Hepatitis C Infection

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Contents

More Specific Terms

Introduction

Etiology

Epidemiology

  • worldwide problem
  • 1-2% of Americans; has surpassed HIV1 as a cause of death in the USA [38]
  • incidence of new infections appears to be declining
  • rarely spread sexually

Pathology

Genetics

Clinical-manifestations

  • most patients remain asymptomatic
  • acute hepatitis is uncommon
  • other skin manifestations:

Laboratory

  • 2nd generation tests available in 1993
  • insensitive for detection of acute HCV infection
  • antibody does not confer immunity
  • HCV is difficult to culture & no good small animal model is available [33]

Radiology

Complications

  • 25-30% progress to cirrhosis over a 20 year period

Management

  • symptomatic
  • combination therapy peginterferon alpha plus ribavirin
  • prior to therapy
  • 3 million units SC or IM 3 times/week
  • prolonged therapy for 12-18 months results in improved sustained responses compared with 6 months of therapy
  • 30-50% remission; 15-20% have sustained response
  • treatment of choice [29]
  • patients with prior treatment failure [18,26]
  • patients co-infected with HIV [21]
  • 20-27% of patients may have sustained antiviral response
  • 48 weeks as effective as 72 weeks for HCV type 1 [25]
  • 24 weeks of therapy for HCV type 2 & 3 [5]
  • response to therapy:
  • 5 million units daily for 4 weeks, then
  • 3 times weekly for 20 weeks
  • peginterferon alfa & ribavirin for 48 weeks
  • < 50% effective
  • telaprevir ( Incivek) in combination with peginterferon & ribavirin may shorten duration of therapy from 48 weeks to 24 weeks & improve response [36]
  • discontinue treatment of type 1 if HCV RNA levels don't decrease by at least log 2 after 12 weeks of treatment
  • types 2 & 3 more responsive to treatment than type 1 [13,21]
  • 12 weeks of therapy for types 2 or 3 sufficient for patients who test negative for HCV RNA after 4 weeks [22]
  • 24 weeks of therapy for types 2 & 3 [5]
  • alcohol is associated with more severe disease
  • patients should not donate blood
  • patients should not share razors or toothbrushes
  • open cuts should be covered
  • avoid unprotected sex during menstruation or in the presence of genital sores
  • progression of disease is slow
  • 10 year mortality is unchanged [10]
  • decision to treat is not urgent
  • safety of breast-feeding is not confirmed
  • risk of HCV transmission
  • follow-up yearly
  • disease progression over 20 years is low in patients without comorbitities [23,27]

Notes

  • Screening:
  • patients notified that they received blood from a donor identified as having HCV in the 'Look Back' program mandated by federal law
  • ref 16 reports that serology may be negative despite chronic HCV infection
  • USPSTF recommends against routine screening [17]
  • ref [40] seems to propose routine screening

More General Terms

Additional Terms

References

  1. Miller & Purcell Proc Natl Acad Sci U S A 1990 Mar;87(6): 2057-61
  2. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 369
  3. Kaiser Permanente Northern California, Hepatitis C Prevention & Screening Recommendations, 9/21/99
  4. Journal Watch vol 19 # 24, pg 193-94, Dec 15, 1999
  5. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
  6. Journal Watch 21(5):43, 2001 Harris DR et al The relationship of acute transfusion-associated hepatitis to the development of cirrhosis in the presence of alcohol abuse. Ann Intern Med 134:120, 2001 PMID: [1]
  7. Journal Watch 21(21):174, 2001 Manns MP et al Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. Lancet 358:958, 2001 PMID: [2]
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    - Hepatitis C virus (New York State Department of Health) ngc-guideline: [54]
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