2. Case 1 (used for small group discussion)
• Mr A B is a 52 y old male, 130 pounds, he has been diagnosed with
Hep C Virus infection in 2010 and presented to you with Hep C ab
positive test.
• He comes one year later telling you he travelled abroad and has been
put on Pegylated interferon (Pegasys ) 180 Microgram weekly and of
Ribavirin 800 mg po daily for 48 weeks because of anaemia, but he
relapsed.
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3. Case 1 (continued)
• -What would you have done when patient first presented with
positive antibody test for HCV?
• -Why do you think this patient may have failed her first HCV therapy?
• -What other risk factor does this patient have for liver injury besides
her HCV?
• -How would you treat this patient now?
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4. Case 2 (used for small group discussion)
• Mrs CD is 76 years old, 76 kg, was diagnosed with Hep C and treated
in Belgium with Peg interferon and ribavirin in 2006, did not respond
to therapy, was tried again at YGH in 2012, did not respond. She is
with a good functional status.
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5. Case 2 (continued)
• Why do you think patient may have failed her first HCV therapy?
• Does this patient have contraindications (relative or otherwise) to
therapy?
• What other testing should be done for this patient prior to
retreatment?
• How would you retreat this patient now?
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6. Case 3 (used for small group discussion)
• Mrs EF is 45 years old with Diabetes Mellitus type I, on hemodialysis,
paid for by insurance, she is known with Hepatitis C for last 10 y , not
yet on treatment. She had heard about the new treatment with DAA
and comes to you requesting to be treated.
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7. Case 3 (continued)
• What are the likely etiologies for this patient’s end stage renal
disease?
• What other co-morbid risks does this patient have?
• What are the treatment options/approaches to this patient?
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8. Case 4
• 45yo female
• Medical history significant for Hepatitis C genotype 3
• No other major medical problems
• Drinks wine 2-3 times weekly
• Has never been treated for HCV
• Viral load is 5 million
• What should you ask in the medical history for this patient?
• What should you look for on physical exam for this patient?
• What labs would you order for this patient as part of your assessment?
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9. Myanmar Staging Protocol
Patient has confirmed chronic HCV infection
Patient has APRI > 1.5 and
no physical signs of
decompensation (cirrhotic)
Patient has APRI < 1.5 and
no physical signs of
decompensation (non-cirrhotic)
Patient has physical signs
of decompensation +/-
APRI > 1.5
Refer to specialist Treat by generalist Treat by Generalist
Note: Duration of treatment is dependent on regimen. Any patient previously treated for HCV should be seen by a specialist.
• Clinical examination
• HIV status
• HBsAg
• Staging of liver
fibrosis (APRI score)
• Liver function test
• Complete blood count
• Renal function –
Creatinine
Recommended
Pretreatment
assessment
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10. Complete medical history
• Identify risk factors for their infection
• Identify if significant medical comorbidities (anemia, renal)
• Identify if significant medical co-infections (HIV, HAV, HBV)
• Identify extrahepatic manifestations
• Identify if pregnant or planning to get pregnant
• Review alcohol history and provide counsel as needed
• Review injecting drug use history and provide counsel as needed
• Review psychiatric history and provide counsel as needed
• Calculate BMI and provide counsel if >25
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11. Complete physical exam
•Perform complete physical exam, especially:
• Calculate BMI
•Look for:
• Spider nevi
• Distended abdominal veins and caput medusa
• Palmar erythema
• Jaundice
• Gynecomastia
• Wasting
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18. Optimal Other Testing & Immunization
•Immunize for HAV and HBV, if available and not
already immunized
•Test for HIV and HBV, if available
•Test for pregnancy if likely to be pregnant
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19. • Physical Exam:
• No Ascites
• No encephalopathy
• No lower extremity edema
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20. How do you want to treat?
• A. Sofosbuvir + Velpatasvir for 12 weeks?
• B. Sofosbuvir + Daclatasvir+ RBV for 12 weeks?
• C. Sofosbuvir + Daclatasvir for 12 weeks?
• D. Sofosbuvir + Daclatsavir for 24 weeks?
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21. Case 5
• 45yo male
• Medical history significant for Hepatitis C genotype 1
• No other major medical problems
• Drinks wine 2-3 times daily
• Previously treated for HCV one year ago with SOF/RBV
• What should you ask in the medical history for this patient?
• What should you look for on physical exam for this patient?
• What labs would you order for this patient as part of your
assessment?
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22. Distended abdominal veins and caput medusa
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24. Myanmar HCV Protocol Rationale
Patient has APRI of > 1.5 and no
physical signs of decompensation
Patient has APRI of < 1.5 and
no physical signs of
decompensation
Patient has physical signs of
decompensation +/- APRI > 1.5
Refer to specialist
Generalist can treat &
monitor for signs of
decompensation; if decomp -> refer
Generalist can treat
• Patient is very ill with high
mortality risk
• Treatment success is less likely
• Patient will need extra monitoring
• Patient will need other specialist
services to care for their disease
• Treatment success probability is
high, but may not be achieved in 12
weeks for all genotypes
• Patient has lower risk of side effects
or drug-induced decompensation
• Patient doesn’t have clinical issues
needing specialist management
• Treatment success probability
is high across all genotypes in
short duration
• Low risk of side effects
• Patient does not have clinical
issues needing specialist
management
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25. • Physical Exam:
• No Ascites
• No Asterixis
• No Lower extremity edema
• APRI score consistent with F4
disease
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26. How do you want to treat?
• A. Sofosbuvir + Velpatasvir for 12 weeks?
• B. Sofosbuvir + Daclatasvir+ RBV for 24 weeks?
• C. Sofosbuvir + Ledipasvir + RBV for 12 weeks?
• D. Sofosbuvir + Daclatsavir for 12 weeks?
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27. What other issues should you address?
• Alcohol cessation
• Dietary and nutritional recommendations
• Others?
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