Hepatitis C Management

Note: Every Hep C patient needs to be discussed with an attending real-time.

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Simplified Hepatitis C Plan: Labs need to be done within 6 months of prescription

1)      Confirm Hep C by ordering

a.      Viral load with reflex to Genotype

2)      Confirm patient has NOT been treated with a Direct Acting Agent in the past

a.      If they have STOP HERE and refer to Dr. Khan

3)      Confirm pt does not have HIV

a.      If they have STOP HERE and refer to Dr. Khan

4)      Confirm patient is NOT pregnant

a.      If they are STOP HERE and refer to Dr. Khan

5)      Confirm the patient does NOT have cirrhosis or a decompensating event ever in their life (varices, hepatic encephalopathy, or ascites)

a.      If they do STOP HERE and refer to Dr. Khan

6)      Order the following tests:

Note: Once you have confirmed the patient does NOT have steps 2-5, you should initiate treatment now, while awaiting the results below.

a.      HepBSAg

i.      If Ag +, refer to Dr. Khan but continue treatment

b.     CBC

i.      If Platelets below 150, refer to Dr. Khan but continue treatment

c.      CMP

d.     Fibrotest

i.      If fibrotest F4, refer to Dr. Khan but continue treatment

7)      Start Hep A/B vaccines if due

8)      Fill out CVS Specialty Pharmacy request for the medication desired (hanging by the white board in the bowling alley) and give that form to Yasmin Cano who will arrange delivery, provide counselling, and track the patient.

a.      Mavyret x 8 weeks

OR

b.     Epclusa x 12 weeks

9)      Run drug-drug interaction (DDI) tool like Liverpool https://www.hep-druginteractions.org/

a.      If DDIs are found, mitigate them as best as possible

b.     If the DDIs cannot be mitigated, stop here and refer to Dr. Khan

10) Discuss common side effects with the patient (~<10%)

a.      Headache, fatigue, nausea, diarrhea

11) Send Cerner message to Dr. Khan and Yasmin Cano that treatment has been initiated

12) Add chosen medication to med list (do not send rx, just reconcile the med list)

a.      The CVS specialty form is your physical Rx for this medication which Yasmin Cano will fax to the pharmacy along with other required paperwork

13) Follow up with patient in 4 weeks to see how treatment is going

14) Upon completion of treatment, order a Hep C RNA for 12 weeks AFTER their final dose of medication. This is known as the SVR 12 (sustained virological response at 12 weeks) and only when this comes back negative do we tell patients they are cured

a.      If they still have detectable RNA, refer to Dr. Khan

b.     If they have varied compliance and adherence to the regimen, refer to Dr. Khan