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One Size Does Not Fit All: Personalizing Care in HCV

  • Authors: Jordan Feld, MD, MPH
  • CME / ABIM MOC / CE Released: 2/24/2017
  • Valid for credit through: 2/24/2018, 11:59 PM EST
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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


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  • Jordan Feld, MD, MPH

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


    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.


  • Charles Howe, PharmD

    Scientific Director, Medscape, LLC


    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


    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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One Size Does Not Fit All: Personalizing Care in HCV

Authors: Jordan Feld, MD, MPHFaculty and Disclosures

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

Valid for credit through: 2/24/2018, 11:59 PM EST


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
Metabolic panel
Alkaline phosphatase U/L
Total bilirubin mg/dL
Albumin g/dL
Creatinine, mg/dL
cGFR, mL/min
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.

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