Hepatitis C Treatment in Primary Care

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Increasing Access to Treatment of Hep C
  

Risk Assessment Tool (RAT)

  
Cerner Dot phrase Hepatitis C Initial visit: Hep C Initial Visit Dot Phrase First, order a Viral load if antibody positive. If Viral load present then proceed with labs and workup below. If NO viral load detected, please discuss with an attending and do NOT workup. If eligible based on above THEN order the following labs (within 12 weeks of initiating treatment): - CBC - Coags - CMP - AFP - Hep C genotype - Fibrotest Order via Quest Flexitest o Name: FibroTest-ActiTest Panel o Test code: 92688 o 3.5 mL FROZEN - HIV (within 30 days) - Hep A/B antibody (within 30 days) or start Hepatitis Vaccination Within the last 6 months: - Abd U/S or CT - Verify patient meets inclusion criteria: o Fibrosis score 0-3 or 4 and compensated cirrhosis (Child-Pugh A) o Have an active viral load o Not have decompensated cirrhosis. Decompensated cirrhosis is defined as: Varices o Ascites Encephalopathy Jaundice o Be treatment naïve to novel agents (IFN exposure okay) o Not have Hep B or HIV. o Not have concurrent immune-modulating disorders such as tuberculosis or be on immunosuppressive therapies such as interferon, TNF alpha inhibitors, cyclosporine, etc. Once labs are back, read inclusion criteria above. If pt meets above criteria, bring pt back for a Hepatitis C treatment consultation visit. If the patient does not meet criteria, then refer to GI Hepatitis C clinic.
  
Cerner Dot phrase Heaptitis C Follow up visit: Hepatitis C Treatment Visit Dot Phrase. Please read in detail and delete what is not relevant. Do not just copy and paste. Clinic Note and Treatment Plan HPI - No H/o Jaundice, GIB, Varices, Encephalopathy, SBP, or Ascites PE - GENERAL - A&O x4, NAD HEENT - HNCAT, PERRLA without scleral icterus, neck supple without gland enlargement HEART - RRR S1+S2, no murmurs, rubs, or gallops LUNGS - CTA bilat, AEE bilat, no crackles, wheezes or rhonchi ABDOMEN - Soft, nontender, BS x4 NA, no organomegaly, no ascites, no r/g EXTREMITIES - no edema, no clubbing DERM - no jaundice, no spider angio, no caput medusa, no abnormal bruising, no ulcers PSYCH - Appropriate mood and affect LABS (INSERT RESULTS WITH DATES) INSERT CREATNINE .heplab HIV (within the last 30 days) AFP result if cirrhotic Fibroscore result Pregnancy test (this visit) Insert Hep C genotype (and NS5A testing result when applicable) Hepatitis A/B antibody results show immunity OR Prior Hepatitis Vaccinations completed or started DIAGNOSTICS Prior Imaging (within the last 6 months) US/CT INSERT RESULTS Prior Studies Bx INSERT RESULTS IF DONE Assessment/Plan I have verified that patient meets inclusion criteria. Prior Tx with novel agent - NO Cirrhosis - NO Decompensated - no h/o Varices, Encephalitis, Ascites, Jaundice, or hospitalization for complications of liver disease *If Evidence of Fibrosis score >4, decompensated cirrhosis, or any h/o failed prior Tx, the patient will be referred to Hepatology Clinic. The following items are present- * Fatty Liver on U/S - NO * Women of child bearing age - NO * Healthcare worker - NO * Hep B co-infection - NO * Diabetes - NO * HIV co-infection - NO * Debilitating Fatigue- Fatigue questionnaire – INSERT SCORE Hepatitis C All Genotypes Based on the above classification the patient will undergo Treatment with the following: 1. F0-3: Mavyret x 8 Weeks, 3 tabs po daily with food. 2. F4 w/ compensated cirrhosis (Child Pugh A): Mavyret x 12 weeks, 3 taps po daily with food. Medication reconciliation to be performed with case manager. Instructions were given on the importance of not missing medication dosage, follow-ups and lab draws. All questions answered. The patient wishes to proceed with treatment and will be scheduled for a Nursing appointment for further information and instructions. Follow Up Visits and Labs: 8 Week Regimen: * At week 4 of treatment: CBC, CMP, Viral Load, Coags * At week 5 of treatment: PCP Visit * At week 6 of treatment: Viral load only if no response at week 4 * At week 8 of treatment: AST/ALT * At week 9 of treatment: PCP Visit * At week 20 of treatment: Viral load * At week 21: PCP Visit 12 Week Regimen: * At week 4 of treatment: CBC, CMP, Viral Load, Coags * At week 5 of treatment: PCP Visit * At week 6 of treatment: Viral load only if no response at week 4 * At week 8 of treatment: AST/ALT * At week 9 of treatment: PCP Visit * At week 12 of treatment: Viral load * At week 13: PCP Visit * At week 24: Viral load * At week 25: PCP Visit