Starting _ Maintaining a HCV Support Group - HCV Advocate by babbian

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									                      HCV Training Workshop




                            ALAN FRANCISCUS
E X E C U T I V E D I R E C T O R , H E PAT I T I S C S U P P O R T P R O J E C T



   J O I N U S O N T W I T T E R & FA C E B O O K – H C VA D V O C AT E

               B L O G : H C VA D V O C AT E . B L O G S P O T. C O M /



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                 People Who Make a Difference

                             • Irina Gavrilova
 C.D. Mazoff


 Lucinda Porter             • Christine M. Kukka

 Rose Christensen           • Clara Maltras

 Liz Highleyman
                             • Kate Frye
 Leslie Hoex
                             • Patrick Daniel


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                      www.hcvadvocate.org




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                      Numbers

 •Website average :
   •Average 550,000 hits/week


 •Educational Materials: 600,000 pieces
     •   Not counting website downloads
     •   Fact Sheets – 400-500 downloads weekly



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Legend: Completed
 www.hcvadvocate.org   Version 12.3
Legend: Completed; Planned
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       Effect on HCV Community

•HCSP Educators: more than 11,000


   •   50 people:
       • In one year outcome is 550,000 people


   •   Ultimate goal:
       •   Improved education, support and services

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                      The Liver




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                      •   About 3 lbs (men) – size of a
       T                  football
       H
                      •   Located in the upper right side
       E                  – beneath the rib cage

                      •   1.5 quarts of blood flow
       L                  through it every minute
       I
                      •   Chemical factory > 500
       V                  functions
       E
                           •   Bile – regulates hormones
       R                       – immune system cells

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             Liver Functions - continued


 •   Sugar & fat metabolism & Nutrient storage

 •   Stores some vitamins & minerals
     • Fat soluble vitamins: A, D, E, & K
         •   People with HCV should be tested

     •   Minerals: copper & iron

 •   Clotting factors: makes proteins to help the blood clot

 •   Filters – breathed in the air, absorbed through the skin and taken by
     mouth

                      *** Regenerates—grows or shrinks***
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             Healthy People:
•H e a l t h y p e o p l e — n o m o r e t h a n :
   •   2 alcoholic drinks a day for men; 1 alcoholic drink a day for women
   •   HCV – NO ALCOHOL

•B e c a u t i o u s a b o u t m i x i n g d r u g s e s p e c i a l l y w i t h a l c o h o l —
   •   Acetaminophen (Tylenol) – 600 products
       •   Over 56,000 emergency room visits & 500 deaths a year
   •   NSAIDs:
       •   16,500 annual deaths
•E a t a h e a l t h y , b a l a n c e d d i e t :
   •   www.choosemyplate.gov

www.hcvadvocate.org                                                                     Version 12.3
                      HEPATITIS

•Means:
            Inflammation of the liver


•Causes:
    •   Viruses, toxins, genetic disorders,
        bacteria and parasites

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                      Hepatitis A (HAV)
  •   US—New infections: 17,000 (US – 2012)

      •   180, 000 in 1997

      •   Vaccine available since 1995 –2 doses (0 & 6 months)

      •   Estimated 33% have been infected with HAV

  •   Resolves (not chronic)

  •   Transmission: fecal/oral
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                      HEPATITIS B (HBV)

•US – 38,000 new infections (CDC – 2012)

  •Vaccine available since 1982 – 3 doses (0, 1, & 6 months)
•US chronic: 1.2 Million

  •   Worldwide: 350-400 million
•U S – 3 , 0 0 0 D E A T H S A Y E A R

  •   Worldwide 660,000 annual deaths

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                      HBV Transmission

    •   Blood borne – can live outside the body for at least 7
        days
    •   Highly infectious in semen and vaginal
        secretions – 50% - sexual transmission
    •   Sharing needles to inject drugs
    •   Needle stick and blood exposure accidents
    •   Sharing personal items
    •   Mother-to-child transmission
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                      HBV Prevention
•Get vaccinated

•Do not share needles or works

•Safer sex

•Standard safety precautions

•Do not share personal items

•HBV-infected mother-to-child intervention
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                                    Chronic HBV
                          Chronic ~5-6% Adults – 90% Infants




*These drugs are recommended as first line of treatment
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    HCV Transmission / Prevention




Hepatitis C is Spread by Blood-to-Blood Contact




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                               HCV Survival

          •   The hepatitis C virus lives for at least 16 hours – but no
              longer than 4 days – outside the body

          •   In syringes up to 63 days

          •   Commercially available Disinfects Kill HCV

          •   Collected shared Swabs – ~ 83% tested positive for HCV

          •   HCV detected in used water for greater than 3 weeks

          •   In bottles – HCV RNA detected even after rinsing out –
              plastic and aluminum retained HCV RNA longer

          •   ~10% of filters wrapped in foil had HCV RNA after 24 and
              48 hours
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               Transmission/Prevention

  •   Sharing needles and drug preparation tools
  •   Blood products & solid organ transplantation before
      1992
  •   Clotting factors before inactivation in 1987
  •   Sexual transmission (0-3%)
  •   Mother-to-child (~4-5%)
  •   Healthcare workers (~2%)
  •   Hemodialysis
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      Possible Transmission Routes
 •   Tattoo & piercing*


 •   Personal care salons


 •   Shared household (hygiene) items


 •   Coke/crank straws & crack pipes


 •   10% of routes can not be identified
 * Higher in unsafe non-commercial settings: prisons/mental institutions/on the streets/home grown

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Safer Tattoos – www.hepatitistattoos.org




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                      Little or no data…….

• Dental and other procedures before
   universal precautions

• Jet gun injections


• Transgender people
   •   Sharing needles and re-assignment
       surgeries
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               HCV is Not Spread by:

  •   Breast feeding
  •   Food or water
  •   Sharing eating utensils or drinking
      glasses
  •   Sneezing
  •   Hugging
                      *Not spread by casual contact*
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                      Prevention:

•Do not share anything:         NEEDLES,
COOKERS, COTTON, TOURNIQUETS, WATER,
WATER CONTAINERS, ETC. – WASH HANDS




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                      Prevention - more

•Do not share non-injection drug
equipment
 •Coke/crank straws
 •Crack pipes


   •Tattoo / Piercing
   •Sterilization, autoclave, separate ink pot,
     new needles
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                       Prevention - more

•S e x u a l : 0 - 3 % – m o n o g a m o u s p a r t n e r s – c o u n s e l

  •   Safer sex – additional risk through sex:
      •   Multiple partners
      •   Coinfection with HIV or HBV
      •   Having herpes, lesions, sores, open cuts, wounds
      •   Sexually transmitted diseases

•M O T H E R - T O - C H I L D

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                      More Prevention

•Health care workers
   •blood borne pathogen protection

•Razors / toothbrushes covered

•Cover all wounds

•Transfusions – estimated that less than one per 2
million transfused units of blood tainted with HCV

•People with HCV: Do not donate blood, sperm, eggs
or organs – EXCEPTIONS…..

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                      HCV Diagnostic Tools


HCV IDENTIFIED IN 1989




   Important: Interpretation of test results and decisions about healthcare are a
              collaboration between a medical provider and a patient

www.hcvadvocate.org                                                       Version 12.3
                      HCV Diagnostic Tools


HCV IDENTIFIED IN 1989




   Important: Interpretation of test results and decisions about healthcare are a
              collaboration between a medical provider and a patient

www.hcvadvocate.org                                                       Version 12.3
                      Lifecycle

 •   Single stranded RNA virus

 •   Mainly infects liver cells—but also found in
     other cells of the body

 •   Cell Culture discovered and available


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           Baby Boomers Account for the Majority of HCV
                     Cases in United States
             Estimated Prevalence by Age Group

                          1.6
Number With Chronic HCV




                          1.4
                          1.2
                          1.0
                          0.8
                          0.6
(millions)
Infection




                          0.4
                          0.2
                           0
                                <1920   1920s                                        1970s   1980s   1990+
                                                1930s      1940s     1950s   1960s


                                                        Birth Year Group

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       Increased Diagnosis and Treatment
The Tipping Point?
    Aged-Based Testing   OraQuick HCV Antibody Test         New Antivirals
     Templates


  The Centers for        •Finger Prick                  New HCV Treatments
  Disease Control        •Whole Blood Draw
                         •Oral Swab                     •New Therapies =
  has recommended                                       ~80%
  a one-time test for    •Results available within 20
  persons born           minutes                        •Higher cure rates will
  between 1945 and                                      mean more treatment
  1965                   •More testing within clinics   naïve and prior non-
                         and mobile sites can lead to   responders will seek
                         increased consultations        treatment
                         about care, management and
                         treatment                      •Interferon-free
                                                        therapies will mean
                                                        more people will be
                                                        treated in the future


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                      HCV Antibody Tests

•H C V E L I S A I I I ( E I A ) , C I A : D E T E C T S A N T I B O D I E S


  •   Signal to cut off ratio = 95% chance true antibody
      positive
  •   Home Access test kit

  •   Window period – 2-26 weeks


www.hcvadvocate.org                                                  Version 12.3
 OraQuick HCV Rapid Antibody Test

• FINGERPRICK & WHOLE BLOOD:
           FDA AND CLIA WAIVER APPROVED –
           2011

• ORAL SWAB – PENDING FDA AND CLIA
   APPROVAL – 2013?



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                      HCV RNA – Viral Load

   •   PCR (polymerase chain reaction) – lowest range

   •   TMA (transcription mediated amplification) – lowest range

   •   DNA (bDNA) assay – highest range



   •   Amount of virus per milliliter of blood

       •   International units

           •   Low – less than 800,000 IU/mL

           •   High – more than 800,000 IU/mL

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                How is Viral Load Used?

  •   Confirm active infection

  •   Soft predictor of treatment response

  •   Confirm HCV medications are working and

      dictate treatment duration

  ***Does Not Correlate with Disease Progression***
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                      Genotype & Quasi-species


      Six major genotypes (plus sub-types)
        Genotypes   numbered 1, 2, 3, 4, 5, 6, (1a, 1b, etc.)
            Genotype 1 – 70% of US population with HCV

            Genotypes 2, 3 – 30% of US population with HCV



        Quasi-species
            High     error prone virus – mutates quickly



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                          Liver Tests

   •   ALT: a non-specific marker of liver
       inflammation

           •   Not a good test to monitor people with HCV

   •   AST, AP, GGT, bilirubin, platelet, prothrombin
       time (PT)
www.hcvadvocate.org                                  Version 12.3
 Liver Biopsy


*Measures liver
health

                       Metavir Scoring System – 0, 1, 2, 3, 4

*Treatment            No activity              Severe activity
decisions


*Benchmark

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             HCV Symptoms, Disease
            Progression & Management



                      “LIVING WITH HCV IS OFTEN EASY, OFTEN
                      DIFFICULT AND SOMETIMES IMPOSSIBLE”

                                         PETER MARE LATHAM




www.hcvadvocate.org                                    Version 12.3
                        Future Disease Burden

 *Institute of Medicine (IOM) Report – 2010

 **Milliman Report – Annual cost of advanced liver
   disease to $85 billion in the next two decades and Medicare
   costs will increase 500%, from $5 billion to $30 billion

 ***Aging of the Hepatitis C Virus-Infected Persons
   in the United States: A Multiple Cohort Model of
   HCV Prevalence and Disease Progression –
   Progression to cirrhosis will peak at 1.0 million in 2020
   *http://www.iom.edu/Reports/2010/Hepatitis-and-Liver-Cancer-A-National-Strategy-for-Prevention-
       and-Control-of-Hepatitis-B-and-C.aspx
   **http://www.milliman.com/expertise/healthcare/publications/rr/pdfs/consequences-hepatitis-c-
       virus-RR05-18-09.pdf
   ***GL Davis and colleagues; PMID: 19861128 [PubMed - as supplied by publisher]

www.hcvadvocate.org                                                                    Version 12.3
 Drug Based Therapies




                                               Health Access
                          HCV Positive




What may be needed
even before considering
treatment                                Ann Shindo
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                      Liver Specialists

•G A S T R O E N T E R O L OG I S T

•H E P A T O L O G I S T




•T H E F U T U R E ?
  •   Primary care, infectious disease specialists and
      others

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                               Acute HCV

• Initial or acute infection
  • Many people have no symptoms

  • Flu-like—fatigue, nausea, fever, indigestion, loss of appetite,
    night sweats, jaundice
  • Lasts up to 6 months
       •   Spontaneous (natural) clearing by gender:
           • Women ~40%

           • Men ~19%



• Treatment of acute HCV—the majority of people with acute
   HCV can clear the virus with interferon monotherapy

www.hcvadvocate.org                                           Version 12.3
                      Chronic Infection
•L O N G E R T H A N 6 M O N T H S
    •   Does not mean severe disease progression
•   CDC ~75%–85% OF CASES BECOME CHRONIC


•   STUDIES – 55% TO 85% BECOME CHRONIC


•10 to 25% have serious disease progression over a 10 to 40
year period – disease progression is not linear

        •   Fibrosis / Cirrhosis / Steatosis
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                      Chronic Symptoms

 Fatigue – mild to                      Liver pain
   severe
                                         Loss of appetite

 “Brain Fog”
                                         Headaches

 Flu-like symptoms
                                         Gastro problems

 Depression                                              And more….

   Symptoms don’t necessarily correlate with disease progression with the
                   exception of end-stage liver disease
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                          HCV Infection:
                    Extrahepatic Manifestations
      Hematologic                                              Salivary
      •   Mixed cryoglobulinemia                               • Sialadenitis
      •   Aplastic anemia
      •   Thrombocytopenia                                     Ocular
      •   Non-Hodgkin’s b-cell lymphoma                        • Corneal ulcer
      Dermatologic                                             • Uveitis
      • Porphyria cutanea tarda
                                                               Vascular
      • Lichen planus
                                                               • Necrotizing vasculitis
      • Cutaneous necrotizing
                                                               • Polyarteritis nodosa
        vasculitis
                                                               Neuromuscular
      Renal
                                                               • Weakness/myalgia
      • Glomerulonephritis
                                                               • Peripheral neuropathy
      • Nephrotic syndrome
                                                               • Arthritis/arthralgia
      Endocrine                                                Autoimmune
      • Anti-thyroid antibodies
                                                               Phenomena
      • Diabetes mellitus
                                                               • CREST syndrome


Hadziyannis SJ. J Eur Acad Dermatol Venereol. 1998;10:12-21.                     Version 12.3
                      U. S. Statistics: CDC

•N E W ( A C U T E ) I N F E C T I O N S :   17,000



•T O T A L C H R O N I C I N F E C T I O N S :   UP TO 3.2 MILLION

•~ 1 5 , 0 0 0 D E A T H S A N N U A L L Y




*NOT FACTORED INTO ABOVE:              PRISONERS, HOMELESS, PEOPLE IN
MENTAL INSTITUTIONS



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                         Disease Progression

 Compensated—extensive scarring, but liver is still
   working fairly well

 Decompensated—very extensive scarring and liver
   function has become severely compromised
      Conditions
          Portal Hypertension / Ascites & Edema / Varices / Encephalopathy
• Liver Cancer
   •   3% to 5% of people with chronic HCV will develop liver cancer – after
       severe fibrosis or cirrhosis
• Transplantation: 250,000 to $314,000 – up to
   $500,000 – Annual costs of medications: ~$21,900
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                           Disease Management
                            Lifestyle Changes
•A V O I D A L C O H O L

        •Lowers immune response & HCV treatment response
        •Helps HCV to replicate and mutate

        •Increases levels of iron and fat in the liver

•A V O I D O R R E D U C E :

        •Cigarette        smoking, drugs or any substance that can harm the liver

•     EAT A HEALTHY WELL BALANCED DIET


              WWW.CHOOSEMYPLATE.GOV

    www.hcvadvocate.org                                                      Version 12.3
                      Disease Management

•H E P A T I T I S A & H E P A T I T I S B V A C C I N E


•A V O I D R A W & U N D E R C O O K E D S H E L L F I S H
  •   HAV / Vibrio vulnificus

•E X E R C I S E
  •   Moderation—balance activity with rest

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                      SUPPLEMENTS


 Avoid high doses of vitamins and supplements


 General recommendations:
      Vitamin supplement (daily requirements with no iron)

 Always check-in with a medical provider




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                      Discrimination & Stigma

 Americans with Disabilities Act—allows for certain
   protections

 Call the ADA (800-949-4232)


 Social Security Disability


 The effect of stigma



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                      Support Groups

•I N F O R M A T I O N A L & E M O T I O N A L


  •   One of the few places where people with HCV can
      connect, advocate, support and learn from peers

•H C S P S U P P O R T G R O U P I N A B A G
  •   Support group manual on web site

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                                           HCV Medical Treatments

              95      HCV Medical Treatment
              85
              75
              65
  Pe rce nt




              55                                                                                   Genotype 1
              45                                                                                   Genotype 2, 3
              35
              25
              15
               5
                   Mono INF   INF + Riba    Peg-Intron + Riba Pegasys + Riba Peg INF + Riba + PI
                                              Genotype
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          General Treatment Guidelines

•O V E R A L L H E A L T H I S S T A B L E


•A C T I V E H C V I N F E C T I O N


•C O M P E N S A T E D L I V E R D I S E A S E
  •   Decompensated generally only in transplant centers
      •   Some case studies with DAA combinations successful


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           Pre-Treatment Predictors of
              Treatment Response
  •Y O U N G E R A G E – U N D E R 4 0 Y O


  •L I T T L E O R N O S T E A T O S I S , I N S U L I N R E S I S T A N C E


  •R A C E
      •   Asian
      •   Caucasians
      •   African Americans

  •L O W H C V R N A ( V I R A L L O A D )


  •L I T T L E O R    NO SCARRING OF THE LIVER

www.hcvadvocate.org                                                            Version 12.3
           Pre-Treatment Predictors of
              Treatment Response
VARIATION OF IL28B – GENOTYPE 1




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             Treatment Goals & Success
•G O A L S O F T R E A T M E N T :
  •   Clear virus out of the body
  •   Improve inflammation & scarring
  •   Slow disease progression,
  •   Improve symptoms and quality of life
  •   To put HCV behind and move on with life

•S U S T A I N E D V I R O L O G I C A L R E S P O N S E ( S V R )
  •   HCV is undetectable during and 6 months following HCV medical
      therapy
       • 5 year follow-up >99% still HCV RNA undetectable

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                      Response to Therapy

• Adherence: Important for overall treatment
   success—more important with new HCV protease
   inhibitors
• Rapid Virological Response (RVR) —4 week HCV
   RNA negative
• Complete Early Virologic Response (cEVR)—12
   week RNA negative
• Extended RVR (eRVR) HCV RNA—negative at
   week 4 and week 12
www.hcvadvocate.org                            Version 12.3
      Treatment of Chronic HCV Genotype 2, 3


 Treatment duration 24 weeks


 Ribavirin fixed dose – 800 mg/daily
   Taken with high fat food



 Currently HCV protease inhibitors are not approved
   to treat genotypes 2 and 3



www.hcvadvocate.org                            Version 12.3
              Treatment: Genotypes 2 and 3
       Pegylated and Ribavirin (FDA Package Insert)


 Merck /Schering – PEG-Intron + Rebetol (800-1400mg)
        Genotypes    2 thru 6 – 75% (48 weeks)
            One large multi-international study


 Genentech/Roche – Pegasys + Copegus (1000-1200 mg)
        Genotypes  2 & 3 – 82% SVR (24 weeks)
        Genotypes 2 thru 6 – 70% SVR (48 weeks)
          Two large multi-international studies


            * Also approved to treat compensated cirrhosis,
           HIV/HCV Coinfection, Renal (mono) and HBV (mono)

www.hcvadvocate.org                                     Version 12.3
                 Treatment of HCV Genotype 1

 Protease combination therapy is only FDA approved
  for treatment of chronic HCV genotype 1

 Treatment with an HCV protease inhibitor is only used
  in combination with pegylated interferon and ribavirin
       Ribavirin taken with food
 The HCV protease inhibitors are taken every 7 to 9
  hours with food:
     Boceprevir – light meal / Telaprevir –not low fat


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               Victrelis (Boceprevir)
             4-week lead in – PEG/RBV

•T R E A T M E N T N A Ï V E – G E N O T Y P E 1

      •   Up to 66% SVR
            • African Americans – up to 53% vs. 23% SVR
      •   Treatment duration either 28 or 48 weeks

•T R E A T M E N T E X P E R I E N C E D – G E N O T Y P E 1

                             to 66% SVR (null responders not studied)
      •Prior non-responders–up
      •Treatment duration 36 or 48 weeks



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                      Incivek (Telaprevir)
   Incivek, pegylated interferon, ribavirin taken for 12 weeks only—followed by
                          pegylated interferon/ribavirin



•T R E A T M E N T N A Ï V E – G E N O T Y P E 1 :
           •   Up to 79% SVR
               • African American patients: 62% vs. 25% SVR
               • People with cirrhosis: 62% vs. 33% SVR

•T R E A T M E N T E X P E R I E N C E D – G E N O T Y P E 1 :
       Up to 86% SVR depending on type of non-response
       •
       (relapsers, non-responders, null responders)
   *Treatment duration 24 or 48 weeks

   ** Warning on serious skin reactions**
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                      Standard Protocol

 Pegylated (injected once a week)

 Ribavirin (pill or capsule – oral twice a day)
   with food

 Victrelis / Incivek (pill – every 7 to 9 hours)
   for genotype 1 only with food

 Treatment is guided by type of on-treatment
   response (week 4 and 12)
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                        Side-effects

Interferon                     Ribavirin

 Physical                     Anemia, rash, dry cough
                               Black box warning:
    fatigue, muscle/joint
                                   Women of childbearing age, their
     pain, headaches, dry           partners and female partners of
     skin, insomnia,                male patients taking ribavirin
                                    must practice two forms of
    Anxiety, depression,
                                    contraception during to 6 months
     mania                          post-treatment


    Low white blood cells
                               Low red blood cells
    Low platelets


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                           Side-effects

               Victrelis                  Incivek

 Up to 50% – anemia               Body rash

                                   Up to 36% – anemia
 Taste changes,
   especially metal taste
                                   Anal itching

                                   Diarrhea



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                      Managing Side Effects

 Time injection                   Daily moisturizing


 Drink lots of water              Vary injection sites


 Low doses of ibuprofen or        Anti-depressants
   acetaminophen
                                   Plenty of rest
 Pain/sleep medications
                                   Small frequent healthy
 Light exercise                    meals


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                               Programs

 Patient Assistance Programs
    Partnership          for Prescription Assistance
        www.pparx.org

    Needy            Meds: www.needymeds.org

 Genentech: www.genentechaccesssolutions.com

 Merck: www.merck-cares.com

 Vertex: www.vrtx.com

 Kadmon: http://kadmon.com/
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                      Drugs in Development

 Phase III Studies—DAA with PEG/RBV
   DAA combinations with interferon and ribavirin
        BI 201335 (faldaprevir) (protease inhibitor),
        BMS-790052 (daclatasvir) (NS5A Inhibitor),
        GS-7977 (sofosbuvir) (polymerase inhibitor),
        TMC435 (simeprevir) (protease inhibitor)



 Phase II – III Studies—DAA Combination with RBV
   Many DAA drugs in combination with other DAA’s and with
    ribavirin (no interferon)


 HCV Advocate Drug Pipeline
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                      Clinical Trials




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                      Complementary Therapies

Herbs: Herbs can interact with other medications and have a
 potential to be unsafe
  Always check-in with medical provider and use a
   reputable herbalist
  Milk Thistle – the most common herb used by people
   with HCV
    May interact and increase blood levels of some
     substances
    St. John’s Wort – Avoid with Protease Inhibitors
     (PI’s) (lowers PI drug levels)
Caution:
• Bupleurum should not be used by someone taking interferon
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                      Complementary Practices

 Acupuncture
    Thin needles are inserted into acupuncture points to
    
    stimulate the flow and balance of qi (the flow of vital
    energy)
 Acupressure
   Finger pressure stimulated flow of qi



 Traditional Chinese Medicine
       Whole body concept to restore qi balance
         Acupuncture, acupressure, t’ai chi, moxibustion,
          massage
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                               Turn In

 Participant checklist
    Plan         of action

 Evaluation
    Demographic              information

 Order by fax form


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                      NeedyMeds Drug
                      Discount Card




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                      What is the
              NeedyMeds Drug Discount Card?


 A FREE drug discount card that can save users up to

    80% off the cost of:
       Prescription medications

       Over-the-counter medications and medical supplies written as
        a prescription

       Pet prescriptions purchased at a pharmacy




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                      How Does it Work?

 No activation or registration needed
 Never expires
 No residency, income or insurance
  guidelines.
 Accepted at over 62,000 pharmacies
  including all the major and local chains.
 Bring the card into the pharmacy along with
  a valid prescription from your doctor and
  save!
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       Are There Insurance Guidelines?

 No insurance guidelines
 The card cannot be combined with insurance
 Those who are uninsured can use the card.
 Those that have a public (such as Medicare or
   Medicaid) or private insurance plan can use the card
   instead of their insurance if for example:
      They have a medication not covered
      They are in a coverage gap, like the “donut hole”
      They have a high copay or deductible

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                      Where Do I Get One?

 You can send a self-addressed stamped envelope to:

      NeedyMeds Drug Discount Card

         PO Box 219

         Gloucester, MA 01931



 Or go online and print a card by visiting:

   http://www.needymeds.org/drugcard/drugcard.pdf

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                      Help for Card Users

 Visit http://drugdiscountcard.org


           Or call (888) 602-2978

                  Additional Services:
 Information about patient assistance programs


 List of low cost medical clinics


 Webinars to explain services


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