2019 Research Forum

Kern Medical, Bakersfield, CA Harleen Sandhu RA, Arash Heidari MD, Drew Mahoney MS III, Royce Johnson MD

A CASE OF HEPATITIS C: TWO DECADES OF WAITING FOR GODOT OR CURE

Conclusions • DAA have proven efficacy for chronic hepatitis C patients with shorter duration of treatment, fewer adverse effects, and higher cure rate. • SVR rate of approximately 99 percent • For patients with Genotype 1a and prior treatment failure, co-formulated Glecaprevir (HCV NS3/4A protease inhibitor)/ Pibrentasvi r (HCV NS5A inhibitor) is recommended as a first line regimen in non cirrhotic HCV genotype 1-6 patients. • Public education required to encourage patients with previous failed treatments regarding availability of the DAA. • Routine screening for HCC with USG abdomen and serum AFP levels every 6 months. References 1. Zeuzem S, Foster GR, Wang S, N Engl J Med. 2018;378(4):354. Glecaprevir- Pibrentasvir for 8 or 12 Weeks in HCV Genotype 1 or 3 Infection PMID 29365309. 2. Bedossa P, Poynard T. An algorithm for the grading of activity in chronic hepatitis C. The METAVIR cooperative Study Group. Hepatology 1996; 24:289. 3. Dennis L. Kasper, Anthony S. Fauci, Stephen L. Hauser, Harrison’s principles of internal medicine – 19th edition Chapter 344, pgs. 2040-2049. 4. Knodell RG, Ishak KG, Black WC, Formulation and application of a numerical scoring system for assessing histological activity in asymptomatic chronic active hepatitis. Hepatology. 1981;1(5):431. PMID 7308988 Acknowledgements We would like to thank our patient for consenting to let us use her health information for case presentation.

Objectives

Retrospective case report Materials and Methods

• Discussing a case of chronic hepatitis C with failed treatments 20 years prior and no progression to cirrhosis. Currently successfully treated with direct acting antiviral (DAA). • Evolution of treatment modalities to DAA with improvement in response rate from less than 20% in early 1990s to over 90% recently.

Case Description

• 56 years old Hispanic female with chronic hepatitis C, genotype 1a diagnosed 20 years prior, viral load of 1.7 million RNA copies, failed treatments with interferon, Interferon and ribavirin due to adverse effects of neutropenia. • Risk factor: exposure to reused needles in Mexico. • Liver biopsy from 20 years prior showed grade 3 - moderate lymphoplasmacytic piecemeal necrosis of all portal tracts and moderate lobular inflammation and necrosis with stage 4 - bridging fibrosis and nodular regeneration. • Repeat presentation in 2018 with viral load of 814,000 RNA copies, fibrosis score F3 , Activity score A3 . • Treated with DAA ( Glecaprevi r plus Pibrentasvir ) for 8 weeks with undetectable viral load. • SVR (sustained virologic response) achieved 12 weeks after completion of treatment.

• HCV: Single stranded RNA virus Introduction

Guide for Initial Treatment of HCV

1. Chronic HCV infection 2. Failed previous treatment with IFN and Ribavirin or contraindications to them. 3. At high risk of disease progression from untreated HCV • Advanced fibrosis (eg, Metavir stage F2) • Coexisting liver disease, cirrhosis • DM • Severe extra hepatic manifestations of HCV infection • HIV coinfection • Transplant recipients • Post liver transplant recurrence of HCV • HCC Indications of Treatment with DAA

Results

• Genotype determination is essential before initiation of treatment as the regimens, dosing, and duration of treatment vary across the genotypes.

HCV RNA viral load with different treatments

2000000

1734327

1800000

1600000

1400000

1200000

1000000

1000000

814000

800000

600000

400000

200000

43000

0

0

Initial presentation

After non pegylated IFN

After IFN and Ribavirin

Before DAA 12 weeks after DAA treatment completion

49