PCPs will play critical role in future HCV treatments

Miranda M. Huffman

As direct-acting antiviral agents for hepatitis C virus become more accessible and affordable, there will be a greater need for primary care physicians to care for patients with HCV.

Although previous HCV treatments usually required the care of specialists, such as gastroenterologists or infectious disease specialists, direct-acting antiviral agents are a simpler regimen. For this reason, PCPs are now involved in managing this burgeoning patient population.

“When we were still treating hepatitis C with interferon therapy, there were enough risks of the treatment, and enough nuance in the treatment that it really did require someone who had advanced training in that treatment,” Miranda M. Huffman, MD, MEd, associate professor, Department of Community and Family Medicine, University of Missouri–Kansas City School of Medicine, told Healio Family Medicine. “HCV treatment over the last two years has become as simple as anything that we manage in primary care.”

As a courtesy to its readers, Healio Family Medicine asked Huffman to discuss the collaborative role PCPs will likely play in the treatment of HCV, and how these efforts and the latest treatments could lead to the eradication of HCV. – by Jennifer Byrne

Question: How can PCPs provide HCV treatment that is equal to that provided by specialists?

Answer: When patients see specialists, the specialists often end up having to contact the patients’ PCP to discuss adjusting their medications. For example, some of the HCV treatments will interact with statins, so the specialist has to contact the PCP to figure out if they can adjust statin therapy. So if the drugs are safe and follow an algorithm, we can provide the same care that the specialists do.

Since PCPs know about the whole patient and their medical history, they are better equipped than gastroenterologists to determine whether it’s safe for a patient to stop statin therapy while they’re treating their hepatitis C. We know when they last had a heart attack, and we know what their atherosclerotic cardiovascular disease risk score is. There are some patients for whom I would say, absolutely stop statin therapy; get your HCV treated and then we will restart it. There are other people whose liver is not that bad, and we can wait 6 months and get their plaque stabilized after a heart attack, and then we can worry about getting the HCV eradicated.

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PCPs are also accessible to patients. I have patients who refuse to see a specialist for the treatment of HCV, and then when I offer to prescribe it myself, they’re happy to start treatment. They just don’t want to have to see another doctor, especially if they have high copays.

Q: How will the increased availability of direct-acting antiviral agents expand the role of PCPs?
A: There have certainly been some PCPs who were already doing that, especially with the ECHO programs. These are programs that the state set up to essentially provide regular training for PCPs, to manage more complicated diseases.

Not all PCPs know how to provide that treatment. So, these programs consist of bi-weekly conference calls, managed by local universities, where experts provide training and answer questions from the doctors in the community.

Historically, these ECHO programs were the way to increase access to HCV treatment. If you knew you didn’t have access to a gastroenterologist or an infectious disease specialist, you could write up a patient case, submit it to one of these Project ECHOs, and they would provide their expertise so that you could manage your patients within your practice. DAA drugs are so safe, there is so little risk, and the algorithms are so clearly defined by the gastroenterology organizations and the infectious disease organizations, I don’t even think PCPs need that level of help anymore.

Q: What will the roles of other medical providers, such as nurse practitioners, pharmacists or physician’s assistants be in providing direct-acting antiviral agents treatment?

A: Nurse practitioners and physician assistants are very well equipped to manage anything that follows an algorithm such as HCV. In many ways, the training they’ve had is better equipped to follow algorithms than medical school training. Here at the University of Missouri–Kansas City School of Medicine, the gastrointestinal clinic has nurse practitioners managing the majority of the HCV treatment.

I also appreciate the input of the pharmacist I work with, who helps make sure I’ve considered all medication interactions, and also counsels patients on how to take their medications and the potential side effects. Practically any member of the health care team can add to the care of patients with HCV.

Q: Where do you see rates of HCV in the U.S. going in the future?

A: It’s very exciting to think that we could eradicate it from the human population in the next 5 to 10 years if we work together. My hope is down the road, HCV can be a learning experience like smallpox was for medical professionals of my generation, evidence of how a coordinated effort can eradicate a human pathogen.

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Q: What limits should PCPs have in terms of HCV treatment?
A: I don’t think the majority of PCPs I know are going to prescribe something they don’t feel safe prescribing. When you look at the risks from HCV treatment, there’s significantly less risk than with other drugs PCPs manage such as insulin and anticoagulants like warfarin. However, most PCPs are very familiar with those drugs, and direct-acting antiviral agents are significantly safer than either of those.

Q: What are some best practices for HCV treatment?
A: The American Association Society for the study of Liver Disease website is an excellent resource. They’re the national body that I rely on for treatment algorithms. Also keep in mind that most insurance companies are only covering one or two drugs for a specific genotype. So, you can have that patient’s formulary pulled up, and then have the guideline algorithm pulled up from the American Association Society for the study of Liver Disease’s website, and then review. As a faculty member, I tell my residents that their expectation upon graduation should be that they manage HCV themselves.
However, it is important to note that there are insurance companies that are only paying for medicine if it is prescribed by a specialist. Also, certain states as part of their Medicaid programs have said they won’t pay for treatment for people who are either continuing to consume alcohol or continuing to use illegal drugs . We have overwhelming evidence that these are the patients we should be treating most aggressively to prevent progression to cirrhosis and to halt the spread of the virus. You should work to treat the virus while the patient is working toward sobriety.

Q: What do you do when the insurance requires a specialist?
A: Most family and primary care practices are affiliated with a hospital, so often patients need to call an appointment line and get the person worked into the schedule.

For more information:

Miranda M. Huffman, MD, can be reached at 2301 Holmes St., Kansas City, MO 64108; email: miranda.huffman@tmcmed.org.

Disclosure: Huffman reports no relevant financial disclosures.