Friday, 14 Dec 2018

You are here

The Consequences and Cure of Hepatitis C

I spent this past week seeing hepatitis C patients with our hepatologists, and being a rheumatologist, I was looking forward to seeing extra-hepatic manifestations of HCV that we read about in text-books - cryoglobulinemic vasculitis, sicca syndrome, porphyria cutanea tarda and many others. I suppose I should not be surprised that the week passed without seeing a single one of these. 

While a wide array of extra-hepatic manifestations, including may rheumatic rheumatologic, will occur in 40-70% of chronic HCV patients, the advent of direct acting antivirals (DAA) has changed HCV outcomes, such that I do not think we will be seeing these cases much longer. 

In the early days of HCV treatment with interferon therapy one could hope to achieve sustained virological response (SVR in 6% of patients, and with significant side effects. Now DAAs boast > 96% cure rates in 8-12 weeks, depending on the drug and presence or absence of cirrhosis. Some of the drugs are even pan-genotypic. 

What can we still do as rheumatologists? We can screen our rheumatology patients for hepatitis C. 

Yesterday I saw a new hepatitis C patient: 71 year old male with a history IV drug abuse in the 1970s and had 20 tattoos, who no one ever thought to screen for hepatitis C until he saw his new primary care doctor last week. In fact, the patient had never heard of hepatitis C before. 

The CDC currently recommends screening for hepatitis C in any adult born between 1945 and 1965, or if any history of IV drug use, hemodialysis, HIV, received products or organs before 1992 or have persistently elevated ALT levels. https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm 

In our rheumatology department, we screen all patients for hepatitis B prior to starting immunosuppression, and our hepatitis remote panel conveniently includes a hepatitis C antibody. If a patient is found to be positive, HCV viral load should be sent and if elevated referred to hepatology.

While there are currently many barriers to administering DAAs to cure hepatitis C (most centered around cost and insurance companies), the World Health Organization’s strategy to eliminate hepatitis C infection by 2020 seems overly ambitious, I do think we are well on our way. 

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Rheumatologists' Comments

One point not mentioned in the article is a false positive RF due to hepatitis C. I pick up two or three hepatitis C cases a year when a patient is referred to me with suspected RA because of arthralgias and a weakly positive RF.

More Like This

Genetic Diagnosis for Previously Undiagnosed Disorders

The NEJM has reported the NIH's Undiagnosed Diseases Network (UDN) study results of genetically identifying new diseases from prospectively followed persons with undiagnosed disorders. The UDN was formed in 2014 as a network of seven clinical sites, two sequencing cores, a coordinating center, central biorepository, a metabolomics core, and a model organisms screening center. It was established to apply a multidisciplinary model in the evaluation of the most challenging cases and to identify the biologic characteristics of newly discovered diseases.

SLE and Risk of Malignancy

The risk for cancer in systemic lupus erythematosus (SLE) patients has been inconsistently studied.  A new metanalysis shows that SLE has an increased risk for 16 specific cancers and decreased risk for prostate cancer and cutaneous melanoma. 

The Benefits of a Lupus Clinic

A comparative cohort study assessing the quality of care in patients with systemic lupus erythematosus (SLE) suggests that a dedicated lupus clinic has better quality measure performance compared to lupus management in a general rheumatology clinic.

A study from Rush University enrolled 150 consecutive SLE patients - with 73 followed in the general rheumatology clinic and 77 followed in a dedicated lupus clinic. 

Diagnosing Early Lupus from Mimics

A multicenter study of early systemic lupus erythematosus (SLE) patients examined manifestations at disease onset and found that certain clinical features can help to distinguish early SLE from other SLE‐mimicking conditions. 

High CV Risk in Lupus

Patients with systemic lupus erythematosus (SLE) remain at risk for accelerated atherosclerosis, and important questions have yet to be answered, British investigators reported.