The Hepalogue

Making Straight The Way

by The Golden Phaeton on 07/12/2016

Apologies for the lengthy gap between posts. Life intervened as as it is prone to do. Perhaps it was inevitable that the high I enjoyed after clearing the virus would have a down side. I’ve always been somewhat bipolar so it makes sense that my springtime of elation and optimism would be balanced by a hard dose of ghastliness and despair.

Anyway, I’m back and there’s some news. As you know, if you’ve been reading this blog, treatment for Hep C can be arranged through a GP if they’re willing. But until now a liver specialist has had to sign off on the treatment plan before anything can happen. This has changed. Partly.

To quote another article from the HRV site ‘the PBAC (Pharmaceutical Benefits Advisory Committee) has amended the prescribing provision of hepatitis C treatments to independently enable experienced medical practitioners to initiate treatment in patients with chronic hepatitis C’.

This is good news. Most liver specialists will be pleased to be relieved of some of the extra unpaid work reviewing patient histories. The scale of Australia’s Hep C treatment rollout has made this form of remote consultation somewhat of a burden to already busy doctors and is likely to be unsustainable in the long run. What’s more, the wait for treatment should become simpler and shorter.

But this only applies to GPs experienced in prescribing the new treatments (most often those who deal in pharmacotherapy and related issues). Though courses exist for doctors to be trained in these treatments, completing them is currently not enough to absolve a GP from the specialist consultation requirement. Though no definition of ‘experienced’ is actually given in the guidelines, one would assume it involves having already treated a ‘reasonable’ number of patients. It is expected that this will be clarified with the next update of the guidelines.

So, good. Not a huge thing, but one less barrier to treatment is one step in the right direction.

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I’d like to finish up on some interesting tidbits from the viral hepatitis conference on The Gold Coast; in particular some of the ways and means being devised, not just to lure people into treatment, but to diagnose, track, and prioritise in parts of the world without the extraordinary access to treatment available to Australians. (And in parts of Australia without access to urban style health networks.)

Clever methods and machines being designed for use in sub-optimal clinical settings. I saw improved versions of the fibroscan machine on display, including a portable which, though heavyish, was believably compact and could indeed prove a useful field tool for anyone able to afford the considerable price per unit.

A device designed to measure one’s ALT in much the way a glucometer measures ones glucose levels is under development, and would surely be a helpful thing, even in the hands of a patient. And there was serious talk on the use of Dried Blood Spot (DPS) analysis – which involves a fingerprick, a blotter and, of course, the analysis.

The usefulness of these types of basic technologies would not necessarily be confined to the third world. For example, it is depressingly common for Australian rural areas to have no fibroscan machine access. Some GPs, having no other option, seek confirmation from specialists on treatment plans which omit these required results. In a percentage of cases this would lead to refusal on medico-legal grounds – or a time-consuming review of other forms of patient data.

This sort of situation is no help at all for a patient who may be prepared for treatment one day, but not so much three weeks later. Wouldn’t it be great if all the requirements could be met by a single fingerprick test? Well, it does seem like the thinking is headed this way.

For instance, the calculation of something called an APRI score can give some indication as to whether a patient is or is not cirrhotic. It is simply a ratio of platelet and AST scores from a normal liver assay. Quick and dirty, but definitely useful in the absence of a fibroscan machine, or as a screening tool for a fibroscan test. (The presence of cirrhosis has an impact on which drugs are prescribed.)

This form of diagnosis is called Rapid Point of Care Testing (RPOCT) and a research group is already trialling it in Sydney. In Melbourne, the Burnett Institute is planning a feasibility study which will operate out of Clinics like HealthWorks, Inner Space and Access Health (LINKS).

It is likely to involve an initial finger prick called a Rapid Antibody Test which takes 20 minutes to analyse and will tell you if you have Hep C or have ever been exposed to Hep C. If it reads as positive, then a subsequent finger prick test will (after 2 hours) reveal if the virus is present in the blood as well as information on the condition of your liver.

The technologies necessary for RPOCT currently exists, but none are yet licensed under the TGA (Therapeutic Goods Administration). Hopefully, the studies will show good results and convince manufacturers that there is a commercial future for such products in Australia.

This is of particular interest to users who have difficulty finding a vein. There is nothing resembling a specialist phlebology clinic in our town, and those with badly scarred veins can face a scary situation when it comes to giving blood. (In extreme cases I have heard that ultrasound may be used, or even the transverse jugular vein.) As for myself, I cannot count the number of times I’ve come out of a pathology clinic with up to a dozen holes in my arm.

In some cases patients may be allowed to draw their own blood if they feel capable (HealthWorks are said to be fine with this). In others, practitioners will refuse, citing their duty of care.

The conundrum facing people with poor veins provides a compelling argument for RPOCT. I know of at least two people who are delaying treatment out of fear of giving blood, and another who continues to delay his final tests after completing the treatment. He may be cured. He may not be, but he’s too leery of the needle to go find out.

In the meantime, there is the shortage of fibroscan machines. Sadly, research into the matter actually discovered that a considerable number of machines lay unused, sitting in cupboards, waiting for staff to be employed to operate them, or else were installed in rooms booked out for other purposes into the foreseeable future. One would hope this will be remedied in a timely manner.

On a more positive note, the Eliminate C partnership, headed by the Burnett institute, has purchased three of the portable fibroscan machines which they intend to loan out across areas of regional Victoria.

Such initiatives will – with no shadow of a doubt – be necessary if we are to achieve the challenging Hep C targets we have set ourselves. Inevitably, barriers to treatment will continue to present themselves, and will continue to be addressed by the genuinely amazing people toiling at the coal face.

The Golden Phaeton

 

 

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