She was kind enough to sit down for an interview to provide some insight into the practice and treatment of hepatitis patients, considering May is Hepatitis Awareness Month.
MDCalc: It has been an exciting couple years in your field, with the discovery of a Hepatitis C cure, an area of your research (PMID: 27047770). What should docs know about these cures?
Gina Choi: The new treatments for hepatitis C are very safe and effective with minimal side effects. Treatment duration is also short, ranging from 8-24 weeks, depending on the type of hepatitis C, or genotype, and the presence of cirrhosis.
MDC: Who should doctors screen and refer for Hepatitis C? What’s the best way for them to do so?
GC: It is estimated that 4 million people in the U.S. are infected with hepatitis C. Testing for hepatitis C is recommended in patients born between 1945 – 1965, regardless of their risk factors, because they have the highest rates of hepatitis C. Other patients to screen include those with a prior history of intravenous or intranasal drug use, long term dialysis, HIV infection, tattoos, recipients of blood transfusions before 1992, and prior history of incarceration.
The best way to screen for hepatitis C is to send a serum hepatitis C antibody test, followed by a HCV RNA if the antibody is positive.
MDC: What are the most promising aspects of recent and past hepatitis research? Are there any areas you would like to see more advancement in?
GC: Significant advancements have been made, particularly for non-cirrhotic patients with genotype 1 disease, which is the most common genotype found in the United States. These treatments have little to no side effects and achieve close to 100% cure rates. However, there are still areas of unmet need including patients with decompensated cirrhosis who have lower cure rates. The treatment of HIV co-infected patients, liver transplant recipients, children, and active IV drug users are also challenging.
MDC: How about for other types of hepatitis? What should be front of mind for the average physician?
GC: Hepatitis E is becoming more common. It is usually a self-limited, acute illness, acquired by Americans while traveling abroad to endemic areas (Asia, Africa, the Middle East, and Central America). It is usually spread via the fecal-oral route, but in developed countries, via undercooked pork and deer meat. It can also progress to chronic hepatitis, mainly among organ transplant recipients who are immunosuppressed.
MDC: What are other promising research breakthroughs? Including Hepatitis C, as well as other types of hepatitis?
GC: Globally, 350 million people are infected with hepatitis B and significant resources are being directed towards the study of hepatitis B. Hepatitis B not only leads to cirrhosis but also hepatocellular carcinoma, even without the presence of cirrhosis, which makes it unique among other causes of liver disease. We have a vaccine and are able to suppress the virus, but we do not have a cure.
MDC: What clinical decision rules, scores or guidelines can you not live without in your daily practice?
GC: I constantly use the MELD calculator throughout the day, not just for liver transplant purposes but to determine whether patients are appropriate TIPS candidates, to determine if they are clinically improving or worsening. I also refer often to the AASLD guidelines and hcvguidelines.org
MDC: What are the most exciting aspects of the research projects in which you are involved?
GC: I am very interested in hepatitis B and hepatocellular carcinoma, particularly among minorities. Hepatitis B is very complex and treatment is quite nuanced.
MDC: Other comments? Any words of wisdom when seeing hepatitis patients?
GC: I think it’s very important to remember to screen for hepatocellular carcinoma in patients with chronic hepatitis B, even if they do not have cirrhosis. It is also important to screen for hepatocellular carcinoma in patients with cured hepatitis C if they have stage 3 fibrosis or cirrhosis. The risk of cancer is still there.
Another important topic to keep in mind is potential hepatitis B reactivation in patients who are receiving immunosuppression. This includes patients on long term steroids and patients receiving chemotherapy and immunomodulators. Please check hepatitis B serologies, including a hepatitis B core antibody, and refer to hepatology if positive.
To view Dr. Choi’s publications, visit PubMed.