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Hepatitis C and the Rheumatologist: Our Role in the Quest for Global Eradication of HCV
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I am pleased to have Healio Rheumatology focus this issue’s Cover Story on the intersection of viral hepatitis and rheumatology, as this is a subject both near to my heart as well as one of great importance to many patients. Our esteemed sources enlighten us on many aspects of the impact of viral hepatitis and rheumatic diseases from not only from the perspective of these viruses as etiologies for many rheumatic syndromes, but also, and far more important, from a prevalence perspective – the impact of chronic viral hepatitis, both hepatitis B and C, as comorbidities.
When a patient with a rheumatic disease has comorbid chronic HBV and HCV infection, numerous complex issues must be parsed to offer optimal antirheumatic therapy. While there are no accurate appraisals of how many patients are infected, it is certainly in the tens of thousands. Having been afforded this Editorial opportunity, I want to focus on one aspect of HCV infection that sounded like a dream just a few years ago, namely the prospect of global eradication of HCV.
Epic Breakthrough
In 2014, Patrice P. Cacoub, MD, PhD, and I were the first in the rheumatology community to comment on the impact of direct-acting antiviral (DAA) drugs for HCV. These spelled the end of interferon therapy and provided a new day for patients with rheumatic diseases, who now could be treated and likely cured of their underlying chronic viral infections. However, little did we know, or at least myself, that this was merely the start of the beginning of an epic breakthrough in therapeutics that has now converted the treatment of HCV into a rapid cure without significant toxicity for nearly all patients with access to therapy. At that time, HCV was still in ascendency and had overtaken HIV infection as the leading cause of death from viral illness in the United States.
So much has changed as now many foresee the prospects of eradicating the pathogen globally, similar to smallpox, if enough people can be diagnosed and treated. Clearly major obstacles exist, but at least there is now hope of such a scenario. While the public health service has not yet changed the screening recommendations from the birth cohort model (ie, screen only those at highest risk; those born from 1945 to 1965), many are clamoring for universal screening.
Voice of Rheumatologists
Rheumatologists can add to this voice with our push to increase screening for chronic viral hepatis in our practices. Obstacles confronting this include outdated screening guidelines by the American College of Rheumatology and EULAR, which should be supporting groups like the American Associations of Societies for Liver Disease, the Infectious Disease Society of America and others in this effort.
The algorithm I have proposed publicly is simple. If you are considering immunosuppression in a rheumatic disease patient, then screen for both HBV and HCV. There are no other questions to ask regarding risk factors and no deciphering of which medications are “immunosuppressive.” If you have to wonder about the intricacies of this question, then just screen. I choose to error on the side of sensitivity rather than specificity with this recommendation. From that point, if the patient is HCV positive and viremic, then refer the patient immediately to a practitioner experienced with DAAs as to undergo curative therapy and then return 2 weeks later for standard of care therapy for the underlying rheumatic disease.
I know this will seem reductionist in design to many rheumatologists. However, my beliefs are not being offered as a guideline or even a recommendation, but more of an alert. This is not only an opportunity to reflect on how you currently screen in your practice, but it is also a call to action. HCV is on a long path toward the goal of global eradication and rheumatologists need to be part of it.
Thanks for reading this issue of Healio Rheumatology. Please share your comments with me by email at calabrl@ccf.org or follow me on Twitter @LCalabreseDO or @HealioRheum.
- References:
- Calabrese L, et al. RMD Open. 2015;doi:10.1136/rmdopen-2014-000008.
- Sagg MS. Universal Screening is a Pathway to Eradication. HCV Next. 2017;4(6):10.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
Disclosure: Calabrese reports he is a consultant for Genentech, Pfizer, Bristol-Myers Squibb, GlaxoSmithKline, Sanofi, Jansen and AbbVie; and is on the speakers bureau for Genentech, AbbVie and Bristol-Myers Squibb and Crescendo Bioscience.