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Review ArticleClinical Review

Hepatitis C for Primary Care Physicians

Miranda M. Huffman and Anne L. Mounsey
The Journal of the American Board of Family Medicine March 2014, 27 (2) 284-291; DOI: https://doi.org/10.3122/jabfm.2014.02.130165
Miranda M. Huffman
From the Department of Community and Family Medicine, University of Missouri–Kansas City (MMH); and the Department of Family Medicine, University of North Carolina at Chapel Hill (ALM).
MD, MEd
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Anne L. Mounsey
From the Department of Community and Family Medicine, University of Missouri–Kansas City (MMH); and the Department of Family Medicine, University of North Carolina at Chapel Hill (ALM).
MD
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Article Figures & Data

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    Figure 1.

    Diagnosing hepatitis C. EIA, enzyme immunoassay; RNA, ribonucleic acid; PCR, polymerase chain reaction.2,8

  • Figure 2.
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    Figure 2.

    Treatment of chronic hepatitis C genotype 1 with telaprevir-based therapy. Dual therapy, peginterferon + ribavirin; HCV, hepatitis C virus; RNA, ribonucleic acid; triple therapy, telaprevir + peginterferon + ribavirin (see Table 4 for dosing).

Tables

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    Table 1. Factors Influencing Patients at High Risk for Hepatitis C Infection5
    High Risk of ExposureKnown Exposure
    History of IV drug use or current IV drug userSexual partners and household contacts infected with hepatitis C
    History of incarcerationInfants born to mothers infected with hepatitis C
    Blood transfusion or solid-organ transplant before screening for hepatitis C (1992)Health care workers with needle-stick exposure
    Patients with hemophilia who received clotting factor transfusion before 1987
    Hemodialysis patients
    HIV-positive patients
    More than 20 sexual partners within lifetime
    • IV, intravenous; HIV, Human Immunodeficiency Virus.

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    Table 2. Absolute and Relative Contraindications for Treatment of Hepatitis C2
    Absolute Contraindications*Relative Contraindications†
    Major uncontrolled depressive illness‡Failed prior treatment (nonresponders and relapsers)
    Untreated thyroid disease‡Current users of illicit drugs or alcohol who are willing to participate in a substance abuse program or alcohol support program
    Solid-organ transplant (renal, heart, or lung)Evidence of either no or mild fibrosis on liver biopsy
    Autoimmune hepatitis or other autoimmune condition known to be exacerbated by peginterferon and ribavirinAcute hepatitis C
    Pregnant or unwilling to comply with adequate contraceptionCoinfection with HIV
    Severe concurrent medical disease such as severe hypertension, heart failure, significant coronary heart disease, poorly controlled diabetes, chronic obstructive pulmonary diseaseYounger than 18 years of age
    Age <2 yearsChronic renal disease (either requiring or not requiring hemodialysis)
    Known hypersensitivity to drugs used to treat hepatitis C virusDecompensated cirrhosis
    Liver transplant recipients
    • ↵* Therapy is currently contraindicated.

    • ↵† Therapy should be individualized.

    • ↵‡ Treatment may be considered after depression and thyroid disease are medically stable.

    • HIV, Human Immunodeficiency Virus.

    • View popup
    Table 3. Initial Testing for Patients With New Diagnosis of Hepatitis C by Primary Care Providers
    Evaluation of disease severity
        Quantitative HCV RNA level
        HCV genotype
        Serum aminotransferase levels
        Coagulation studies
        Complete blood count
        Liver biopsy (optional)
        Liver ultrasound (optional)
        Hepatitis B surface antigen
        Ferritin level
    Evaluation for contraindications to treatment
        Depression screening instrument, such as PHQ-912
        Alcohol abuse screening test, such as AUDIT-C13
        Urine drug screen
        Urine hCG in women of childbearing age
        HIV antibody
        Creatinine
        Thyroid function tests
        Antinuclear antibody to evaluate for autoimmune hepatitis
    Health maintenance
        Hepatitis A antibody
        Hepatitis B surface antibody
    • AUDIT-C, AUDIT Alcohol Consumption Questionnaire; hCG, human chorionic gonadotropin; HCV, hepatitis C virus; PHQ-9, 9-item Patient Health Questionnaire; RNA, ribonucleic acid.

    • View popup
    Table 4. Triple Therapy Dosing Regiments Based on Type of Peginterferon Selected
    TherapyRegimen 1Regimen 2
    Telaprevir750 mg every 8 hours with a non-low-fat meal750 mg every 8 hours with a non-low-fat meal
    Peginterferon-α2a; 180 μg subcutaneously every week2b; 1.5 μg/kg subcutaneously every week
    Ribavirin1000 mg daily if <75 kg
    1200 mg daily if >75 kg
    800 mg daily if <65kg
    1000 mg daily if >65 and <85 kg
    1200 mg daily if >85 kg and <105 kg
    1400 mg daily if >105 kg
    • View popup
    Table 5. Strength of Recommendation Taxonomy Table
    Strength of Recommendation
    Patients born between 1945 and 1965 or with risk factors should be screened for hepatitis C.B
    Patients for whom there is no contraindication should be offered treatment for hepatitis C.A
    Patients with the hepatitis C genotype 1 should be treated with triple therapy (peginterferon-α, ribavirin, and a protease inhibitor).A
    Patients without documented immunity to hepatitis A and B should be offered vaccination.C
    Patients with chronic hepatitis C should be encouraged to abstain from alcohol and offered treatment if needed.C
    Nonsteroidal anti-inflammatory drugs should be avoided in patients with cirrhosis. Acetaminophen and opioids can be used at low doses if needed.C
    Statin drugs may be used in patients with hepatitis C if serum aminotransferase levels are <5 times the upper limit of normal.C
    Patients with cirrhosis due to hepatitis C should be screened for hepatocellular carcinoma with annual ultrasound testing.C
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The Journal of the American Board of Family     Medicine: 27 (2)
The Journal of the American Board of Family Medicine
Vol. 27, Issue 2
March-April 2014
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Hepatitis C for Primary Care Physicians
Miranda M. Huffman, Anne L. Mounsey
The Journal of the American Board of Family Medicine Mar 2014, 27 (2) 284-291; DOI: 10.3122/jabfm.2014.02.130165

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Hepatitis C for Primary Care Physicians
Miranda M. Huffman, Anne L. Mounsey
The Journal of the American Board of Family Medicine Mar 2014, 27 (2) 284-291; DOI: 10.3122/jabfm.2014.02.130165
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