 |
| Source: cadenaser.com |
Definition
Hepatitis C is an Infection with Hepatitis virus Typ c. It leads to
inflammation of the liver and leads in his end-stage to liver cirrhosis. HCV
makes 20 % of all acute hepatitis in the USA and 40% of chronic hepatitis.
Spontaneous resolution may occurs in 20-50% of cases.
Transmission
- Inject illicit drugs
- Sexual transmission, especially M2M
- Blood transfer
- Meternal fetal transmission
- Tattooing, sharing razors, acupuncture
Clinical manifestation
General nonspecific symptoms:
- Arthralgias
- Myalgias
- Pruritus
- Sensory neuropathy
- Symptoms of liver cirrhosis:
- Hepatic encephalopathy
- Ascites/ Ankle edema
- Hematemesis/Melena
Signs on clinical examination are in general the signs of advanced liver
disease:
- Icterus
- Spider nevi
- Palmar erythema
- Fetor hepaticus
- Finger clubbing
- Petechia
- Ascites/ caput medusa
- Gynecomastia/ small tests
- Signs of pruritus and scratching on skin
Diagnosis
To confirm the infection:
- HCV antibody, when positive HCV RNA (PCR)
- HCV antibody negative but clinical suspect HCV RNA or follow up controlling HCV antibodies every 2 months for 6 months.
- HCV genotyping:
o 1 (a,b,c); most spread worldwide 40-80%, associated with severe
disease and high rate an HCC
o 2 (a,b,c): besser response to medication
o 3 (a,b)-4-5-6
HCV antibodies
|
HCV RNA (PCR)
|
Meaning:
|
+
|
+
|
Active disease
|
+
|
-
|
No active disease
|
- but
suspect
|
Do PCR
RNA
|
Repeat HCV Antibodies
|
Other tests to do in general:
- Liver transaminase, Bilirubin
- Liver synthesis tests: albumin, quick, CHE
- Kidney tests
- CBC
- Thyroid function
- Screening for coinfection with HIV and Hepatitis B
- Screening for cryoglobulinemia: to be found in 50 % of cases
- Liver biopsy: to assess the liver fibrosis
- ultrasound of the liver
Treatment
Good to know:
Hepatitis C has become a curable disease with the use of antiviral agents (>95%)
There are two goals of the therapy: two goals
1-
To achieve sustained
eradication of HCV (SVR), which is defined as the persistent absence of HCV RNA
in serum 12 weeks after completing antiviral treatment.
2-
To prevent progression
to cirrhosis, hepatocellular carcinoma (HCC), and decompensated liver disease
requiring liver transplantation.
Old therapies:
- Interferon 1, Interferon 2a, Interferon 2b, PEG-Interferon 2a/2b
- Interferon+ Ribavirin 30-40% sustained virologic response (SVR)
- PEG-Interferon 2a + Ribavirin: standard dose for 48 months Gynotyp 1/ low dose Ribavirin for 24 months Genotype 2 or 3: 40-55% SVR
- SE: hematologic depression, Depression
- Interferon is NO longer recommended
Neu therapies:
- Direct antiviral agents (DAAs): target specifically various sites of viral replication: just for Patients over 18 years old.
- NS3/4 targeting protease inhibitors
·
Grazoprevir
·
Glecaprevir
- NS5B targeting polymerase inhibitors
·
Nucleotide: Sofosbuvir
·
Non-nucleotide: Dasabuvir
- NS5A targeting agents
·
Elbasvir
·
Velpatasvir
Considerations for the therapy:
- Before initiating the therapy HCV Genotype and resistance-associated substitutions (RASs) should be defined.
- Monitoring for spontaneous clearance for a minimum of 6 months before initiating treatment.
Some recommended regimes in naïve patients:
The daily fixed-dose combination of elbasvir (50 mg)/grazoprevir
(100 mg) (Zepatier) for 12 weeks: 94-97% SVR:
- With RASs: treat 16 weeks + Ribavirin
- Without RASs: treat 12 weeks without Ribavirin
- Contraindication: Liver cirrhosis CHILD B and C
The daily fixed-dose combination of sofosbuvir (400 mg)/velpatasvir
(Epclusa) (100 mg) for 12 weeks: 98-99%
SVR:
- Can be given regardless liver cirrhosis
One of the recommended regimes in decompensated liver
cirrhosis:
The daily fixed-dose combination of ledipasvir (90 mg)/sofosbuvir
(400 mg) with a low initial ribavirin dose (600 mg, increase as tolerated)/ or
weight-based Ribavirin for 12 weeks
Complications
Hepatic
complication:
- Liver cirrhosis
- Hepatocellular carcinoma HCC
Extrahepatic
complications:
- Cryoglobulinemia
- Membranoproliferative glomerulonephritis
- Idiopathic thrombocytopenic purpura
- Raynaud syndrome
- Sjögren syndrome
- Porphyria cutanea tarda
- Necrotizing cutaneous vasculitis
0 Comments