Post-its from Practice:
Has NICE guidance improved Hepatitis C treatment in your area? (Jun 2007)
Fran was excited about her follow-up hepatitis appointment as she was hoping this time to be accepted for treatment. She was now beginning to experience symptoms such as lethargy and poor concentration from her disease. I had re-referred her earlier than planned for a review with the hepatologists as her last visit had been before the latest NICE guidance which now recommends treatment for mild to moderate disease and for active injectors (Ref 1).
Fran was very stable on oral methadone, no longer injected, did not drink and had normal liver function tests. She had been told at her previous visit that she did not "need" treatment and she couldn't have it!
When the updated NICE guidance came out we informed all patients to highlight the changes. We wanted to see if anyone who hadn't previously accepted referral or who was currently being followed up would now "qualify" for treatment, explained that liver biopsy was no longer mandatory, and that early treatment gave the best results. For me Fran now fell into this latter group, and as she was genotype 3a she wanted to get started as soon as possible.
Hence I was shocked when I saw her a few days after her liver appointment looking really fed-up. She explained that she had again been told that she didn't need treatment. I have tried to speak to the consultant without success and have waited several weeks for a reply to my enquiring letter.
Although the NICE guidance was a step forward for hepatitis C it seems many things still need to change before the situation improves: 1) hospital units need to implement the guidance 2) some consultants need to stop practicing opinion-based rather than evidence-based medicine, 3) PCTs need to promote local awareness, clinical networks and provide funding for treatment and 4) awareness, testing and referral for treatment in primary care needs to increase.
To help with the fourth point we have produced new guidance to improve the management of Hepatitis C in primary care. It is estimated that between 0.4-1 per cent of the UK population are infected with HCV, equating to 250,000 - 600,000 sufferers. Early treatment of chronic hepatitis C (CHC) is more effective at clearing the virus in 50 to 80 per cent of people, depending on their genotype, but Britain currently has a poor record in treating patients with CHC. Out of the total UK infected population, fewer than 17 per cent have been diagnosed and it is estimated that only about one in 20 of those diagnosed are being treated each year. Every GP is likely to have between 8 to 18 infected individuals on their patient list, so it is essential that we work in general practice to strengthen our knowledge about this disease, increase our testing and encourage those who test positive to attend for early treatment (Ref 2). We hope that the guidance will be useful in bringing about this change. We have also developed a Hepatitis C e-module (Ref 3).
To treat more people makes complete sense in human terms but it also makes economic sense as many of the Fran's will develop end-stage liver disease and costs the state much more ultimately. Let's get out there - test and refer for treatment all those people with CHC that consent (NTA asking for 100% screening is worthless and potentially damaging to people without the added target of people getting treatment) and let's not forget to challenge consultants and specialist nurses who refuse to treat people who currently inject drugs or have previously done so - you have the evidence base and NICE on your side!!
1. National Institute for Health and Clinical Excellence (NICE). Peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C. NICE technology appraisal guidance 106. August 2006 (www.nice.org.uk)