Ask the Experts

HCV Care Requires Collaborative Effort

Ask the Chief Medical Editors

Progress in the future management and treatment of patients with hepatitis C virus will require increasing communication and collaboration between gastroenterologists, hepatologists and infectious disease physicians.

HCV Next asked Co-Chief Medical Editors Michael S. Saag, MD, professor of medicine, Jim Straley Chair in AIDS Research and director of the Center for AIDS Research at the University of Alabama at Birmingham, and Ira M. Jacobson, MD, chief of the division of gastroenterology and hepatology and Vincent Astor distinguished professor of medicine at the Joan Sanford I. Weill Medical College of Cornell University; attending physician at New York-Presbyterian Hospital Cornell Campus; and medical director of the Center for Study of Hepatitis C, to discuss the joint care of patients with HCV, from two different points of view.

Michael S. Saag, MD 

Michael S. Saag

Ira M. Jacobson, MD 

Ira M. Jacobson

HCV Next: Traditionally, what has been your specialty’s role in the diagnosis, management and treatment of HCV?

Saag: By tradition, ID providers have screened for HCV, but most did not venture into treatment. The reasons are multifaceted, but mostly relate to the terrible side-effect profile of interferon-based therapies, the lack of interest in or eligibility of patients in taking interferon-based treatments, and the need to monitor patients with cirrhosis so carefully when they are placed on interferon (indeed, all patients with decompensated cirrhosis should be managed by a hepatologist and, ironically, these are the folks who need treatment the most.

Jacobson: Hepatologists and gastroenterologists have played a central role in the care of HCV infection. One reason for this evolution dates back decades when the causative agent of this virus was unknown, and the disease manifestations were, and remain, reflected in laboratory and/or clinical liver abnormalities. Accordingly, diseases like hepatitis A, B and C fell into the province of gastroenterologists who are trained in hepatology. Over the years, some gastroenterologists focused at the outset of their careers, or increasingly as time passed, on hepatology, and many became prominent among the clinical investigators who worked with new regimens and provided clinical care for large numbers of HCV patients as therapy evolved. In addition, some gastroenterologists whose primary career focus may have remained on other areas of the specialty have still maintained a keen interest and done excellent work in caring for these patients. In patients with advanced liver disease, care of HCV has been provided predominantly by hepatologists.

HCV Next: What are the benefits and challenges of different specialists involved in the care of patients with HCV?

Saag: The benefits are obvious: With 3 to 4 million HCV-infected persons in the United States, most of whom do not know their status, there are not enough liver specialists around to provide care to all of the newly diagnosed folks. Actually, even with the ID community fully participating, there are not enough ID and hepatologists/gastroenterologists combined to meet the need.

Over time, I believe the treatment of HCV will be under the purview of primary care providers; however, they need to be brought up to speed on the new drugs and have a refresher course in the basis of liver disease: How to assess liver fibrosis, what to watch for while treating HCV and when to refer.

Jacobson: The benefits of “casting the net more widely” to expand the pool of health providers who care for HCV stem from the fact that HCV is an enormous worldwide public health problem that is estimated to affect 170 million people. Further, the adoption of the screening guidelines for baby boomers will result in the identification of a large volume of patients with HCV. The benefit of cross-specialty involvement is that newly identified patients will have easier access to caregivers qualified in the management of HCV. Our collective goal should be to make care available for every patient diagnosed with HCV.

One challenge is that traditional HCV caregivers have perspectives on the evaluation and treatment of patients with liver disease that others may not have; for example, the need to assess for other liver diseases present in a patient with HCV. It is also important to be mindful of the need to assess the degree of liver fibrosis prior to a course of therapy, which will persist even in the face of very high cure rates. Patients with advanced fibrosis will need continued monitoring, including regular imaging, for liver cancer even after their cure, despite the decline in the level of risk for this dreaded complication after cure is attained. Primary care providers must be aware of the modalities available to assess for liver fibrosis, and the interpretation of these tests. Finally, particularly in patients with advanced liver disease, questions frequently arise in the context of general medical care, such as concomitant medications or planned surgical procedures — issues where guidance from a hepatology colleague will be important.

HCV Next: What is the need for collaborative care for HCV?

Saag: The hepatologists/gastroenterologists are experts in the management of liver disease, especially advanced liver disease. They manage folks with decompensated cirrhosis, those who need and receive liver transplants, and those with liver cancer. The ID specialists are very familiar with treating viral infections with antiviral agents. For those who are experts in the management of HIV, learning how to manage the drugs used to treat HCV is quite straightforward. The drugs, their side effects and drug interactions are so similar to HIV it is almost comical. HCV drugs are classified as protease inhibitors, nucleotide and non-nucleotide inhibitors, and some of the drugs require ritonavir boosting. In addition, the ID specialists are used to watching for drug interactions owing to inhibition or enhancement of CYP isoenzymes (eg, 3A4 or 2D6) and understand the critical nature of medication adherence.

Jacobson: Collaboration between ID physicians and hepatologists caring for HIV/HCV-coinfected patients who present with issues related to potential drug-drug interactions or antiretroviral drug switches prior to HCV therapy will be important, as well issues pertaining to the prevention and management of liver-related complications in patients with cirrhosis. Having the ID providers and hepatologists working together is the ideal way forward.

Another important area with a need for collaborative care involves substance users. I think HCV care providers working with addiction medicine specialists, for example, is a good idea. There is an intense debate beginning to coalesce around the question of whether active drug users can or should be given the new direct-acting antivirals due to potential issues with compliance. One, how do you ensure compliance in active drug users? Two, how do you prevent reinfection if they continue to actively use drugs? Many providers feel uncomfortable with these issues based on a lack of personal training and experience. The collaboration between liver and ID doctors with addiction medicine specialists to address some of these issues is going to be an important area in the new era.

This might be best achieved by physically creating space in which these patients are seen at the same time by both sets of specialists. Led by my colleague, Andrew H. Talal, MD, MPH, we did this at Weill Cornell over the years, and it is also being done in other places around the country. I don’t believe co-location is absolutely essential, but if it’s not present there need to be open lines of communication to ensure that patients are receiving care from both sets of specialists at once.

In terms of collaborations between ID specialists and hepatologists in addressing issues in coinfected patients or advanced liver disease, it will be natural for such physicians to develop relationships with particular colleagues and work via good communication and ready access. I have personally been involved in teleconferencing both with primary care physicians and ID specialists to assist in developing their expertise in HCV care, and the results have been mutually beneficial for all concerned.

HCV Next: How has the prevalence of HCV among baby boomers and screening recommendations further changed the current management of HCV?

Saag: We simply have more patients identified with HCV, meaning there is more to do. All of these newly diagnosed patients need evaluation. The question is: Where is the capacity to absorb all of the newly diagnosed folks. We need all hands on deck!

Jacobson: The high prevalence of HCV is going to result in a challenge of getting the new baby boomer screening guidelines adopted on a much more widespread scale than they appear to have been adopted so far. The issue of the anticipated identification of many newly diagnosed patients with HCV goes along with the aforementioned need for traditional HCV providers/centers expanding sufficiently to accommodate these patients, and also encouraging the care of patients at centers featuring other providers, including primary care providers, in the high prevalence locations who have a commitment to understand the context of liver disease and the need to evaluate patients for other liver diseases and liver fibrosis.

This will expand both the depth of the programs that already exist, and also the breadth of programs that need to exist (or need to expand their capacity in other specialties). At our institution, and I’m sure many others who have been involved in this area for years, we plan to accommodate every single patient who wants to come to us for HCV-related care, whether their liver disease is mild or advanced, but we are also realistic enough to know that the world needs to expand.

HCV Next: How do you envision the future management of patients with HCV?

Saag: I really see this ultimately as an infection that can and will be mostly managed by PCPs, with back up from the ID and hepatology communities. In this way, we create the needed capacity to test, treat and cure as many folks with HCV as we can.

Jacobson: The major theme has been a marked leveling of the playing field of opportunity for cure amongst much broader populations than has been hitherto possible. By that, I mean not only treatment-naive patients, but also treatment-experienced patients, cirrhotic patients, and eventually post-transplant patients and others. These patients can be offered great hope based on the new treatment regimens.

There is an ongoing fundamental paradigm shift not only in the drugs we use, but the mindset we will bring to the “bedside” — from the old dilemma of “watch or wait” to “let’s get going on treating this.” As the population of treated patients expands, I believe the centers dedicated to treating these patients will remain unwavering in their commitment to this disease and will continued to treat patients in large numbers, but the treater population will be expanded by other committed physicians including those in primary care in settings where HCV is prevalent. There will also be an important opportunity for nurse practitioners and physician assistants, in collaboration with physicians, to augment our capacity to treat the numerous patients who will present for treatment.

For more information:
Michael S. Saag, MD, is professor of medicine, Jim Straley Chair in AIDS Research and director of the Center for AIDS Research at the University of Alabama at Birmingham. Ira M. Jacobson, MD, is chief of the division of gastroenterology and hepatology and Vincent Astor distinguished professor of medicine at the Joan Sanford I. Weill Medical College of Cornell University; attending physician at New York-Presbyterian Hospital Cornell Campus; and medical director of the Center for the Study of Hepatitis C. The Co-Chief Medical Editors can be reached at SLACK Incorporated, 6900 Grove Road, Thorofare, NJ 08086; email: hcv@healio.com.

 

Ask the Chief Medical Editors

Progress in the future management and treatment of patients with hepatitis C virus will require increasing communication and collaboration between gastroenterologists, hepatologists and infectious disease physicians.

HCV Next asked Co-Chief Medical Editors Michael S. Saag, MD, professor of medicine, Jim Straley Chair in AIDS Research and director of the Center for AIDS Research at the University of Alabama at Birmingham, and Ira M. Jacobson, MD, chief of the division of gastroenterology and hepatology and Vincent Astor distinguished professor of medicine at the Joan Sanford I. Weill Medical College of Cornell University; attending physician at New York-Presbyterian Hospital Cornell Campus; and medical director of the Center for Study of Hepatitis C, to discuss the joint care of patients with HCV, from two different points of view.

Michael S. Saag, MD 

Michael S. Saag

Ira M. Jacobson, MD 

Ira M. Jacobson

HCV Next: Traditionally, what has been your specialty’s role in the diagnosis, management and treatment of HCV?

Saag: By tradition, ID providers have screened for HCV, but most did not venture into treatment. The reasons are multifaceted, but mostly relate to the terrible side-effect profile of interferon-based therapies, the lack of interest in or eligibility of patients in taking interferon-based treatments, and the need to monitor patients with cirrhosis so carefully when they are placed on interferon (indeed, all patients with decompensated cirrhosis should be managed by a hepatologist and, ironically, these are the folks who need treatment the most.

Jacobson: Hepatologists and gastroenterologists have played a central role in the care of HCV infection. One reason for this evolution dates back decades when the causative agent of this virus was unknown, and the disease manifestations were, and remain, reflected in laboratory and/or clinical liver abnormalities. Accordingly, diseases like hepatitis A, B and C fell into the province of gastroenterologists who are trained in hepatology. Over the years, some gastroenterologists focused at the outset of their careers, or increasingly as time passed, on hepatology, and many became prominent among the clinical investigators who worked with new regimens and provided clinical care for large numbers of HCV patients as therapy evolved. In addition, some gastroenterologists whose primary career focus may have remained on other areas of the specialty have still maintained a keen interest and done excellent work in caring for these patients. In patients with advanced liver disease, care of HCV has been provided predominantly by hepatologists.

HCV Next: What are the benefits and challenges of different specialists involved in the care of patients with HCV?

Saag: The benefits are obvious: With 3 to 4 million HCV-infected persons in the United States, most of whom do not know their status, there are not enough liver specialists around to provide care to all of the newly diagnosed folks. Actually, even with the ID community fully participating, there are not enough ID and hepatologists/gastroenterologists combined to meet the need.

Over time, I believe the treatment of HCV will be under the purview of primary care providers; however, they need to be brought up to speed on the new drugs and have a refresher course in the basis of liver disease: How to assess liver fibrosis, what to watch for while treating HCV and when to refer.

Jacobson: The benefits of “casting the net more widely” to expand the pool of health providers who care for HCV stem from the fact that HCV is an enormous worldwide public health problem that is estimated to affect 170 million people. Further, the adoption of the screening guidelines for baby boomers will result in the identification of a large volume of patients with HCV. The benefit of cross-specialty involvement is that newly identified patients will have easier access to caregivers qualified in the management of HCV. Our collective goal should be to make care available for every patient diagnosed with HCV.

PAGE BREAK

One challenge is that traditional HCV caregivers have perspectives on the evaluation and treatment of patients with liver disease that others may not have; for example, the need to assess for other liver diseases present in a patient with HCV. It is also important to be mindful of the need to assess the degree of liver fibrosis prior to a course of therapy, which will persist even in the face of very high cure rates. Patients with advanced fibrosis will need continued monitoring, including regular imaging, for liver cancer even after their cure, despite the decline in the level of risk for this dreaded complication after cure is attained. Primary care providers must be aware of the modalities available to assess for liver fibrosis, and the interpretation of these tests. Finally, particularly in patients with advanced liver disease, questions frequently arise in the context of general medical care, such as concomitant medications or planned surgical procedures — issues where guidance from a hepatology colleague will be important.

HCV Next: What is the need for collaborative care for HCV?

Saag: The hepatologists/gastroenterologists are experts in the management of liver disease, especially advanced liver disease. They manage folks with decompensated cirrhosis, those who need and receive liver transplants, and those with liver cancer. The ID specialists are very familiar with treating viral infections with antiviral agents. For those who are experts in the management of HIV, learning how to manage the drugs used to treat HCV is quite straightforward. The drugs, their side effects and drug interactions are so similar to HIV it is almost comical. HCV drugs are classified as protease inhibitors, nucleotide and non-nucleotide inhibitors, and some of the drugs require ritonavir boosting. In addition, the ID specialists are used to watching for drug interactions owing to inhibition or enhancement of CYP isoenzymes (eg, 3A4 or 2D6) and understand the critical nature of medication adherence.

Jacobson: Collaboration between ID physicians and hepatologists caring for HIV/HCV-coinfected patients who present with issues related to potential drug-drug interactions or antiretroviral drug switches prior to HCV therapy will be important, as well issues pertaining to the prevention and management of liver-related complications in patients with cirrhosis. Having the ID providers and hepatologists working together is the ideal way forward.

Another important area with a need for collaborative care involves substance users. I think HCV care providers working with addiction medicine specialists, for example, is a good idea. There is an intense debate beginning to coalesce around the question of whether active drug users can or should be given the new direct-acting antivirals due to potential issues with compliance. One, how do you ensure compliance in active drug users? Two, how do you prevent reinfection if they continue to actively use drugs? Many providers feel uncomfortable with these issues based on a lack of personal training and experience. The collaboration between liver and ID doctors with addiction medicine specialists to address some of these issues is going to be an important area in the new era.

This might be best achieved by physically creating space in which these patients are seen at the same time by both sets of specialists. Led by my colleague, Andrew H. Talal, MD, MPH, we did this at Weill Cornell over the years, and it is also being done in other places around the country. I don’t believe co-location is absolutely essential, but if it’s not present there need to be open lines of communication to ensure that patients are receiving care from both sets of specialists at once.

In terms of collaborations between ID specialists and hepatologists in addressing issues in coinfected patients or advanced liver disease, it will be natural for such physicians to develop relationships with particular colleagues and work via good communication and ready access. I have personally been involved in teleconferencing both with primary care physicians and ID specialists to assist in developing their expertise in HCV care, and the results have been mutually beneficial for all concerned.

PAGE BREAK

HCV Next: How has the prevalence of HCV among baby boomers and screening recommendations further changed the current management of HCV?

Saag: We simply have more patients identified with HCV, meaning there is more to do. All of these newly diagnosed patients need evaluation. The question is: Where is the capacity to absorb all of the newly diagnosed folks. We need all hands on deck!

Jacobson: The high prevalence of HCV is going to result in a challenge of getting the new baby boomer screening guidelines adopted on a much more widespread scale than they appear to have been adopted so far. The issue of the anticipated identification of many newly diagnosed patients with HCV goes along with the aforementioned need for traditional HCV providers/centers expanding sufficiently to accommodate these patients, and also encouraging the care of patients at centers featuring other providers, including primary care providers, in the high prevalence locations who have a commitment to understand the context of liver disease and the need to evaluate patients for other liver diseases and liver fibrosis.

This will expand both the depth of the programs that already exist, and also the breadth of programs that need to exist (or need to expand their capacity in other specialties). At our institution, and I’m sure many others who have been involved in this area for years, we plan to accommodate every single patient who wants to come to us for HCV-related care, whether their liver disease is mild or advanced, but we are also realistic enough to know that the world needs to expand.

HCV Next: How do you envision the future management of patients with HCV?

Saag: I really see this ultimately as an infection that can and will be mostly managed by PCPs, with back up from the ID and hepatology communities. In this way, we create the needed capacity to test, treat and cure as many folks with HCV as we can.

Jacobson: The major theme has been a marked leveling of the playing field of opportunity for cure amongst much broader populations than has been hitherto possible. By that, I mean not only treatment-naive patients, but also treatment-experienced patients, cirrhotic patients, and eventually post-transplant patients and others. These patients can be offered great hope based on the new treatment regimens.

There is an ongoing fundamental paradigm shift not only in the drugs we use, but the mindset we will bring to the “bedside” — from the old dilemma of “watch or wait” to “let’s get going on treating this.” As the population of treated patients expands, I believe the centers dedicated to treating these patients will remain unwavering in their commitment to this disease and will continued to treat patients in large numbers, but the treater population will be expanded by other committed physicians including those in primary care in settings where HCV is prevalent. There will also be an important opportunity for nurse practitioners and physician assistants, in collaboration with physicians, to augment our capacity to treat the numerous patients who will present for treatment.

For more information:
Michael S. Saag, MD, is professor of medicine, Jim Straley Chair in AIDS Research and director of the Center for AIDS Research at the University of Alabama at Birmingham. Ira M. Jacobson, MD, is chief of the division of gastroenterology and hepatology and Vincent Astor distinguished professor of medicine at the Joan Sanford I. Weill Medical College of Cornell University; attending physician at New York-Presbyterian Hospital Cornell Campus; and medical director of the Center for the Study of Hepatitis C. The Co-Chief Medical Editors can be reached at SLACK Incorporated, 6900 Grove Road, Thorofare, NJ 08086; email: hcv@healio.com.