Managing Multiple Diseases Hepatitis B

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Managing Multiple DiseasesHepatitis B C

• Kathleen Clanon, M.D., F.A.C.P.

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Audience Survey

• Audience demographics I am
• MD/DO
• ARNP/PA
• RN/LPN
• Medical Assistant
• Other

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Audience Survey

• HIV experience I/We care for ___HIV pts.
• lt20
• 21-100
• 101-300
• 301-500
• gt500

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Audience Survey

• Number of years you have been caring for HIV
• lt1 yr
• 1 to lt4 yrs
• 4 to lt10 yrs
• 10 to lt20 yrs
• gt20 years

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Audience Demographics

• Type of practice in which you work
• Infectious Disease
• Internal Medicine
• Family Practice
• Gastroenterology/Hepatology
• General Practice
• Other

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Hepatitis C and HIV

• How do you manage the coinfected patient with
  Hepatitis C in your HIV practice
• All patients are referred to a Hepatologist for
  treatment
• All patients are treated as a part of our HIV
  practice within our office
• A combination of 1 and 2 above

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Hepatitis C and HIV

• If you do not treat Hepatitis C as a part of your
  HIV practice, which of the following best
  describes why
• Lack of knowledge to be comfortable in providing
  the service
• Lack of time within the scope of the practice to
  take on this additional treatment issue
• Lack of support staff within the practice to
  educate and monitor the patients
• This care is best provided by an
  expert/specialist in issues of Hepatitis
  evaluation and treatment.

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HIV and Hepatitis C

• 47 y/o white male, known HIV since 12/2000
• Pre-HAART CD4 210 and VL gt100,000
• Onset ARV therapy 2002 with NVP CBV
• CD4 has remained stable at 4-500 range and VLlt50
  copies for gt2yr
• Comorbid conditions diabetes Type II well
  controlled on insulin (normal HgbA1c) Hepatitis
  C infection past history depression and suicide
  attempt

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• Depression/suicide attempt was 2 years ago during
  a time of severe stress homeless, using drugs,
  loss of relationship and job.
• Patient adamant no depression since and that
  episode above was related to his despondency and
  life changes related to substance abuse.
• 2 years recovered without relapse of IDU
• No alcohol intake

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• What are your feelings about IFN/RBV treatment in
  this patient?
• Treatment should not be considered due to the
  past history of suicide attempt
• Treatment should be withheld until psychiatric
  evaluation and release for treatment can be
  obtained
• Prophylactic use of antidepressant therapy should
  be prescribed, pre-treatment and regular
  depression scale evaluations should be done
  during treatment and treatment should not be
  withheld if mental health assistance is not
  available

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HIV and Hepatitis C_2

• Hepatitis C genotype 1
• Stable hepatitis C VL in the 50-100,000 range
  until 6 months ago when Hep C VL of 35,800,000
  copies/mL
• Transaminases were stable 1X ULN and now
  repeatedly 2-3 X ULN
• No new drugs/OTC/intercurrent illness/ETOH/and
  Physical Exam remains normal

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• You recommend a Liver Biopsy and consideration of
  treatment of his Hepatitis C infection. The
  patient really wants his Hepatitis treated. You
  order prescreening hepatitis C labs. The patient
  refuses Liver biopsy. At this point
• Hepatitis C therapy should not be considered
  without a baseline liver biopsy
• Order FibroScan in place of the liver biopsy
• Assure the patient understands the rationale for
  liver biopsy and future implications of not
  having the baseline test but proceed with the
  workup and treat the patient with IFN/RBV
• 2 and 3 above

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• Hepatitis A total Ab is negative
• Hepatitis B Surface Antigen is Neg Surface
  Antibody is Positive, Core Ab is Positive
• ANA negative
• PT and PTT are normal, as is platelet count
• Alpha-fetoprotein is normal, liver ultrasound
  without abnormality although liver mildly
  enlarged
• TSH and thyroid profile are normal
• CBC is normal except Hgb of 12, normocytic,
  normochromic and Fe and Ferritin are WNL

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• Considerations at this point and time
• Hepatitis A vaccination should be started
• The patient should begin pegIFN/RBV therapy
• Prior to starting pegIFN/RBV, the ARV regimen
  (NVP CBV) should be changed
• 1 and 3 above

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• The patient receives his Hepatitis A vaccination
  and ARV therapy is changed to Atazanavir
  Emtricitabine/Tenofovir FDC. Six weeks later his
  VL lt50 and CD4 now 530 with Hgb of 13.9
• Patient is stable on Paroxetine Therapy and
  Pegylated Interferon and Ribavirin therapy is
  started
• At week four epoetin is added due to a 2 g drop
  in Hgb from baseline

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• At week 12, the patients Hepatitis C Viral Load
  is 22,500,000 (just over a 2 log drop). He has
  made it though the therapy but has had to take a
  leave of absence from work due to overwhelming
  fatigue, and insomnia. He has lost 10lbs due to
  anorexia. At this point
• The interferon dose should be increased by 25 to
  boost treatment response
• Treatment should continue as there has been a 2
  log drop in the Hepatitis C viral load
• Consideration should be given to stop therapy as
  the Hepatitis C Viral load is not undetectable
  and the chance of successful therapy is
  statistically less
• Treatment should continue in hopes of a
  histologic response despite lack of virologic
  response

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HIV and Hepatitis B infection

• 41 y/o Caucasian male HIV positive since 1995
  currently on first ARV regimen of Kaletra and
  Combivir
• Known Hepatitis B Surface Antigen Hepatitis E
  Surface Antigen Hep B core and surface
  antibodies are still recently Neg.
• Pt. is bipolar and poorly controlled with issues
  of missing one dose of ARV meds occasionally

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Hepatitis B HIV

• VL confirmed elevated at gt20,000 copies and CD4
  remains gt400 cells/mm3
• His hepatic transaminases remain lt2X ULN and his
  Hepatitis B DNA PCR remains chronically elevated
  but no evidence of decompensated liver disease
• Patient feels he can improve ARV compliance with
  a once daily regimen.

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Which of the following would you recommend?

• LPV/r 4 tabs once daily TDF/FTC FDC
• EFV ABC/3TC
• ATV TDF/FTC FDC
• NVP qd TDF/FTC FDC
• fos-APV qd RTV ABC ddI

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Hepatitis B HIV

• The patient is changed to LPV qd plus TDF/FTC FDC
  which he tolerates well and has excellent
  compliance and HIV virologic control but within
  the year loses Hepatitis B viral control again

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What is your next recommendation for treatment of
Hepatitis B

• Refer to a liver specialist for evaluation and
  treatment
• Add 3TC to current regimen
• Begin interferon therapy
• Add Entecavir to current therapy
• I do not know what to do