Practice Pearl 1: Understanding Misconceptions of Hepatitis C
A review of the common misconceptions of hepatitis C reviewed by the experts in the field.
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Christian B. Ramers, MD, MPH, AAHIVS: One thing I hear in the clinic sometimes is that patients think that when they get their hepatitis C treated, it's just dormant. Chris, could you comment about if you get a cure from hepatitis C, does that mean that hepatitis C is still there?
Christopher Hulstein, PharmD, CSP: No, your body has fully cleared the virus at that point. We've seen long-term studies going out past 5 years that continue checking viral loads following treatment with the new direct-acting antivirals, and the viral loads remain 0. The antibody will be positive because they've been exposed, but there's no virus left in your liver, viremic. There's nothing there anymore.
Christian B. Ramers, MD, MPH, AAHIVS: The word dormant does really apply to hepatitis C.
Christopher Hulstein, PharmD, CSP: Not C.
Christian B. Ramers, MD, MPH, AAHIVS: Maybe with B.
Christopher Hulstein, PharmD, CSP: That's correct.
Christian B. Ramers, MD, MPH, AAHIVS: With C, if it's gone, it's gone.
Christopher Hulstein, PharmD, CSP: Correct.
Christian B. Ramers, MD, MPH, AAHIVS: Another sort of misperception here is: Do people need to have cirrhosis in order to be treated? Caroline?
Caroline Derrick, PharmD, BCPS: No, currently the standard of care is to treat everyone. If you have a positive test for hepatitis C, RNA is present, let's go ahead and get you on treatment. You do not need to wait for some sort of fibrosis or cirrhosis to occur. We can go ahead and try to get all patients on treatment. That's really what the guidelines and everyone is pushing toward, so we can help prevent new cases of hepatitis C.
Christian B. Ramers, MD, MPH, AAHIVS: Another common thought is: Do you need to be a specialist in order to treat? Bhavesh, in your system in Massachusetts, are all your treaters liver specialists?
Bhavesh Shah, RPh, BCOP: Actually, we’ve trained our primary care providers. We have 9 primary care providers who actually took the AASLD [American Association for the Study of Liver Diseases] course, and then they shadowed our hepatologist. They treat the noncirrhotic patients. We treat our hepatitis C in primary care. A lot of our FHQCs [Federally Qualified Health Centers] also have primary care providers that do treat hepatitis C.
Christian B. Ramers, MD, MPH, AAHIVS: One other misperception is about the cost of treatment. There’s a kernel of truth to this, perhaps when these therapies were first started. Bhavesh, the cost: are things as expensive as they were in 2014?
Bhavesh Shah, RPh, BCOP: I think the cost has gone down significantly with the authorized generics, which we will talk about later on. Having more competition in the space, that also has more competitive pricing with products. We've seen a significant decline in cost of treating hepatitis.
Christian B. Ramers, MD, MPH, AAHIVS: The final misperception for this section is for Caroline. It has to do with hepatitis C being a liver disease primarily. Is it just a liver disease or are there other things that hepatitis C can do to you?
Caroline Derrick, PharmD, BCPS: There are definitely other things. Hepatitis C is no longer thought of as just a liver disease. When you have hepatitis C, you can have a boatload of extrahepatic manifestations.
There are a lot of things that go with that—diabetes, things that can put you at a faster progression for your renal disease as well. Then there are other comorbidities that come along with hepatitis C that you may not be aware of and your signs and symptoms may be minimal. Getting into care and making sure you can potentially attribute some of your other comorbid conditions like diabetes or renal disease to hepatitis C, maybe you can get better comprehensive care and get a lot of things more well controlled.
Christian B. Ramers, MD, MPH, AAHIVS: The realization that this is not just a liver disease is really what drove our current guidelines to be treating everybody. Because if somebody has cognitive effects from hepatitis C or fatigue, kidney disease, or skin disease from it, their liver might be fine, yet they still really deserve to be treated.
One of my favorite studies is from the interferon era. It’s patients who did cognitive testing before and after treatment in those who were cured had improvements in their cognitive functioning. There is something to that brain fog that some people sometimes complain about.
Caroline Derrick, PharmD, BCPS: Fatigue is a big one. I think when I’m talking with patients and we’re getting them on treatment, they may not realize that they felt tired or weak or cognitively impaired. Then they got on treatment. One month later they’re like, “I’m a little more active. I feel a little better.” That’s something that, with a patient report, typically can go away rather quickly.