Hepatitis C Infection with Case

00:01 We'll move on to our next case.

00:04 A 37-year-old woman is seen in clinic after a recent diagnosis of hepatitis C infection.

00:10 She has a history of injection drug use 15 years ago.

00:13 She feels well and takes no medications.

00:16 Vitals and physical exam are normal.

00:19 Lab studies show the following: Her hepatitis C antibody is positive.

00:23 Her RNA, PCR is also positive with 1.2 million copies.

00:29 She has a positive hepatitis B surface antibody.

00:33 And her surface antigen and core antibody are both negative.

00:37 What is the best next step in management? So let's go through some key features here.

00:43 She has a known history of hepatitis C infection from her exposure to intravenous drug use.

00:50 She has a positive hepatitis C antibody and a positive viral load which indicates that she has an active infection.

00:59 She also has an isolated positive hep B surface antibody.

01:04 We will talk about what that means.

01:08 So, let's talk now about hepatitis C.

01:12 Hepatitis C begins with an acute infection.

01:15 A majority of patients will then go on to develop chronic inflammation and only a small proportion of patients will develop spontaneous cure, so this is in contrast to hepatitis B where most patients develop spontaneous cure.

01:31 Then, after chronic inflammation, a small minority will then go on to develop fibrosis and eventually, cirrhosis of the liver.

01:39 After patients have developed advanced fibrosis or cirrhosis, they are then at risk for cancer of the liver or hepatocellular cancer.

01:51 So hepatitis C is the most common blood-borne infections in the United States.

01:55 All adults 18 years and older should be screened for chronic infection at least once in their lifetime.

02:01 And patients are usually asymptomatic carriers of this infection.

02:06 So the treatment for hepatitis C has actually evolved quite a bit in the last 10 years.

02:12 We now have new therapies that are over 95% effective in allowing treatment for all individuals with hepatitis C.

02:21 The goal really is to stop disease progression, prevent cirrhosis and prevent the end-stage complications that occur with cirrhosis.

02:29 The initial direct acting antiviral regimens no longer fully depend on the patient’s hepatitis C genotype.

02:37 Preferred combinations include sofobuvir and velpatasvir or glecaprevir and pibrentasvir.

02:45 Alternatives, if these are not available, include elbasvir and grazoprevir or ledipasvir and sofosbuvir.

02:55 So now let's return to our case.

02:57 Our 37-year-old woman with a known hepatitis C infection from her IV drug use.

03:04 She has a positive antibody to hepatitis C and a positive viral load which indicate an active infection.

03:10 And we review now her positive hepatitis B surface antibody, because it's an isolation, indicates that she has had prior vaccine and immunity to hep B.

03:22 So, what is the best next step in management? We know that she has an active hepatitis C infection, so she should be treated for hepatitis C.

03:32 You can start with one of the preferred direct-acting antiviral combinations, and you’ll want to check her hepatitis C genotype (if it is easily accessible), as there may be some treatment considerations for certain genotypes.

03:46 And as part of the screening, you should obtain an abdominal ultrasound or transient elastography to screen for fibrosis.