Hepatitis C

Availability

North South North West Statewide

Pre-referral work-up

History

Pre-referral work-up

The clinic’s focus will be those people with advanced liver disease and those at high risk of complications including those co- infected with HIV or Hepatitis B.

Most patients with minimal liver damage can be managed in the community by Primary Care without a requirement for specialist advice for prescription completion.

Please note that direct acting antiviral medication for Hepatitis C can be prescribed by a medical practitioner experienced in the treatment of chronic hepatitis C infection; or in consultation with a gastroenterologist, hepatologist or infectious diseases physician experienced in the treatment of chronic hepatitis C infection. Those clinicians uncertain of prescribing or requiring support from the hepatology team to provide care should refer the patient to clinic


History

Please provide all requested information in your referral. Please refer patients to the clinic in your region.

Note: All referrals should comply with the Referral Standards and for all patients the following parameters assist in triage and potential choices of care. Please provide:

  • Estimated duration of HCV infection
  • Previous HCV treatment experience - date, regimen and response
  • Co factors for liver disease progression: alcohol intake, marijuana use, virological cofactors (HIV, HBV), diabetes, obesity
  • Current / past renal disease
  • Ischaemic heart disease or cardiovascular risk factors
  • Vaccinations history especially for Hepatitis A and B
  • Physical and psychiatric comorbidities
  • Ongoing risk factors for viral transmission and reinfection
  • Social issues — potential barriers to medication adherence Medication
  • Concomitant medications (prescription, over-the-counter, illicit)

Examination

  • Features of cirrhosis: hard liver edge, spider naevi, leukonychia
  • Features of decompensation or portal hypertension: jaundice, ascites, oedema, bruising, muscle wasting, encephalopathy
  • Weight and BMI

Tests

Required

  • HCV genotype and subtype including HCV RNA level (quantitative)
  • HBV (HBsAg, anti-HBc, anti-HBs), HIV, HAV serology  FBE, LFT, U&Es, eGFR, INR, BetaHCG (in woman of child bearing potential)
  • Liver ultrasound
  • Liver fibrosis assessment (Hepatitis C Guidelines - Consensus Statement), eg: Elastography / FibroScan, or Serum biomarker (APRI, Hepascore, ELF test, FibroGENE*)
  • Electrocardiogram (if 50 years of age or has cardiac risk)
  • If elastography / fibroscan not available by reasonable access please note this and ensure AST and ALT and FBE available in referral.  In southern Tasmania elastography / fibroscan is available at the RHH and privately.

Interim/GP management

To refer a patient with this condition, please see the Gastroenterology clinic page for the full referral process and templates.

At any stage early referral of co-infected patients and health care workers is recommended.


Acute infection

This has evolving evidence for treatment.

Refer early to clinic those who are:

  • co-infected with HIV or Hepatitis B
  • health care workers
  • unwell

Others repeat PCR after four weeks and review for consideration of referral for treatment if PCR remains positive.

Advise on harm minimisation from other liver toxins.

Vaccination for Hepatitis B is recommended and consider vaccination for Hepatitis A.

Further information available on the Health Pathways website.


Chronic infection


Please refer to the Hepatitis C consensus statement for current treatment protocols available from the Gastroenterology Society of Australia Hepatitis C page.  This page includes a video presentation "A Practical guide to Prescribing the New Hepatitis C Antiviral drugs in General Practice".

For more information please see the Tasmanian Health Pathways website.

Emergency

Decompensated liver disease

Urgent / category 1

Jaundice

ALT>400 or documented acute onset hep A, B or C

Hypoalbuminaemia <35 g/l

Decompensated liver disease:

  • Ascites
  • Peripheral oedema
  • Wasting

Suspected malignancy or liver mass on imaging

Semi-urgent / category 2

  • Elastography score>.F2
  • Elevated INR
  • Platelet level ?

Red flags are clinical indicators of possible serious underlying conditions requiring further medical intervention. They may or may not indicate an emergency.

Gastroenterology Society of Australia Hepatitis C page

Primary Health Tasmania - Hepatitis C Treatment form

Emergency:

Proceed to Emergency Department (ED). Please contact ED Medical Officer in Charge:
LGH ED – Phone: (03) 6777 6405  Fax: (03) 6348 7382
MCH ED – Phone: (03) 6478 5120  Fax: (03) 6441 5923
NWRH ED – Phone: (03) 6493 6340  Fax: (03) 6464 1926
RHH ED - Phone: (03) 6166 6100  Fax: (03) 6173 0489

Urgent:

We will endeavour to see these patients within four weeks

Urgent referrals should be accompanied by a phone call to the clinic and the relevant doctor for urgent assessment, or patient should be directed immediately to the Emergency Department.

Semi-urgent:

We will endeavour to see these patients within 12 weeks

Routine:

Next available appointment