March 18, 2014
Hepatitis C infection is typically treated by gastroenterologists and hepatologists, but primary care physicians can feel confident that they too can treat this illness — especially if they have the right interdisciplinary team to help, say clinicians wanting to expand care.
"We found that in our urban primary care practice, hepatitis C treatment was feasible; we achieved good treatment initiation and response rates," said Keith Sigal, MD, from the Mount Sinai School of Medicine in New York City. "Plus, we achieved these results in the era of the first generation of direct-acting antiviral medications and in a very vulnerable population," he told Medscape Medical News.
The treatment of hepatitis C infection "tends to be difficult," Dr. Sigal said. "At the time we were doing this study, the shortest treatment course was about 6 months and involved weekly injections of interferon and then a lot of pills. The reason it had been handled by specialists is because there are a lot of complexities regarding the decision-making process to put people on treatment, and the monitoring can be intense as well," he explained.
Dr. Sigal described the experience of his primary care practice, which has been serving very vulnerable patients since 2003, at the International Conference on Viral Hepatitis 2014 in New York City.
"We're at Mount Sinai, which is at the intersection of the Upper East Side and Harlem. There is a pretty significant burden of hepatitis C in our community, and we recognized that people were not getting evaluated and treated," he said. "The protocol that we've developed over the years takes a lot of the complexity out of the treatment process. We feel it is a program that anyone could potentially do."
The primary care clinic is composed of physicians, nurse practitioners, and patient navigators.
“This is a treatment that can be delivered in primary care, but the system does require a bit of extra help.”
"We rely heavily on patient navigators, who act as case managers and help guide the patients through their complex evaluation and treatment," Dr. Sigel noted. "This is a treatment that can be delivered in primary care, but the system does require a bit of extra help."
Dr. Sigal presented data on 125 patients with genotype 1 hepatitis C virus infection who were treated at the clinic from August 2011 to April 2013.
Of these patients, 39 (31%) were started on triple therapy (weekly injections of pegylated interferon plus ribavirin, with either telaprevir or boceprevir).
"Traditionally, initiation rates of treatment have been very low, ranging from 10% to 40%; our number is actually at the high end," he noted. "It's especially gratifying because our patient population had a very significant burden of mental illness and pretty significant drug-abuse histories."
Patients who started treatment were younger than those who did not, but the demographic characteristics and severity of liver fibrosis were similar in the 2 groups.
Also, patients who were treated and achieved sustained viral suppression at 4, 12, or 24 weeks were less likely to have a history of major depression or substance abuse than patients who did not achieve viral suppression.
Post-treatment viral suppression was achieved by 16 patients (45%), although 2 (6%) relapsed, and viral breakthrough was achieved by 6 (16%).
The treatment regimen was toxic and this caused 9 (25%) patients to stop treatment early. Additionally, 3 (8%) patients were nonadherent.
"With the rapid advances in hepatitis C therapy and the availability of potent, relatively nontoxic, and increasingly shorter durations of therapy, it is essential that we make these treatments sourceable by those in need," said Mark Nelson, MD, from Chelsea and Westminster Hospital in London, United Kingdom.
"Primary care — properly educated and supported — will need to be an important player in this aim," he told Medscape Medical News.
This study was funded by the New York State AIDS Institute of the New York State Department of Health and the RobinHood Foundation. Dr. Sigal has disclosed no relevant financial relationships. Dr. Nelson reports financial relationships with Bristol-Myers Squibb, Gilead Sciences, Janssen Pharmaceuticals, Merck Sharpe & Dohme, Roche Laboratories, ViiV Healthcare, and Boehringer Ingelheim,
International Conference on Viral Hepatitis (ICVH) 2014: Abstract 62. Presented March 17, 2014.