Clinical Assessment of Pharmacotherapeutic Plan for Virologic Response of Hepatitis C Virus
Hepatitis C is triggered by the presence of hepatitis C virus (HCV) where acute and chronic hepatitis causes mild to severe illness lasting for few weeks to lifelong illness. The HCV is a bloodborne virus having most common modes of infection through exposure to even small quantities of contaminated blood and this may trigger through contaminated injection drug use, unsafe injection practices, hazardous health care, transfusion of unscreened blood or blood products and sexual practices. In 2016, WHO estimated roughly 399, 000 people died from HCV frequently from liver cirrhosis and hepatocellular carcinoma (HCC) which is primary liver cancer. Presently, there is no effective vaccine in contradiction of hepatitis C. Fever, fatigue, decreased appetite, abdominal pain and joint pain are common clinical presentations. Investigation for anti-HCV antibodies alongwith serological testing identifies individuals who have been infected with HCV. Ribavirin and sofosbuvir are the main anti-viral drugs which can treat the hepatitis C. In this case scenario, referred patient of 40 years old female is suffering from hepatitis C having severe abdominal pain along with generalized body weight. Confirmation of hepatitis C for this patient was done by anti-HCV antibodies, LFT report and ultrasound which also reveal fatty liver. Symptomatically, she was treated by antiviral drug therapy which finally stabilizes her severe abdominal pain and other clinical presentations along with the condition of hepatitis C.
Introduction
Hepatitis C virus (HCV) is a foremost leading reason of liver diseases globally and an impending source of significant morbidity as well as mortality in future [1]. HCV is considered in Hepacivirus genus and Flaviviridae family [2]. Up to 7 million individuals internationally are infected with both of the viruses including human immunodeficiency virus (HIV) & heaptitis C virus (HCV) [3]. HCV infection is connected with higher rates of liver cirrhosis, fibrosis, hepatocellular carcinoma and overall higher mortality [4]. Re‐use of contaminated and inadequately sterilized syringes as well as needles used in medical, paramedical & dental measures [5]. The annual rate for HCC development between patients of liver cirrhosis is presently predicted as 1.6% [6]. Combination of sofosbuvir with ribavirin for 24 weeks has also revealed proper treatment for patients with genotype 1 of HCV [4]. Ribavirin when used in combination with pegylated interferon alfa (INF), leads to improved restoration of patient's immune response from HCV [7].
Case Presentations
A 40 years old female comes to physician for the clinical presentations of severe abdominal pain, generalized body weakness, Sore muscles and anorexia (decreased appetite). She is also suffering from fever. Her past medical history includes peptic ulcer. She frequently Ultra sound of patient shown that the size of liver is 15.8cm and also fatty liver is present. Anti-HCV test is positive for this patient. Other diagnostic tests are described in Tables 2 and 3.
uses Panadol, in case of mild pain and fever. She belongs to a Poor Socio-economic status.
On Examination (O/E)
| Sign | Normal Range | Results | ||||||
|---|---|---|---|---|---|---|---|---|
| Blood Pressure | 120/80 mmHg | 110/80 mmHg | ||||||
| Heart Rate | 72 BPM | 78 beats/min | ||||||
| Temperature | 98°F | 102°F |
Table 1: Vital signs of patient.
Laboratory Findings
| Tests | Normal Range | Unit | Values | Comment | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Wbcs | 4-11 | x 103 /µL | 12.7 | Above Normal | ||||||||
| Total Rbc Count | 4.0-5.5 | x 106 /µL | 4.5 | Normal | ||||||||
| Hemoglobin | 13-17 (MALE), | g/dL | 13 | Normal | ||||||||
| 12-15 (FEMALE) | ||||||||||||
| Platelets | 150-400 | x 103 /µL | 230 | Normal | ||||||||
| HCT (PCV) | 40-75 | % | 40 | Normal | ||||||||
| MCV | 20-45 | fl | 50 | Above Normal | ||||||||
| MCH | 1-20 | Pg | 22 | Above Normal | ||||||||
| MCHC | 65-110 | % | 33 | Normal |
Table 2: Complete blood count of (CBC) patient.
| Liver Function Test | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Test | Normal Range | Unit | Value | Comments | |||||||||
| Bilirubin Total | 0.2-1.2 | (mg/dl) | 1.4 | Above Normal | |||||||||
| Bilirubin conjugated | < 0.5 | (mg/dl) | 0.7 | Above Normal | |||||||||
| Bilirubin unconjugated | 0.1-1 | (mg/dl) | 0.5 | Normal | |||||||||
| ALT (SGPT) | 5-55 | (U/L) | 73 | Above Normal | |||||||||
| AST (SGOT) | 5-35 | (U/L) | 77 | Above Normal | |||||||||
| Alkaline Phosphatase | 40-150 | (U/L) | 120 | Normal | |||||||||
| GAMMA G.T. | 10-64 | (U/L) | 72 | Above Normal | |||||||||
| Total protein | 6-8.5 | (g/dl) | 8.1 | Normal | |||||||||
| Serum Albumin | 3.5-5.0 | (g/dl) | 3.6 | Normal | |||||||||
| Serum Globulin | 1.8-3.4 | (g/dl) | 3.9 | Above Normal | |||||||||
| A/G Ratio | 1.2-2.2 | (g/dl) | 0.9 | Below Normal |
Table 3: Liver function test (LFT) of patient.
Pharmacotherapeutic Plan
| Current Prescribed Medication | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Brands | Generics | Dosage form | Frequency | Dose | Indications | ||||||||||||
| Sovaldi, | Sofosbuvir | Tablet | OD | 400mg | HCV infection | ||||||||||||
| Daclavia | Daclatasvir | Tablet | OD | 60mg | HCV infection | ||||||||||||
| Risek | Omeprazole | Capsule | OD | 40mg | Treat Gastric disturbance |
Table 4: Prescribed Medication for hepatitis C treatment.
Clinical Pharmacist Interventions
Tab. Sovaldi & Daclavia are more effective in patients with compromised liver function, when given with Ribavarin, 800 mg OD. Hence, Ribavirin 800 mg OD (400mg, 2 caps. BD) was added to prescribed pharmacotherapeutic plan of this patient.
Care Plan
- Follow up for routine tests and examination is advised.
- LFTs and other lab tests to be repeated after every 3 months.
- Adherence to therapy is advised and assessed at each follow up.
Follow Up Requirement
To assess the following parameters
- HCV progression into HCC (hepatocellular carcinoma)
- Liver Function test
- Adherence to therapy
Discussion
Hepatitis C virus (HCV) contaminates an expected 170 million individuals globally and therefore epitomizes a viral disease as pandemic case [8]. According to WHO Report in 2001, chronic liver diseases were accountable for 1 to 4 million deaths, comprising 796,000 due to liver cirrhosis and 616,000 deaths due to liver cancer [9]. In this case study, 40 years old patient is complaining about the severe abdominal pain, generalized body weakness, Sore muscles and anorexia. Her previous history is about peptic ulcer which has been cured after triple therapy.
According to clinical assessment Under prescription of HCV medications for patient was done. So, the first priority should be given to prescribing all required drugs to the patient during problem prioritization. As the goal of therapy is reduction of HCV infection in patient with ultimate cure. Hence Ribavarin, 800 mg OD (400mg, 2 caps. BD) was recommended by clinical pharmacist for this patient. Oral regimen of sofosbuvir along with ribavirin for 12 or 24 weeks predominantly treats hepatitis C [10]. Daclatasvir with sofosbuvir and ribavirin for almost 12 weeks resulted in a treatment of virologic response in patients either coinfected with HIV-1 and HCV genotypes 1 or only HCV [11]. Follow up for routine tests and examination was advised to patient for evaluation of treatment. Adherence to therapy was advised for prevention of hepatocellular carcinoma.
Conclusion
In this case scenario, the patient was suffering from hepatitis C. Recently, hepatitis is leading liver disorder so our aim was to treat severe abdominal pain of patient due to HCV and further progression of disease into hepatocellular carcinoma (HCC). She was treated with Antiviral therapy. Abdominal pain, generalized body weakness of patient was relieved after using sofosbuvir, daclatasvir and Ribavarin. Patient was stable after treatment with these antiviral agents.
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