Infectious Disease Compendium

Hepatitis C

Microbiology

Virus.

Here are the 2018 IDSA Guidelines.

6 genotypes, mostly 1 in the US, the worst is 3.

It has no latent reservoir, unlike other chronic viral infections. It is always replicating and mutating, in the cytosol.

Epidemiologic Risks

5 to 10 million US infected, around 2%.

Blood exposure for the most part, some sexual contact, especially in men who have sex with men (PubMed). And amateur tattoos (PubMed). Avoid amateur tats, but those who get their friends to do the tats probably are not particularly fastidious in the first place (PubMed).

The sex, drugs and rock 'n' roll have caught up with boomers (born between 1945 and 1965; wait, that includes me). The CDC suggests all boomers be tested for Hepatitis C.

This century the disease is shifting from male boomers to young drug users of both sexes.

The incidence of HCV transmission among couples was 3.6 per 10,000 person-years with an estimated risk per sexual encounter of 1 per 380,000 (PubMed).

5% of Hep C will be spread to newborn.

China has the most.

Meantime to seroconversion is 8-9 weeks.

25% have spontaneous resolution. Treat acute infection or wait to see if it goes away in 6 months.

5% will get disease from a needle stick.

20% will have symptoms.

Diagnosis

Screen all boomers (1945 to 1965) and risk behaviors.

Check antibody, and if positive, viral load.

There is a finger stick that gives an answer 15 minutes; great for mass screening.

The average viral load is 2 million but the load does NOT correlate with disease.

Needs to stage the disease for how much cirrhosis for long term prognosis. No need to biopsy. Inflammation is grade, fibrosis is stage.

Look for nodularity on Fibroscan.

There are a variety of lab tests.

Don't worry about resistance in 2019/

Syndromes

Hepatitis, often chronic (Review)leading to cirrhosis.

Liver cancer, in 1-7% a year in cirrhosis, need screening q 6 months with US and AFP.

Interesting immunologic complications like mixed cryoglobulinemia (10-25% of patients), glomerulonephritis, aplastic anemia, B-cell lymphoma, porphyria cutaneous tarda, lichen plantis, necrotizing vasculitis, and hepatic carcinoma.

Hepatitis C patients also have a higher risk of MI (PubMed).

Treatment

Here are the 2018 IDSA Guidelines. Go there for specifics for who gets what.

It is a curative treatment. Relapse is reinfection. If it is going to relapse after therapy it will be in 4 weeks.

Side effects < 1 %, require little follow-up: at start and end.

All have 95-98% cure rate; which one to use may depend on what the insurance pays for. Lots of drug-drug interactions.

Don't use protease inhibitors in decompensated cirrhosis, but they should be treated by hepatologist/transplant center.

Protease inhibitor antiviral medications (NS3/4A inhibitors)

paritaprevir, for genotype 1

simeprevir (Olysio), for genotypes 1 and 4

grazoprevir, for genotypes 1 and 4

Protease inhibitors (NS5A inhibitors) These drugs are used to treat all HCV genotypes

ledipasvir (part of the combination drug Harvoni)

ombitasvir (part of the combination drug Viekira Pak)

elbasvir (part of of the combination drug Zepatier)

daclatasvir (Daklinza)

Nucleotide/nucleoside and nonnucleoside polymerase inhibitors (NS5B inhibitors)

sofosbuvir (Sovaldi)

dasabuvir

Combination drugs

Ledipasvir-sofosbuvir (Harvoni)

Dasabuvir-ombitasvir-paritaprevir-ritonavir (Viekira Pak)

Elbasvir-grazoprevir (Zepatier)

Ombitasvir-paritaprevir-ritonavir (Technivie)

Sofosbuvir-velpatasvir (Epclusa)

Sofosbuvir-velpatasvir-voxilaprevir (Vosevi)

Glecaprevir-pibrentasvir (Mavyret)

Notes

Tattoo inks can be virucidal; when getting your tat make sure you use the right ink (PubMed).

Low testosterone common.

Using herbal medicine containing aristolochic acid increases the risk of primary liver cancer (PubMed). Traditional Chinese Pseudo-Medicine at work again.

Check for B before C as it can reactivate.

Last Update: 10/12/19.