The prevention, testing, treatment and management of
hepatitis C in primary care
Scope of the guidance
This item relays guidance on the prevention,
testing, treatment and management of hepatitis C in primary care.
It was produced by the collaboration of the RCGP Substance Misuse
Unit, the RCGP Sex, Drugs & HIV Task Group, Substance Misuse
Management in General Practice (SMMGP), the Hepatitis C Trust and
the UK Hepatitis C Resource Centre. The guidance is
aimed at GPs, practice nurses and other clinicians involved in the
care of patients who abuse drugs.
Source
Royal College of General Practitioners. Guidance for
the prevention, testing, treatment and management of hepatitis C in
primary care. London: RCGP; 2007.
www.smmgp.org.uk/download/guidance/guidance003.pdf
Key Points
1. Background
- HCV is a blood-borne ribonucleic acid (RNA)
virus - an important cause of liver disease.
- The effects of HCV infection vary: some
people remain symptom free, some develop cirrhosis and a few
develop liver failure or hepatocellular carcinoma (HCC).
- The prevalence of HCV is estimated to be
between 0.4-1.0% of the UK population (that is, 250,000 to 600,000
people).
- Based on an average list size of 1,800
patients, every full time GP is likely to have 8-18 infected
patients, partly depending upon the local population demographics.
However many of those with hepatitis C may be undiagnosed.
- Unlike hepatitis A and B, there is no vaccine
for HCV, but infection is preventable through strategies to reduce
its transmission.
- The major risks for infection in the UK are
mainly due to exposure to infected blood. Risks include: injecting
drug use (past or current), blood transfusion before 1991 or
receipt of other blood products before 1987, and medical or dental
treatment abroad. Other risk factors are unprotected sexual
exposure, vertical transmission from mother to baby, having a
tattoo or acupuncture with equipment that is not sterile, renal
failure requiring haemodialysis.
- Injecting drug users account for the largest
proportion of cases.
- Many people with HCV infection do not realise
that they have the virus as it can take years or even decades for
symptoms to appear. Early treatment clears the virus in most
cases.
2. Symptom and signs
o
Incubation period: six to nine weeks, but may take up to six months
before HCV antibody is detected.
o
Detection of HCV RNA (usually using a polymerase chain reaction
(PCR) test) may be the only marker in early infection.
o
Acute infection is usually asymptomatic but some people may become
briefly unwell with mild ‘flu like symptoms or nausea and vomiting
and rarely jaundice.
o
25% will clear the virus at the acute stage.
o
Approximately 75% develop chronic HCV, most without knowing that
they are infected.
o
Once patients develop chronic HCV they are at significant risk of
cirrhosis and HCC.
o
Most people will remain well and without symptoms for many
years. So the infection is difficult to recognise.
Patients may not become symptomatic until their liver disease is at
an advanced stage.
o
Where symptoms do occur, they include mild to severe fatigue,
muscle aches, nausea, depression or anxiety, pain or discomfort in
the liver and poor memory and concentration.
o
Many of these symptoms may come and go and may be wrongly diagnosed
as due to ongoing drug use or maybe chronic fatigue syndrome.
o Severity of symptoms does not
necessarily relate to the extent of liver damage.
o In patients where the
infection has progressed to cirrhosis (usually over a period of
20-40 years), complications can include oesophageal varices,
ascites, bleeding, hepatic encephalopathy. Cirrhosis can also
lead to hepatocellular carcinoma.
3. Predictors of disease progression
- Certain groups of people with chronic HCV
infection are more likely to progress to cirrhosis:
o
Alcohol: excessive alcohol strongly associated with progression to
severe liver complications.
o Age at infection: infection
at an older age progresses more rapidly to cirrhosis.
o
Gender: men are more likely to progress than women.
o Ethnicity: HCV progresses
less rapidly in black patients than non-blacks, and may be worse in
Asian patients.
o
Co-infection: patients who are also infected with HIV or hepatitis
A or B are likely to progress to serious disease more rapidly.
o Viral genotype: Different
genotypes of virus have no effect on progression to cirrhosis but
have different sensitivities to therapy.
o
Body mass index: a BMI > 25 is associated with hepatic steatosis
and in some studies more rapid disease progression.
o
Smoking: is an independent risk factor for disease progression in
patients with chronic HCV.
4. Testing in general practice
- Initial HCV antibody test: the first line test. It will
be positive for patients who have been infected with HCV at
sometime in the past and have cleared the virus in the acute
period.
- Detection of HCV RNA: if the antibody test is
positive, then you need to know whether the patient is still
infected by the HCV virus (and therefore has a chronic HCV
infection) or whether the patient has cleared the virus. The
HCV RNA blood test is usually done by a polymerase chair reaction
(PCR).
- Results:
o HCV antibody positive, but
HCV RNA negative: the patient should be re-tested in six
months. Meanwhile, discuss with the patient - preventing
re-infection, alcohol intake, injecting behaviour, etc.
o HCV antibody test equivocal:
further investigation if there are abnormal liver function tests,
or symptoms are suggestive of HCV infection.
o HCV antibody positive and HCV
RNA positive: these patients have chronic HCV infection and require
specialist care. Refer according to local arrangements:
hepatologist, gastroenterologist, or infectious disease
specialist.
- Other ‘baseline’ blood tests to carry
out:
o
Hepatitis A and B tests (Hep B: surface antigen, surface antibody,
core antibody, ‘e’ antibody) and an HIV test (after appropriate
pre-test discussion).
o
Full blood count – look for signs of high alcohol consumption.
o Electrolytes, creatinine,
calcium.
o
Liver function tests, especially alanine aminotransferase (ALT) and
gamma-glutamyl transferase (GGT).
o
Glucose.
o
Thyroid function tests – treatment with interferon can cause
thyroid dysfunction.
- Specialist tests which GPs may be asked to
do:
o
Genotype: a test to determine the type of the HCV.
o
Viral load: useful for seeing the response to treatment.
o Clotting studies: clotting
may be impaired if there is significant liver damage.
o
Alfa-fetoprotein (AFP): a test to look for progression to
HCC. A small increase in AFP is difficult to interpret.
o Others: immunoglobulins,
antinuclear antibodies (ANA), mitochondrial cell antibodies.
5. Management
o
Needle exchange programmes – definite evidence for reduction of HIV
infection rates, less good evidence for reduction of HCV infection
rates.
o Advice on strategies to move
away from injecting drugs e.g. methadone substitution
programmes
o
Advice on safe sex including condom use
o Infection control procedures
in healthcare settings to prevent needlestick injuries
o
Discussing alcohol consumption with all patients and providing
advice on stopping or cutting down, and treating any alcohol
problem.
o
Advice on smoking cessation; explaining to all HCV positive
patients that smoking can increase the rate of progression to
cirrhosis.
o
NICE recommends that all patients with chronic HCV should be
considered for treatment (irrespective of stage of disease, or
whether the patient is still injecting drugs).
o
Current treatment is a combination therapy of pegylated interferon
and ribavirin. It is successful in clearing HCV in 40-80% of
patients.
o
Treatment lasts 24-48 weeks, and involves a self-administered
subcutaneous injection of interferon once a week, plus a daily dose
of oral ribavirin.
o
Cautions and contraindications: ribavirin is teratogenic and causes
abnormalities in sperm; so two forms of contraception should be
used during treatment and for up to six months after treatment has
finished. Patients with renal failure should be carefully
monitored. There may be interactions with HIV drugs.
o
Side-effects include: lethargy, flu-like symptoms, headaches,
nausea, anaemia, other cytopenias, oral disease, insomnia and
depression.
Practical
tips for the busy GP >>
EGP 1. May 2008