The Diagnosis and Management of Hepatitis C: The Role of the Physician Assistant

Julie Neighbors

摘要

Hepatitis C will pose a serious challenge to the health care system during the next 2 decades. Physician assistants can play an important role in the screening, diagnosis, and management of hepatitis C infection, and in educating patients about this disease. Screening for risk factors for hepatitis C virus (HCV) can be used to identify most infected individuals, who can then be tested for the presence of anti-HCV antibodies and HCV RNA. Hepatitis C can be treated with a combination of pegylated interferon plus ribavirin, and the virus can be cleared in a significant percentage of infected individuals. Hepatitis C: Scope of the Problem The United States faces a major public health challenge over the next 2 decades from the largely silent but widespread infection of adults by HCV. This is now the most common blood-borne infection in the United States. 1 About 2% of adults in this country are infected, but only a small fraction of these individuals have been identified and are aware of their positive viral status. 123 The Centers for Disease Control and Prevention (CDC) estimated that there were approximately 30,000 new cases of HCV infection in 2003. 4 These estimates are probably conservative, because the National Health and Nutrition Examination Survey (NHANES) data on which they were based excluded people who were incarcerated or homeless, individuals known to have high rates of HCV infection. 3,4 Chronic HCV infection is defined as the persistence of HCV RNA in the blood for at least 6 months. 2 Chronic HCV is frequently asymptomatic in its early stages, and years or decades may pass before affected individuals seek treatment. 5 Even symptomatic individuals may complain of only vague feelings of tiredness or malaise, leading to delays in diagnosis if HCV is not suspected. 5 HCV-infected patients may progress to very grave illnesses, chief among them being the occurrence of silent but progressive fibrotic liver disease. 6 The rate of progression to cirrhosis varies widely in infected patients, but it is currently estimated that up to 20% of patients infected with HCV will develop cirrhosis over a 20- to 25-year period. 7 Many of these patients may progress to end-stage liver disease and death unless a transplant is performed, and HCV infection has now become the most common reason for liver transplantation in the US. 7,8 Once an HCV-infected individual develops cirrhosis, the risk of hepatocellular carcinoma is also present, contributing to mortality rates. 7 Because HCV is a systemic disease, infected patients can also develop serious extrahepatic complications of immunologic origin, including rheumatoid symptoms, kidney disease, and skin disorders. 2 If HCV-infected individuals are not identified and treated, deaths due to HCV infection are expected to increase 2- to 3-fold by 2010 to 2020, and annual deaths from HCV infection will exceed deaths from HIV/AIDS. 9 Physician assistants (PAs) can play important roles in identifying these individuals and helping to manage their disease, with the goal of lessening the overall health care burden and reducing the risks of mortality and morbidity from this deadly but still largely silent outbreak. Hepatitis C: A Treatable Disease The current standard of care for HCV infection is combination therapy with pegylated interferon (IFN) alfa and ribavirin. 10 Interferons are naturally occurring proteins that have antiviral, immunomodulatory, and anti-inflammatory properties. 11 Interferon alfa-2a and interferon alfa-2b have been shown to inhibit HCV replication and strengthen the host immune response to the virus. 11 Pegylated interferons are interferons that have been conjugated to inert polyethylene glycol (PEG) moieties. 11 Interferon alfa-2b is conjugated 1:1 to an unbranched, 12-kilodalton (kd) PEG moiety to form peginterferon alfa-2b, whereas interferon alfa-2a is conjugated 1:1 to a branched, 40-kd PEG moiety to form peginterferon alfa-2a. 12 Pegylation protects the molecules from e

机译：在接下来的20年中，丙型肝炎将对卫生保健系统构成严重挑战。医师助理在丙型肝炎感染的筛查，诊断和管理以及对患者进行有关这种疾病的教育方面可以发挥重要作用。筛查丙型肝炎病毒（HCV）的危险因素可用于鉴定大多数感染的个体，然后可以对其进行抗HCV抗体和HCV RNA的检测。可以使用聚乙二醇化干扰素加利巴韦林的组合治疗丙型肝炎，并且可以在很大比例的感染个体中清除病毒。丙型肝炎：问题的范围在接下来的20年中，美国将面临严重的公共卫生挑战。现在这是美国最常见的血源性感染。 1这个国家约有2％的成年人受到感染，但是这些人中只有一小部分已经被识别出并知道其阳性病毒状态。 123疾病控制与预防中心（CDC）估计，2003年约有30,000新的HCV感染病例。4这些估计值可能是保守的，因为排除了基于它们的国家健康和营养检查调查（NHANES）数据被监禁或无家可归的人，已知HCV感染率高的人。 3,4慢性HCV感染定义为HCV RNA在血液中持续存在至少6个月。 2慢性HCV在其早期通常无症状，并且可能在数年或数十年后才受影响的个体寻求治疗。 5即使有症状的人也可能仅抱怨疲倦或不适的模棱两可的感觉，如果不怀疑HCV会导致诊断延误。 5 HCV感染的患者可能会发展为严重疾病，其中主要是无声但进行性纤维化肝病的发生。 6感染患者的发展为肝硬化的速度差异很大，但是据目前估计，多达20％的HCV感染患者会在20至25年内发展为肝硬化。 7这些患者中的许多人除非进行移植，否则可能会发展为终末期肝病和死亡，而HCV感染现在已成为美国肝移植的最常见原因。 7,8一旦被HCV感染的人发展为肝硬化，还存在肝细胞癌的风险，从而导致死亡率上升。 7由于HCV是一种全身性疾病，被感染的患者还会出现严重的免疫原性肝外并发症，包括类风湿症状，肾脏疾病和皮肤疾病。 2如果不对HCV感染者进行鉴定和治疗，那么到2010年至2020年，由HCV感染引起的死亡预计将增加2到3倍，每年因HCV感染导致的死亡将超过艾滋病毒/艾滋病造成的死亡。 9医师助理（PA）可以在识别这些人并帮助控制他们的疾病方面发挥重要作用，其目标是减轻总体医疗保健负担，并减少这种致命但仍无声的疾病暴发的死亡率和发病率。丙型肝炎：可治疗的疾病当前，HCV感染的护理标准是将聚乙二醇化干扰素（IFN）α和利巴韦林联合使用。 10干扰素是具有抗病毒，免疫调节和抗炎特性的天然蛋白质。 11种干扰素α-2a和干扰素α-2b已显示抑制HCV复制并增强宿主对该病毒的免疫反应。 11聚乙二醇化干扰素是已与惰性聚乙二醇（PEG）部分偶联的干扰素。 11干扰素alfa-2b与非支链的12-kaldalton（kd）PEG部分以1：1结合形成聚乙二醇干扰素alfa-2b，而干扰素alfa-2a 1：1与分枝的40-kd PEG部分结合形成。聚乙二醇干扰素α-2a。 12聚乙二醇化保护分子免受e

The Diagnosis and Management of Hepatitis C: The Role of the Physician Assistant

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