GPs leading the charge to treat and cure Hepatitis C!
Treatment is no longer difficult!
HCV treatment has totally changed
Liver cancer is the fastest growing cause of death from cancer in Australia, with the main cause being hepatitis C. New hepatitis C drugs became available on the PBS in March 2016 that are simple, safe, oral medications taken for 12 weeks that almost always leads to total cure. Now there are medications that treat ALL HCV genotypes and NSW Health is aiming to eliminate hepatitis C by 2028. For the first time all GPs can prescribe hepatitis medications through S85 prescribing (see below).
This exciting change means that GPs are now positioned to lead the way in the treatment of hepatitis C. Treatment used to be difficult, only prescribed by specialists with weekly interferon injections for 6-12 months. There were high rates of major adverse effects and treatment failure, and patients needed a liver biopsy prior to commencing treatment.
A liver biopsy is no longer required. Fibrosis and cirrhosis can be assessed through calculating an APRI score (AST-to-platelet ratio index) or through a Fibroscan-transient elastography -like an ultrasound. Most community based patients just have the APRI calculation and a fibroscan is only required if the APRI score is ≥ 1. Fibroscans if required can be obtained at larger hospital gastroenterology departments and some private radiology settings.
Who can be treated in primary care?
If cirrhosis is not evident then generally the patient is suitable for treatment with a GP. All non-complex cases of hepatitis C should now ideally be treated in primary care and not in hospital outpatient departments. Most hepatitis C treatment courses will only require 3 GP visits over 3 months and a follow up test to confirm virological response at 3 months post treatment. You will be curing your patient’s chronic disease, not just treating it.
Complex cases (that should see a specialist) are those that are:
- Cirrhotic / advanced liver disease
- Co-infection with HBV, HIV or complex co-morbidities
- Concurrent chronic kidney disease
- Anyone who has been treated previously
- Patients under 18
All patients with detectable hepatitis C antibodies should have a HCV RNA test to determine if they have ongoing (chronic) hepatitis C and be assessed for hepatitis B vaccination. Then the GP should assess if the patient is suitable for treatment in general practice. In mid-2018 antivirals that treat all genotypes will be available that may require only 8 weeks of treatment, making care and cure even easier.
How does hepatitis C S85 prescribing work?
- GPs can prescribe the treatment through S85 prescribing, preferably after doing some HCV education. This means either;
- Sending patients’ consultation details to a specialist (via fax or email) who will assess and then sign off on your prescribing if the case is non-complex. Support is provided by the specialist and full treatment details are found in the South Western Sydney Health Pathways program
- If you have had prior experience in prescribing hepatitis C treatment you may prescribe without submitting a remote consultation form. You may feel comfortable to do this after doing the S85 process with a specialist a few times or further education in hepatitis C.
- The patient consultation form is available in Medical Director and Best Practice in Health Pathways and Refer to the South Western Sydney Health Pathways hepatitis C clinical pathway for full treatment details at: https://sws.healthpathways.org.au/28219.htm
- (If you haven’t used health pathways before contact the Health Pathways Team at: firstname.lastname@example.org or telephone 0455 052 140 (Monday to Friday) for login details.
- HCV NAVIGATE is designed to provide education on the process for screening and assessing patients with chronic HCV in five quick steps. Visit https://www.hcvnavigate.com.au/ today and add to your mobile home screen or bookmark in your web browser
What HCV education is available and how is it delivered?
There is a range of HCV education options for GPs. CPD education events coordinated with the PHN are advertised at http://www.swsphn.com.au/cpd-events.
The RACGP has a range of category 1 & 2 online modules that you can do at a time that suits you, available at https://www.racgp.org.au/home
SWSLHD also provides ongoing training and mentoring through Project Echo, an online tele- mentoring platform accessed through computer, phone or tablet. To participate you fill out the consultation form with your patients information and send to the Project Echo team from Liverpool Hospital (refer to https://sws.healthpathways.org.au/28219.htm - Project Echo). The specialist multidisciplinary team will both train and advise you about patient management-contact on 0408 968 191.
ASHM also provides training across the Sydney metro region and these may sometimes be closer to home/ work for some local GPs. See the ASHM website for course information http://www.ashm.org.au/training/.
Pharmacy and pathology issues
When patients are treated by their GP, medication is ordered and accessed through community pharmacies, not hospital pharmacies, although it may a take a week for the initial delivery.
Many GPs have had concerns with restrictions on pathology -the ‘episode cone’ -and some important points to clarify are:
- You can order HCV RNA (quantitative) and HCV GENOTYPE (funded if you indicate as preparation for treatment) once per year. A genotype is required prior to commencing treatment.
- An additional 3 x HCV RNA (qualitative) can be ordered per year allowed (funded if you indicate patient is on treatment). However, it may be prudent to check with your pathology service.
Support and advice
Clinical Nurse Consultant GP Liaison Hep C Initiative
The project collaboration between South Western Sydney PHN and LHD aims to increase treatment uptake in people with HCV within the General Practice setting. It is a supportive model which enables GPs and Practice Nurses to consult with a Viral Hepatitis CNC for care coordination for clients with HCV, providing support in the screening, management and treatment. Priority populations for this project include people who inject drugs (PWID), Aboriginal and Torres Strait Islander communities and people from culturally and linguistically diverse backgrounds (CALD).
Support from the Hep C CNC includes:
- Assisting general practice with identifying cases of HCV and those who may be at risk (see risk factors below)
- Support the use of, electronic health and audit tools such as Best Practice, Medical Director and PenCAT.
- Determining patient’s suitability for treatment, assistance with work-up to treatment, and support to prescribe direct acting antiviral medications
- Assist with follow up if required
- Support and provide Hep C education within the practice setting and, in the community
Risk of hepatitis C infection is increased if patients;
- Have ever injected or inhaled illicit drugs
- Have HIV
- Received a piercing or tattoo in an unclean environment using unsterile equipment
- Received a blood transfusion or organ transplant before 1992
- Received clotting factor concentrates before 1987
- Received haemodialysis treatments for a long period of time
- Were born to a woman with a hepatitis C infection
- Were ever in prison
- Were born between 1945 and 1965, the age group with the highest incidence of hepatitis C infection
- Are health care workers who have been exposed to infected blood, which may happen if an infected needle pierces the skin
Who to contact for support;
Point of contact: Katherine McQuillan Community Hepatitis C CNC | HIV & Targeted Programs
Contact Number: 0436 819 237
HCV notification project
SWSLHD has recently commenced a HCV notification project. On receiving a new HCV notification from a laboratory, the SWSLHD Public Health Unit will send a letter to the notifying GP about how to assess, manage and treat HCV. Links to the Health Pathways and the contact details for the SWSLHD Hepatitis Clinical Nurse Consultants will be provided as discussed above. The LHD will also follow up by sending some HCV information for patients and practices.
“Hepatitis C Virus Infection Consensus Statement Working Group. Australian recommendations for the management of hepatitis C virus infection: a consensus statement 2016.”
Melbourne: Gastroenterological Society of Australia, 2016. http://www.gesa.org.au/
“Managing hepatitis C in general practice”-Simone Strasser, Associate professor AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney.
SWSLHD Hepatitis C Health Pathway