Drug Therapy For Hepatitis C

Will Community Pharmacies Be Able To Dispense These New Hepatitis C Drugs

Community pharmacists will be able to dispense the drugs. However, because these are new drugs, it may take time for pharmacies to order in sufficient stock to meet demand.

This means that patients may need to wait a couple of days after providing their script for the drugs to be available from their local pharmacy.

What Can People Do To Help The Medications Work Best

• Take the medications every day
• Stay in touch with pharmacy to be sure that all refills are ready on time
• Take the medications exactly as prescribed
• Do not skip doses
• Get all blood tests done on time
• Go to all visits with providers as recommended
• Tell the provider about all other medications that are being taken – including over-the-counter medicines, vitamins, herbs, and supplements
• Complete the entire course of medication

D Assessment Of Methodological Quality Of Individual Studies

To assess the methodological quality of included studies, we will use a set of modified criteria developed by the U.S. Preventive Services Task Force.41 Two independent reviewers will assign a quality rating of the internal validity for each study. Disagreements will be resolved by discussion and consensus or by consulting a third, independent reviewer. A rating of good, fair, or poor will be assigned by using the predefined criteria for each study design. Such criteria include: adequate randomization methods , consideration of potential confounders, maintenance of comparable groups, reliable and valid measurements, clear definition of interventions, and appropriate analyses . Generally, a good-quality study meets all criteria for that study design a fair-quality study does not meet all criteria but is judged to have no major flaw that invalidates its results, such as a substantial loss to followup or failure to conceal treatment allocations and a poor-quality study contains a fatal flaw. In addition, the quality assessment of adverse effects and harms data will be informed by the Methods Guide for Effectiveness and Comparative Effectiveness Reviews42 developed by the Agency for Healthcare Research and Quality. Quality ratings will be recorded in the evidence tables. No studies will be excluded based on this quality assessment, although the impact of quality assessments on outcomes will be explored during data synthesis.

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Sofosbuvir Velpatasvir And Voxilapresvir

This drug combination is similar to Epclusa but also includes a drug called voxilapresvir.

Facts about Vosevi include:

• Treatment time is 12 weeks for people without cirrhosis or compensated cirrhosis .
• Dosage is fixed at 400 mg of sofosbuvir, 100 mg of velpatasvir, and 100 mg of voxilapresvir once per day with food.
• Common side effects include tiredness, a headache, diarrhea, and nausea.

Doctors often recommend Vosevi for people who have had previous treatment for hepatitis C that did not work.

Pricing Policy And Pricing Mechanisms

Historically, since 1950 a strict compulsory pricing policy has been in place, intending to make medicines affordable to the lowest socioeconomic segments of the population, later formulated into legislation that was based on cost-plus and mark-up regulation. In 2009, external reference pricing was introduced and later combined with mark-up regulation in more recent legislation in 2012 . The prices of pharmaceuticals are determined during the registration process through a pricing committee and based on a ministerial decree 499/2012 that has come into force since July 2012. It combines External Reference Price with markup regulation, detailing profit margins for pharmacists and distributors.

EDA also reviewed the price of Daclatasvir , which originally entered the USA market at US$ 63,000 for a 12-week course and decided to be EGP 8000 per box, for generics and because of the competitions, the price is EGP 120 . The initially published price in the US for the innovator Ledipasvir plus Sofosbuvir for 12-week courses of treatment was US$ 94,500 . In Egypt, the price per bottle of Harvoni® for a 1-month supply is EGP 5500 . The price of generics is around EGP 1100 . Table shows the prices of selected registered DAAs in Egypt.

Table 1 Prices of selected registered DAAs in Egypt

The study is subject to some limitations including the following:

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Can Hepatitis C Be Treated

Yes, since 2010 enormous progress has been made in the treatment of chronic hepatitis C. New therapies called direct-acting antivirals are pills that act on the virus itself to eradicate it from the body, unlike older medicines like interferon injections which work by stimulating an immune response. These new treatments are very effective and can achieve cure rates of over 90%. In most situations now, there is no need for interferon, which was responsible for many of the side effects previously associated with HCV treatment. The new treatment combinations require shorter treatment durations , have reduced side effects and appear to be effective at all stages of the disease.

Because these new therapies are very new, they remain very expensive. As such, drug coverage from both government and private companies may require that your liver disease has progressed to a certain stage before they are willing to cover the cost of these drugs.

Your primary care physician may refer you to a specialist to determine whether you are eligible for treatment. A specialist will help you decide which drug therapy is best for you based on the severity of your liver disease, your virus genotype and whether or not you have been treated in the past.

How Is Hepatitis C Treated

Hepatitis C is treated using antiviral drugs.

Treatment in the first 6 months focuses on:

• treating symptoms
• preventing the spread of the disease
• preventing complications, such as liver damage

For someone who has the disease beyond 6 months, treatment includes a combination of medications. However, not everyone with this form of hepatitis C will need treatment.

Whether or not you are getting treatment, you can help lower the risk of damage to your liver by:

• avoiding alcohol

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Who Can Prescribe The New Drugs

A section 85 listing on the Pharmaceutical Benefits Scheme will allow general practitioners, as well as specialists, to prescribe the new treatments. This means that people with hepatitis C will be able to be treated by a general practitioner in the community. However, people with more advanced care needs, such as cirrhosis, may still need to see a specialist.

Nonstructural 5a Complex Inhibitors

The NS5A complex plays a role in HCV RNA replication regulation as well as viral assembly and packaging, and directly interacts with the RNA-dependent RNA polymerase . The exact antiviral action of NS5A inhibitors is unknown they are theorized to inhibit hyperphosphorylation of the NS5A protein and alter the proteins location from the endoplasmic reticulum, likely causing faulty HCV assembly. Ledipasvir, ombitasvir, daclatasvir , elbasvir, velpatasvir, odalasvir, samatasvir, ravidasvir, ruzasvir, and pibrentasvir currently make up the class of NS5A inhibitors . Ledipasvir is one of the most potent inhibitors of the NS5A complex, but may have lower activity in HCV genotypes 2 and 3 infections.,, Ombitasvir is approved in combination with paritaprevir, ritonavir, and dasabuvir as part of the 3D regimen for the treatment of HCV genotypes 1 and 4 infections, but also has a higher pill burden, which could affect compliance. Velpatasvir has antiviral activity against HCV replicons in genotypes 1 through 6. NS5A complex inhibitors have high potency, multigenotypic coverage, and generally a low barrier to resistance. Newer agents in this class have the promise to increase the resistance threshold.

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Recommended Monitoring For Pregnancy

RECOMMENDED RATING Women of childbearing potential and their partners should not receive ribavirin during or for at least 6 months prior to pregnancy. I, C Women of childbearing potential should be counseled not to become pregnant while receiving a ribavirin-containing antiviral regimen, and for at least 6 months after stopping the regimen. I, C Male partners of women of childbearing potential should be cautioned to prevent pregnancy while they are receiving a ribavirin-containing antiviral regimen, and for up to 6 months after stopping the regimen. I, C Serum pregnancy testing is recommended for women of childbearing potential prior to beginning treatment with a regimen that includes ribavirin. I, C Assessment of contraceptive use and of possible pregnancy is recommended at appropriate intervals during ribavirin treatment for women of childbearing potential, and for female partners of men who receive ribavirin treatment. I, C

Ribavirin causes hemolysis. Patients receiving ribavirin should have hemoglobin levels checked during treatment, often after 2 weeks, and the ribavirin dose reduced if the patient develops significant anemia, often defined as hemoglobin < 10 g/dL.

• Related References

Treatment Of Patients With Decompensated Cirrhosis

Treatment of patients with decompensated cirrhosis ) is limited to regimens containing sofosbuvir and NS5A inhibitors. Protease inhibitors are not recommended due to the hepatic metabolization and subsequently significantly higher drug exposure in this group of patients. Thus, grazoprevir/elbasvir, glecaprevir/pibrentasvir or SOF/VEL/VOX should not be administered. To improve efficacy the remaining combination of sofosbuvir and NS5A inhibitor should be combined with RBV . Many studies and real-world data have shown that IFN-free antiviral therapy is safe in patients with advanced liver disease. However, patients are still at risk of hospitalization during therapy, mainly because of complications from liver disease . The efficacy of sofosbuvir/ledipasvir plus RBV was studied in the SOLAR-1 and -2 study. In GT 1 patients, SVR rates ranged between 87 and 96% and between 72 and 85% in CPS B and CPS C patients, respectively . The ASTRAL-4 study evaluated the use of sofosbuvir/velpatasvir in patients with CPS B, but not CPS C. Treatment duration of 12 weeks showed high rates of SVR for patients with GT 1, 2, 4 and 6 infection. SVR rates of GT 3 were low at 50% but could be increased to 85% by the addition of RBV . Even though the rate of treatment discontinuations is higher in patients treated with RBV, the additional antiviral substance significantly increases SVR rates .

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What Does It Mean To Have A Successful Treatment What Is A Sustained Virologic Response

In an untreated state, the hepatitis C virus infects the cells of the liver and then continuously lives there, making copies of itself that circulate in the bloodstream. Antiviral medications can destroy the ability of the virus to reproduce, so the amount of virus in the bloodstream then decreases. The amount of virus in the blood is measured by aviral load.

Treatment is successful when the viral load drops toundetectablelevels, which means the virus cannot be detected in the bloodstream at all. The viral load becomes undetectable during treatment and remains undetected after treatment has ended. If there is still no detectable virus in the blood 12 weeks after the end of the treatment, the treatment was successful. This is called a Sustained Virologic Response .

A patient who has achieved an SVR is considered to be cured of the hepatitis C virus.

B Searching For The Evidence: Literature Search Strategies For Identification Of Relevant Studies To Answer The Key Questions

Results from previously conducted meta-analyses and systematic reviews on these topics will be sought and used where appropriate and updated when necessary. In addition to using MEDLINE® to identify systematic reviews, a research librarian will search the Cochrane Databases of Systematic Reviews and Controlled Trials and Database of Abstracts of Reviews of Effectiveness.To identify articles relevant to each Key Question , the librarian will search the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Evidence-Based Medicine Reviews and Ovid MEDLINE® . We will search all electronic bibliographies from 1947 to present. Grey literature will be identified by searching clinical trial registries , grants databases and the Web sites of individual funders. Scientific Information Packets will be solicited from industry stakeholders through the Scientific Resource Center.

Abstracts and full-text articles will be reviewed in duplicate for inclusion and exclusion for each KQ. After finalizing literature searches, the research team will review titles and abstracts using pre-established inclusion/exclusion criteria to determine potential eligibility for inclusion in the evidence synthesis. All citations that are judged to meet the inclusion criteria by at least one reviewer will be retrieved for full text review.

Table 1. Sample search strategy

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Ddi As Complication In Hcv Therapy

Table 3.

Induction and inhibition of enzymes or transporters by active substances for HCV therapy

However, theoretical potential for interactions does not always result in clinically relevant DDI. When predicting clinically relevant DDI, the following point needs to be kept in mind. DDI studies with reliable clinical end points or pharmacokinetic data are most eligible to determine clinical significance but still need an expert for interpretation, and in most cases such studies are not available . Table 4 shows commonly used concomitant medications in HCV, clinically relevant DDI with modern HCV regimens and the suggested management based on prescription information , www.hep-druginteractions.org and authors expertise .

Table 4.

For additional information:

Actions For This Page

• Recent advances in antiviral treatment have led to the development of new highly effective drugs for the treatment of all types of hepatitis C.
• The new hepatitis C treatments are sofosbuvir with ledipasvir sofosbuvir daclatasvir and ribavirin .
• These new treatments are now available on the Pharmaceuticals Benefits Scheme.

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F Grading The Evidence For Each Key Question

We will grade the strength of evidence for primary outcomes using the standard process of the Evidence-based Practice Centers as outlined in the AHRQ Methods Guide.43 The grade will be based on four major domains: risk of bias, consistency, directness, and precision of the evidence. We will classify the bodies of evidence pertaining to each primary outcome into four basic grades: high, moderate, low, and insufficient . As advised in the AHRQ Methods Guide, the number of studies that form that basis of given findings or conclusions will also be recorded. Additional domainssuch as dose-response association, plausible confounding, strength of association, and publication biaswill be assessed and reported as appropriate.

G. Assessing Applicability

How Effective Is Treatment

Direct acting antivirals cure 9 out of 10 patients with hepatitis C.

Successful treatment does not give you any protection against another hepatitis C infection. You can still catch it again.

There’s no vaccine for hepatitis C.

If treatment does not work, it may be repeated, extended, or a different combination of medicines may be tried.

Your doctor or nurse will be able to advise you.

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What Are Genotypes And Do They Matter

Six different genotypes of hepatitis C have been identified. Genotypes 1 and 3 are the most common causes of hepatitis C in Australia and make up 90 per cent of all cases. They are important because they help determine the treatment you need. Unlike in the past, however, your genotype is not important in terms of the chance of cure. With the treatment drugs, all six genotypes have a very high chance of cure.

Background And Objectives For The Systematic Review

Hepatitis C virus infection is the most common chronic blood-borne infectious disease in the United States. The Centers for Disease Control and Prevention estimates that 18,000 Americans were newly infected with the virus in 2008, and between 2.7 and 3.9 million people are living with chronic HCV infection.1 Chronic HCV infection is associated with increased rates of cirrhosis, liver failure, and liver cancer and with 12,000 deaths per year in the United States. It is estimated that the direct medical costs of HCV-related diseases will top $10 billion over the next 10 years.2

The prevalence of HCV infection is highest in non-Hispanic blacks when compared to all other ethnic groups and is highest in the 4049 age group.3 The prevalence also increases with lower family income and less education. The transmission of HCV is primarily through large and repeated percutaneous exposure to infected blood.4 The most common mode of HCV transmission in the United States is the use of injection drugs. HCV can also be transmitted through needle-stick injuries and via vertical transmission from an infected mother to infant. The less common modes of transmission include sexual activities with an HCV-infected person and receipt of donated blood, blood products, and organs that are infected.4

In this review, we propose to address the following:

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Limitations Of Drug Treatments

Though the latest generation of hepatitis C drugs can effectively cure the disease, patients whose hepatitis C infection has progressed to the point of causing advanced cirrhosis or liver failure may require a liver transplant to fully recover.

Its important to let your doctor know what other medications and supplements youre taking so you can avoid harmful interactions. If youre nursing or pregnant, youll also want to let your healthcare provider know, as this can affect your treatment options.

How Hepatitis C Used To Be Treated

Along with abstinence from alcohol , the standard treatment for chronic hepatitis C used to be a combination antiviral therapy consisting of a pegylated interferon and ribavirin, sometimes called PEG/riba therapy.

A pegylated interferon is a long-acting form of an interferon, a synthetic copy of an infection-fighting protein secreted by immune system cells in response to pathogens. Ribavirin is a drug that interferes with HCV’s ability to replicate. In some cases, pegylated interferon was used without ribavirin, but ribavirin alone isn’t effective against hepatitis C.

To treat hepatitis C, doctors prescribed weekly injections of the pegylated interferons along with twice-daily oral doses of ribavirin. PEG/riba therapy was not a cure-all.

Interferon is not an option for people with liver failure, autoimmune diseases, and psychiatric illness. It can also cause a range of life-threatening complications that prevent many people from completing their therapy.

Newer drug regimens that can cure hepatitis C have forced a change in the standard treatment for the disease, and in the United States, these medications have largely replaced interferon. But pegylated interferon and ribavirin together or separately may still be used in combination with newer antiviral drugs.

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