Experts in the management of hepatitis C identify some of the complications of the disease, particularly cirrhosis and decompensated cirrhosis.
Christian B. Ramers, MD, MPH, AAHIVS: Let's move on. For the end of this introductory section, just on the complications from hepatitis C infection, we think of 3 major things. I'll give 1 of these to each of you. Cirrhosis in and of itself; secondly, decompensated cirrhosis; and then thirdly, liver cancer. We will get to some of the non-liver-related manifestations later on. Chris, could you just walk us through what cirrhosis is?
Christopher Hulstein, PharmD, BCPS: It's essentially permanent scarring of the liver that can happen over the course of a few decades when we're thinking about chronic hepatitis C. As Caroline was discussing, there are a subset of patients who can clear the virus spontaneously without any type of therapy, but the vast majority of patients do actually go on to develop chronic hepatitis C, around 80% or so. Of that 80%, 10% to 20% may develop cirrhosis over the course of 10 to 30 years or so because it is very slowly progressing. Essentially, as the virus is infecting the liver, there's a lot of oxidative stress and cell disruption that can happen that causes that scarring over the long term.
Christian B. Ramers, MD, MPH, AAHIVS: So 10 to 30 years is a pretty wide range.
Christopher Hulstein, PharmD, BCPS: It is.
Christian B. Ramers, MD, MPH, AAHIVS: Are there factors that we know about that may make that go faster or slower?
Christopher Hulstein, PharmD, BCPS: Coinfection with HIV and hepatitis B can make that go a little faster. If you are a man, that tends to speed up the process. If you are overweight, that tends to speed up the process as well. Alcohol use and daily marijuana use are all things that can speed up that process to cirrhosis.
Christian B. Ramers, MD, MPH, AAHIVS: That's a good point. The way I think about this from a clinical standpoint is that we know they have 1 liver disease, which is hepatitis C infection. If you add a second on top of that, it really pushes things. You mentioned obesity. That would be essentially fatty liver disease, a second source of inflammation in the liver. HIV for mysterious reasons makes things go faster. Alcohol use in excess of what's recommended; also, it's a secondary liver disease and just pushes you faster. Then there have been very strange cases in the HIV coinfection literature of ultra-rapid progression from diagnosis to cirrhosis within just a couple of years.
Caroline Derrick, PharmD, BCPS: There are 2 ways to look at decompensated cirrhosis. One would be a clinical event., such as hepatic encephalopathy and ascites, and when you're on medications for these types of events. As a pharmacist looking at someone who might be on lactulose for hepatic encephalopathy, those are some ways we can look at patients who may have decompensated or don't have the ability to compensate for this disease.
Also we can look at the Child-Turcotte-Pugh score. When a patient has a score of 7 or above, they're put into classification of B. B and C are when we're trying to really look at patients for hepatic decompensation. Those patients are a very subset and specialized population that really need to be taken care of by specialists. We're often referring those patients to hepatologists for more specific care.
Christian B. Ramers, MD, MPH, AAHIVS: We're wanting to promote more widespread hepatitis treatment, and there may be folks out there in a primary care setting. Why is it important to identify who's decompensated and who's not?
Caroline Derrick, PharmD, BCPS: Decompensated patients walk a tightrope for treatment, and their treatment is very specialized and may include utilizing ribavirin, which requires intensive monitoring, dosing adjustments based on weight, and laboratory values. Hepatologists or a center that is very well adjusted to monitoring these types of patients are very important. They can decompensate while on treatment, and you just want to make sure you have a close eye on this population.
Patients who are decompensated have various things that need to be closely monitored. In primary care settings, time or education may be a factor.
Christian B. Ramers, MD, MPH, AAHIVS: So it's more important to get a specialist involved if you do identify decompensation. What about the idea that somebody could be really sick at one point and you call them decompensated? They've had an episode in the hospital in which they had esophageal varices that were bleeding, but then they come see you a year later and they've stopped drinking, they're looking better, and their Child-Turcotte-Pugh score goes down to 5 or 6? Would you still consider them decompensated?
Caroline Derrick, PharmD, BCPS: In our clinical practice, we're not currently treating patients who have a history of these types of events. That's physician discretion. That's the way we're handling those patients.
Bhavesh Shah, RPh, BCOP: In our practice, we would refer those patients. The primary care wouldn't be treating those patients. They would be referred. Even though they've resolved in a lot of their symptoms and they may not be having the decompensation, they would still need that long-term follow-up in specialized care. I think our primary care providers wouldn't be comfortable treating those patients.
Christian B. Ramers, MD, MPH, AAHIVS: Good idea to get a specialist involved there.