Friday, 22 Mar 2019

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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. 

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. 


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.

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