I work with an incarcerated population in which 40% of my patients have hepatitis C. Given limited resources, which patients would benefit most from specialist referral? — Sally Davis, PA-C, Chico, Calif.

The standard of care for many patients with hepatitis C consists of combination therapy with an oral protease inhibitor (boceprevir [Victrelis] or telaprevir [Incivek]), along with pegylated interferon and ribavirin (Copegus, Rebetol, Ribasphere, Virazole).

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Patients undergoing treatment may experience profound fatigue, depression, and a slew of side effects (e.g., blood dyscrasias, infections, muscle and joint pain, hair loss, thyroid dysfunction, psychiatric changes). The treatment is expensive and long-term (24-48 weeks, longer in the immunosuppressed).

There are four genotypes of hepatitis C. Patients with genotype 1 can expect a 40% to 45% response rate after 48 weeks of treatment. Patients with genotypes 2 or 3 can expect a 70% to 80% response rate after only 24 weeks of treatment. Studies suggest that a drop in hepatitis C viral load within 12 weeks of treatment is correlated with treatment success.

High success rates are also seen in patients with an elevated CD4 count prior to treatment and those in otherwise good health. For patients with hepatitis C who are not candidates for treatment or who have a lower chance of treatment response, it remains important to protect and support the liver as well as to keep the immune system healthy. — Claire Babcock O’Connell, MPH, PA-C (181-4)

These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.