HCV treatment has come a long way making cure possible but we need to go for economically priced effective drugs - Prof. Anwar A. Khan

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 Int. Medical Conference of Shalamar Medical & Dental College 

HCV treatment has come a long way making
cure possible but we need to go for economically
priced effective drugs - Prof. Anwar A. Khan

H. Pylori was the most common chronic bacterial infection and
Type-I carcinogen - Prof. Ghiasun Nabi Tayyab

LAHORE: Prof. Anwar A. Khan an eminent gastroenterologist was the first speaker in the Gastroenterology session during the First International Medical Conference organized by Shalamar Medical & Dental College from February 3-5, 2017. This session was chaired by Prof. Anwar himself along with Prof.Rizwan Zafar and Prof. M. Haroon Yusaf.  The title of his presentation was “Hepatitis-C and its management in 2017 and beyond”. Tracing the history of development of drugs for the treatment of Hepatitis-C Prof.Anwar Khan said that the first antiviral drug Ribavirin was introduced in 1992 and this was the beginning of management of HCV but it had some complications and adverse effects. Interferon was introduced in 2005 and Genotype specific treatment response increased from 40 to 75%. Telaprevir and Brocepevir was then developed and marketed which were found to be effective in 90% of the patients. This was followed by the discovery of Sofosobuvir and Dasabuvir which were the FDA approved Direct Acting Inhibitors which have revolutionized the treatment of Hepatitis-C being the oral therapy.

He then briefly referred to AASLD/IDSA guidelines and also talked about when and whom to treat? HCV therapy, he said, is indicated in all patients with advanced fibrosis and patients with cirrhosis etc. He also talked about severe extra hepatic manifestations of HCV.  Healthcare workers, women in child bearing age, patients on hemodialysis should be treated on priority. One drug, Prof. Anwar Akan said is not good enough for all patients. Response is different based on Genotype.  Combination therapy has a response rate of up to 95-97% at present and it is different in treatment naïve and treatment experienced patients and duration of therapy is also different in both these group of patients. Most drugs are now used for twelve weeks, if need be ribavirin is added and treatment is extended to twenty four weeks in case of patients with cirrhosis  Majority of HCV patients in Pakistan are  of Genotype-3 which comprise of 80-90% while the remaining 10% of the patients  are of Genotype-2. Genothype-4 is most common in Egypt while Genotype 5 & 6 are rare. Response rate in Genotype-3 in treatment naïve patients with cirrhosis is 88% while those without cirrhosis it is now almost 97%. He then referred to a study conducted by Prof.Abid Farooqui which enrolled 1397 patients treated with the combination of Sofosobuvir, Ribavirin and Interferon and the response rate was 95-97% with and without cirrhosis respectively. Sofosobuvir was used in a dose of 400mg. Declatasvir can be used in combination with Ribavirin for twelve weeks and if need be in some patients treatment can be extended up to twenty four weeks. He also briefly mentioned about other treatment combinations and its response rate.  His conclusions were that HCV treatment has come a long way to cure and it can now be eradicated. We should go for economically priced effective drugs.

 Prof. Anwar A. Khan presenting mementoes to Prof. Ghiasun Nabi Tayyab, Prof. Althaf Alam and other speakers 
in the Gastroenterology Session during the International Conference organized by 
Shalamar Medical & Dental College, Lahore.

Prof. Altaf Alam from Sheikh Zayed Hospital Lahore was the next speaker who discussed   “Chronic Hepatitis-B and its management in new era”. His presentation was based on management to three cases. He discussed at length the importance of education of the patients, natural history of the disease, Vaccination for Hepatitis-A, role of diet, drugs, alcohol, and family vaccination. He also talked about Non Invasive markers and said that now we do not do liver biopsy of every patient but in United States people do liver biopsy to save themselves from litigations. His advice to his colleagues in Pakistan was that do not do liver biopsy first and do not treat HBV patients in immuno tolerant phase. Similarly we do not treat patients who have inactive course state.  In 2017 we do treat re-activation cases. For HBV Interferon and Peg Interferon are viable options. Young patients respond much better but proper selection of the patient is the key.

Continuing Prof. Altaf Alam said that before starting treatment, it is important to take proper history, physical examination, do the desired laboratory tests, tests for HBV replication, find out the cause of liver disease and do assessment of fibrosis. Treatment of interferon for one year is enough. Dose of the drug should be adjusted after checking the GFR of the patients. In order to ensure renal safety, in renal failure patients the dose has to be drastically reduced. He then highlighted the safety and efficacy of Tenofovir, Alafenamide Fumarate (TAF) combination. It is an expensive drug and some patients might need lifelong treatment. Future is of combination therapy, he remarked.

Prof. Ghiasun Nabi Tayyab discussed Role of H. Pylori in Acid Peptic Diseases and its management. Causes of acid peptic diseases, he said include H. Pylori, NSAIDs intake, and Zollinger syndrome. Peptic ulcer occurs because of imbalance between aggressive factors and protective factors. H. Pylori, he stated, was the most common chronic bacterial infection and it is Type-I carcinogen. It is usually acquired in childhood but the reasons are not known. Its incidence and prevalence varies based on sanitary conditions. The sequence of H Pylori infection was also discussed.  Speaking about the management guidelines he referred to Maastricht guidelines published in Gut in 2016 and Toronto Guidelines as well as H. Pylori Eradication Guidelines 2017 which are all from Europe and America. We do not have any local guidelines. He was of the view that all patients with acid peptic diseases should be tested.  Those who have past history of peptic ulcer diseases can have early gastric cancer presentation. All patients coming for endoscopic procedures are also candidates for testing. Patients with uninvestigated dyspepsia, patients taking low dose aspirin for long time as well as patients suffering from iron deficiency anaemia needs to be tested.  Others which need to be tested include adults with ITP, those with family history of gastric ulcer but for asymptomatic patients there is no need for any tests nor are they indicated. Patients with dyspepsia and many other patients are recommended for tests. There are various invasive and non-invasive tests. Without serology tests, no patients should be started on treatment. The tests include endoscopy, rapid unease test, histology, culture, stool antigen; 13c Unease breath test detects active infection. It has up to 97% sensitivity and specificity provided the patient has not taken any antibiotics for the last one month

Continuing Prof. Ghiasun Nabi Tayyab stated that it is said no acid no ulcer but in fact if there is no H.Pylori infection, there is no ulcer in 97% of the cases. For eradication of H. Pylori two weeks therapy is recommended. Use of triple therapy has a response rate of 70% but four drugs are most effective. He then gave details of first and second line therapy and also talked about rescue therapy.  Drug resistance is a problem in eradication. Other problems include compliance with therapy. According to reports resistance to Metronidazole is about 45%, Clarithromycin 39%, Levofloxacin 32% hence with such a resistance figures, one should be careful while using these. Clarithromycin based therapy is not recommended for our patients he added.

Prof. Arif Nadeem gave an Update on Non Alcoholic Fatty Liver Disease. Patients with overweight, obese patients, those suffering from diabetes mellitus are at greater risk of developing NAFLD.  NASH, he said, was the No. 1 indication for liver transplant. In Pakistan liver diseases are the most common cause of liver transplant. One should avoid use of soft drinks and patients with cholecystitis are likely to develop NASH. He also talked about excessive use of fructose diet and obstructive sleep apnea. NAFLD has increased morbidity and mortality. Central obesity, insulin resistance, hypertension all lead to NAFLD and NASH. It could be hereditary as well. He then talked about clinical predictors of NASH and patients with NAFLD. Most of these patients, he said, have no symptoms. About 75% of patients may have Hepatomegaly. These patients rarely present with active liver failure.

Speaking about treatment Prof. Arif Nadeem suggested life style modification, cut in food intake, reduction of weight while bariatric surgery was yet another treatment modality. Even just 10% reduction in weight will lead to regression of fibrosis. Sugary drinks should be avoided. Moderate intensity exercise is advised but there is no FDA approved drug for treatment. Vitamin E and Pioglitazone are being used. About 50% of patients do not improve with vitamin E and there is also risk of prostate cancer. Bariatric surgery improves clinical parameters. He also talked about emerging therapies for NAFLD which are currently under trials. Gastric bypass surgery is quite useful but liver transplant is the ultimate choice. Fatty liver is reversible if properly managed, he remarked.

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