Snapshots Alan Franciscus, Editor-in-Chief

Article: Hepatitis C in children in times of change—RD Baker et al.
  Source:  Curr Opin Pediatr. 2015 Jul 18. [Epub ahead of print]

Results and Conclusions
The main focus of the abstract was when to initiate treatment and when it is safe to wait for approval of the new highly effective direct-acting antiviral therapies to treat hepatitis C (HCV).

Pegylated interferon and ribavirin is the current standard of care to treat children with hepatitis C.  There are pediatric clinical trials of sofosbuvir/ledipasvir, ribavirin, and Vieikira Pak, with and without ribavirin. Approval of these drugs is expected in the near future.    

The authors make a good case for their recommendations:

• Wait: Children generally have a slow disease progression so in most cases it is safe to wait for the interferon- and ribavirin-free medications to be approved.
  
  
• Treat: In the case of children who do have serious disease progression treatment now is warranted.  Genotype information should be factored into the treatment decision process since genotype 2 and 3 cure rates are higher and treatment durations are shorter with pegylated interferon and ribavirin combination therapy.   

The Bottom Line
All children with HCV should be monitored on a regular basis.  Any treatment decisions for children should be evaluated on a case-by-case basis.

Editorial Comment
The general consensus is to wait (if possible) until the interferon- and ribavirin- free therapies are available. However, there is a small percentage of children with HCV who progress on to serious liver disease very quickly—this is why it is so important to identify and monitor children on a regular basis. 

It will be very interesting once the new therapies are approved to treat children with HCV.  Will insurance companies be as restrictive as they are with adults?  Hopefully not!  But if they are it just might be enough to raise the level of public ire to demand that they cover the medications for everyone.  It might also be enough that the public finally demand that the prices come down so that everyone affected by hepatitis C can afford the medications. 

Coming soon:  An Overview of HCV in Children

Article:  Prevalence of Cirrhosis in Hepatitis C Patients in the Chronic Hepatitis Cohort Study (CHeCS): A Retrospective and Prospective Observational Study—S C Gordon et. al
  Source:  Am J Gastroenterol. 2015 Jul 28. doi: 10.1038/ajg.2015.203. [Epub ahead of print]

Results and Conclusions
In the Chronic Hepatitis Cohort Study (CHeCS) there were 9,783 patients, 2,788 (28.5%) were cirrhotic by at least one method. Biopsy identified cirrhosis in only 661 (7%).  Other parameters, such as the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) were not assigned to the biopsy proven cirrhosis results. 

The Bottom Line
The authors noted that the since the ICD-9 codes may not be the best codes to indicate the prevalence of cirrhosis and that there may be a ‘fourfold’ higher prevalence of cirrhosis in studies previously reported. 

Editorial Comment
This is an important study.  We need to understand the true prevalence of cirrhosis in this country.  It will help to push for better funding and making sure that people are treated sooner rather than waiting until people become sick. 

Article:  Chronic Hepatitis C Virus Infection Is Associated with Subclinical Coronary Atherosclerosis in the Multicenter AIDS Cohort Study (MACS): a Cross-Sectional Study—RA McKibben
  Source: J Infect Dis. 2015 Jul 27. pii: jiv396. [Epub ahead of print]

 

Results and Conclusions
Eighty-seven men with chronic hepatitis C were evaluated for the risk of cardiovascular disease (CVD).

Note: the study also looked at HIV and HIV/HCV coinfected men but did not find an association. 

The men were assessed for coronary plaque using non-contrast coronary CT and CT angiography and evaluated the associations of CHC with measures of plaque (substances that lead to hardening of the veins/arteries), prevalence, extent, and stenosis (narrowing of the veins). It was found that all types of plaques were significantly higher in men with chronic hepatitis C.

Bottom Line
This is not the first study that has shown that there are cardiovascular problems associated with hepatitis C.  But it is important to remember that this is a small study.  It also needs to be replicated in a larger patient population and in women with HCV. 

Editorial Comment:
As we come to understand more and more about hepatitis C it becomes clear how much damage hepatitis C causes to many organs outside of the liver.  Everyone with hepatitis C needs to be monitored on a regular basis.  In this case men and women need to be monitored for cardiovascular disease.  This is another reason why people with hepatitis C should be treated before these types of health issues are allowed to begin.

http://hcvadvocate.org/news/newsLetter/2015/advocate0815_mid.html#4

Liver damage in hepatitis C patients significantly underestimated, says Henry Ford study

DETROIT - The number of hepatitis C patients suffering from advanced liver damage may be grossly underestimated and underdiagnosed, according to a study led by researchers at Henry Ford Health System and the U.S. Centers for Disease Control and Prevention.

The findings were the result of a study of nearly 10,000 patients suffering from hepatitis C, and could have a significant effect on patient care and healthcare policy regarding the chronic disease.

"Knowledge of the prevalence of liver damage will help decision making regarding screening for the effects of hepatitis C, when to start anti-viral therapy, and the need for follow-up counseling," says Stuart Gordon, M.D., lead researcher and Director of Hepatology at Henry Ford Hospital.

Read more...

Vietnam era veteran carries battle cry of hepatitis C

ATHENS – Mike Blackburn didn’t serve in Vietnam but he was a veteran of that era. He never served in combat. But his war continues to this day. And according to his doctors, his war will end soon.

Blackburn, 62, has hepatitis C virus with stage 4 liver failure. A few weeks ago he was placed on hospice with 3-6 months life expectancy. His diagnosis of hepatitis C didn’t come until Aug. 10, 2014, just six days before his 62nd birthday, when he went to the hospital with severe stomach pain.

Last year’s birthday of course is a blur for Blackburn and his wife, Pam. But he’s a self-proclaimed old country boy from Kentucky and he’s a fighter and he hasn’t given up hope.

Read more...

What's behind fatigue, elevated liver enzymes?

'I'm more tired than usual, doctor," the patient said, though she really thought nothing was wrong. At 60, she assumed age was catching up with her, and was at the doctor's office for her routine checkup.

Indeed, all her blood work was normal - except for the panel revealing elevated liver enzymes. A liver ultrasound suggested the damage had been going on for some time.

Aside from hypertension, she had no other active medical conditions. The only drugs she took were a diuretic and a multivitamin.

Read more at http://www.philly.com/philly/health/20150628_What_s_behind_fatigue__elevated_liver_enzymes_.html#afUCSI50z4BEYo88.99