Wednesday, October 31, 2018

Potential markers identified for early detection and prevention of liver cancer

Potential markers identified for early detection and prevention of liver cancer
A shift in glucose metabolism hails progression from liver cirrhosis to liver cancer, finds a new study

Liver cancer is the second leading cause of cancer-related mortality worldwide, claiming 700,000 lives each year. Most cases are discovered too late for a cure -- but now a study offers hope of early detection, and targets for new treatments. Published in Frontiers in Cell and Developmental Biology, the results show a dramatic increase in expression of sugar-burning 'glycolytic' enzymes in precancerous cirrhotic livers. This increase is associated with a significantly higher risk of developing hepatocellular carcinoma (HCC) -- the main type of liver cancer -- and could lead to a biomarker which identifies those at risk of malignancy.

"We know that 90% of all hepatocellular carcinoma cases start with liver cirrhosis," explains study senior authors Dr Salvatore Papa of the University of Leeds and Dr Concetta Bubici of Brunel University London, UK. "So by pinpointing when cirrhosis progresses to cancer, we could improve early detection and treatment -- with surgery, chemo and radiotherapy, but perhaps also with new treatments which reverse the transition."

Metabolic changes in cancer cells
In cirrhosis, chronic damage caused by hepatitis viruses B or C, alcohol, or obesity leads to scarring and formation of regenerative nodules in the liver. High cell turnover in these nodules, with accumulation of genetic damage, can eventually produce cancerous cells.

"We set out to find features of cirrhotic cells that might predict cancerous change," says Papa.

For nearly a century, scientists have recognized that cancer cells shift the way they generate energy. Normally the body obtains energy from macronutrients -- sugars, fats, proteins and their intermediaries -- primarily using oxygen. But our cells can also extract energy from sugars without using oxygen. This anaerobic process, called glycolysis, produces the lactate that 'burns' our muscles during intense exercise -- and is also used by cancers to fuel their rampant growth.

"Like virtually all cancers, highly-proliferating HCC cells seem to readjust their energy metabolism towards glycolysis, irrespective of oxygen availability."

The cause of this shift in glucose metabolism -- known as the Warburg effect -- remains unknown, but inflammation is thought to play a role.

"Given that cirrhosis is an inflammatory process, we decided to look at whether the metabolic shift to glycolysis is present already in cirrhotic cells -- and whether this predicts progression to hepatocellular carcinoma."

Cancer metabolic changes are present in cirrhotic cells

Papa and colleagues analyzed normal, cirrhotic and cancerous (HCC) liver samples from patients followed up over 10 years following a liver biopsy.

"To have a complete overview of energy metabolism changes in HCC and premalignant stages of disease, we measured the expression of genes encoding enzymes involved in glycolysis and other metabolic pathways."

They found that glycolysis-related genes -- including hexokinase 2 (HK2), aldolase A (ALDOA) and pyruvate kinase M2 (PKM2) -- are highly expressed not only in HCC, but also in cirrhosis as compared to normal liver samples.

"In other words: the shift to glycolysis occurs in the precancerous stage," says Bubici.

Even more striking, the level of expression of glycolysis-related genes showed positive correlation with progression of cirrhosis to HCC -- and with poor outcome in those with HCC already at the time of biopsy.

"This suggests expression of glycolytic enzymes could be used as a new biomarker to predict the risk of later development of HCC in patients with cirrhosis," claims Bubici.

Towards early detection
The team stresses the study is preliminary: "Further studies are needed to establish whether these changes in gene expression are borne out as changes in glycolytic activity."

Nevertheless, the findings reveal a promising means to improve HCC survival through early detection and treatment. According to Papa, the shift to a glycolytic expression profile in cirrhotic cells could even be a target for new HCC therapies.

"For example, clinical trials are currently underway to explore the effect of statins -- which are used to help prevent cardiovascular disease -- on HCC development in cirrhotic patients or HCC recurrence following surgical removal.

"It is very likely that by blocking cholesterol synthesis, statins would also suppress glycolysis as these chemical pathways overlap. If these trials show that statins reduce HCC risk, further studies would be necessary to establish whether inhibition of glycolysis in cirrhotic cells is responsible," says Papa.

Original research article: 

Monday, October 29, 2018

Gilead $1,100 a day drug. Now it will launch a generic at quarter the price

Gilead charged $1,100 a day for this drug. Now it will launch a generic at quarter the price
By Ron Leuty – Reporter, San Francisco Business Times
A generic version of Harvoni — one in a series of life-changing hepatitis C drugs Gilead Sciences Inc. introduced four years ago at a price of over $1,000 a pill — will hit the market early next year at a quarter the price of the branded drug.

But while lower-priced generics generally a problem for drug makers because they eat into revenue, Foster City-based Gilead (NASDAQ: GILD) is looking forward to the generic: It will keep control of the drug and expand its market.

The "authorized generics" of Harvoni and another Gilead hepatitis C drug, Epclusa, will be marketed under the flag of Asegua Therapeutics LLC, a new Gilead subsidiary.

Read more:

On This Blog
The controversy over expensive new drugs for hepatitis C
Link to a collection of current research articles regarding the effectiveness and safety of generic hepatitis C medicines. Read news articles addressing the high cost, insurance restrictions; private insurers/Medicaid and availability of generic versions/India, Egypt and other lower-income countries or through online "buyers clubs"

Risk factors for developing liver cancer in people with and without liver disease

Risk factors for developing liver cancer in people with and without liver disease 
Jae Kyung Suh , Jayoun Lee , Jeong-Hoon Lee, Sangjin Shin, Ha jin Tchoe, Jin-Won Kwon

Published: October 29, 2018

Full-text article 
Available online
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The National Liver Cancer Surveillance Program (NLCSP) targets patients with liver diseases that lead to liver cancer in South Korea. This study aimed to investigate the risk of liver disease leading to liver cancer using nationally representative data to establish an efficient NLCSP.

This study used data from the National Health Insurance Service National Sample Cohort (NHIS-NSC) from 2002 to 2013. A retrospective matched cohort design was applied to compare the development of liver cancer in patients with and without liver disease. Cox- proportional hazard regression for liver cancer with competing risk of death was performed for all subjects or each group stratified according to age or income level.

A total of 66,192 patients with liver disease and matched subjects without liver disease were included in the study. The incidences of liver cancer among patients with and without liver disease within a median 8-year follow-up period were 2.68% (n = 1,772) and 0.34% (n = 210), respectively. Cox- regression analysis for liver cancer incidence indicated that cirrhosis had the highest risk (hazard ratio [HR]: 18.13, 95% confidence interval [CI]: 15.24–21.58), followed by hepatitis B (HR: 9.32, 95% CI: 8.00–10.85). Subgroup analysis showed that the presence of liver disease was an important risk factor in younger as well as elderly people, and a higher risk of liver disease was also observed in the patients with Medicaid.

Attention should be paid to the development of liver cancer in young people under 50 years old and preventive efforts to decrease the incidence of liver cancer among Medicaid recipients is needed.

What's Up Doc?: Hepatitis C, a killer that can be stopped

What's Up Doc?: Hepatitis C, a killer that can be stopped
By Dr. Malavika Varma with Dr. Aravind Ganesh
Hepatitis C (HepC) is an infectious disease caused by the hepatitis C virus (HCV) that primarily affects the liver. The virus can cause both acute (rapid onset) and chronic (long-term) symptoms. Symptoms include a fever, dark urine, abdominal pain, and yellow tinged skin (“jaundice”). Hepatitis C can often lead to liver disease and occasionally cirrhosis. In some cases, it can cause complications such as liver failure, hepatocellular carcinoma (liver cancer), and death.

Read the article:

What’s Up, Doc? is a medical column that covers the most interesting doctors, health researchers, and health-care issues or innovations in Canada and in our wider global community.

Novartis, Pfizer join forces on potentially lucrative fatty liver disease

Novartis, Pfizer join forces on potentially lucrative fatty liver disease
John Miller, Michael Erman

ZURICH/NEW YORK (Reuters) - Novartis AG and Pfizer Inc are teaming up to develop treatments for a liver disease many drug companies believe will become a hugely lucrative market, as it is tied to the obesity and diabetes epidemics.

The Swiss and U.S. drugmakers announced on Monday that they will collaborate to develop combination therapies involving medicines they have been working on separately to treat nonalcoholic steatohepatitis, or NASH.

Though hardly a household name, the progressive fatty liver disease with no approved treatments is poised to become the leading cause of liver transplants by 2020. 

Mavyret (glecaprevir/pibrentasvir) 8 Wks Improved Cardiovascular and Metabolic Outcomes and Stable Renal Function

Infect Dis Ther. 2018 Oct 27. doi: 10.1007/s40121-018-0218-x. [Epub ahead of print]

Pan-Genotypic Hepatitis C Treatment with Glecaprevir and Pibrentasvir for 8 Weeks Resulted in Improved Cardiovascular and Metabolic Outcomes and Stable Renal Function: A Post-Hoc Analysis of Phase 3 Clinical Trials. 
Tran TT1, Mehta D2,3, Mensa F3, Park C3, Bao Y3, Sanchez Gonzalez Y4.

First Online: 27 October 2018

Treatment with Glecaprevir and Pibrentasvir G/P for as short as 8 weeks showed improved glucose and triglyceride levels by post-treatment week 4 irrespective of treatment history and cirrhosis status. These benefits were especially pronounced in patients with elevated triglycerides, pre-diabetes and diabetes at baseline. Treatment with G/P also resulted in stable eGFR function in both during and post-treatment periods. Future studies are needed to determine whether these effects are maintained over longer periods of time.


Chronic hepatitis C (CHC) infection is associated with extrahepatic manifestations (EHMs) which can affect renal, cardiovascular and other comorbidities. The effect of CHC treatment with short-duration regimens on these EHMs is not well defined. Hence, we examined longitudinal estimated glomerular filtration rate (eGFR), triglycerides and glucose values to assess the impact of short-duration CHC therapy on renal, cardiovascular and metabolic diseases, respectively.

We conducted analyses of all patients without cirrhosis treated with glecaprevir and pibrentasvir (G/P) for 8 weeks in two phase 3 clinical trials. In addition, one phase 3 trial was carried out to explore the effects of treatment on renal EHMs in patients with advanced renal impairment at baseline. As a sensitivity analysis, we included all CHC patients treated with G/P for 8 or 12 weeks enrolled across five phase 3 trials. Adjusting for baseline demographics and clinical properties via mixed regression models enabled evaluation of changes in EHMs through end of treatment.

G/P treatment for 8 weeks resulted in statistically significant declines in triglycerides (− 28.6 mg/dl) and glucose (− 11.2 mg/dl), while there was no statistically significant decline in eGFR. Biomarker improvements were greatest among patients with elevated triglycerides and elevated glucose at baseline. Similar effects were observed across all patients treated with G/P for 8 or 12 weeks.

Short-duration treatment with G/P resulted in stable renal function and improvements in cardiovascular and metabolic EHM markers, especially in patients with severe EHMs at baseline.

Continue reading:

Additional Reading
HCV Advocate
Hepatitis C is NOT just a liver disease-it affects the entire body. Check out our fact sheet that lists some of the more common and uncommon extrahepatic manifestations of hepatitis C.

Navigate this blog 
Sift through current research articles on the extrahepatic manifestations of hepatitis C.

Sunday, October 28, 2018

Now's the ideal time to get your flu vaccination

Elsewhere On This Blog
Did you know that you are more susceptible to flu-related complications if you're over 65, living with chronic liver disease, or viral hepatitis?

Roll Up Your Sleeves to Avoid the Flu
By Robert Preidt
SUNDAY, Oct. 28, 2018 (HealthDay News) -- With flu season looming, don't wait too long to get your flu shot, a health expert advises.

"The best way to avoid the flu is to get vaccinated," said Cindy Weston, an assistant professor at the Texas A&M College of Nursing.

"When it comes to you and your family's health, it's best to take the cautious approach and get your shot," she added in a school news release.

Flu season typically lasts from fall to spring, Weston said. The outbreak may peak at various times during those seasons, but people should be vaccinated before the holidays to prevent widespread infection, she noted.

Getting a flu shot is a minor inconvenience compared to the risks posed by flu, experts say. Every year, the flu causes millions of illnesses, hundreds of thousands of hospitalizations and thousands of deaths, according to the U.S. Centers for Disease Control and Prevention.

If you're not concerned about protecting yourself from the flu, think of others. Children under 6 months of age are too young to receive the flu vaccine in either mist or shot form, and other people may have severe allergies to flu vaccines or an ingredient in them.

"These people are dependent upon everyone else getting immunized in order to stay at low risk for the flu," Weston said.

If you don't like needles, don't worry. After being unavailable during the last couple of seasons, the FluMist nasal spray vaccine is an option again for most people aged 2 to 49.

Now's the ideal time to get your flu vaccination.

"It takes two weeks after the immunization to develop appropriate antibodies in the body," Weston said. "The coverage is strongest for about six months, and it will help keep you and your community safer."

There are a number of other things you can do to reduce the spread of the flu.

"It is very important to practice good hygiene," Weston said. "Washing your hands properly, covering your cough, avoiding hand contact with your face and eyes, and wiping down surfaces with disinfectant are all ways to help stop the spread of the flu."

More information
The U.S. Centers for Disease Control and Prevention has more on flu prevention.
SOURCE: Texas A&M University, news release, October 2018

Long term outcome of antiviral therapy in HBV patients with cirrhosis

World J Gastroenterol. Oct 28, 2018; 24(40): 4606-4614
Published online Oct 28, 2018. doi: 10.3748/wjg.v24.i40.4606
Long term outcome of antiviral therapy in patients with hepatitis B associated decompensated cirrhosis 
Young-Cheol Ju, Dae-Won Jun, Jun Choi, Waqar Khalid Saeed, Hyo-Young Lee, Hyun-Woo Oh 

Full-text Article

Core tip: It is well known that antiviral treatment improves clinical outcomes of chronic hepatitis B-associated decompensated cirrhosis. However, long term and large scale clinical data regarding survival rate, and incidence of hepatocellular carcinoma in patients with decompensated cirrhosis in the antiviral era are lacking. We investigated the survival rate and incidence of hepatocellular carcinoma (HCC) in patients with decompensated cirrhosis by using the Health Insurance Review and Assessment database. Long term outcome of treating hepatitis B-associated decompensated cirrhosis using antiviral agents improved much compare to previous reports. Cumulative mortality rate and incidence of HCC was sharply decreased after one year antiviral treatment.

To investigate survival rate and incidence of hepatocellular carcinoma (HCC) in patients with decompensated cirrhosis in the antiviral era. 

We used the Korean Health Insurance Review and Assessment. Korea’s health insurance system is a public single-payer system. The study population consisted of 286871 patients who were prescribed hepatitis B antiviral therapy for the first time between 2007 and 2014 in accordance with the insurance guidelines. Overall, 48365 antiviral treatment-naïve patients treated between 2008 and 2009 were included, and each had a follow-up period ≥ 5 years. Data were analyzed for the 1st decompensated chronic hepatitis B (CHB) and treatment-naïve patients (n = 7166). 

The mean patient age was 43.5 years. The annual mortality rates were 2.4%-19.1%, and 5-year cumulative mortality rate was 32.6% in 1st decompensated CHB treatment-naïve subjects. But the annual mortality rates sharply decreased to 3.4% (2.4%-4.9%, 2-5 year) after one year of antiviral treatment. Incidence of HCC at first year was 14.3%, the annual incidence of HCC decreased to 2.5% (1.8%-3.7%, 2-5 year) after one year. 5-year cumulative incidence of HCC was 24.1%. Recurrence rate of decompensated event was 46.9% at first year, but the annual incidence of second decompensation events in decompensated CHB treatment-naïve patients was 3.4% (2.1%-5.4%, 2-5 year) after one year antiviral treatment. 5-year cumulative recurrence rate of decompensated events was 60.6%. Meanwhile, 5-year cumulative mortality rate was 3.1%, and 5-year cumulative incidence of HCC was 11.5% in compensated CHB treatment-naïve patients. 

Long term outcome of decompensated cirrhosis treated with antiviral agent improved much, and incidence of hepatocellular carcinoma and mortality sharply decreased after one year treatment.
Continue reading......

Saturday, October 27, 2018

Researchers identify potential new target to inhibit the progression of liver disease

Interleukin IL-22, a new target to inhibit the progression of liver disease  

Montreal, October 26, 2018 - Naglaa Shoukry, Ph. D., and her team have made a significant breakthrough in their research aiming to limit the progression of liver disease. They have characterized the mechanisms of action of type 3 inflammatory cytokines that are produced by the cells of the immune system, which result in a progression of hepatic scarring known as fibrosis. These research efforts have identified new potential targets to inhibit the progression of liver disease and prevent cancer.

Researchers from the liver immunology research unit of the University of Montreal Hospital Research Center (CRCHUM) have discovered how a protein called interleukin 22 (IL-22) accelerates fibrosis during episodes of chronic hepatitis by amplifying the signal of the fibrogenic cytokine TGF-β. The fibrogenic nature of IL-22 had been unknown up to now. The new finding allows us to understand its interaction when combined with TGF-β, a cytokine that is produced during liver inflammation. Indeed, cases of advanced fibrosis confirm the pathogenic aspect of IL-22.

Another type 3 cytokine, namely interleukin 17A (IL-17A), had been known as an agent amplifying the inflammation and fibrosis leading to liver cirrhosis, which can cause cancer. The team has identified neutrophils and mast cells as the prime source of IL-17A in humans. Indeed, their number increases in inflammation induced by the immune system during liver disease.

It appears now that two type 3 cytokines, IL-17A and IL-22, can by independent mechanisms sensitize hepatic stellate cells (HSC) to the action of TGF-β. The HSCs, thus more sensitized to signals of proliferation and fibrosis, remodel the extracellular matrix leading to a deterioration of the architecture and function of the affected patient's liver.

Experiments successful in blocking the production of IL-17A and IL-22
The balance between the two cytokines IL-17A and IL-22 during different stages of liver disease and their combined roles remain unknown and further studies are needed. However, experiments in mice have determined that the inhibition, by small molecules, of programmes associated with production of IL-17A and IL-22 delays the development of hepatic fibrosis. These discoveries allow us to better characterize the pathogenic role of type 3 cytokines, and elucidate how to intervene to prevent the development of fibrosis as well as liver cancer.

The next steps
The next steps will make it possible to determine when cells producing IL-17A and IL-22 receive the signal to penetrate the liver, triggering a tissue-repair response. The objective will be to examine how the balance between the pro-inflammatory and anti-inflammatory signals is disrupted, since this is how fibrosis progression is influenced. Given that the replacement of healthy tissue by scar tissue favours the development of more serious pathologies, such as cirrhosis of the liver and liver cancer, it is vital to learn how to block inflammatory cells from entering, which over the course of time may induce cancer. The various types of treatment, as well as frequency and intensity of doses that would make it possible to block the effects of type 3 responses, must be pursued in preclinical mouse models prior to being ultimately tested in humans. Medications already developed for the treatment of psoriasis in humans, successfully target type 3 cytokines such as IL-17 and IL-22. This avenue appears promising.

Prevalence of liver disease in Canada and Quebec
An estimated eight million Canadians may be affected by liver disease, an illness that exhibits few or no symptoms, and that can affect anyone. Chronic liver disease can lead to fibrosis, cirrhosis, and cancer of the liver. An increase in the risk of liver disease, including non-alcoholic hepatic steatosis (NASH) (known as fatty liver disease), chronic hepatitis B and C, and liver cancer, is the reason that, in just 10 years, the number of Canadians affected by liver disease has increase from 1 in 10 to 1 in 4. Our nutrition, sedentary behaviour, and lifestyle are key causes. This scientific breakthrough may make it possible to develop strategies whose goal is to limit the development and progression of fibrosis.

Naglaa Shoukry and her team's research interests
Naglaa Shoukry, Ph. D., and her team's research involves investigating the immune response against hepatitis C virus (HCV), an infection that affects approximately 71 million individuals worldwide, and is a major cause of chronic liver disease including cancer. The team is also interested in understanding the role of immune regulation in the progression of hepatic fibrosis and the development of liver cancer. In particular, it examines the complementary and at times opposing roles of IL-17 and IL-22 in hepatic fibrosis and cancer, and the populations of inflammatory versus regulatory cells involved in this process.

The discovery, published today in Science Immunology, was the work of a multidisciplinary research team consisting of Thomas Fabre, Manuel Flores Molina (graduate students at the Université de Montréal), Geneviève Soucy (CHUM Pathology Department), Jean-Philippe Goulet (Caprion), Bernard Willems, Jean-Pierre Villeneuve, and Marc Bilodeau (CHUM Hepatology Department). For more information, see the study: 

University of Montreal Hospital Research Centre (CRCHUM)

Friday, October 26, 2018

Today On Twitter - Medical Marijuana for Chronic Pain

Today On Twitter From: The New England Journal of Medicine (NEJM)
"An interactive feature about the use of #medicalmarijuana offers a case vignette accompanied by essays that support either recommending or discouraging the use of medical marijuana for the treatment of chronic pain."

Medical Marijuana for Chronic Pain
Lisa Caulley, M.D., M.P.H., Benjamin Caplan, M.D., and Edgar Ross, M.D.
N Engl J Med 2018; 379:1575-1577
DOI: 10.1056/NEJMclde1808149

A Woman with Chronic Pain
Lisa Caulley, M.D., M.P.H.
Ms. Rothstein is a 31-year-old woman who comes to your office to consult with you regarding a long-standing history of complex regional pain syndrome in her right leg and foot. She is a graduate student and former varsity soccer player who became disabled 7 years ago after having a hairline fracture in the right fibula. Since several weeks after her injury, she has had intractable pain in her foreleg and foot even though the fracture has healed. She describes.....

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Hepatitis C - Potential drug‐drug interactions between DAAs and concomitant medications

Comorbidities, concomitant medications and potential drug‐drug interactions with interferon‐free direct‐acting antiviral agents in hepatitis C patients in Taiwan 
Chen‐Hua Liu Ming‐Lung Yu Cheng‐Yuan Peng Tsai‐Yuan Hsieh Yi‐Hsiang Huang Wei‐Wen Su Pin‐Nan Cheng Chih‐Lin Lin Ching‐Chu Lo Chi‐Yi Chen Jyh‐Jou Chen Qian Ma

First published: 25 October 2018

Full-text article
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While direct‐acting antivirals have been approved for treating hepatitis C, the guidelines highlight the importance of considering potential drug‐drug interactions between DAAs and concomitant medications.

To assess comorbidity prevalence, concomitant medication use and potential drug‐drug interactions between DAAs and concomitant medications for hepatitis C patients in Taiwan.

This cross‐sectional study enrolled 822 patients from May to August 2016 in Taiwan. Patient demographics, comorbidities and concomitant medications were evaluated by physician surveys.

A total of 709 (86.3%) patients had ≥1 comorbidity; the most prevalent comorbidity categories were diseases of the digestive system (40.1%), circulatory system (38.7%) and endocrine/nutritional/metabolic diseases (35.2%). Elderly patients had more comorbidities. A total of 622 (75.7%) patients received ≥1 concomitant medication; the average number of concomitant medications was 3.2. The most common concomitant medication classes were cardiovascular (34.4%), gastrointestinal (25.7%) and central nervous system drugs (22.7%). Among patients without cirrhosis or with compensated cirrhosis, contraindications were most prevalent with paritaprevir/ritonavir/ombitasvir plus dasabuvir, daclatasvir/asunaprevir and glecaprevir/pibrentasvir (13.3%, 6.0% and 5.4% respectively), and least prevalent with sofosbuvir, sofosbuvir/daclatasvir, sofosbuvir/ledipasvir and sofosbuvir/velpatasvir (0.8%, 1.3%, 1.4% and 2.1% respectively). Sofosbuvir‐based regimens had no contraindications in patients with decompensated cirrhosis.

Our population represented an elderly demographic, with a high prevalence of comorbidities and widespread use of concomitant medications. The potential drug‐drug interactions between these concomitant medications and DAA regimens differed, with the fewest potential interactions with sofosbuvir‐based regimens.

Q&A: Patient initiative will drive fight against rising liver cancer rates

Q&A: Patient initiative will drive fight against rising liver cancer rates

Tom Nealon, president and CEO of the American Liver Foundation, spoke with Healio Gastroenterology and Liver Disease about these alarming trends and how important is it for patients to take initiative to speak with their doctors about potential risk factors and liver function examinations. – by Talitha Bennett

Healio: With the exceptional rise of liver cancer rates in the U.S., what is necessary for a plan of action? 

Read the article over @ Healio
Free registration may be required to access article. 

American Liver Foundation
Check out this years Liver Cancer Awareness Campaign aimed at encouraging individuals with an increased risk for liver cancer to receive ongoing screening, launched by the American Liver Foundation (ALF) and Bayer Healthcare. Find out if you're at risk for liver cancer.

Thursday, October 25, 2018

Cirius Therapeutics Reports On Phase 2b Trial in NASH Patients with Fibrosis

Cirius Therapeutics Reports Positive Data for MSDC-0602K in Interim Analysis of Phase 2b Clinical Trial in NASH Patients with Fibrosis

- Interim analysis showed statistically significant reductions in liver enzymes, including ALT and AST, measured from baseline at six months

- In two highest dose groups, at least 50% of patients with high baseline ALT or AST improved to normal range at six months

- Statistically significant reductions in HbA1c and other measures of glycemic control and insulin resistance were observed

- Overall adverse event rate was similar across placebo and all doses of MSDC-0602K

- Largest Phase2b clinical trial including paired biopsies conducted in NASH; biopsy data after 12 months of treatment expected to be reported in the second half of 2019

SAN DIEGO and KALAMAZOO, Mich., Oct. 25, 2018 /PRNewswire/ -- Cirius Therapeutics today announced positive results from an interim analysis of exploratory endpoints from its ongoing, fully enrolled Phase 2b clinical trial (the EMMINENCE trial) evaluating MSDC-0602K in 402 patients diagnosed with non-alcoholic steatohepatitis (NASH) with fibrosis. The interim analysis, which was conducted in the first 328 patients to reach their six-month follow-up visit, showed that patients treated with MSDC-0602K had significant improvements from baseline in measures of liver function and insulin resistance at six months. MSDC-0602K, a second-generation insulin sensitizer, is designed to selectively modulate the mitochondrial pyruvate carrier (MPC), which at the cellular level mediates the effects of overnutrition, a major cause of NASH and other metabolic disorders.

The subjects included in this interim analysis had significant liver disease, as established by liver biopsy, with an average non-alcoholic fatty liver disease (NAFLD) activity score at baseline of 5.3. Almost sixty percent of these subjects had a baseline fibrosis score of 2 or 3 and approximately fifty percent also had a diagnosis of Type 2 diabetes at baseline. Overall, baseline characteristics were well-balanced across treatment groups.

Key findings from the interim analysis include improvements in liver enzymes, with placebo-corrected reductions at 6 months of 14.3 U/L (p<0.001) and 7.9 U/L (p=0.012) in ALT and AST, respectively, in the 125mg cohort, and 10.6 U/L (p=0.004) and 4.0 (NS) in ALT and AST, respectively, in the 250mg cohort. Placebo-corrected reductions, relative to baseline, were 25% and 18% in ALT and AST, respectively, in the 125mg cohort, and 19% and 9% in ALT and AST, respectively, in the 250mg cohort. Importantly, normalization of hepatic enzymes was observed across all three dose levels of MSDC-0602K. 

Percentage of patients with high baseline values who returned to normal range
*ALT normal range defined as 6-34 U/L and 6-43 U/L for women and men, respectively; AST normal range defined as 9-34 U/L and 11-36 U/L for women and men, respectively) 

"We believe these interim results around improved measures of liver function and glycemic control, together with the preliminary adverse event profile, support MSDC-0602K's potential to be used in the treatment of NASH with fibrosis, including for those patients with Type 2 diabetes, a group which represents approximately 50% of patients with NASH," said Cirius' chief medical officer Howard Dittrich, M.D. "These results support the view that therapies directed toward the MPC have the potential to achieve insulin sensitizing pharmacology with an improved profile over first generation insulin sensitizers. We look forward to presenting full data to the scientific community." 

In addition to the improvement in ALT and AST, observations included significant improvement at six months in fasting glucose, HbA1c, insulin levels and HOMA-IR at the 125mg and 250mg dose levels.  Significant improvement in HbA1c was also observed in subjects with a diagnosis of Type 2 diabetes in the 125mg and 250mg cohorts.  

In this interim analysis, the overall rate of treatment emergent adverse events was similar across placebo and all MSDC-0602K cohorts. There was a higher rate of treatment emergent adverse events reported in the 250mg dose compared to placebo in the musculoskeletal and connective tissue disorders category. Within this category, arthralgia and back pain were the most frequently reported individual adverse events across the pooled 328 subjects. A modest dose-dependent increase in body weight was seen in MSDC-0602K treated subjects, a finding seen with insulin and with other therapies that seek to improve insulin resistance. The rate of peripheral edema observed at six months was similar to that observed at baseline and was comparable across placebo and all MSDC-0602K cohorts. 

"The interim results from the EMMINENCE trial, the largest Phase 2b clinical trial to include paired biopsies ever conducted in NASH, are compelling," said Stephen Harrison, M.D., the principal investigator in the EMMINENCE trial. "The improvements in hepatic enzymes observed to date are impressive, especially when combined with the meaningful improvements in glycemic control." 

About the EMMINENCE Trial
The EMMINENCE trial is a 12-month, randomized, double-blind, placebo-controlled trial evaluating three oral dose levels of MSDC-0602K. Endpoints of the clinical trial include hepatic histological changes measured by biopsy after 12 months of treatment, changes in liver and metabolic function measured by the liver enzymes ALT and AST, markers of liver fibrosis, glycemic control and safety and tolerability. Not all of these endpoints were examined in this interim analysis; rather, in addition to the safety variables of incidence of treatment-emergent adverse events and  peripheral edema grades, changes from baseline relative to placebo for a number of endpoints, including liver functions tests such as ALT and AST, among others, biomarkers and indirect measures of apoptosis and fibrosis, circulating inflammatory markers and markers of bone metabolism, serum triglycerides and fasting cholesterol, markers of insulin sensitivity, and blood pressure, were examined in an exploratory manner. 

About Cirius Therapeutics
Cirius is a clinical-stage pharmaceutical company focused on the development and commercialization of innovative therapies for the treatment of liver and metabolic diseases. Our lead product candidate, MSDC- 0602K, is a novel small molecule being developed as a once-daily oral therapy to treat NASH with fibrosis. MSDC-0602K is designed to selectively modulate the MPC, which mediates at the cellular level the effects of overnutrition, a major cause of NASH and other metabolic disorders. We are conducting a Phase 2b clinical trial of MSDC-0602K, which we have fully enrolled with 402 patients diagnosed with NASH with fibrosis. We expect to report final data from this clinical trial in the second half of 2019.

Curing hepatitis C reduces the risk of cardiovascular events

Liz Highleyman
Published: 25 October 2018
Several studies have found that people with hepatitis C are more prone to developing cardiovascular conditions such as coronary artery disease, peripheral vascular disease, myocardial infarction and stroke; however, other studies have not seen this association.

A growing body of evidence shows that HCV treatment can help reverse this increased risk. A recent study from France, for example, found that curing hepatitis C reduces the risk of cardiovascular events in people with compensated cirrhosis. But again, some large studies from the interferon era did not see a similar benefit. 

On This Blog
A collection of current research articles on ailments related to HCV
Article directory on the extrahepatic manifestations of hepatitis C.

The following study investigated the prevalence of early signs of cardiovascular damage in patients with HCV cirrhosis. Is such damage reversible following treatment with DAAs? 

Full-text article available online @ Medscape, or purchase article, here

A Prospective Study
Aliment Pharmacol Ther. 2018 Oct;48(7):740-749. doi: 10.1111/apt.14934. Epub 2018 Aug 10.

Subclinical cardiovascular damage in patients with HCV cirrhosis before and after treatment with direct antiviral agents: a prospective study.
Novo G1, Macaione F1, Giannitrapani L2, Minissale MG2, Bonomo V1, Indovina F1, Petta S3, Soresi M2, Montalto G2, Novo S1, Craxi A3, Licata A2,3.

Cirrhosis is associated with morpho-functional cardiovascular alterations.

To detect early features of cardiovascular damage in HCV-compensated cirrhotic patients using myocardial deformation indices and carotid arterial stiffness, and, further, to evaluate their short-term behaviour after HCV eradication with direct antiviral agents (DAAs).

Thirty-nine consecutive patients with HCV cirrhosis, without previous cardiovascular events, were studied and matched for age, gender and cardiovascular risk factors to 39 controls without liver or cardiovascular disease. Patients and controls underwent a baseline echocardiographic evaluation including global longitudinal strain and ultrasound scan of carotid arteries. HCV-cirrhotics were reassessed by echocardiography and carotid ultrasound after obtaining sustained virological response (SVR) on DAAs.

HCV-cirrhotics showed at baseline a significantly reduced global longitudinal strain compared to controls -18.1 (16.3-20.5) vs -21.2 (20.4-22.3), P < 0.001. They also had a significantly higher pulse wave velocity 8.6 (7.7-9.1) m/s vs 6.6 (6.0-7.1) m/s, P = 0.0001, and β-stiffness index 12.4 (11.1-13.5) vs 8.6 (8.0-9.2) P = 0.0001. At multiple regression analysis, diabetes and HCV cirrhosis were independent predictors of global longitudinal strain. All HCV-cirrhotic patients had SVR on DAAs. Follow-up available in 32 of 39 (82%) at 9 (8-10) months showed a significant improvement of tricuspid annular plane systolic excursion (P = 0.01) and lateral E' velocity compared to baseline (P = 0.001).

HCV-cirrhotics show a significant rate of subclinical cardiac and vascular abnormalities. At a time when their survival is less linked to progression of liver disease, due to viral eradication on DAAs, cardiovascular morbidity and mortality may take a significant role.
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Wednesday, October 24, 2018

'The food supplement that ruined my liver'

'The food supplement that ruined my liver'
Tristan Quinn
It should have been one of the happiest days of his life. But Jim McCants looks back on his youngest son's high school graduation with mixed emotions. As he sat down next to his wife Cathleen in the university auditorium, just outside Dallas, Texas, she turned to look at him.

"She said 'Do you feel OK?'" Jim recalls. "I said, 'Yeah I feel fine, why?' 'Your face is yellow, your eyes are yellow, you look terrible.' When I looked in the mirror it was shocking."
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On This Blog
Current articles investigating herbal and dietary supplement-induced liver injury 

New drug to treat the flu - Roche announces FDA approval of Xofluza

In The Media
US approves first new type of flu drug in 2 decades
Associated Press · 38 mins ago

Press Release
Roche announces FDA approval of Xofluza (baloxavir marboxil) for influenza 

• First and only single-dose oral medicine approved to treat the flu  
• Xofluza significantly reduced the duration of flu symptoms compared to placebo  
• First novel proposed mechanism of action to treat the flu in nearly 20 years

Basel, 24 October 2018 - Roche (SIX: RO, ROG; OTCQX: RHHBY) today announced that the US Food and Drug Administration (FDA) has approved Xofluza ™ (baloxavir marboxil) for the treatment of acute, uncomplicated influenza, or flu, in people 12 years of age and older. Xofluza is a first-in-class, single-dose oral medicine with a novel proposed mechanism of action that inhibits polymerase acidic endonuclease, an enzyme essential for viral replication.[1-2] Xofluza has demonstrated efficacy against a wide range of influenza viruses, including oseltamivir-resistant strains and avian strains (H7N9, H5N1) in non-clinical studies.[3-5]

“Xofluza is the first new flu medicine with a novel proposed mechanism of action approved in nearly 20 years, and we’re excited to offer a convenient treatment option that reduces flu symptoms by more than a day with a single oral dose,” said Sandra Horning, MD, Roche’s Chief Medical Officer and Head of Global Product Development. “If patients see their doctors within 48 hours of symptom onset, one dose of Xofluza can significantly reduce the duration of flu symptoms.”

The flu is one of the most common, yet serious, infectious diseases, representing a significant threat to public health. Globally, annual epidemics result in 3 to 5 million cases of severe disease, millions of hospitalisations and up to 650,000 deaths worldwide. [6-9] 

Xofluza was approved based on results from the phase III CAPSTONE-1 study of a single-dose of Xofluza compared with placebo or oseltamivir 75 mg, twice daily for five days, in otherwise healthy people with the flu, as well as results from a placebo-controlled phase II study in otherwise healthy people with the flu. Xofluza significantly reduced the duration of flu symptoms compared to placebo, and demonstrated similar efficacy compared to oseltamivir.[10] In clinical trials, Xofluza was safe and well-tolerated with a side effect profile similar to placebo. The CAPSTONE-1 and phase II study results were recently published in the 6 September 2018 issue of the New England Journal of Medicine.[10] 

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Organic Food's Dubious Cancer Benefits

Organic Food's Dubious Cancer Benefits
Hi folks, today Medscape launched both a video & article by F. Perry Wilson, MD, MSCE, reviewing the following study: Association of Frequency of Organic Food Consumption With Cancer Risk - Findings From the NutriNet-Santé Prospective Cohort Study, investigating the association between organic food consumption and the risk of cancer, published this week in JAMA Internal Medicine.

Check it out:
Organic Food's Dubious Cancer Benefits
Today we are looking at an observational study that shows that people who eat lots of organic food have slightly lower rates of cancer than people who don't eat lots of organic food...
Look, organic food is a luxury good. And luxury goods are associated with a survival benefit because rich people live longer. Is it fair? No. But it's true. 
Free registration may be required to view article. 

Yesterday, UK's NHS website published this analysis nicely summing up both media coverage and the research article:

Eating organic food linked with lower cancer risk
"Organic food lowers blood and breast cancer risk, study finds," the Mail Online reports.

The news website reports on a large study in France that questioned 69,000 people on their consumption of organic food, and then monitored them for 5 years to see how many developed cancer.

Organic food is grown without the use of pesticides, manmade fertilisers or genetic modification (GM) techniques. Organic meat, poultry, eggs and dairy products come from animals that are given no antibiotics or growth hormones.

Researchers found that people who ate the most organic food had a 24% reduced risk of cancer compared to those who ate the least.

Despite the encouraging media reports, this study does not prove that eating organic food will protect you against cancer.

The study does not demonstrate that organic food is the direct cause of the reduced risk. People who ate more organic food had healthier lifestyles in general, doing more exercise and eating more fruit and vegetables than other people. Though the researchers tried to adjust for such health and lifestyle factors, it's still possible these things had an influence.

So, claims that "eating organic food will reduce cancer rates" remain unproven. It would be better to focus on eating a healthy diet high in fruit, vegetables and fibre and low in processed meat, and to maintain a healthy weight. Eating well, along with taking regular exercise and not smoking, can significantly reduce your risk of developing cancer. 

Where does the study come from? 
The research was conducted by the Institut National de la Sante et de la Recherche Medicale, and Universit é Paris 13. Funding was provided by several French organisations including the Ministry of Health, Institute for Health Surveillance, and the National Institute for Prevention and Health Education.

One of the researchers declared that they had an advisory role promoting the use of organic products to 2 non-profit organisations.

The study was published in the peer-reviewed medical journal JAMA Internal Medicine.

The UK media took the findings at face value without acknowledging other factors that could have potentially influenced the results, and the small number of cancer cases recorded. For example, the Mail's statement that: "The biggest impact was seen on non-Hodgkin's lymphoma risk [a cancer of the lymphatic system], which plummeted among those who shunned chemical-sprayed food" is certainly overblown, given that this was based on tiny numbers and could be a chance finding.

But to their credit, the UK media did point out that people who eat organic food tend to have a healthier lifestyle than people who don't. 

What kind of research was this?
This was a population-based cohort study that aimed to see whether eating organic food was associated with risk of developing cancer.

The organic food market avoids the use of chemical fertilisers, pesticides and GM methods, and restricts the use of medications in animals.

Previous research has demonstrated other potential beneficial effects of eating an organic diet, such as a lowered level of pesticides in urine samples. But few studies have looked at the potential link with cancer.

Observational studies such as this are useful for exploring potential links but can't prove cause and effect, as other health and lifestyle factors could be having an influence. 

What did the researchers do?
This study involved 68,946 participants (78% women, average age 44 years) of the internet-based French cohort study, NutriNet-Sante. The cohort was set up in 2009 to look at links between diet, nutrition and health.

At the start of the study, participants provided information on their sociodemographic status, body measurements, health status and lifestyle behaviours. 

They were asked 2 months later how often they ate 16 different organic products, including fruit and vegetables, dairy and eggs, meat and fish, grains and cereals, ready meals, wine, chocolate and coffee. 
They were asked to tick 1 of the following:
most of the time
never ("too expensive")
never ("product not available")
never ("I'm not interested in organic products")
never ("I avoid such products")
never ("for no specific reason")
I don't know

For each product, 2 points for were given for "most of the time", 1 point for "occasionally" and 0 for all other responses. The 16 items therefore had a total organic food score ranging from 0 to 32 points. The analysis was split into 4 quartiles, from lowest to highest intake.

Health outcomes of participants were recorded for an average of 4.5 years. This information was gathered through annual questionnaires. If participants reported receiving a diagnosis of cancer, they were asked for medical records (obtained for 90%) and details of the treating doctor or hospital.

The fully adjusted analysis took account of the following potential confounders:
age and gender
marital status
education, occupational status and monthly income
smoking and alcohol intake
body mass index
physical activity
overall food energy intake and intake of fibre, fruit and vegetables, processed foods and red meat
hormonal factors in women, such as use of hormone treatment and whether they'd been through the menopause 

What were the basic results?
In total, 1,340 cancers developed among the 68,946 participants (2% of the cohort). These included breast cancer (34%), prostate cancer (13%), skin cancer (10%) and bowel cancer (7%).

Consumption of organic food was more common among:
those with a higher education or occupational status
those who did more physical activity and who had healthier diets in general

Those who ate the most organic food had a 24% lower risk of developing cancer compared to those with the lowest intake (hazard ratio (HR) 0.76, 95% confidence interval (CI) 0.64 to 0.90).

There were no differences in people who ate moderate amounts of organic food compared with those who ate the least.

By specific cancer, significant links with organic food intake were only found for:
postmenopausal breast cancer
lymphomas overall
non-Hodgkin's lymphoma specifically

However, these results should be taken with caution, particularly because of the very low number of cases. 

What do the researchers conclude?
The researchers conclude: "A higher frequency of organic food consumption was associated with a reduced risk of cancer. Although the study findings need to be confirmed, promoting organic food consumption in the general population could be a promising preventive strategy against cancer." 

This study is a valuable investigation into potential links between eating organic food and cancer risk. However, the author's conclusion could be a little premature. This study alone cannot prove that eating organic food will prevent you getting cancer.

There are a few points to note.

Cancers still developed among people who ate the most organic food – it's just there were fewer cases (269 vs 360 among those eating the least amount of organic food). So even if there is a direct link, eating organic food is not guaranteed protection against cancer.

The conclusions about the links with specific cancers were based on tiny numbers – for example, 15 non-Hodgkin's lymphomas among those eating the least organic food vs 2 among those eating the most organic.

Organic food intake was taken at a single point in time and self-reported. This may be inaccurate and not reflect lifetime habits.

There was a notable difference in sociodemographics and lifestyles of those eating the most organic food. The researchers tried to adjust for these factors, but there's still a chance these things influenced the results. This means the study can't prove that eating organic food is responsible for the reduced risk – it could just be down to living a healthier lifestyle in general.

The study benefits from a large sample size, but these were online volunteers to a health and nutrition study who may not represent the general population of France.

Experts have added similar notes of caution. For example, Professor Tom Sanders of King's College London says: "[The authors'] conclusion, that promoting organic food in the general population could be a promising cancer preventive strategy, is overblown."

It's understandable to want to eat organic food for health or environmental reasons. But in terms of protecting against cancer, what's far more proven to have an effect is a healthier diet in general with a high amount of fruit and vegetables and fibre and low amount of processed meat, along with regular physical activity, and maintaining a healthy weight. 

Links to the headlines 
Mail Online, October 22 2018 
The Sun, October 23 2018 
The Times (subscription required), October 23 2018

Links to the science
Baudry J, Assmann KE, Touvier M, et al. 
JAMA Internal Medicine. Published online October 22 2018

Analysis by Bazian
Edited by NHS Website

Tuesday, October 23, 2018

Making The Opioid Use Disorder Cascade Of Care A Reality, Despite Data Limitations

“Making The Opioid Use Disorder Cascade Of Care A Reality, Despite Data Limitations, " Health Affairs Blog
October 23, 2018. 
DOI: 10.1377/hblog20181018.540807

Recent discussion on the Health Affairs Blog has described both the development of a cascade of care model and corresponding quality measures to assess addiction treatment system performance, as well as the collection of data needed to implement the cascade of care. In this follow up, we offer an approach that combines administrative data sets and provides a starting point for the nation and individual states to measure progress and barriers to success in addressing the opioid epidemic. Despite imperfect data collection and reporting systems, we are past due for an honest attempt to create baseline measures of opioid use disorder management from which to improve. We propose a method to develop baseline calculations that uses approved Healthcare Effectiveness Data and Information Set (HEDIS) measures and national survey and administrative claims data organized into a cascade of care.

Monday, October 22, 2018

Hepatitis C Virus in Women of Childbearing Age, Pregnant Women, and Children

Of Interest
Recent increases in hepatitis C among women of child-bearing age have led public health advocates to call for universal HCV screening in all pregnant women, regardless of reported risk factors. Read our new fact sheet for an overview of the reasons why HCV screening should be expanded. 
View and download the fact sheet here.

The American Journal of Preventive Medicine
Am J Prev Med. 2018 Nov;55(5):633-641. doi: 10.1016/j.amepre.2018.05.029.
Hepatitis C Virus in Women of Childbearing Age, Pregnant Women, and Children.
Schillie SF1, Canary L2, Koneru A2, Nelson NP2, Tanico W3, Kaufman HW4, Hariri S2, Vellozzi CJ2.
Full-text article online:
Download PDF

This study identified trends in hepatitis C virus testing and positivity in women of childbearing age, pregnant women, and children aged less than 5 years. Among women who delivered live births in 2015, hepatitis C virus–infected women were more likely to be aged 20–29 years, white, non-Hispanic, covered by Medicaid, and living in rural areas. From 2011 to 2016, hepatitis C virus testing increased by 39% among women of childbearing age, 135% in pregnant women, and 25% among children. Hepatitis C virus positivity increased by 36% among women of childbearing age, 39% in pregnant women, and 13% among children. 

Perinatal transmission is an increasingly important mode of hepatitis C virus transmission. The authors characterized U.S. births among hepatitis C virus-infected women and evaluated trends in hepatitis C virus testing and positivity in women of childbearing age, pregnant women, and children aged less than 5years.

In 2017, National Center for Health Statistics birth certificate data (48 states and District of Columbia) were analyzed to assess the number of hepatitis C virus-infected women delivering live births in 2015, and commercial laboratory data were analyzed to assess hepatitis C virus testing and positivity among women of childbearing age, pregnant women, and children aged <5years from 2011 to 2016.

In 2015, a total of 0.38% (n=14,417) of live births were delivered by hepatitis C virus-infected women. Births delivered by hepatitis C virus-infected women, compared with births overall, occurred more often in women who were aged 20-29years (60.7% vs 50.9%); white, non-Hispanic (80.2% vs 52.8%); covered by Medicaid or other government insurance (79.2% vs 43.9%); and had rural residence (26.0% vs 14.0%). From 2011 to 2016 laboratory data, among women of childbearing age, hepatitis C virus testing increased by 39%, from 6.1% to 8.4%, and positivity increased by 36%, from 4.4% to 6.0%. Among pregnant women, hepatitis C virus testing increased by 135%, from 5.7% to 13.4%, and positivity increased by 39%, from 2.6% to 3.6%. Among children, hepatitis C virus testing increased by 25%, from 0.47% to 0.59%, and positivity increased by 13%, from 3.6% to 4.0%.

The potential for perinatal hepatitis C virus transmission exists. Expanded hepatitis C virus testing guidelines may address the burden of disease in this population.

Saturday, October 20, 2018

Weekend Update: Hepatitis C Prior Authorization: Tricks of the Trade

HCV Education 
Listen to experts discuss important HCV related topics in the following easy to access webinar programs presented by HepCure.

On Tuesday, October 9th, Susan Lee, PharmD BCPS CDE of Northwell Health, presented on:
Hepatitis C Prior Authorization: Tricks of the Trade
1. Discuss tests needed to apply for Hepatitis C (HCV) therapy prior authorization.
2. Identify essential resources for patients approved for treatment.
3. Describe options for patients denied HCV therapy
Begin here.....

October 23, 2018
UPCOMING: Hepatitis C Anti-Viral Therapy Guidance Review 2018

In The News

HepCBC is a non-profit organization run by and for people infected and affected by viral hepatitis. Our mission is to provide education, prevention and support to those living with viral hepatitis.
Weekly Review: read the latest issue of the Weekly Bull.

MedPage Today
AGA Reading Room
Hep C Rates High Among People with Mental Health Disorders
With the advent of direct-acting antiviral (DAA) therapy, the possibility of eradicating hepatitis C virus (HCV) is real; however, HCV treatment needs to be broadly available and utilized. The prevalence of HCV is likely high among individuals with mental health disorders who may also suffer from substance use disorders. Partnerships between mental health providers and clinicians treating HCV could potentially increase access to DAA therapy and improve overall care. If underlying mental health disorders are not addressed, the risks of nonadherence to DAA therapy or re-infection with HCV are greater. Additionally, mental health providers should recognize the increased risk for HCV in their patient population and have the tools needed to link them to care. More research is needed to understand the optimal care delivery approaches for patients with both mental health disorders and HCV.
Begin here.....

Top Story From Healio
Healio features the industry’s best news reporting, dynamic multimedia, question-and-answer columns, educational activities in a variety of formats, blogs, and peer-reviewed journals.
October 20, 2018
This year at the American College of Gastroenterology Annual Meeting, several hepatology specialists discussed the changing landscape of liver disease health care, such as increasing rates of nonalcoholic fatty liver disease which is quickly becoming the number one indication for liver transplantation. Healio presents the following liver disease highlights from ACG 2018 including an improved liver biopsy attenuation technique, the risks and course of NAFLD depending on patient demographics, and liver disease in pregnant patients.

On Twitter - @HenryEChang
Hepatitis C Virus
Improving #hepatitis C direct-acting antiviral access & uptake: a role for patient-reported outcomes & lived-experience→

Hepatitis B Virus On-treatment improvement of MELD score reduces death & hepatic events in patients with #hepatitis B-related #cirrhosis

Enjoy the weekend.