Hepatitis C for Primary Care Physicians

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Figure 1.
Diagnosing hepatitis C. EIA, enzyme immunoassay; RNA, ribonucleic acid; PCR, polymerase chain reaction.^2,8
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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).

Table 1. Factors Influencing Patients at High Risk for Hepatitis C Infection⁵

High Risk of Exposure	Known Exposure
History of IV drug use or current IV drug user	Sexual partners and household contacts infected with hepatitis C
History of incarceration	Infants 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

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 ribavirin	Acute hepatitis C
Pregnant or unwilling to comply with adequate contraception	Coinfection with HIV
Severe concurrent medical disease such as severe hypertension, heart failure, significant coronary heart disease, poorly controlled diabetes, chronic obstructive pulmonary disease	Younger than 18 years of age
Age <2 years	Chronic renal disease (either requiring or not requiring hemodialysis)
Known hypersensitivity to drugs used to treat hepatitis C virus	Decompensated 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.

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.

Table 4. Triple Therapy Dosing Regiments Based on Type of Peginterferon Selected

Therapy	Regimen 1	Regimen 2
Telaprevir	750 mg every 8 hours with a non-low-fat meal	750 mg every 8 hours with a non-low-fat meal
Peginterferon-α	2a; 180 μg subcutaneously every week	2b; 1.5 μg/kg subcutaneously every week
Ribavirin	1000 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

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