Baseline Lab Test to initiate HCV treatment

Transcript

Anthony Martinez, MD: Screening’s gotten a little bit easier. The baseline workup has also gotten significantly easier. Tipu, in your setting, what baseline tests are you getting right now?

Tipu V. Khan, MD: So like Nancy said, once we’ve got the reflex and the RNA back and we’ve confirmed hepatitis C [virus; HCV], it’s a bread-and-butter set of labs, labs that all of us use all the time in interpreting other disease states. So it’s a complete blood count to evaluate their platelets, their CBC [complete blood count], et cetera, comprehensive metabolic panel, to take a look at the liver and kidney function. I get a set of coagulation labs as well to again get a sense of intrinsic liver function. Then I think, “OK, I want to make sure that they don’t have other comorbidities that would impact which medication or how I would treat them.” And that would be HIV. So, I’ll get an HIV test. I’ll get a hepatitis panel to see if they’ve got concurrent hepatitis B, but also do they need to be vaccinated for hepatitis A and hepatitis B? Do they have immunity? And, lastly, the final test we always get is a pregnancy test. Not that that would change how we manage it, but it does change how we approach the discussion with the pregnant patient.

Anthony Martinez, MD: Sure. Nancy, you’re our expert hepatologist. We’ve gotten this baseline workup. How can our new providers identify that the patient may be at risk for having more advanced liver disease, more advanced fibrosis based on those tests?

Nancy Reau, MD: Right, so if you ask a hepatologist, we sometimes make things overly complicated. One of the easiest things to do is like Tipu said, simply look at your platelets. If your platelets are less than 150, you need to think about that patient. Now there are many legitimate reasons to have low platelets, like the aluzemia will give you low platelets, but you start there and if your platelets are low then you need to do something else and the easiest thing is using those same labs, calculate a Fib-4 [Fibrosis-4 score]…. Free, easy calculation based on your age, your ALT [alanine transaminase], your AST [aspartate aminotransferase], and your platelet count. There are other mini scoring systems, and you can do things like a [fibrosis] scan, but the vast majority of the time your Fib-4 is going to perform well enough. And in our patients, especially in our addiction clinics, our patients tend to be young. You should not have significant fibrosis. And I’ll add to Tipu, in addition to the things you just told, you should be getting an alcohol screening test because [we should do] anything we can do to reduce risk, and concomitant alcohol use disorder is not unusual in our hepatitis C patients. We have 20 and 30 [young female] patients with cirrhosis because they’ve recovered from acute alcoholic hepatitis. So that it is not impossible to have advanced disease at a young age.

Anthony Martinez, MD: So we’re paying close attention to the platelet count, the albumin, and the total bilirubin. If we determine that our patient does have advanced disease and they look to be cirrhotic, we’re going to treat them all the same, obviously, but what ongoing surveillance would be required once we’ve identified those patients?

Nancy Reau, MD: If you read the guidelines, the guidelines will normally tell you that you need to transition this patient to subspecialty care, but you have to look at the patient in front of you. And if this is someone that needs care, but will not transition easily, then you should do what you feel comfortable with. These patients need liver cancer screening, so ultrasound and albumin protein at 6-month intervals. If their platelets are low and you had access to a [fibrosis] scan that was elevated, they need an upper endoscopy to make sure that they don’t have risk for variceal bleeding. Or, the new Baveno VII guidelines say if you have a person at risk for portal hypertension, low platelets, elevated [fibrosis] scan, you can just start a nonselective β-blocker, especially carvedilol, because that agent will risk-reduce them and they don’t need an upper endoscopy by the Baveno VII guidelines. Not everyone thinks that’s a great idea, but you do now have guideline backing to help you do things that are simplistic to decrease the chance of a complication that also allow you to keep them in primary care and not have to transition someone to subspecialty care when they’re unlikely to go, or they don’t have access to someone close to them.

Anthony Martinez, MD: So, making it really simple, we pay attention to those red flag tests; if any of them are there we’re getting an ultrasound and an AFP [alpha-fetoprotein test] every 6 months, lifelong screening and surveillance, and might need a baseline endoscopy if they’re thrombocytopenic and at risk of portal hypertension.

Transcript was AI-generated and edited for clarity.