Outpatient Clinics

This condition is treated in the Gastroenterology clinic

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

• See THS Hepatitis C Pathway.  Related to this pathway you may wish to look at the following advice sheets:

1. Decision Making in Hepatitis C.
2. Medication choices and process - ASHM Quick Ref Tool.

• Vaccination for Hepatitis B is recommended and consider vaccination for Hepatitis A
• Liver fibrosis assessment - see page 2  of the Decision making guide.
• An overview of care and assessment is found on the ASHM website - Primary Care Providers and Hepatitis C.
• See Decision-making in Viral Hepatitis Related Advanced Liver Disease.
• Direct - acting antiviral (DAA) medicines for the treatment of chronic hepatitis C virus (HCV) infection have been associated with reactivation of hepatitis B virus (HBV) in patients with a current or previous HBV infection. Prescribers should consider retesting for Hepatitis B (recheck LFTS and HBs Ag or HBV DNA) during treatment with DAAs when the patient is known to have had Hepatitis B infection in the past; (serology= HBsAg negative, with anti HBc positive and anti HBs positive).
• For hepatitis B information please refer to the THS Outpatient Hepatitis B (HBV) Clinic page.
• Useful decision making charts for Hepatitis B can be found on the ASHM website; Decision-Making in HBV & Decision-Making in Viral Hepatitis Related Advanced Liver Disease for advanced disease.
• Please note further Prescriber Resources are available on the ASHM website.

For more information please see the Tasmanian Health Pathways website.

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