Case Spotlight

Gastroenterology

Hepatology

Summary

  • 68 year old male with history of untreated Hepatitis C, now with suspected compensated cirrhosis.
  • PCP asked if it was appropriate to document cirrhosis and if he/she could treat that condition, if additional genotype testing was needed, and asked questions about medication. PCP also wants to initiate antiviral therapy given lack of specialty care access.
  • Specialist suggested waiting for additional diagnostic findings, but suspected the patient’s diagnosis, and also suggested additional laboratory testing and some things to monitor before starting the patient on medication.

eConsult transcript

PCP submission:

68 year old male with history of Hepatitis C from history of IVDU, hx of etoh and substance dependence but in remission since 2010. Hx of leiomyosarcoma in 2014 with PE/DVT now on eliquis, PDV with chronic LE ulcer, neutropenia (usually 1200-1300 ish). I have tried to get him to GI ever since I’ve known him and he’s had 1 appointment then no-showed. I would like to get his hep c treated. I looked at the AASLD/IDSA treatment algo and calculated his FIB-4 which was 6.01 so according to that he was presumed cirrhosis, I queried him for any sx of decompensated cirrhosis which he denied. I ordered liver ultrasound with elastography.

(1) With a fib-4 score of > 3.25, can I document cirrhosis?

(2) Cirrhosis falls under the ineligible category for the AASLD/IDSA but then it says “Cirrhosis (see simplified treatment for treatment-naive adults with compensated cirrhosis)” so can I treat it?

(3) I have attached the last labs from 5/2021. If I can treat it, do I need to check genotypes?

(4) There is a caveat regarding warfarin; is there any implication regarding DOACs?

Specialist response:

I would wait for the US and elastography findings but there is high suspicion this patient has cirrhosis and for purposes of HCV treatment should be treated as cirrhotic. I’m attaching the PDF handout for treating HCV in a compensated cirrhotic from the HCC guidelines website which reviews pre-treatment testing – depending on which medication regimen you use, genotype testing may be needed. Other laboratory testing prior to initiating antiviral therapy includes Quantitative HCV RNA (HCV viral load), HIV antigen/antibody test, Hepatitis B surface antigen, HCV genotype (if treating with sofosburvir/velpatasvir) and pregnancy test (if treating a female). Within 3 months of starting medication, CBC, INR, LFTs, and eGFR should be checked. 

Compensated cirrhotic patients initiating treatment should also have a calculated FIB-4 score, CTP score, ultrasound to evaluate for HCC and subclinical ascites, a complete medication reconciliation with assessment on potential drug-drug interactions, and education on medication administration, adherence, and prevention of reinfection. In terms of drug interactions, I would suggest checking the University of Liverpool website as recommended in the attached handout (www.hep-druginteractions.org/checker). Finally, the patient will probably need EGD to assess for varices and ongoing HCC screening and referral to GI/hepatology would likely be helpful given the concern for cirrhosis.

Tags: Hepatitis C, antiviral therapy, documentation, initiating treatment