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CME / ABIM MOC / CE

One Size Does Not Fit All: Personalizing Care in HCV

  • Authors: Jordan Feld, MD, MPH
  • CME / ABIM MOC / CE Released: 2/24/2017
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 2/24/2018
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Target Audience and Goal Statement

This activity is intended for gastroenterologists, primary care physicians, ID/HIV specialists, and nurses.

The goal of this activity is to improve clinicians ability to treat hepatitis C virus (HCV) infection in patients with stage 4/5 chronic kidney disease and human immunodeficiency virus (HIV) infection, and identify appropriate use of elbasvir/grazoprevir.

Upon completion of this activity, participants will:

  • have increased knowledge regarding the:
    1. Key safety and efficacy data for emerging/newer HCV antivirals
  • have greater competence related to:
    1. Appropriately incorporating newer HCV antiviral agents into clinical practice in the context of severe renal impairment
    2. Appropriately incorporating newer HCV antiviral agents into clinical practice in the context of HIV coinfection


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Faculty

  • Jordan Feld, MD, MPH

    Associate Professor of Medicine, University of Toronto, Ontario, Canada

    Disclosures

    Disclosure: Jordan Feld, MD, MPH, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: AbbVie Inc.; Bristol-Myers Squibb Company; Gilead Sciences, Inc.; Janssen Pharmaceuticals; Merck & Co., Inc.
    Received grants for clinical research from: Abbott Laboratories; AbbVie Inc.; Gilead Sciences, Inc.; Janssen Pharmaceuticals; Merck & Co., Inc.; Regulus Pharmaceutical Consulting, Inc.

    Dr Feld does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Feld does intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editor

  • Charles Howe, PharmD

    Scientific Director, Medscape, LLC

    Disclosures

    Disclosure: Charles Howe, PharmD, has disclosed he
    Owns stock in GlaxoSmithKline

CME Reviewer / Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.


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Medscape, LLC is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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    For Nurses

  • Awarded 1.0 contact hour(s) of continuing nursing education for RNs and APNs; 0.50 contact hours are in the area of pharmacology.

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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

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CME / ABIM MOC / CE

One Size Does Not Fit All: Personalizing Care in HCV

Authors: Jordan Feld, MD, MPHFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 2/24/2017

Valid for credit through: 2/24/2018

processing....

The following cases are modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and read evidence-based information that supports the most appropriate answer choice. The questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the activity, there will be a short post-test assessment based on the material presented.

Case 1: Patient History

Daniel is a 57-year-old white man with chronic hepatitis C virus (HCV) infection, who was recently seen by a primary care physician (PCP) for the chief complaints of fatigue that has worsened over the past 3 to 4 months, pain upon swallowing, decreased appetite, and recent weight loss. Upon questioning Daniel, the PCP learned that Daniel was diagnosed with human immunodeficiency virus (HIV) infection 6 years ago, but he has never been in HIV care or treated with antiretroviral therapy (ART). Before Daniel was referred to you, selected laboratory tests (Table 1) and a FibroScan® were done.

Table 1. Daniel's Test Results Sent With Referral

Test Result
HIV RNA, copies/mL 65,000
CD4 cell count, cells/mm3 190
HCV RNA, IU/mL 2.3 million
HCV genotype 1a
HBV HBsAg negative, anti-HBs negative
HAV anti-HAV negative
FibroScan®, kPa 15.5
anti-HAV = hepatitis A virus antibody; anti-HBs = hepatitis B virus surface antibody; HAV = hepatitis A virus; HBsAg = hepatitis B surface antigen; HBV = hepatitis B virus; HCV = hepatitis C virus; HIV = human immunodeficiency virus; kPa = kilopascal.

You perform an esophagogastroduodenoscopy and order additional laboratory tests (Table 3).

Table 2. Daniel's History and Physical Examination

History Findings
Medical Odynophagia, dysphagia, GERD, risk of HIV/HCV was intravenous drug use
Social Divorced with 2 adult children, currently drinks 2-3 beers/week
Current medications 1 multivitamin tablet daily
Physical Examination Findings
Vital Signs BP = 130/87 mm Hg, HR =75 bpm, RR = 15/min, afebrile
General impression Appears tired and uncomfortable
BMI 27 kg/m2
Skin Clear, no rash
Chest and lungs Clear to auscultation
Head and neck Oral candidiasis
Abdomen Soft, normal bowel sounds
Lower extremities Unremarkable
BMI = body mass index; BP = blood pressure; bpm = beats per minute; DS = double strength; GERD = gastro-esophageal reflux disease; HR = heart rate; RR = respiratory rate.

Table 3. Daniel's Additional Test Results

Test Result
Hemoglobin, g/dL
WBC count, cells/μL
Platelet count, cells/μL
Prothrombin time, sec
INR
12.1
5000
125,000
12
1.0
Metabolic panel
AST, U/L
ALT, U/L
Alkaline phosphatase U/L
Total bilirubin mg/dL
Albumin g/dL
All WNL
87
63
65
2.0
3.8
Creatinine, mg/dL
cGFR, mL/min
1.0
110
EGD No evidence of varices, esophageal candidiasis
CTP classification A
ALT = alanine transaminase; AST = aspartate transaminase; cGFR = calculated glomerular filtration rate; CTP = Child-Turcotte-Pugh; EGD = esophagogastroduodenoscopy; GERD = gastroesophageal reflux disease; INR = international normalized ratio; WBC = white blood cell count; WNL = within normal limits.

You prescribe Daniel fluconazole 100 mg by mouth daily for esophageal candidiasis (Figure 1) and explain that it is a sign of advanced HIV infection or acquired immune deficiency syndrome (AIDS).

Figure 1. Endoscopic Image of Esophageal Candidiasis

You also schedule a return appointment in 1 week to review his test results and to educate him about the benefits of treating his HIV infection and HCV infection, and the serious consequences of not being treated. You point out that both treatment regimens are much simpler and more tolerable than a decade ago, and the HCV treatment regimen is relatively short. Daniel agrees to your treatment recommendations.