Hepatitis C

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Hepatitis C
2
49 year old woman

• Hx of depression, acne, Raynauds,
  hypothyroidism.
• Minocycline, Fluoxetine, Levothyroxine,
  Paracetamol
• 2 week Hx of general malaise, myalgia, anorexia,
  nausea, fever, cough. No specific symptoms.
• Pale, normal general, CVS, Resp and GI
  examinations

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Blood Results

• Hb 12.1, WCC 2.7 (Ne 1.6), Plt 336
• Na 138, K3.9, U 3.5, Cr 54
• ALT 586, Bil 34, AP 364, Alb 42
• CRP 14

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Fast-Track Jaundice Clinic

• No jaundice
• Normal urine and stools
• Normal USS
• Previous blood transfusion in 1985
• Hx consistent with viral infection or Minocycline
  use

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Why should we be interested?

• BMJ 2007 Most cases are undiagnosed
• Treatable disease
• Family Planning 2006
• Primary Care important setting for case finding
• Cost effective
• In Tayside 1700 diagnosed. A further 3000 cases
  go undiagnosed
• New SIGN and NICE guidelines within last year

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What is it?

• Blood-borne, infectious, viral disease
• Can remain viable outside the body
• Causes liver inflammation (often asymptomatic)
• Acute infection (first 6 months) 15 20
  symptomatic
• Fatigue, anorexia, abdo pain, jaundice and
  itching, flu-like symptoms
• 20-30 clear the virus in first 6 months
• Remaining 70-80 develop chronic (6 months)
  infection
• Chronic infection leads to cirrhosis
• 1-4 p.a develop hepatocelluar Ca.

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How do you catch it?

• Blood transfusions/blood products
• Dirty needles (10 times commoner in IVDUs than
  HIV)
• Vertical transmission
• Very little incidence of sexual transmission
• Former drug users 35yrs at greatest risk (may
  only have injected once)

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Who should be tested?

• According to latest SIGN guidelines
• Past or present IVDU
• Blood transfusion/products pre 1987
• BTs, tatoos, medical or dental treatment in
  developing countries
• Contacts of any of these
• Unexplained raised ALT
• Healthcare workers exposure prone treatments
• Patients on haemodialysis
• People wit HIV

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Benefits of testing

• Availability of treatment
• Success of treatment
• Prevention of secondary transmission
• Disease modifying factors

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Testing

• 2 tests available Antibodies (1 yellow top tube)
• Viral RNA PCR (2 purple top tubes)

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Referral

• Should be considered for all patients
• Specialist treatment important even if supportive
• Treatment given during acute phase more
  successful
• Multidisciplinary care should be offered
• Increases uptake when lifestyles are chaotic
• Often drug/alcohol abuse

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Treatment

• Current treatment is (oral ribavarin) and weekly
  interferon for 6 to 12 months.
• Trials show cure rates of 50-80
• Until recently only those with mod-severe
  symptoms being treated
• Now recommended that mild infection should also
  be treated
• Treat 3 to 6 months after diagnosing acute Hep C
  (for 24 weeks)
• 4 genotypes of chronic 12-24 weeks for genotypes
  2 or 3
• 48 weeks for genotype 1 or 4

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Improved Treatment Success

• Genotype 2 or 3
• Less fibrosis in liver
• Gender better if female
• Age better if younger
• Smaller viral load
• Lower body weight

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Adverse Effects

• Flu-like symptoms (advise paracetamol)
• Anaemia
• Depression
• Skin reactions
• Thyroid dysfunction
• Retinopathy
• Alopecia

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Progression of Disease

• Age, gender and ethnicity
• BMI 25
• Tobacco smoking
• Alcohol
• ALT
• HIV co-infection

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Summary The Role of the GP

• Prevention primary and secondary traansmission
• Detection awareness of at-risk groups
• Knowledge of presenting symptoms
• Testing
• Treatment and its adverse effects
• Monitoring
• Disease modifying factors
• Support

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