Reinfection rates low after successful HCV treatment in people who inject drugs

Abstract: https://www.acpjournals.org/doi/10.7326/M21-4119

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A cohort study found that reinfection rates are low after successful hepatitis C virus (HCV) treatment in people who inject drugs (PWID), suggesting a benefit of treatment in this population.  Risk for reinfection was highest in the first 24 weeks after treatment completion and among people with ongoing injecting drug use, and especially among those who shared needles. The findings are published in Annals of Internal Medicine.

Direct-acting antiviral (DAA) medications are safe and effective for people receiving opioid agonist therapy (OAT) and people with recent injecting drug use. However, there are concerns that HCV reinfection may reduce the benefits of cure among people who inject drugs (PWID) and compromise HCV elimination efforts.

Researchers from the Kirby Institute, UNSW, Sydney, Australia studied 286 participants from the CO-STAR trial who were receiving opioid agonist therapy to evaluate the rate of HCV reinfection for 3 years after successful treatment with antivirals. Patients were followed every 6 months for up to 3 years. During that time, 10 participants had a total of 11 reinfections, or a reinfection rate of 1.7 per 100 person-years. Six of those reinfections occurred within 24 weeks of completing treatment. Reinfection rates were higher among participants who had injected drugs or those who engaged in needle or syringe sharing within the previous 24 weeks. The authors suggest that based on their findings, this 24-week period is important for optimizing treatment of opioid use disorder and for providing access to syringe programs that have documented benefits for preventing HCV transmission and reinfection.

According to the authors, individual- and population-level strategies for HCV elimination among PWIDs should include efforts to address, prevent, and manage HCV reinfection. They add that at an individual level, an assessment of HCV reinfection risk should be done before initiating DAA therapy, and at a population level, efforts to reduce primary and reinfection incidences require the appropriate provision of health care with universal access to programs for persons with both HCV infection and injection drug use.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Jason Grebely, PhD, please contact Lucienne Bamford at Lbamford@kirby.unsw.edu.au.

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2. Physicians debate treatment strategy for patient with pulmonary embolism

‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center

Abstract: https://www.acpjournals.org/doi/10.7326/M22-0989  

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In a new Annals “Beyond the Guidelines” feature, a hematologist and a cardiology and vascular medicine specialist discuss guidelines from the American Society of Hematology (ASH) in the context of the care of a patient with pulmonary embolism (PE). All “Beyond the Guidelines” features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine. 

Pulmonary embolism increases mortality risk and is often stratified in the acute setting into low, intermediate, and high risk based primarily on the absence or presence of markers of RV strain or hemodynamic compromise. Almost all cases of PE are managed with anticoagulation for 3 to 6 months to treat the initial clot, and some cases are further treated with additional anticoagulants to prevent future VTE events. Intermediate and high-risk PE is managed in inpatient settings, sometimes with access to more advanced therapies, including intravenous systemic thrombolysis, surgical embolectomy, and catheter-based therapies. VTE can be provoked or unprovoked by risk factors.

BIDMC Grand Rounds discussants, Jason A. Freed, MD, a hematologist, and Brett J. Carroll, MD, a cardiologist and vascular medicine specialist, recently debated the management of Ms. P, a 47-year-old woman taking oral contraceptives who presented with intermediate-risk PE.

Dr. Freed recommends only a limited role for advanced therapies in cases of intermediate-risk PE, citing the negative results of the PEITHO (Pulmonary Embolism Thrombolysis) trial as well as the lack of high-quality data for catheter-directed therapies. Dr. Carroll argues that advanced therapies, in particular catheter-directed therapies, may be a good option for patients with intermediate-risk PE and concerning clinical features who are at low risk for bleeding. Dr. Freed recommends indefinite anticoagulation for patients with unprovoked PE or proximal DVT who are not at high risk for bleeding. For a provoked PE, he recommends against secondary prevention anticoagulation, even if the provoking factor was minor. In contrast, Dr. Carroll classifies patients with PE along a spectrum from strongly provoked to strongly unprovoked rather than into two nonoverlapping categories; he incorporates persistent risk factors as well as thrombophilia and D-dimer testing in select patients to determine recurrence risk and the strength of an indication for secondary-prevention anticoagulation. For patients whose conditions may warrant longer term anticoagulation, particularly for those with an initially weak provoking factor, he often recommends apixaban and rivaroxaban at half dose to mitigate bleeding risk.

A complete list of “Beyond the Guidelines” topics is available at www.annals.org/grandrounds.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. For an interview with the discussants, please contact Kendra McKinnon at Kmckinn1@bidmc.harvard.edu.

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In the Clinic: Eating Disorders Update

Blair Uniacke, MD; B. Timothy Walsh, MD

In the Clinic

Abstract: https://www.acpjournals.org/doi/10.7326/M22-1340