"Diagnosis, management, and treatment of hepatitis C: An update"

[Marc1955]

Sorry if this has already been posted, but I wanted to let the group know that the April 2009 issue of Hepatology includes a very long detailed article about current diagnosis, treatment, and patient management issues regarding HCV:

Diagnosis, management, and treatment of hepatitis C: An update (p 1335-1374)
Marc G. Ghany, Doris B. Strader, David L. Thomas, Leonard B. Seeff

It is written as a guide to the medical community. The article seems quite thorough and full of useful information. It brings together a great deal of research and discusses a wide range of topics including treatment of hard to treat groups and children. I suspect folks on this board will be making reference to it for some time to come. (Among other things it discusses extension of treatment to 72 weeks for slow responders, which may be helpful with some of our insurance companies.)

Unfortunately I can't figure out any way to get the body of the article to you folks. I have access through a university library, but my attempts to download the PDF have been unsuccessful. Maybe someone more tech-savvy than me can help.

Here is the "preamble" to the article:

"These recommendations provide a data-supported approach to establishing guidelines. They are based on the following: (1) a formal review and analysis of the recently published world literature on the topic (Medline search up to September 2008); (2) the American College of Physicians' Manual for Assessing Health Practices and Designing Practice Guidelines;[1] (3) guideline policies, including the American Association for the Study of Liver Diseases' (AASLD) Policy on the Development and Use of Practice Guidelines and the American Gastroenterological Association's Policy Statement on the Use of Medical Practice Guidelines;[2] and (4) the experience of the authors in regard to hepatitis C.

"Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic and preventive aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies to be followed in every case. Specific recommendations are based on relevant published information. To more fully characterize the quality of evidence supporting recommendations, the Practice Guidelines Committee of the AASLD requires a Class (reflecting benefit versus risk) and Level (assessing strength or certainty) of Evidence to be assigned and reported with each recommendation (Table 1, adapted from the American College of Cardiology and the American Heart association Practice Guidelines)

I think many on this board will find it helpful reading.

[CoWriter]

Thank you Mark!

I was excited when I started reading.....now I have to go count to ten....LOL

Re: Risk factors, they said....

"body piercing, tattooing and commercial barbering are potential modes for transmission of HCV infection"

But then they say.......

"Transmission of HCV infection by body piercing is, however, rare and many HCV infected persons who have undergone body piercing acquired their infection by other means.  Therefore, there is no need to routinely test persons who have received tattoos or undergone piercings in the absence of other risk factors"

Let me get this straight.....
HCV infection by body piercing is rare....therefore, there's no need to test people who have tattoos.

Well....that makes sense....LOL

And how do they know that people got HCV by "other means" and not piercings?  They love to blame you guys for drug use.  

"Because symptoms are generally absent in individuals with chronic HCV infection, recognition of infection requires risk factor screening, which should be done whenever it is possible to link with appropriate HCV testing and counseling."

Recognition of infection requires risk factor screening.....and since tattoos and body piercings and considered risk factors, I guess he's recommending getting tested after all.....LOL

And once more, they forgot to list MILITARY SERVICE as a risk factor.....even though Veterans have the highest rate of infection.  
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On Table 2....Comparison between Peg products....It's interesting that the SVR is the same even though PegIntron used only 800mg of Riba and Pegasys used 1000mg-1200mg (and relapse rate was also the same for both).

EOT  PegIntron 67%,  Pegasys 69%
SVR  PegIntron 54%,  Pegasys 56%
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On the data on "Studies Comparing Short Versus Standard Therapy Based Upon RVR in Genotype 2 and 3 Patients".....

The dose of PegIntron used was 1mg/Kg which is a suboptimal dose not routinely used.  So that data is worthless.  And they should standarize the term "low viral load".  One study considered <200,000 a "low viral load" while another one said <600,000 .... and I've seen some studies use <400,000.

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On the section on Non-responders, it says.....
"Approximately thirty percent of patients treated with pegylated interferon and ribavirin are unable to clear virus from the serum"

30%?  Yeah, right.....and they probably used the 1mg/Kg dose....LOL
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Re: Hep A.....
"A single report has suggested that superimposition of hepatitis A virus infection in persons with chronic liver disease, particularly those with hepatitis C, was associated with fulminant hepatitis"

But there was also a case where Hep A superinfection caused the HCV viral load to become undetectable......

"Clearance of HCV RNA following acute hepatitis A superinfection."
http://www.ncbi.nlm.nih.gov/sites/entrez

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And the most important host factor in the prediction of Tx response gets mentioned ONCE....

"Additionally, weight reduction and improvement in insulin resistance may improve the response to peginterferon plus ribavirin therapy. This is sound advice for its potentially positive impact not only on the liver disease but also on the other conditions associated with being overweight."

They didn't say how important IR is or the huge number of studies that have shown it lowers SVR...or that trials are being done on insulin sensitizers....

And they certainly didn't recommend TESTING for IR.  So doctors will continue to refuse to do it.

That really makes me mad.

Co
P.S. These guidelines may help people who want to either decrease or increase the length of Tx....so I'll save that section ; )  

[newleaf09]

I really, really want to thank you again for posting the latest (Dec. 09) AASLD guidelines.  After I found it, I read it and it answered a huge mystery for me.  This was the part of the para. that answered my mystery:

"The SVR rate was 89% in patients who achieved an RVR and 19% in those who did not achieve an RVR, and was similar among those treated for 24 or 48 weeks.[104] Features predictive of an RVR were a low baseline viral load (200,000 IU/mL) and HCV subtype 1b."

I went into treatment 5 months ago and had a bizarre (but happy) start.  I'm in a Boceprevir trial and it has a 1 month lead-in with SOC before starting the trial protease inhibitor.  I had NO physical reaction to the interferon (no flu symptoms, injection site reaction), which alarmed me and doctor.  I have cirrhosis (caused by taking high doses of Aleve and unwittingly adding alcohol).  Doctor thought and, stupidly, told me that no physical interferon reaction meant I might not respond, mostly because of the cirrhosis.  Then very 1st PCR came back Undetectable.  I started with very low VL (89,000) and have no doubts that my immune system has been holding down the virus since I had an acute case in 1971.  I am geno 1b.  The article, if I had seen it before I started treatment, would have relieved a LOT of anxiety (though getting a clean PCR so early did the same thing).  Now the mystery is answered by the AASLD article.  Low VL and 1b trump cirrhosis.  Thank you so much for posting it.

Treatment is bearable but also a bit miserable.  Having positive reinforcement guarantees you can make it to the end, no matter what.

[newleaf09]

http://www3.interscience.wiley.com/cgi-bin/fulltext/121542372/HTMLSTART
Ask and you shall receive.  EVERYTHING is on the internet.  If this link won't work (I have trouble with the links on this site) back up to http://www3.interscience.wiley.com/journal/106570044/home?CRETRY=1&SRETRY=0 or google the name of the article.

Thanks for posting it.