CCE-CBD-219

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key steps in confirming the diagnosis and assessing disease severity?

• Prompt: What investigations are required to assess liver fibrosis?
• Prompt: How do you differentiate acute vs chronic Hepatitis C?

Q2. How would you explain Hepatitis C to the patient, including prognosis and treatment options?

• Prompt: How would you reassure the patient about curability?
• Prompt: What lifestyle modifications should be discussed?

Q3. What are the treatment options for Hepatitis C in primary care?

• Prompt: What are the first-line antiviral therapies?
• Prompt: When is specialist referral required?

Q4. What preventive measures should be discussed, including harm minimisation and vaccination?

• Prompt: Which vaccinations are recommended for this patient?
• Prompt: How can transmission be prevented?

Q5. What long-term follow-up is required after successful treatment?

• Prompt: How often should liver function be monitored post-treatment?
• Prompt: When should hepatocellular carcinoma screening be considered?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the key steps in confirming the diagnosis and assessing disease severity?

Confirming Hepatitis C Diagnosis

1. HCV Antibody Test (already positive) – Indicates past or present infection.
2. HCV RNA (PCR) Test – Confirms active infection and quantifies viral load.

Assessing Disease Severity

• Liver Function Tests (LFTs) – Assess hepatocellular injury (e.g., ALT, AST).
• Fibrosis Assessment:
  • FIB-4 Score (Age, AST, ALT, Platelets) – Non-invasive marker of liver fibrosis.
  • Transient Elastography (FibroScan®) – Measures liver stiffness to detect fibrosis/cirrhosis.
• Additional Tests:
  • Hepatitis B and HIV screening – Co-infections affect treatment decisions.
  • Hepatitis A & B serology – Determines need for vaccination.

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Q2: How would you explain Hepatitis C to the patient, including prognosis and treatment options?

Key Points About Hepatitis C

• Chronic Hepatitis C is curable with direct-acting antiviral (DAA) therapy.
• If left untreated, it can lead to liver fibrosis, cirrhosis, or hepatocellular carcinoma (HCC).
• Many people with Hepatitis C have no symptoms until advanced liver disease develops.

Treatment Options

• DAA therapy is oral, well-tolerated, and achieves >95% cure rates within 8-12 weeks.
• Minimal side effects compared to older interferon-based treatments.
• Treatment can be initiated in general practice, with specialist referral only for advanced cases.

Lifestyle Advice

• Avoid alcohol to reduce liver damage.
• Healthy diet and exercise support liver function.

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Q3: What are the treatment options for Hepatitis C in primary care?

First-Line Therapy

• Pangenotypic DAAs (e.g., Sofosbuvir/Velpatasvir, Glecaprevir/Pibrentasvir)
• Course Duration: 8-12 weeks, depending on liver fibrosis.

Criteria for Specialist Referral

• Evidence of cirrhosis (e.g., high FIB-4 score, FibroScan >12.5 kPa).
• Co-infection with HIV or Hepatitis B.
• Prior treatment failure.

Monitoring During Therapy

• LFTs and HCV RNA at 4 weeks to confirm response.
• HCV RNA at 12 weeks post-treatment to confirm cure.

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Q4: What preventive measures should be discussed, including harm minimisation and vaccination?

Vaccination

• Hepatitis A & B vaccination (since patient is not immune).

Transmission Prevention

• HCV is bloodborne, not spread via casual contact.
• Avoid sharing razors, toothbrushes, injecting equipment.
• Safe sex practices, particularly in high-risk settings.

Harm Reduction

• Referral to needle syringe programs (if ongoing risk of bloodborne infections).
• Counselling on alcohol and substance use.

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Q5: What long-term follow-up is required after successful treatment?

Post-Treatment Monitoring

• HCV RNA at 12 weeks post-treatment – Confirms cure.
• LFTs and Fibrosis Assessment:
  • If no fibrosis → Routine follow-up.
  • If cirrhosis present → Ongoing 6-monthly liver ultrasounds for HCC screening.

Lifestyle & Health Optimisation

• Continue alcohol avoidance and metabolic health monitoring.
• Encourage regular GP follow-up for general health and liver function.

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SUMMARY OF A COMPETENT ANSWER

• Confirms Hepatitis C diagnosis with RNA testing and assesses fibrosis severity.
• Explains Hepatitis C in a patient-friendly manner, highlighting curability and prognosis.
• Provides an evidence-based treatment plan, including DAAs and monitoring.
• Emphasises preventive strategies, including vaccination, harm reduction, and lifestyle changes.
• Outlines appropriate follow-up, with cirrhosis monitoring if needed.

PITFALLS

• Failing to assess fibrosis severity, missing cirrhosis risk.
• Not considering co-infections (HIV, Hepatitis B).
• Omitting harm reduction advice, particularly safe injecting practices.
• Neglecting vaccination for Hepatitis A and B.
• Inadequate long-term follow-up, particularly HCC screening in cirrhosis.

REFERENCES

• RACGP Guidelines on Management of Hepatitis C in General Practice
• Australian Liver Association on Hepatitis C Clinical Practice Guidelines
• Better Health Channel on Hepatitis C Overview
• Hepatitis Australia on Patient Education Resources

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages patient in discussion of sensitive health issues.
1.2 Uses non-judgmental, patient-centred communication techniques.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a thorough history of risk factors and symptoms.
2.2 Identifies appropriate screening and diagnostic investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises key features of Hepatitis C and its complications.
3.2 Determines appropriate staging and treatment considerations.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based management of Hepatitis C.
4.2 Discusses antiviral therapy and liver health optimisation.

5. Preventive and Population Health

5.1 Provides harm minimisation and vaccination advice.

6. Professionalism

6.1 Ensures culturally sensitive and ethical discussion of Hepatitis C.

7. General Practice Systems and Regulatory Requirements

7.1 Understands prescribing guidelines for direct-acting antivirals (DAAs).

9. Managing Uncertainty

9.1 Recognises when specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies complications such as cirrhosis and hepatocellular carcinoma.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD