Hepatitis C
Characteristics of Viral Hepatitis
Hepatitis
virus A
Hepatitis
virus B
Hepatitis
virus C
Hepatitis
virus D
Hepatitis
virus E
Incubation
(days)
15–50
30–180
15–160
30–180
10–60
Transmission
F/O
fecal/oral
BBF
BBF
BBF
F/O
Onset
Abrupt
Insidious
Insidious
Insidious
Abrupt
Chronic
hepatitis
Rare
Possible
Possible
Possible
Unlikely
blood and
body fluids
 Chief Complaint
“My family doctor told me that my liver function tests were
abnormal. I’ve been a little more tired than usual, but I
thought that was because of menopause. I’ve also been
retaining more fluid in my legs, been dizzy and lightheaded
at times, and having more headaches than I did last year.
I’ve lost some weight lately, too, but that’s good, isn’t it?”
 HPI
Linda Lane is a 49-year-old woman who has been referred by
her family physician to the liver clinic for assessment of her
abnormal liver enzymes. She reports remote use of
recreational drugs in high school, including marijuana,
alcohol, occasional amphetamines, and IV cocaine. She
still drinks alcohol occasionally (2–4 glasses of wine once
or twice a week), but otherwise has been “drug free” since
her mid-twenties when she was married.
She states that she feels fine much of the time, but
sometimes has fatigue, fluid retention, headaches, and
difficulty sleeping. She tends to get dizzy on exertion at
times. She has lost about 10 pounds in the last 2 months,
which she attributes to reduced appetite, since her activity
level has diminished. She is perimenopausal and has
isolated episodes of hot flashes and flushes but still
menstruates on a regular 25-day cycle. She has no past
history of liver problems.
 PMH
 IV drug abuse in high school
 HTN
 GERD
 Early menopause
 FH
No known family history of liver disease. Both parents are alive, still
living independently, and doing reasonably well considering they are in
their early 80’s. Her father has HTN, her mother has hypothyroidism
and a chronic “bathroom problem.” One older brother with DM Type 2,
HTN, and GERD.
 SH
Married for 24 years; two children in college. Non-smoker;
denies illicit drug or inhalant use; drinks two to four glasses
of wine once or twice weekly.
 ROS
Denies any signs or symptoms of liver diseases except for
nonspecific constitutional symptoms such as fatigue and
headaches. No changes in urine color. Recalls having
icteric sclerae and a period of severe fatigue and nausea in
high school.
Meds





MVI 1 tablet po daily × 1 year
Calcium citrate with vitamin D 1 tablet po BID × 1 year
Protonix 40 mg po once daily × 2 years
Norvasc 10 mg po once daily × 5 years
Acetaminophen 500 mg 1–2 tablets up to 3 times daily
PRN for headaches and other body aches (averages 3–4
tablets per day)
Physical Examination
 Gen
Well-nourished woman
 VS
BP 100/63, P 72, RR 17, T 37.0°C; Wt 61 kg, Ht 5'4''
 Skin
No jaundice; no spider angiomata or palmar erythema
 HEENT
PERRLA; EOMI; sclerae anicteric; funduscopic exam normal
 Lungs
Normal breath sounds
 CV
RRR, S1, S2 normal; no S3 or S4
 Abd
Liver span 11 cm; spleen not palpable; no evidence
Labs
 Hgb 13.0 g/dL
AST 177 IU/L
HbsAg (–)
 ALT 198 IU/L
Anti-HAV (–) Alk phos 86 IU/L
AntiHCV (+)
 T. bili 1.5 mg/dL HCV RNA (bDNA assay) 4.4 million
copies / ml BUN 11 mg/dL Alb 3.5 g/dL
 SCr 1.0 mg/dL HCV genotype 1
 Glu 111 mg/dL
HIV (–)
 Liver Biopsy (Performed after Liver Clinic Visit)
Moderate degree of fibrosis and inflammation consistent with
chronic hepatitis
 Diagnosis
Chronic hepatitis C
 What physical findings, laboratory values, and medical
history information suggest the presence of chronic
hepatitis C virus (HCV) infection?
 First exam at the doctor's office
 Your doctor will:
 Ask questions about your medical history.
 Do a physical exam.
 Check your livere nzymes to see if they are high. This may
be the first sign that you have the virus.
 Tests for the hepatitis C virus
 If your doctor thinks that you may have hepatitis C, he or she may
order:
 A hepatitis C virus test. This is a blood test that looks
for antibodiesagainst the hepatitis C virus. It shows whether you have
been exposed to the virus. A rapid test is available that gives results in
20 minutes.
 A blood test that looks for the genetic material (RNA) of the hepatitis C
virus. This test shows whether you are infected with the virus now.
 A blood test to find out the kind of hepatitis C virus (genotype) you
have. Knowing your genotype will help you and your doctor decide if
and how you should be treated.
 Tests for liver problems
 To check how well your liver is working, you may have:
 Liver function tests. These are blood tests that can help
your doctor find out if you have liver damage.
 A liver biopsy. The doctor puts a needle in the liver to find
out whether the virus has caused scarring or damage to
your liver.
 Imaging tests such as a CT scan, an MRI, or
an ultrasound to make sure that you don't have liver
cancer.
 What are the goals of treatment for chronic HCV infection?
 To eradicate HCV infection, which prevents the
development of chronic HCV infection and sequelae
 What non-pharmacologic measures should be considered
for this patient?
 You should get plenty of bed rest, drink plenty of fluids, and
eat healthy foods
 Avoid alcohol.
 DO NOT share needles
 Check with your provider before taking any over-thecounter medications or herbal supplements. This includes
medicines such as acetaminophen, aspirin, or ibuprofen.
 What pharmacotherapeutic alternatives are available for
treatment of this patient?
The latest drug to get approved for hepatitis C is called
Harvoni. It's a once-daily pill that combines Sovaldi
(sofosbuvir) and ledipasvir. It cures the disease in most
people in 8-12 weeks. Other options include taking a
combination of Sovaldi, Olysio (simeprevir), interferon
and/or ribavirin. Talk with your doctor about what's right for
you, based on your medical needs and insurance
coverage, since the newer hepatitis C drugs are very
expensive.
 Design a pharmacotherapeutic plan for this patient.
Treatment options include:
 Daclatasvir (Daklinza)
 Ledipasvir and sofosbuvir (Harvoni)
 Ombitasvir-paritaprevir-ritonavir (Technivie)
 Ombitasvir-paritaprevir-ritonavir plus dasabuvir (Viekira Pak)
 Simeprevir (Olysio)
 Sofosbuvir (Sovaldi)
 These medications are, in general, well tolerated. The FDA has issued
a warning that Technivie and Viekira Pak can cause severe liver injury
especially if you already have severe liver disease.
 Interferon and ribavirin used to be the main
treatments for hepatitis C and are now used
less frequently. They can have severe side
effects including fatigue, flu-like
symptoms, anemia, skin rash,
mild anxiety,depression, nausea,
and diarrhea.
 Does this patient have any medical conditions that
are considered contraindications to receiving the
treatments discussed in the previous question?
 Contraindications to treatment include: autoimmune
hepatitis, decompensated liver disease, women who are
pregnant or patients whose female partners are pregnant,
hemoglobinopathies, creatinine clearance <50 mL/ min,
hemodialysis, or ischemic cardiovascular or
cerebrovascular disease
Monitoring Chronic Hepatitis
 To manage chronic hepatitis B or C, your doctor will order
regular blood tests to check how well your liver is working.
 Ultrasounds and CT scans can also reveal signs of
damage. If the virus is not causing any liver problems, you
may not need treatment. But it's important to have regular
tests to watch for changes. Complications are easiest to
treat when found early.
Outcome Evaluation
 How should the therapy you recommended for HCV
infection be monitored for efficacy and adverse effects?
You can know the efficacy adverse effects of the therapy by
2 ways
1- Clinical Parameters like signs and symptoms
2- Laboratory data
 Which baseline parameters of this patient have been
suggested as predictors of poor response to the treatment
you recommended?
AST 177 IU/L
ALT 198 IU/L
HCV RNA (bDNA assay) 4.4 million copies / ml
What are the complications of
hepatitis
 Hepatitis can lead to cirrhosis, liver cancer, and liver
failure.
Common side effects of peginterferon
and ribavirin
 Common side effects of ribavirin are fatigue, flu-like
symptoms, neutropenia, thrombocytopenia, and anemia
 Common side effects of peginterferon are* :
 Fatigue , Arthralgia , Fever , Musculoskeletal pain , Headache,
Insomnia , Nausea , Depression , Anorexia , Anxiety/emotional lability
, Rigors,
Alopecia , Myalgia , Injection site reactions
* Experienced by > 20 % of patients