Treatment Initiation In Hepatitis Research Articles

What barriers delay treatment in patients with hepatitis C?

A Multiple patient-specific and provider-perceived factors delay initiation of treatment in patients with hepatitis C. Patient-specific barriers to initiation of treatment for hepatitis C virus (HCV) include age, race, gender, economic status, insurance status, and comorbidities such as HIV coinfection, psychiatric illness, and other psychosocial factors.Provider-perceived patient factors include substance abuse history, older age, psychiatric illness, medical comorbidities, treatment adverse effect risks, and factors that might limit adherence (eg, comprehension level).Study limitations included problems with generalizability of the populations studied and variability in reporting or interpreting data associated with substance or alcohol use disorders (strength of recommendation: B, based on 2 prospective and 5 retrospective cohort studies).

Has Increased Rollout of Direct Acting Antiviral Therapy Decreased the Burden of Late Presentation and Advanced Liver Disease in Patients Starting Hepatitis C Virus Therapy in Germany?

International guidelines recommend prioritized treatment initiation in hepatitis C virus (HCV)-infected patients with advanced liver disease. We aimed to evaluate whether the widespread usage of direct acting antivirals (DAAs) has led to a decrease in late presentation for care. Data derived from the multicenter German Hepatitis C Cohort (GECCO) was analyzed. Treatment naive HCV-infected patients initiating DAA-based treatment between January 2014 and September 2017 were included. Advanced liver disease was defined by aspartate aminotransferase to platelet ratio index score ≥1.5, METAVIR≥F3, or FibroScan ≥9.5 kPa. Period prevalence and risk factors for late presentation were evaluated. Six hundred fifty-three HCV-monoinfected and 210 HIV/HCV-coinfected patients (mean age, 48.6±12.7 y; 65.5% male) were included. Overall 32.5% of patients had advanced liver disease. In 2014 39.4% of patients presented with advanced liver disease, decreasing to 30.1%, 34.4%, and 26.4% in the years 2015, 2016, and 2017 (P=0.057), respectively. Patients with and without advanced liver disease differed in age (P<0.0001), CD4 ≤350/µL (P=0.027), genotype (P=0.005), transmission route (P=0.047), body mass index (P<0.001), and time since diagnosis (P=0.007). In the multivariable binary logistic regression analysis GT3, age above 45 years and being diagnosed >2 years ago were positively and HCV transmission through men who have sex with men was negatively associated with advanced liver disease. Overall 32.5% of patients presented with advanced liver disease. We observed a trend toward a lower proportion of patients starting treatment late.GT3, age, years since HCV diagnosis and HCV transmission route were identified as risk factors for presentation with advanced liver disease.

Nephrotoxicity of Antimicrobials and Antibiotics.

Medication-induced nephrotoxicity remains one of the most common causes of acute kidney injury (AKI) among hospitalized patients. Within the extensive group of medications associated with AKI, antibiotics and other antimicrobials are well recognized triggers of structural and functional renal impairment. Clinical manifestations range from mild forms of tubular injury to significant deterioration of kidney function requiring acute renal replacement therapy. Several mechanisms are described, although the most frequent are acute interstitial nephritis, acute tubular necrosis, intratubular crystal deposition, and proximal/distal tubulopathy with electrolyte wasting abnormalities. General risk factors for antimicrobial-induced AKI include pre-existing chronic kidney disease, and concomitant use of medication with nephrotoxic potential. Prevention and early recognition of AKI represent the standard approach to mitigate AKI and avoid morbidity.

2218. Low Hepatitis C Treatment Rates Among Patients Screened as Inpatients at a Rural Academic Medical Center

BackgroundThe rise in injection drug use in the rural United States has led to an increase in admissions for injection-related conditions. Hepatitis C (HCV) infection is prevalent amongst people who inject drugs and might be diagnosed during such episodes of acute care. Linkage to care and initiation of treatment for hepatitis C in this group has been difficult, especially in rural settings lacking comprehensive care for people with substance use disorder (SUD).MethodsWe reviewed the charts of patients admitted to an inpatient service at Dartmouth-Hitchcock Medical Center (DHMC) who had positive HCV serology in 2016. We determined the proportion of patients who had follow-up testing for HCV RNA, were referred, followed up and initiated treatment for HCV by the end of 2017.ResultsIn 2016, 504 inpatients at DHMC were screened with an HCV antibody test, of which 65 (13%) were positive. Of these, 50 (77%) had follow-up HCV RNA testing, resulting in 38 (76%) patients with detectable viremia. Of the 53 patients with detected (38) or unknown viremia (15), five died on the index admission, one was discharged to a hospice, 16 were referred to the DHMC hepatology (GI) clinic and 11 to the DHMC infectious disease (ID) clinic, but 20 received no referral. Thirty-two (60%) patients had an active SUD, and 7 (13%) were in remission.Through December 31, 2017, 15 (31%) of the surviving 48 patients had no further follow-up in the Dartmouth-Hitchcock Health System. Fourteen (29%) patients followed up in the GI clinic, 11 (23%) followed up in the ID clinic and 8 (17%) had subsequent encounters in clinics for conditions other than HCV. Only 5 (10%) patients were treated for HCV and achieved sustained virologic response (SVR), all of which had followed up in the GI clinic. The odds of follow-up or treatment were independent of a history of SUD. Providers frequently deferred treatment due to ongoing substance use or a focus on more urgent medical issues. Insurance coverage for direct-acting antivirals was evolving during the study period, preventing treatment in some patients.ConclusionOnly 10% of patients screened positive for HCV during an inpatient admission to a rural academic medical center received treatment for HCV in the year following their diagnosis. Linkage to care, patient engagement and provider perceptions have to improve to achieve elimination of HCV.Disclosures All authors: No reported disclosures.

Acute Kidney Injury in a Patient on Tenofovir Alafenamide Fumarate After Initiation of Treatment for Hepatitis C Virus Infection.

HIV treatment with tenofovir alafenamide fumarate (TAF) has decreased renal toxicity compared with tenofovir disoproxil fumarate in clinical trials. We report the case of a patient with HIV/HCV coinfection who was started on a TAF-based HIV regimen and developed acute kidney injury that worsened with the addition of sofosbuvir-ledipasvir.

FRI-479 - Effectiveness and cost-effectiveness of antiviral treatment initiation in hepatitis C related decompensated cirrhosis in France

FRI-479 - Effectiveness and cost-effectiveness of antiviral treatment initiation in hepatitis C related decompensated cirrhosis in France

Predictors of antiviral treatment initiation in hepatitis C virus‐infected patients: a Danish cohort study

Predictive factors for initiation of antiviral therapy in chronically infected hepatitis C virus (HCV) patients are not fully elucidated. The aim of this study was to determine predictive factors for initiation of treatment with standard or pegylated interferon either alone or combined with ribavirin. A Danish cohort of individuals chronically infected with HCV was used and observation time was calculated from the date of inclusion in the cohort to date of death, last clinical observation, 1 January 2007, or start of HCV antiviral treatment in treatment-naïve patients. Kaplan-Meier survival analysis was used to construct time to event curves. Cox regression was used to determine the incidence rate ratios as estimates of relative risk (RR) and 95% confidence intervals (CI). A total of 1780 patients were enrolled in the study. The cumulative chance of treatment initiation over 5 years was 33.0%. We found several strong predictors of treatment initiation: elevated alanine aminotransferase [>2 times upper limit (RR = 2.17, 95% CI 1.64-2.87), >3 times upper limit (RR = 3.64, 95% CI 2.75-4.81)], genotype 2 or 3 (RR = 1.86, 95% CI 1.49-2.31) and HIV co-infection (RR = 0.28, 95% CI 0.15-0.53). To our knowledge, this study is the first to estimate factors predicting initiation of antiviral treatment in patients with chronic HCV infection on a nationwide scale. We found that several of the factors predicting initiation of antiviral treatment correlate with factors known to predict a better response to treatment and factors known to increase the progression of liver disease.

Hepatitis C viral kinetics during treatment of hepatitis C virus/HIV coinfected patients

Studies of hepatitis C virus and HIV kinetics during treatment have been instrumental in elucidating the viral lifecycle and mechanisms of action of antiviral therapies. We sought to review data on hepatitis C virus kinetics in hepatitis C virus/HIV coinfected patients and to illustrate how viral kinetics might direct therapeutic decisions in these patients. Few studies have so far analysed the dynamic changes in hepatitis C virus RNA after treatment initiation in hepatitis C virus/HIV coinfected patients. These studies applied mathematical models previously developed in hepatitis C virus mono-infected patients, and the results obtained did not reveal major differences in viral kinetics between the two patient groups. Similar to mono-infected patients, early measurements of hepatitis C virus RNA levels after treatment initiation have been shown to have utility in predicting treatment response in coinfected patients. Confirmatory studies are required to determine definitively whether differences exist between hepatitis C virus kinetics in mono compared with coinfected patients. With additional data, these methods have the potential to direct decisions in hepatitis C virus/HIV coinfection.