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Haridy J, Wigg A, Muller K, Ramachandran J, Tilley E, Waddell V, Gordon D, Shaw D, Huynh D, Stewart J, Nelson R, Warner M, Boyd M, Chinnaratha MA, Harding D, Ralton L, Colman A, Liew D, Iyngkaran G, Tse E. Real-world outcomes of unrestricted direct-acting antiviral treatment for hepatitis C in Australia: The South Australian statewide experience. J Viral Hepat 2018; 25:1287-1297. [PMID: 29888827 DOI: 10.1111/jvh.12943] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 04/30/2018] [Indexed: 02/06/2023]
Abstract
In March 2016, the Australian government offered unrestricted access to direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) to the entire population. This included prescription by any medical practitioner in consultation with specialists until sufficient experience was attained. We sought to determine the outcomes and experience over the first twelve months for the entire state of South Australia. We performed a prospective, observational study following outcomes of all treatments associated with the state's four main tertiary centres. A total of 1909 subjects initiating DAA therapy were included, representing an estimated 90% of all treatments in the state. Overall, SVR12 was 80.4% in all subjects intended for treatment and 95.7% in those completing treatment and follow-up. 14.2% were lost to follow-up (LTFU) and did not complete SVR12 testing. LTFU was independently associated with community treatment via remote consultation (OR 1.50, 95% CI 1.04-2.18, P = .03), prison-based treatment (OR 2.02, 95% CI 1.08-3.79, P = .03) and younger age (OR 0.98, 95% CI 0.97-0.99, P = .05). Of the 1534 subjects completing treatment and follow-up, decreased likelihood of SVR12 was associated with genotype 2 (OR 0.23, 95% CI 0.07-0.74, P = .01) and genotype 3 (OR 0.23, 95% CI 0.12-0.43, P ≤ .01). A significant decrease in treatment initiation was observed over the twelve-month period in conjunction with a shift from hospital to community-based treatment. Our findings support the high responses observed in clinical trials; however, a significant gap exists in SVR12 in our real-world cohort due to LTFU. A declining treatment initiation rate and shift to community-based treatment highlight the need to explore additional strategies to identify, treat and follow-up remaining patients in order to achieve elimination targets.
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Affiliation(s)
- J Haridy
- University of Melbourne, Parkville, Vic., Australia.,Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - A Wigg
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, SA, Australia
| | - K Muller
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, SA, Australia
| | - J Ramachandran
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, SA, Australia
| | - E Tilley
- Hepatology and Liver Transplantation Unit, Flinders Medical Centre, Adelaide, SA, Australia
| | - V Waddell
- Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Adelaide, SA, Australia
| | - D Gordon
- Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Adelaide, SA, Australia.,Flinders University, Bedford Park, SA, Australia
| | - D Shaw
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, SA, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - D Huynh
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - J Stewart
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, SA, Australia.,Department of Infectious Diseases, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - R Nelson
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Infectious Diseases, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - M Warner
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Infectious Diseases, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - M Boyd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Infectious Diseases, Lyell-McEwin Hospital, Adelaide, SA, Australia
| | - M A Chinnaratha
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Gastroenterology, Lyell-McEwin Hospital, Adelaide, SA, Australia
| | - D Harding
- Department of Gastroenterology, Lyell-McEwin Hospital, Adelaide, SA, Australia
| | - L Ralton
- Department of Infectious Diseases, Lyell-McEwin Hospital, Adelaide, SA, Australia
| | - A Colman
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - D Liew
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Vic., Australia
| | - G Iyngkaran
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - E Tse
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, SA, Australia
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Pateria P, Jeffrey GP, MacQuillan G, Speers D, Ching H, Chinnaratha MA, Watts GF, Adams LA. The association between chronic hepatitis C infection and cardiovascular risk. Intern Med J 2016; 46:63-70. [PMID: 26477784 DOI: 10.1111/imj.12936] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/29/2015] [Accepted: 10/10/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Vascular disease is a common cause of death in patients with chronic hepatitis C (CHC) infection; however, the association between CHC and atherosclerosis is unclear. AIMS To determine whether patients with CHC have increased subclinical vascular disease and whether genotype or antiviral treatment modifies this risk. METHODS Fifty CHC patients and 22 age-matched and sex-matched healthy controls underwent clinical and biochemical assessment for vascular risk factors. In addition, vascular risk was assessed by measuring arterial stiffness (aortic augmentation index and carotid-femoral pulse wave velocity (PWV)), endothelial dysfunction (brachial artery flow-mediated dilatation (FMD) and dilatation post-glycerol trinitrate administration) and carotid intima-media thickness (CIMT). Assessment was repeated in subset of CHC patients (n = 12) undergoing antiviral treatment 18 months after initiation of treatment. RESULTS Baseline vascular risk factors and measures of arterial stiffness, endothelial dysfunction and CIMT were not different between cases and controls (P > 0.2 for all). Genotype 1 CHC patients had greater endothelial dysfunction with lower FMD (8.2 ± 3.5% vs 10.9 ± 5.2%, P = 0.03) and higher right CIMT (0.6 ± 0.1 mm vs 0.5 ± 0.07 mm, P = 0.04) compared with non-genotype 1. Patients who achieved sustained virological response (7/12) showed significant improvement in insulin resistance (homeostasis model of assessment of insulin resistance 2.3 ± 1.2 vs 1.8 ± 0.8, P = 0.02) and arterial stiffness (PWV 7.4 ± 1.1 m/s vs 6.5 ± 0.6 m/s, P = 0.04). CONCLUSIONS Subclinical vascular disease is not greater in CHC subjects compared with controls. However, among CHC subjects, genotype 1 infection is associated with greater endothelial dysfunction and increased carotid-intima medial thickness compared with non-genotype 1 infection. Successful viral eradication may improve insulin resistance and arterial stiffness.
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Affiliation(s)
- P Pateria
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital
| | - G P Jeffrey
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - G MacQuillan
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - D Speers
- PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre
| | - H Ching
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - M A Chinnaratha
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital
| | - G F Watts
- School of Medicine and Pharmacology, University of Western Australia.,Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia
| | - L A Adams
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
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Chinnaratha MA, Chaudhary S, Doogue M, McCormick RJ, Woodman RJ, Wigg AJ. Prevalence of hepatic osteodystrophy and vitamin D deficiency in cirrhosis. Intern Med J 2016; 45:1230-5. [PMID: 26247615 DOI: 10.1111/imj.12866] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/20/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hepatic osteodystrophy (HO) is a major complication of cirrhosis. However, the prevalence of HO in a general cirrhotic patient population is not well defined as previous studies were in single aetiology or pre-liver transplant patients. AIMS The aims of this study were to investigate the prevalence of HO and vitamin D deficiency in patients with cirrhosis of mixed aetiology and disease severity and to determine the risk factors for HO. METHODS This is a single-centre cross-sectional study of all patients newly diagnosed with cirrhosis between September 2009 and December 2012. All patients underwent bone mineral density assessment using dual energy X-ray absorptiometry within 3 months of diagnosis. Demographic and biochemical factors, severity of underlying liver disease, previous fragility fractures, smoking status and alcohol use were collected on diagnosis. Logistic regression analysis was used to assess risk factors for HO. RESULTS Among the 406 patients (67% males), the median (range) age was 56 years (21-85) and most (84%) were Childs-Pugh A or B with a median (range) model for end-stage liver disease score of 11 (5-40). Alcohol (41%) was the most common underlying aetiology. The prevalence of HO and vitamin D deficiency (≤50 nmol/L) was 56% and 54%, respectively, and previous fragility fractures had occurred in 3%. Increasing age (odds ratio (95% confidence interval): 1.49 per 10 years (1.02-2.18), P = 0.04), excessive alcohol intake (2.34 (1.03-5.32), P = 0.04) and lower body mass index (0.92 per kg/m2 (0.87-0.98), P = 0.009) were independent risk factors for HO. CONCLUSION There is a high prevalence of HO and vitamin D deficiency in patients with cirrhosis at presentation irrespective of disease severity or underlying aetiology.
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Affiliation(s)
- M A Chinnaratha
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - S Chaudhary
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - M Doogue
- Southern Adelaide Diabetes and Endocrine Services, Southern Area Local Health Network, Adelaide, South Australia, Australia
| | - R J McCormick
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - R J Woodman
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - A J Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia
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Pateria P, Jeffrey GP, MacQuillan G, Speers D, Ching H, Chinnaratha MA, Watts GF, Adams LA. Author reply. Intern Med J 2016; 46:863. [DOI: 10.1111/imj.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 04/10/2016] [Indexed: 11/30/2022]
Affiliation(s)
- P. Pateria
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - G. P Jeffrey
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - G. MacQuillan
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - D. Speers
- PathWest Laboratory Medicine WA; Queen Elizabeth II Medical Centre; Perth Western Australia Australia
| | - H. Ching
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - M. A. Chinnaratha
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - G. F. Watts
- Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - L. A. Adams
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
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