PresentationbyDrShayKeatingHepC10-12-03

Report
0N-SITE TREATMENT OF HEPATITIS C
- A PILOT STUDY
Shay Keating, MB, PhD
Medical Officer
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Background
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World Health Organisation – 170 million people infected
with hepatitis C world-wide
80% of Intravenous Drug Users in the Dublin area
(approximately 10,000) are thought to be have been
exposed
Without treatment, as many as 20% are expected to
develop liver cirrhosis in 20years – 6% liver Ca.
6 genotypes world-wide, genotypes 1 and 3 commonest
in Intravenous Drug Users in Dublin
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Who to treat?
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It has been projected that hepatitis C will represent a
substantial economic burden in the US over the next 1020 years – this may be reflected here
Treatment is believed to be cost effective
Ideally everyone who is infected with hepatitis C should
be offered treatment.
Genotype ‘non-1’ more responsive to current treatment
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Goals of treatment
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Viral clearance
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Slow or reverse the disease progression
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Reduce the risk of hepatocellular
carcinoma
Improve health related quality of life
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Current treatment of
hepatitis C
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Very effective, especially with genotype ‘non-1’
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Pegylated interferon – subcutaneous injection once a
week
Ribavirin – capsule – twice a day
Treatment lasts 24 – 48 weeks according to
genotype
Success of treatment – sustained viral clearance
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Side-effects
of treatment
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Interferon
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Flu-like symptoms
Haematological problems
Depression – up to 30% of patients
Ribavirin
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Anaemia
Fetal abnormalities – contraception is
essential
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Treating Hepatitis C
positive drug users
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Many unstable regarding drug and alcohol use
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Many drug users do not keep out-patient hospital
appointments
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Adherence to treatment is often poor – chaotic lifestyles,
homelessness, unemployment, poverty
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Retention in treatment can be poor – side effects not well
tolerated
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Relapse into active addiction - a real possibility
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On site treatment
at the DTCB
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Rationale: ‘To treat the patients with
hepatitis C in the same location in which
they receive their methadone with a view
to retaining the patients in treatment’
Regular medical review with referral pathway to
specialist care
Regular psychiatric review – monitor for
psychiatric complications/relapse into active
addiction
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On-site hepatitis C
treatment ‘pilot study’
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Pilot study of nine patients
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all hepatitis C positive
drug stable
Directly observed therapy initiated at DTCB in
liaison with Dr. Colm Bergin at St. James’s
hospital
Regular psychiatric review by Dr. Jacinta O’Shea,
registrar to Dr. Eamon Keenan
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Pilot study
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Not to show that the treatment works
But
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A proof of concept – that patient retention in
treatment can be improved if therapy is initiated
in a specialist drug treatment setting with directly
observed therapy and with appropriate medical
and psychiatric support on site.
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The hepatitis C
treatment team
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Medical Officer
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Psychiatric Registrar
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Under the guidance of Dr. Eamon Keenan – Consultant
Psychiatrist in Substance Misuse, DTCB
Dedicated Nurse
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Direct liaison with Dr. Colm Bergin - Consultant in
Infectious Diseases. St. James Hospital, Dublin.
Ms. Anne Bolger, Hepatitis C Liaison Nurse, DTCB
Dedicated Counsellor
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Mr. Alan Furlong. Senior Counsellor, DTCB
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Study phases
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Phase 1
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Phase 2
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Patient Recruitment – commenced March
2003.
Treatment
Phase 3
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Follow up
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To date…………
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9 patients have been recruited
 8 have continued on treatment
Results of the study will be presented in
February 2004, at end of the pilot study.
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Efficacy and Tolerability
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Preliminary finding suggest that the treatment
efficacy is comparable to that of a hospital based
hepatitis C treatment setting
5 of the 9 patients experienced haematological
difficulties, 4 of whom were supported
haematologically on-site
5 out of 9 reported significant depressive
symptoms – were treated on-site
3 out of 9 relapsed briefly into active addiction –
addressed on the day
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Cost
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Financial cost of treatment has many
components – medical, nursing,
administration, laboratory – comparable to
a hospital based clinic
The cost of on-site haematological support
is offset by the savings on hospital
admission
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Conclusion
This pilot study appears to validate the
proof of concept that that patient
retention in treatment can be improved,
for drug users, if therapy is initiated in a
specialist drug treatment setting with insite directly observed therapy and
appropriate nursing, medical, psychiatric
and counselling support
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Thank You
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