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December 3, 2013 Issue

Clinical Practice Points


Medical Knowledge

Pegylated Interferon- α2a With or Without Low-Dose Ribavirin for Treatment-Naive Patients With Hepatitis C Virus Genotype 1 Receiving Hemodialysis. A Randomized Trial

Despite its efficacy when added to pegylated interferon for the treatment of hepatitis C virus (HCV), ribavirin has been considered contraindicated in patients receiving hemodialysis because of concerns for hemolytic anemia. This trial of patients with HCV receiving dialysis found that the combination of peglyated interferon and ribavirin was superior to interferon alone in achieving sustained virologic response and that adverse events were similar in the 2 groups.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask your learners why the prevalence of HCV infection is increased among patients receiving dialysis. Who else is at increased risk?
  • Review the clinical spectrum of hepatitis C infection, how it is diagnosed, and the treatment options. Use a recent In The Clinic to answer these questions and download already prepared teaching slides.
  • Review the recent U.S. Preventive Services Task Force recommendations for screening for HCV infection in adults.

Medical Knowledge
Patient Care

Examination of Links Between Herpes Zoster Incidence and Childhood Varicella Vaccination

Some persons have speculated that increases in herpes zoster in older adults could be because of routine childhood varicella vaccination, which leads to less frequent external boosting of varicella-specific immunity in adults. This study showed that the age-specific increase in herpes zoster incidence began before routine childhood varicella vaccination was introduced and does not vary by state vaccination coverage rates.

Use this study to:

  • Review the pathogenesis of herpes zoster.
  • Ask your learners how the diagnosis of herpes zoster is made. How is it treated?
  • Ask who the Advisory Committee on Immunization Practices recommends to receive the varicella zoster vaccination.
  • Use the figures provided in ACP Smart Medicine Herpes Zoster to help teach. These include images of grouped vesicles, the Ramsay Hunt syndrome, the divisions of the trigeminal nerve, and more.

Medical Knowledge
High Value Care

Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians

This guideline recommends a restrictive red blood cell transfusion strategy in hospitalized patients with coronary heart disease (CHD) and also recommends against the use of erythropoiesis-stimulating agents (ESAs) in patients with mild to moderate anemia and CHD or congestive heart failure.

Use this guideline to:

  • Review the recommendations listed in Figure 1.
  • Ask your learners to list the potential complications of red blood cell transfusion. Why might a more liberal approach to using red blood cell transfusions be harmful in patients with CHD?
  • Review the information presented on the use of ESAs. What are the dangers of their use? How much do they cost to use? What does the recommendation conclude regarding available evidence for the use of intravenous iron treatment of anemia?
  • Log on to claim CME credit for yourself—you’ve already reviewed the material for teaching, so answer a few quick questions and claim credit!

Understanding Health Care


Systems-based Practice
Professionalism

Health Policy Basics: Health Insurance Marketplaces

This brief article provides an overview of health insurance marketplaces (also known as exchanges), how they are meant to work, and their implications for both patients and physicians.

Use this article to:

  • Ask your learners what they know about the Affordable Care Act.
  • Review the basics of exchanges.
  • Ask your learners whether their patients have asked about them and whether they feel qualified to answer such questions. Should they be able to answer questions about the U.S. health system? Should doctors discuss the political issues surrounding changes in healthcare with patients?

Medical Knowledge
Systems-based Practice
In the Clinic

Generalized Anxiety Disorder

This concise and eminently practical review asks—and provides answers to—questions residents need to know. It includes MKSAP questions, so structure an interactive teaching session around them.

Use this review to:

  • Ask how the diagnosis of generalized anxiety disorder is made.
  • Review what medical conditions need to be considered when evaluating a patient with anxiety.
  • Discuss when to consult other healthcare professionals in the care of a patient with generalized anxiety.
  • Download the teaching slides that accompany this In The Clinic.
  • Use the multiple-choice questions provided to break up a teaching session. Log on and claim more CME credit for yourself!

mksap16

A 55-year-old man is evaluated for chronic hepatitis C infection. He takes no medications.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 135/82 mm Hg, pulse rate is 66/min, and respiration rate is 16/min. BMI is 30.

Abdominal ultrasound demonstrates cholelithiasis but is otherwise normal. Liver biopsy demonstrates mild inflammation and advanced fibrosis without established cirrhosis.

Which of the following is the most appropriate management?

A. Corticosteroids
B. Initiation of antiviral therapy
C. Referral for liver transplantation
D. Repeat liver biopsy in 6 months
E. Serial aminotransferase monitoring

Correct Answer
B. Initiation of antiviral therapy

Key Point
The best available therapy for chronic hepatitis C is the combination of peginterferon and ribavirin, with the addition of an NS3/4A protease inhibitor for genotype 1 hepatitis C virus.

Educational Objective
Treat chronic hepatitis C infection.

In this patient with chronic hepatitis C virus (HCV) infection and advanced fibrosis, antiviral therapy with peginterferon and ribavirin is indicated. Chronic HCV infection is often progressive and may result in cirrhosis and hepatocellular carcinoma. Effective therapy for active HCV infection can delay or prevent these complications. The best available therapy for chronic hepatitis C is the combination of peginterferon and ribavirin, as well as an NS3/4A protease inhibitor if the patient has genotype 1 hepatitis C. The ideal candidate for therapy is the patient with detectable virus, some indication of hepatic inflammation (elevated liver chemistry tests or inflammation on the biopsy), and no contraindication to therapy (decompensated liver disease [ascites, hepatic encephalopathy, jaundice], pregnancy, severe psychiatric disease, or severe preexisting cytopenias). The goal of therapy is to achieve a sustained virologic response, which is defined as undetectable HCV beyond 6 months after the end of treatment. Antiviral therapy for hepatitis C is associated with significant morbidity; therefore, careful consideration should be made regarding which patients are candidates for antiviral therapy.

Extrahepatic manifestations of chronic HCV infection include hematologic conditions (mixed cryoglobulinemia, lymphoma), skin diseases, autoimmune diseases (thyroiditis), and kidney disease. Some of these conditions may benefit from corticosteroid and antiviral therapy, but this patient has no indication for corticosteroid therapy. Corticosteroid therapy results in increased viral replication and should not be given to patients with hepatitis C unless there is a defined indication for corticosteroids.

Liver transplantation is performed when patients with hepatitis C develop decompensated cirrhosis. This patient has good liver function without signs or symptoms of liver decompensation; therefore, referral for liver transplantation is not warranted at this time.

Repeating the liver biopsy in 6 months will provide no additional information that will be helpful in this patient's management.

Serial monitoring of aminotransferases without consideration of antiviral therapy is not appropriate because this patient has advanced fibrosis. Although the overall risk of developing cirrhosis from hepatitis C is up to 25%, one of the risk factors for progression to cirrhosis is advanced fibrosis. Therefore, this patient's lack of established cirrhosis should not be reassuring that cirrhosis will not develop.

Bibliography
Ghany MG, Strader DB, Thomas DL, Seeff LB; American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology. 2009;49(4):1335-1374. PMID: 19330875

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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