHEN AND IN WHAT COMBINATIONS WILL BE DETERMINED BY THE FDA

SO HOW GOOD ARE THE NEW TREATMENTS?

•VERY, VERY GOOD

CLASS DRUGS MECHANISM

NS3/NS4/NS5BPROTEASE INHIBITORS

SIMEPREVIR*FALDAPREVIRASUNAPREVIR

VIRAL SERINE PROTEASE INHIBITOR

NS5AINHIBITOR

DACLATASVIRLEDIPASVIR

REGULATOR OF RNA POLYMERASE AND

INTERFERON RESPONSEINHIBITOR

NS5BINHIBITOR

SOFOSBUVIR*SETROBUVIR

FILBUVIR

VIRAL RNA POLYMERASE

INHIBITOR

* AVAILABLE NOW

SOFOSBUVIR AND DACLATASVIR FOR 24 WEEKS

•

GENOTYPE 1a/1b TX NAIVESVR 100%

GENOTYPE 1a/1bTX FAILURESVR 100%

GENOTYPE 2/3TX NAIVESVR 100%

THESE WERE ALL NON CIRRHOTIC

SOFOSBUVIR, LEDIPASVIR, RIBAVIRIN IN GENOTYPE 1a AND 1b

•

TREATMENT SVR RESULTS

NAIVES+L X 8 WKS

95%

NAIVES+L+R X 8 WKS

100%

NAIVES+L X 12 WKS

95%

TX FAILURES+L X 12 WKS

95%*

TX FAILURES+L+R X 12 WKS

100%*

*40% HAD CIRRHOSIS

HEPATITIS C THE FUTURE

• SOME RESULTS WILL VARY

• GENOTYPE 3 WILL BE SLOWEST TO TX

• CIRRHOTICS WILL LIKELY HAVE SLOWER RESPONSES BUT LIKELY JUST NEED LONGER TX

• VIRAL RESISTANCE CAN OCCUR

• WE KNOW LITTLE ABOUT NON 1,2,3 GENOTYPES

HEPATITIS C THE FUTURE

•COST: $160,000!

• TIME INVOLVED IN GETTING THE DRUG IS 2 HOURS

• BRIGHT

• GETTING BRIGHTER

HEPATITIS C THE FUTURE

• CURRENTLY THE DRUG COMPANIES ARE VERY, VERY HELPFUL AT GETTING A GOOD DEAL FOR THE PATIENTS

WHO SHOULD THE NON HEPATOLOGIST/GASTROENTEROLOGIST

REFER?

WHO SHOULD THE NON HEPATOLOGIST/GASTROENTEROLOGIST

REFER?

n CIRRHOTICS

n ANYONE YOU ARE NOT COMFORTABLE TREATING

n TREATMENT FAILURES

n ANYONE NEEDING TREATMENT UNTIL THESE NEW AGENTS AND COMBINATIONS ARE READY

n ANYONE WHO NEEDS A COLONOSCOPY--JUST KIDDING

HEPATITIS C THE FUTURE

• WHEN WILL THE DRUGS BE HERE

• THEY’RE HERE NOW--BUT ARE NOT APPROVED BY THE FDA IN COMBINATION

• SO INSURANCE WON’T BUY THEM

• MORE WILL COME LATER THIS YEAR AND FOR THE NEXT FEW YEARS

HEPATITIS C SUMMARYHEPATITIS C SUMMARY

IT IS A COMMON DISEASE, WATCH FOR ITIT IS A COMMON DISEASE, WATCH FOR IT

IT IS A CAUSE OF REMARKABLE MORBIDITY AND IT IS A CAUSE OF REMARKABLE MORBIDITY AND MORTALITYMORTALITY

IT CAN BE CUREDIT CAN BE CURED

YOU CAN CURE ITYOU CAN CURE IT

IF WE CAN PAY FOR ITIF WE CAN PAY FOR IT

IF YOU HAVE THE TIME TO PRESCRIBE THE IF YOU HAVE THE TIME TO PRESCRIBE THE MEDSMEDS