Patient Education and Treatment Strategies Implemented at a Pharmacist-Managed Hepatitis C Virus Clinic

Bonnie Kolor, Pharm.D.

Disclosures

Pharmacotherapy. 2005;25(9):1230-1241. 

In This Article

Treatment Approaches at a Pharmacist-Managed Hepatitis C Virus Clinic

After complete evaluation, patients considered good candidates for treatment are referred to the pharmacist-managed HCV clinic (Figure 1). The clinical pharmacist performs a thorough review of the patients' charts before scheduling treatment. Those who have not undergone all the required testing or do not meet all the established criteria for treatment are scheduled to meet with the referring nurse practitioner or physician for further evaluation.

At their initial meeting, the pharmacist typically spends about 1 hour with each patient. Among the topics discussed are basic information regarding HCV infection, including HCV genotype and its association with treatment duration and likelihood of achieving a sustained viral response, severity of disease based on liver biopsy results, techniques associated with administration of the drug treatment regimen, possible adverse effects of treatment (which can be considerable), and methods for monitoring and managing these adverse effects. Patients are encouraged to ask questions regarding their diagnosis and the treatments available for HCV infection, and to participate actively in decisions regarding their care. Additional counseling provided at this time covers information regarding the importance of abstinence from alcohol.

Subsequent patient visits to the HCV clinic are outlined in Table 1 . Patients are typically seen by the pharmacist at baseline, 1-2 weeks and again 4 weeks after the start of treatment, and every 4 weeks thereafter. During these visits, the pharmacist evaluates the results of routine blood testing. For patients infected with HCV genotype 1, serum HCV RNA levels are monitored at baseline and 12 weeks after the start of treatment to determine whether the patient has experienced an early virologic response. This response is defined as either an undetectable amount or a decrease in serum HCV RNA of at least 2-log (i.e., 100-fold) compared with the patient's pretreatment level.[7]

Current AASLD guidelines allow for discontinuation of combination therapy 12 weeks after the start of treatment in patients infected with HCV genotype 1 who do not achieve an early virologic response.[7,39] In addition, serum HCV RNA levels are monitored at 24 weeks for patients infected with HCV genotype 2 or 3, and at 48 weeks for patients infected with genotype 1, to determine whether an end-of-treatment response has occurred. This response is defined as an undetectable amount of serum HCV RNA at the end of the treatment period. At my clinic, viral load is measured at 24 weeks for patients with genotype 1 who exhibit an early virologic response but still have detectable levels of virus at 12 weeks. Treatment is discontinued at this time if levels of virus are still detectable. Finally, serum HCV RNA levels are monitored 6 months after the end of treatment to determine whether a sustained viral response has been achieved.[7] A recommended testing schedule is shown in Table 1 .

Administration of peginterferon alfa and ribavirin has been associated with development of hemolytic anemia and bone marrow suppression, as evidenced by neutropenia and decreased platelet counts.[15,16,17] Thus, it is particularly important that hemoglobin levels and differential white blood cell and platelet counts be performed routinely. Other systems possibly affected by treatment with either peginterferon alfa or ribavirin should be monitored, such as endocrine functions (e.g., thyroid function) and blood glucose levels.

In addition, patients are evaluated periodically for neuropsychiatric events such as depression, suicidal ideation, and relapse of drug or alcohol addiction. Assessments of pulmonary, cardiac, and ophthalmologic disorders are performed when necessary. Patient referrals to psychiatry, ophthalmology, dermatology, cardiology, social services, or any other needed service are made by the pharmacist. Management of adverse events of peginterferon alfa and ribavirin combination therapy may involve dosage reductions of one or both drugs, or interruption of therapy.

These visits, as well as telephone contact with the patient, enable the pharmacist to provide additional information regarding combination therapy with peginterferon alfa and ribavirin, to evaluate the patient's ability to perform subcutaneous self-injections of peginterferon alfa, and to address treatment-related issues.

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