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Guidance for the prevention, testing, treatment and management of hepatitis C in primary care

• Royal College of General Practitioners •

Introduction

  • Hepatitis C infection is an under-diagnosed (five out of every six people infected are undiagnosed) and under-treated important cause of morbidity and mortality
  • Hepatitis C is a common and potentially curable disease, but only 1 to 2% of infected people are currently receiving National Institute of Health and Clinical Excellence (NICE) recommended therapy

Transmission and prevention

  • Unlike hepatitis A and B, there is no vaccine but infection is avoidable through strategies that reduce transmission
  • Major route of transmission in the UK is sharing injecting equipment. Other risk factors include: blood transfusion (prior to 1991) or blood products (prior to 1987) and born or spent a significant amount of time in a high risk country. This may include health care given in early childhood so those born in some parts of the developing world may be at increased risk. A small but important number of infected people have acquired their infection through the use of non-sterile surgical equipment. This is most likely in those who have received health care in the developing world, including East Europe and Africa
  • Practical suggestions to help prevention in primary care:
    • provide hepatitis A and B vaccinations in all patients using drugs and other high risk groups such as men who have sex with men
    • provide clear information about safer injecting and safer sex including condoms
    • ensure that all patients using drugs have easy convenient access to local needle exchanges, which provide injecting paraphernalia as well as needles and syringes and advise about safer smoking and snorting of drugs
    • advise injectors of strategies how to move away from injecting
    • run a needle exchange in the surgery
    • discuss alcohol with all patients, advise to stop and treat or refer on any alcohol problem
    • provide drug treatment including substitute medication or refer to secondary agency for help
    • monitor weight and provide help with weight reduction (risk of non-alcoholic fatty liver disease which causes cirrhosis irrespective of any other causes
    • provide nutrition advice and support people who are hepatitis C virus (HCV) positive to optimise their nutrition
    • advise all patients to stop smoking and explain to people who are HCV positive that smoking can increase progression

Testing

  • As HCV is under-diagnosed, testing in general practice is important, after ideally assessing all patients for risk factors – make no assumptions
  • Ensure the patient understands the condition and the test before taking blood for:
    • HCV antibody blood test, to check if patient has been exposed to the hepatitis C virus
    • HCV RNA (usually by a polymerase chain reaction (PCR)), to check if the infection is active or not

Guidance for the prevention, testing, treatment and management of hepatitis C in primary care continued

Disease outcomes and symptoms

  • Acute infection is usually asymptomatic but jaundice and malaise may occur. The incubation period of acute hepatitis C infection is usually between six and nine weeks, with the specific antibody usually present by three months from infection, although in some cases it may take up to six months before the antibody is detected. Most people who become infected with hepatitis C are unaware of it at the time. Around 25% of those infected with hepatitis C infection will clear the virus at the acute stage
  • Chronic hepatitis C infection is a slowly progressive and often asymptomatic disease of the liver caused by the hepatitis C virus. Early studies in patients infected for up to 20 years indicated that the prevalence of cirrhosis was very low suggesting the disease progressed at a very slow rate. However recent studies suggest the disease does not progress in a linear fashion and that mild disease may accelerate with time so careful surveillance of all infected patients is important
  • Many with chronic hepatitis C infection will have no symptoms, while others will feel unwell to varying degrees. Symptoms, though not common, may include mild to severe fatigue, muscle aches, nausea, depression or anxiety, pain or discomfort in the liver and poor memory or concentration

Treatment

  • Early referral is advantageous. It is now thought that chronic HCV does not progress in a linear fashion and that the disease accelerates with ageing so most patients with HCV may develop cirrhosis long term. Furthermore therapy is more effective when administered in the early stages of the disease and hence early referral is advisable
  • The most recent NICE guidance advocates treatment for all that want it including:
    • active injectors
    • for mild to moderate hepatitis C (previous NICE guidance was only for severe disease)
  • The current treatment is combination therapy with pegylated interferon and ribavirin. This treatment is successful in clearing the virus (defined as no detectable virus) six months after treatment has ceased) in between 40 to 80% of those treated, accordingly to genotype
  • Where treatment is provided from a hospital base: primary care can continue to play an important role in the patient’s treatment by providing ongoing General Medical Services (GMS) to support the patient through the treatment process, supporting patients on therapy and giving practical advice to them on managing side-effects such as paracetamol for pyrexia, anti emetics if nauseated and moisturisers and steroid cream for itchy skin along with ongoing harm reduction information, support regarding drug dependency and monitoring of mental health, especially depression

full guidelines available from…
Royal College of General Practitioners, Office 314, Frazer House, 32–38 Leman Street, London, E1 8EW (Tel – 020 7173 6090)
http://www.rcgp.org.uk/

Chris Ford. RCGP Substance Misuse Unit, RCGP Sex, Drug and HIV Task Group, Substance Misuse Management in General Practice, Hepatitis C Trust, UK Hepatitis C Resource Centre & Release. Guidance for the prevention, testing, treatment and management of hepatitis C in primary care. 1st edition. May 2007

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eGuidelines.co.uk (22 May 2012)
© 2012 MGP Ltd
First included: Oct 07 .
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