Irish Society of Gastroenterology Summer Meeting 2018

Ireland is making steady progress in the objective to eliminate the hepatitis C virus (HCV), the Clinical Lead for the National Hepatitis C Treatment Programme told the summer meeting of the Irish Society of Gastroenterology ISG. He said that 2,600 patients have commenced treatment since 2015.

Prof Aiden McCormick, Consultant Hepatologist at St Vincent’s University Hospital, Dublin, said that 80 per cent of patients with HCV in this country become infected through IV drug use. However, the condition is rarely acute and is chronic in about 60 per cent of patients. There are six genotypes of the virus, with genotype 1 accounting for about 60 per cent of HCV patients.

There have been a number of welcome developments in this field, said Prof McCormick. The new direct-acting antivirals (DAAs) have few side-effects, require eight-to-12 weeks’ treatment and can cure more than 95 per cent of patients. The programme also currently has no restrictions on treatment eligibility.

“There are no restrictions with regards to alcohol and drug use or anything else. We want to treat everyone and get rid of this virus in this country,” he said.

Prof McCormick highlighted that the EASL (European Association for the Study of the Liver) treatment guidelines, which were recently published, would be mirrored in Ireland’s own forthcoming guidelines, which will be finalised once a procurement process has been concluded. He added that €30 million is available for the hepatitis C treatments.

While the issue of procurement was complex, the Programme wants to give clinicians the maximum freedom of choice in terms of regimen and ensure that the taxpayer gets good value for money. He praised the pharmaceutical industry for stepping-up to the plate in this regard.

While second-line drugs are expensive, they are useful for people who are drug resistant or have been treated with DAAs previously and have relapsed, Prof McCormick said. Before these second-line drugs are used, there is a formal drug advisory group meeting that decides on whether to approve them or not. Prof McCormick said the programme anticipates that less than 5 per cent of patients would actually need these drugs.

The treatment Programme has been running since 2015 and, to date, approximately 2,600 people have been treated.

The Programme has also established a small community treatment steering group and a treatment registry. An oversight group on the treatment registry is also currently being set up with the hepatitis C research network.

“We’re trying to hit the WHO elimination targets for 2030,” he told the audience. “The WHO wants 80 per cent of chronic HCV patients treated, a 90 per cent reduction in HCV incidence and 65 per cent in HCV-related mortality. Everyone in the world agrees with this… and we think we can do this by 2026.”

In 2015, 350 patients were treated; in 2016, 540 were treated;1,052 in 2017, and so far this year, 722. This number for 2018 is expected to rise to between 1,800 and 2,000.

“We have probably had about 5,000 SVRs for HPC over the last 20 years. So it’s quite a number of patients that have actually been treated already.”

It has been estimated that 20,000-to-30,000 people are infected with the virus and up to 60 per cent could be undiagnosed, but there has been significant progress in recent years. The haemophilia community has been declared HCV-free since the end of 2016 and all patients known to have been infected by blood products have been offered treatments by the end of 2017. Furthermore, all patients known to have cirrhosis-related hepatitis C were offered treatment by the end of 2017. However, not all of these patients wished to receive treatment or were fit to have it. Pilot treatment programmes in the methadone treatment clinics were also started in 2017.

Looking at other countries’ experiences, Ireland is comparing well with NHS England, he said.

In terms of challenges, Prof McCormick stated that as a lot of those with the virus are intravenous drug users (IVDUs), they cannot or will not go to the hospital.

“So the treatment has to go out to the patients,” he said.

But as many are in the methadone treatment programmes, this avenue is being used to reach patients and almost complete compliance is being achieved in pilot schemes.

He added that the prison treatment programme was very effective but prisoners serving shorter sentences in custody presented unique challenges. In these cases, the Programme will allow more expensive, quicker-acting medication to be used.

The Programme is also developing protocols for GPs and community pharmacists and the non-dispensing methadone clinics. It is also working on arranging central purchasing in an attempt to reduce barriers.

Furthermore, as IVDUs can be taking a lot of legal and illicit drugs, linkages are being planned between GPs and hospital pharmacists in terms of identifying and advising on drug interactions. It is hoped that after the GP has evaluated the patient, they will send the data to hospital pharmacists, who will then review it and send it back. The GP issues the prescription with the hospital pharmacist’s recommendation, and the community pharmacist dispenses it.

“That is what we are hoping to bring in later this year,” said Prof McCormick.

Other challenges include changing behaviours around the abuse of alcohol and the professor added that a substantial proportion of the Programme’s patients have alcohol problems.

“And as clinicians, we know that these patients run into trouble much earlier and are much sicker,” he said.  IVDUs are also at risk of re-infection due to reusing needles.

Despite these issues, he believed that Ireland, with its healthcare professionals, the medication and funding in place, was now prepared to meet the WHO’s targets.

“The time is now to try and get rid of this.”