Hepatitis C
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Chronic: Clinical or biochemical evidence of liver disease greater than 6 months duration.
B.One of the most common liver diseases.
C.Blood-borne disease of the liver caused by the hepatitis C virus.
D.70% to 85% of those infected develop chronic illness.
Incidence
A.According to the Centers for Disease Control and Prevention (CDC), estimates of new hepatitis C infections from 2015 were 33,900 in the United States.
B.Estimated prevalence is approximately 3.6 million people.
C.Accounts for 8,000 to 13,000 deaths each year in the United States.
D.Infection rates have dramatically increased among young adults in the past decade due to the opioid epidemic.
Pathogenesis
A.Transmission through blood from a contaminated individual or blood products.
B.After 1990, blood and blood products underwent screening.
Predisposing Factors
A.Intravenous (IV) drug use and needle sharing.
B.Healthcare worker.
C.Transfusion before 1990.
D.Body piercing and tattoos.
E.Shared razors.
F.Baby boomer—CDC recommendations to test those born between 1945 and 1965.
G.Dialysis patient.
H.Maternal history of hepatitis C virus (HCV)—vertical transmission rate is 5%.
Subjective Data
A.Common complaints/symptoms.
1.Most people have no symptoms.
2.Among those who do have symptoms, they complain of fatigue, muscle and joint pain, pruritus, nausea, loss of appetite, weakness, and weight loss.
B.Common/typical scenario.
1.Incidental diagnosis for elevated liver tests, insurance screening, or pneumocystis pneumonia (PCP) following CDC recommendations.
C.Family and social history.
1.Injection drug use.
2.Sexual or household contact.
3.Incarceration.
D.Review of systems.
1.In chronic illness, there are very few symptoms unless advanced to cirrhosis.
Physical Examination
A.Generally there are no obvious features of chronic hepatitis C unless cirrhosis is present.
Diagnostic Tests
A.Hepatitis C antibody.
B.Hepatitis C viral RNA quantitative level and genotype.
C.Screening tests to rule out coinfection for HIV or hepatitis B.
D.Complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), drug, and alcohol screen.
E.Imaging—Ultrasound or MRI if advanced disease present.
F.Procedure to assess the degree of fibrosis: Elastography (FibroScan), liver biopsy.
Differential Diagnosis
A.Autoimmune hepatitis.
B.Cholangitis.
C.Hepatitis A, B, D, and E.
Evaluation and Management
A.General plan.
1.Treatment with antiviral therapy is well tolerated and effective in curing the disease.
2.The decision to treat is based on genotype, the person’s overall health and comorbidities, and stage of fibrosis.
B.Patient/family teaching points.
1.If the decision is made to pursue antiviral treatment, medication adherence is essential to achieve optimal outcomes.
2.Skipping doses may lead to resistant strains and impact success of therapy.
3.Alcohol is prohibited as well as herbal supplements.
4.Successful treatment can mitigate progression to cirrhosis.
C.Pharmacotherapy.
1.Antiviral therapy—must be ordered by specialist. Drug options include: Harvoni, Epclusa, Vosevi, Mavyret, Zepatier, Ribavirin.
2.Common side effects: Usually mild and may include fatigue, headaches, or nausea.
D.Discharge instructions.
1.Follow-up with gastrointestinal (GI)/hepatologist.
2.Will need vaccinations for hepatitis A or B if indicated.
3.Avoid alcohol or any over-the-counter (OTC) supplements.
Follow-Up
A.GI/Hepatologist to initiate treatment and monitor therapy and side effects.
B.For the cirrhotic patient, biannual imaging of the liver to screen for hepatocellular cancer.
Consultation/Referral
A.GI/Hepatologist.
B.If they have hepatocellular carcinoma (HCC), will be referred to interventional radiology or oncology.
C.Consider transplant for any patient with decompensated cirrhosis or HCC.
Special/Geriatric Considerations
A.Decision to treat any dialysis patient is undertaken on a case-by-case basis.
B.A patient with HIV/hepatitis C coinfection may require changes in his or her highly active antiretroviral therapy (HAART) due to drug interactions with hepatitis C treatment.
C.Pregnancy is contraindicated for treatment.
Bibliography
Centers for Disease Control and Prevention. (n.d.). Hepatitis C information. Retrieved from https://www.cdc.gov/hepatitis/hcv/index.htm
Chopra, S., & Pockros, P. J. (2018, June 5). Overview of the management of chronic hepatitis C virus infection. In A. Bloom (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-management-of-chronic-hepatitis-c-virus-infection
Dhawan, V. K. (2019, January 17). Hepatitis C clinical presentation. In B. S. Anand (Ed.), Medscape. Retrieved from https://emedicine.medscape.com/article/177792-clinical