HEPATITIS CASE

A 47-YEAR-OLD MALE PRESENTED TO THE MEDICINE DEPARTMENT WITH COMPLAINTS OF RIGHT UPPER QUADRANT PAIN AND FATIGUE. IN ADDITION, HE HAS RECENTLY BEEN EXPERIENCING A FLARE OF HIS PUD SYMPTOMS WHICH HAS

CAUSED HIM TO EAT MORE FREQUENTLY AND POP MORE TUMS IN ORDER TO RELIEVE HIS PAIN. HE REPORTS THAT DESPITE FEELING POORLY, HIS DEPRESSION IS CONTROLLED ON HIS CURRENT THERAPY.

HPI:
PT HAS BEEN FEELING PROGRESSIVELY WORSE FOR ABOUT A YEAR; HOWEVER, HE ONLY MENTIONED THIS TO A PHYSICIAN ABOUT 1 MONTH AGO. AT THAT TIME A FULL HEPATITIS WORK-UP WAS DONE AND WAS FOUND TO BE POSITIVE FOR ANTI-HCV BY ELISA AND RIBA CONFIRMATORY TESTS.

PMH:

HYPERTENSION X 10 YEARS DEPRESSION X 5 YEARS PEPTIC ULCER DISEASE X 1 YEAR SH: (+) ETOH X 20 YEARS (NONE FOR PAST 5 YEARS) (+) IVDA X 15 YEARS (NONE FOR PAST 10 YEARS) (+) TOBACCO SMOKES 1 PPD MARRIED WITH 2 TEENAGE CHILDREN OCCUPATION: DRIVER

FH: UNKNOWN ALL: RANITIDINE - THROMBOCYTOPENIA MEDS: LISINOPRIL 10MG PO DAILY X 10

YEARS

SERTRALINE 50 MG PO DAILY X 5 YEARS SUCRALFATE 1 G PO 4 TIMES DAILY X 1 YEAR CALCIUM CARBONATE (TUMS) 750MG PO 4 TIMES DAILY PRN ABDOMINAL PAIN X 6
MONTHS

PE : VS: BP 132/82 HR 72 RR 21 T 37 C WT 50 KG HT 53 GEN: WELL DEVELOPED WELL NOURISHED

MALE

HEENT: PERRLA (PUPILS EQUAL, ROUND, REACTIVE TO LIGHT AND ACCOMMODATION) COR: NO MURMURS OR GALLOPS CHEST: CLEAR TO ANTERIOR &POSTERIOR

ABD: RIGHT UPPER QUADRANT PAIN

GU: DEFERRED RECT: GUAIAC (-) EXT: WITHIN THE NORMAL LIMITS NEURO: ALERT &ORIENTATION X 3 (NAME, PLACE, DOB)

LABS: NA 140 GLU 100 MG 2.0 K 4.5 HCT 35 CA 9.5 CL 99 HGB 15 PO4 1.2 HCO3 26 WBC 6 ALBUMIN 3.5 BUN 16 PLT 250 ALT 350 SCR 1.0 MCV 84 AST 330 ALK PHOS 250 INR 1.0 TBILI 1.5 TSH 1.0 HCV RNA: 585,000 COPIES/ML HEPATITIS C GENOTYPE: 1 HIV (-) HBSAG (-) PREGNANCY TEST: NEGATIVE LIVER BIOPSY: HEPATOCYTE NECROSIS AND STAGE 3 BRIDGING FIBROSIS C/W CHRONIC HEPATITIS ENDOSCOPY: 0.3 CM ULCERATION IN DISTAL DUODENUM; H. PYLORI (-)

PROBLEM LIST 1. CHRONIC HEPATITIS C 2. PEPTIC ULCER DISEASE 3. DRUG-INDUCED PROBLEM 4. HYPERTENSION 5. DEPRESSION

SUBJECTIVE & OBJECTIVE EVIDENCE CHRONIC HEPATITIS C __ R UPPER QUADRANT PAIN __ FATIGUE __ + ANTI-HCV __ HCV RNA 585,000 __ LIVER BIOPSY C/W CHRONIC HEP C __ AST 330 __ ALT 350 __ T BILI 1.5 __ ALK PHOS 250 __ ALBUMIN 3.5 __ HCV GENOTYPE 1

CURRENT MEDICATIONS __ NONE ASSESSMENT ETIOLOGY __ HCV RISK FACTORS : __ INTRA VENOUS DRUG ABUSE __ ETOH

EVALUATE NEED FOR THERAPY; EVALUATE CURRENT OR NEW THERAPY __ YES, PT NEEDS THERAPY TO

__ PREVENT PROGRESSION TO CIRRHOSIS __ ERADICATE VIRUS __ PREVENT NEED FOR LIVER TRANSPLANTATION & RISK FOR HEPATOCELLULAR CARCINOMA __ MUST BALANCE BENEFITS AND RISKS OF
THERAPY SINCE PT ALREADY HAS DEPRESSION

__PT ALREADY TAKING AN SSRI FOR DEPRESSION __WILL NEED TO ASSESS STATUS PRIOR TO
STARTING THERAPY TO MAKE SURE DEPRESSION IS
CONTROLLED

PT HAS SEVERAL NEGATIVE PREDICTORS TO BENEFICIAL RESPONSE WITH IFN: __ GENOTYPE 1 , AGE > 40 __ STAGE 3 FIBROSIS ON LIVER BIOPSY PT HAS SEVERAL POSITIVE PREDICTORS OF BENEFICIAL RESPONSE WITH IFN: __ MALE, LOWER BODY WEIGHT (< 70KG) ,HCV RNA < 1 MILLION

TREATMENT OPTIONS: __ STANDARD INTERFERON ___SUBOPTIMAL RESPONSE SHOWN IN CLINICAL STUDIES __PEG INTERFERON __ADDITION OF PEG INCREASES HALF-LIFE, RESULTING IN
SUSTAINED SERUM CONC __CURRENT STANDARD OF CARE WITH RIBAVIRIN __PT HAS NO CONTRAINDICATIONS __NO DIFFERENCE BETWEEN 2 FORMULATIONS (PEG A-2A VS A-2B) __RIBAVIRIN __CURRENT STANDARD OF CARE WITH PEG INTERFERON __PT HAS NO CONTRAINDICATIONS

PLANNING RECOMMEND DRUG TREATMENT; DRUGS TO BE AVOIDED; FURTHER TESTS __ PEGINTERFERON ALFA-2A 180 MCG SC /WEEK + __ RIBAVIRIN 400MG PO/AM 600MG PO/PM WITH FOOD X 48
WEEKS

OR __ PEGINTERFERON ALFA-2B75 MCG SC /WEEK + __ RIBAVIRIN 400MG PO/AM 600MG PO/PM WITH FOOD X 48 WEEKS __CHECK HCV RNA AT 12 WEEKS FOR EARLY VIROLOGIC RESPONSE (EVR)

__IF HCV RNA NEGATIVE OR HAS FALLEN BY AT LEAST 2 LOG 10 UNITS (TO 5850 OR LESS) __CONTINUE THERAPY FOR FULL 48 WEEKS __IF NOT, THEN STOP THERAPY __ CHECK A BASELINE TSH __ ASSESS PTS MENTAL HEALTH STATUS (E.G. DEPRESSION) PRIOR TO STARTING THERAPY __AVOID HEPATOTOXINS SUCH AS __ACETAMINOPHEN (LIMIT TO 2-4G/DAY) __ALCOHOL

GOALS & MONITORING PARAMETERS GOALS: __ ERADICATE VIRUS __ DECREASE M & M __ NORMALIZE BIOCHEMICAL MARKERS __ IMPROVE CLINICAL S/SX __ PREVENT SPREAD OF DISEASE __ PREVENT PROGRESSION TO CIRRHOSIS AND HEPATOCELLULAR CA __ PREVENT DEVELOPMENT OF END-STAGE
LIVER DISEASE AND ITS COMPLICATIONS

MONITOR: __AST/ALT / MONTH __CBC W/DIFF, PLT /MONTH __TSH /3 MONTHS __HCV RNA __DEPRESSION __FATIGUE __BUN/SCR __BLOOD GLUCOSE/HGBA1C __PREGNANCY TEST / MONTH

Side Effects of IFN: injection site reactions flu-like symptoms neutropenia thrombocytopenia depression induction of autoimmune disorders such as: diabetes RA increased Anti Nuclear Antibodies

SE of Ribavirin: hemolytic anemia cough/dyspnea rash/pruritis insomnia anorexia teratogenicity

PATIENT EDUCATION __SUB CUTANEOUS ADMINISTRATION

TECHNIQUES

__SIDE EFFECTS OF IFN ESPECIALLY __FLU-LIKE SYMPTOMS __DEPRESSION __FATIGUE, MALAISE __PSYCHIATRIC CHANGES __SIDE EFFECTS OF RIBAVIRIN ESPECIALLY COUGH, RASH __CONSIDER TAKING IFN AT BEDTIME TO
ALLEVIATE SYMPTOMS

__CAN ALSO TRY TAKING WITH NSAIDS FOR FIRST

MONTH TO HELP ALLEVIATE

SIDE EFFECTS,

__ ALTHOUGH WOULD NEED TO BALANCE WITH PUD

ISSUES

__TAKE RIBAVIRIN WITH FOOD TO REDUCE GI SIDE

EFFECTS

__COMPLIANCE WITH THERAPY __LONG-TERM YET POTENTIALLY LIFE-SAVING

THERAPY

__DO NOT DONATE BLOOD/ORGANS/TISSUES __SAFE SEX PRACTICES TO __PREVENT TRANSMISSION OF VIRUS AND __PREVENT PREGNANCY

__AVOID SHARING RAZORS AND TOOTHBRUSHES

WITH HOUSEHOLD FAMILY MEMBERS

__COVER OPEN WOUNDS __NO ALCOHOL __LIMIT ACETAMINOPHEN __CHECK ALL OTC PRODUCTS (E.G. COLD PRODUCTS ETC) FOR PRESENCE OF ACETAMINOPHEN __AVOID OTHER POTENTIAL HEPATOTOXINS (HERBALS), CHECK WITH PHARMACIST __CONSIDER HAVING HUSBAND AND 2 CHILDREN TESTED FOR HEPC

SUBJECTIVE & OBJECTIVE EVIDENCE PEPTIC ULCER DISEASE __PT REPORTS FLARE __EATING MORE FREQUENTLY __POPPING TUMS TO RELIEVE PAIN __ENDOSCOPY SHOWS ULCER IN DISTAL
DUODENAUM

__H. PYLORI NEGATIVE CURRENT MEDICATIONS __SUCRALFATE 1GM PO QID __CALCIUM CARBONATE 750MG PO QID PRN

ASSESSMENT ETIOLOGY __UNKNOWN RISK FACTORS: __AGE > 45 YRS __SMOKING __ PHYSIOLOGIC STRESS DUE TO HEPATITIS C?? __ETOH

EVALUATE NEED FOR THERAPY; EVALUATE CURRENT OR NEW THERAPY __YES, PT NEEDS THERAPY TO ALLEVIATE SYMPTOMS AND
PREVENT FURTHER ULCERATION THAT MAY LEAD TO

__GI BLEEDING __CURRENT THERAPY NOT WORKING TO ALLEVIATE SYMPTOMS __SUCRALFATE IN COMBINATION WITH CALCIUM CARBONATE IS CAUSING HYPOPHOSPHATEMIA (D/I PROBLEM) __CONSIDER D/CING SUCRALFATE AND CALCIUM CARBONATE
AND CHANGING TO ALTERNATIVE THERAPY __H. PYLORI NEGATIVE, SO DO NOT NEED TO CONSIDER PYLORI REGIMENS

H.

TREATMENT OPTIONS: ANTACIDS: __AVOID ALUMINUM-BASED ANTACIDS DUE TO

HYPOPHOSPHATEMIA

__AVOID SODIUM BICARBONATE-BASED ANTACIDS

DUE TO HYPERTENSION

__AVOID CALCIUM-BASED ANTACIDS DUE TO

HYPOPHOSPHATEMIA

__MG-BASED ANTACIDS MAY BE AN ALTERNATIVE (NO CONTRAINDICATION) BISMUTH SUBSALICYLATE: __ACTIVE VS H. PYLORI; PT NEGATIVE FOR H. PYLORI, WORKS LOCALLY, NO CONTRAINDICATION IN
THIS PT

H2 ANTAGONISTS: __PT GETS THROMBOCYTOPENIC WITH RANITIDINE (ALLERGY) __WOULD BE BEST TO AVOID H2 ANTAGONISTS DUE TO POTENTIAL FOR CROSS-REACTIVITY __SMOKING DECREASES EFFECTIVENESS OF H2S PROTON PUMP INHIBITORS: __PROVIDE MORE CONSISTENT INTRAGASTRIC ACID PH CONTROL VS H2S __NEED TO BE GIVEN 30 MIN PRIOR TO A MEAL TO
MAXIMIZE THERAPEUTIC ACTIVITY

__WELL-TOLERATED __NO CONTRAINDICATIONS

PLANNING RECOMMEND DRUG TREATMENT; DRUGS TO BE AVOIDED; FURTHER TESTS __D/C SUCRALFATE __D/C CALCIUM CARBONATE __D/C SMOKING (CREDIT FOR ANY PPI) __OMEPRAZOLE __20-40MG POQD30 MIN BEFORE A MEAL X 4-8 WEEKS
OR __ESOMEPRAZOLE 20MG POQD30 MIN BEFORE A MEAL X 4-8 WEEKS OR __LANSOPRAZOLE 30-60MG PO QD 30 MIN BEFORE A MEAL X 4 WEEKS OR __PANTOPRAZOLE 40MG PO QD 30 MIN BEFORE A MEAL X 4 WEEKS OR __RABEPRAZOLE 20MG PO QD 30 MIN BEFORE A MEAL X 4 WEEKS

GOALS & MONITORING PARAMETERS GOALS: __RELIEVE SYMPTOMS __REDUCE GASTRIC ACIDITY AND SECRETION __PROMOTE ULCER HEALING __PREVENT ULCER RECURRENCE AND
COMPLICATIONS MONITOR: __EPIGASTRIC PAIN __WEIGHT

SE OF PPIS: __N/D, ABDOMINAL PAIN __DIZZINESS __HA __RASH __LFTS PATIENT EDUCATION __STOP SMOKING __NO ETOH __EAT SMALLER MEALS __AVOID SPICY FOODS OR FOODS THAT SEEM TO AGGRAVATE
SX

__AVOID ACETYL SALICYLIC ACID, NSAIDS IF POSSIBLE (MAY NEED LOW-DOSE/SHORT COURSE FOR IFN TREATMENT ABOVE) PPI PT ED: __TAKE 30 MIN BEFORE A MEAL

__DO NOT CRUSH OR CHEW CAPS __SWALLOW WHOLE __NOTIFY DOCTOR IF VOMITING BLOOD OR
HAVING DIFFICULTY SWALLOWING

SUBJECTIVE / OBJECTIVE DRUG-INDUCED HYPOPHOSPHATEMIA __PO4 = 1.2 SUBJECTIVE & OBJECTIVE EVIDENCE CURRENT MEDICATIONS __NONE ASSESSMENT ETIOLOGY __SUCRALFATE __CALCIUM CARBONATE

EVALUATE NEED FOR THERAPY; EVALUATE CURRENT OR NEW THERAPY __YES, PT NEEDS TREATMENT TO RESTORE PO4 TO
NORMAL VALUES AND PREVENT SX COMPLICATIONS __PT IS CURRENTLY ASYMPTOMATIC SO CAN TREAT WITH

AN ORAL AGENT __HAVE ALREADY D/CD SUCRALFATE AND __CALCIUM CARBONATE ABOVE __PO4 OF 1.2 IS CONSIDERED MILD-MODERATE SO CAN TREAT WITH AN ORAL AGENT

PLANNING RECOMMEND DRUG TREATMENT; DRUGS TO BE AVOIDED; FURTHER TESTS __SODIUM PHOSPHATES 250MG PO DISSOLVE IN WATER OR JUICE QID WITH MEALS AND AT BEDTIME X 1 DAY OR __SODIUM/POTASSIUM PHOSPHATE 250MG PO DISSOLVE IN WATER OR JUICE QID WITH MEALS AND AT BEDTIME X 1 DAY OR __SODIUM PHOSPHATE 250MG PO DISSOLVED IN WATER OR JUICE QID WITH MEALS AND AT BEDTIME X 1 DAY __CHECK PO4 AFTER GIVING PO4 REPLACEMENT

GOALS & MONITORING PARAMETERS GOALS: __NORMALIZE SERUM PO4 TO 2.5-4.5 MG/DL __MANAGE UNDERLYING CONDITION (DRUGS FOR PUD) MONITOR: __SERUM PO4 SE OF SODIUM PHOSPHATE __DIARRHEA

PATIENT EDUCATION __STOP SMOKING __DO NOT SWALLOW THE TABLET OR CAPSULE __DISSOLVE POWDER OR TABLET OR CAPSULE IN WATER
OR JUICE __DRINK WITH MEALS TO OBTAIN MAXIMUM EFFECT

FOODS HIGH IN PHOSPHORUS: __DAIRY PRODUCTS __MEATS __POULTRY __FISH __CEREAL PRODUCTS