HEPATITIS C INFECTION
As hepatology NPs at the Portland [Oregon] VA Medical Center, we were pleased to see the recent update on hepatitis C (HCV) by Jennifer Eames, MPAS, PA-C (Clinician Reviews. 2012;22:16-21). This is a timely and important topic for primary care providers, especially given recent changes in screening and treatment recommendations for HCV.
However, we found parts of the article confusing, and even inaccurate, and would like to respectfully offer a number of concerns. Certain aspects of the article contradict professional practice guidelines for HCV management and treatment from the American Association for the Study of Liver Disease (AASLD) and the Veterans Administration.
Chronic HCV. In the introduction, the author states that HCV is often asymptomatic “until the disease converts to chronic form.” This is not true. Chronic HCV is simply defined as infection for longer than six months. In reality, the disease often remains asymptomatic for decades.
Hepatocellular cancer (HCC) screening. The author states that it is important to screen patients early for HCC, implying that everyone needs twice-yearly screening. However, HCC screening is currently recommended only for cirrhotic patients. The benefit of screening individuals with HCV and stage 3 fibrosis is uncertain (according to current AASLD guidelines).
Sensitivity of ultrasonography as HCC screening. The author states that the sensitivity of ultrasound and serum alpha-fetoprotein (AFP) used together for HCC screening is 100%, citing Gebo et al (Hepatology. 2002;36[5 suppl 1]:S84-S92). The study to which Ms. Eames refers was included in this systematic review of screening tests for HCC but is rated by Gebo et al as weak. Unfortunately, no currently available test or combination of tests has been found to be reliably 100% sensitive for HCC screening. AASLD practice guidelines for HCC (2010) report ultrasound screening alone to have a sensitivity of between 65% and 80% and specificity greater than 90% when used as a screening test.
Prognosis. The author states that antiviral therapy should be offered to people with HCV, “otherwise, serious, life-threatening complications can be expected.” AASLD guidelines state the risk for developing cirrhosis ranges from 5% to 25% over decades and do not recommend that everyone be treated with antiviral therapy. We believe the author’s statement is unnecessarily alarming; most people with chronic HCV live with the disease rather than die of its complications.
Details of hepatitis C treatment regimens. Table 2 implies that HCV genotype determines the brand of interferon to be used. However, neither AASLD nor VA guidelines differentiate between the two pegylated interferons based on genotype or efficacy.
HCV treatment of patients with underlying psychiatric illness. In Table 3, psychiatric illness is listed as a contraindication to treatment. However, although interferon-based therapy is known to have neuropsychiatric side effects, there is no contraindication to initiating treatment of people with well-managed depression, anxiety, substance abuse disorders, or other psychiatric illnesses, especially with good mental health support.
Betsy L. Zucker, RN, MSN, FNP-C, Hepatology Nurse Practitioner, and Patty Taylor-Young, PhD, RN, FNP-BC, Nurse Practitioner, Hepatology Clinic; Nurse Scientist, Nursing Research Department, Portland VA Medical Center, Portland, OR
I am thankful for this opportunity to discuss such important issues with peers. Dialogue and discourse on this topic are very important, as we strive for continued improvement in management of this disease.
Regarding their point marked “Chronic HCV,” Ms. Zucker and Dr. Taylor-Young are correct. This was an error in wording.
About screening for HCC, an updated guideline regarding HCC management was published in 2011 by Bruix and Sherman for the AASLD (Hepatology. 2011;53: 1020-1022). “Surveillance [for HCC] is deemed cost-effective if the expected HCC risk exceeds 1.5% per year in patients with hepatitis C … The recommended screening interval is 6 months,” the researchers conclude. Of note, patients with HCV are unaware of their fibrosis stage until they have undergone a liver biopsy. Many with cirrhosis present before decompensation (ie, without recognizable signs).
Additionally, regarding sensitivity and specificity of various screening modalities, different studies report different percentages. While Bruix and Sherman cite “analysis of recent studies [showing] that alpha-fetoprotein determination lacks adequate sensitivity and specificity for effective surveillance (and for diagnosis)” and conclude that “surveillance has to be based on ultrasound examination,” the take-home point is that imaging combined with AFP is an excellent screening tool.
As for “Prognosis,” many patients do not experience complications of HCV, but serious complications can arise. It is difficult to predict who may progress and develop complications and who will not. The goal is for no case to be ignored. Often, if treatment is delayed until patients develop advanced fibrosis or cirrhosis, treatment can be more difficult.
Ms. Zucker and Dr. Taylor-Young point out inaccuracies in Table 2, some of which are addressed in a “Corrections” box [see page 27]. It should be noted that the article was intended, not as a treatment guideline, but an update of available treatments for primary care clinicians—including the fact that two new agents, boceprevir and telaprevir, are available. Specific treatment decisions are made by specialists and are multifactorial. Certainly, the intricacies of therapy could constitute a whole different paper—or multiple papers.
The letter-writers make an excellent point regarding the use of interferon-based therapy in patients with psychiatric illness. Perhaps better wording would be that uncontrolled psychiatric illness should be treated to a stable state prior to start of interferon therapy, with close monitoring for any changes throughout therapy.
Jennifer Eames, MPAS, PA-C, Department of PA Studies, University of Texas Medical Branch, Galveston