A novel program for treating patients with trimorbidity: Hepatitis C, serious mental illness, and active substance use

aMedical Psychiatry Program, University Health Network, Toronto General Hospital Departments of bPsychiatry cPsychology dMedicine, University of Toronto eSouth Riverdale Community Health Centre fToronto East General Hospital, Toronto, Ontario, Canada.
European journal of gastroenterology & hepatology (Impact Factor: 2.25). 05/2013; 25(12). DOI: 10.1097/MEG.0b013e3283624a28
Source: PubMed


Advances in hepatitis C virus (HCV) treatment have yielded improved virological response rates, and yet, many individuals with psychiatric illness still fail to receive HCV therapy. Concerns about safety, adherence, and efficacy of HCV treatment are compounded and treatment is further deferred when substance use is also present. This is especially problematic given the disproportionately high rates of both mental health issues and substance use among individuals living with HCV.Objective
This study sought to examine HCV treatment outcomes in clients with serious mental illness (SMI) and with high rates of active substance use who were participating in a community-based HCV treatment program.Patients and methodsA retrospective chart review of 129 clients was carried out. Patients were classified as having an SMI if they had a history of bipolar disorder, psychotic disorder, past suicide attempt or mental health related hospitalization.ResultsFifty-one patients were defined as having an SMI. Among the 46 patients with SMI and a detectable HCV viral load, HCV antiviral therapy was initiated in nine (19.6%). A relapse or an increase in substance use was common (77.8% or n=7), as was the requirement for adjustment or initiation of psychotropic medications (66.7% or n=6) during HCV antiviral therapy. Despite these barriers, rates of adherence to antiviral therapy were high and overall sustained virological response rates were comparable with published trials.Conclusion
This study is the first to report HCV treatment outcomes in a population in which SMI and active polysubstance use was prevalent and suggests that with appropriate models of care, clients with trimorbidity can be treated safely and effectively. (C) 2013 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

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    • "Further, awareness and education of the entire interdisciplinary treatment team is important in order to assist with prompt recognition of psychiatric symptoms, appropriate selection of psychotropic agents with minimal drug interactions and to minimize adverse effects to increased overall treatment adherence. The importance of interdisciplinary models of HCV care is evident from studies showing comparable HCV treatment adherence rates and outcomes for patients with either active substance use [84,90] or severe mental illness [91,92] as compared to controls. "
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    ABSTRACT: Background Despite recent advances in hepatitis C (HCV) treatment, specifically the addition of direct acting antivirals (DAAs), pegylated interferon-alpha remains the backbone of HCV therapy. Therefore, the impact of DAAs on the management of co-morbid psychiatric illness and neuropsychiatric sequalae remains an ongoing concern during HCV therapy. This paper provides a review of the neuropsychiatric adverse effects of DAAs and drug-drug interactions (DDIs) between DAAs and psychiatric medications. Methods We conducted a Pubmed search using relevant search terms and hand searched reference lists of related review articles. In addition, we searched abstracts for major hepatology conferences and contacted respective pharmaceutical companies for additional studies. Results Limited data is available on the neuropsychiatric adverse effects of DAAs; however, data from major clinical trials suggest that DAAs have minimal neuropsychiatric risk. DAAs can potentially interact with a variety of psychotropic agents via cytochrome P450 and p-glycoprotein interactions. Triazolam, oral midazolam, St. John’s Wort, carbamazepine and pimozide, are contraindicated with DAAs. DDIs between DAAs and antidepressants, anxiolytics, hypnotics, mood stabilizers, antipsychotics and treatments for opioid dependence are summarized. Conclusions Although DAAs do not add significant neuropsychiatric risk, the potential for DDIs is high. Consideration of DDIs is paramount to improving medication adherence and mitigating adverse effects during HCV therapy.
    BMC Gastroenterology 05/2013; 13(1):86. DOI:10.1186/1471-230X-13-86 · 2.37 Impact Factor
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    ABSTRACT: Hepatitis C virus (HCV) currently infects approximately 250,000 individuals in Canada and causes more years of life lost than any other infectious disease in the country. In August 2011, new therapies were approved by Health Canada that have achieved higher response rates among those treated, but are poorly tolerated. By 2014⁄2015, short-course, well-tolerated treatments with cure rates >95% will be available. However, treatment uptake is poor due to structural, financial, geographical, cultural and social barriers. As such, 'Barriers to access to HCV care in Canada' is a crucial topic that must be addressed to decrease HCV disease burden and potentially eliminate HCV in Canada. Understanding how to better care for HCV-infected individuals requires integration across multiple disciplines including researchers, clinical services and policy makers to address the major populations affected by HCV including people who inject drugs, baby boomers, immigrants and Aboriginal and⁄or First Nations people. In 2012, the National CIHR Research Training Program in Hepatitis C organized the 1st Canadian Symposium on Hepatitis C Virus (CSHCV) in Montreal, Quebec. The 2nd CSHCV was held in 2013 in Victoria, British Columbia. Both symposia were highly successful, attracting leading international faculty with excellent attendance leading to dialogue and knowledge translation among attendees of diverse backgrounds. The current article summarizes the 3rd CSHCV, held February 2014, in Toronto, Ontario.
    10/2014; 28(9):481-487.
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    ABSTRACT: have emerged. These significantly boost the likelihood of sustained viral response, including for genotype 1, and do not seem to have the side effects of interferon-alpha or ribavirin. Relevant data are reviewed to assess the degree that these new treatments might reduce the portion not eligible for treatment due to psychiatric comorbidities, and might reduce the emergence of psychiatric symptoms during treatment. Several organizations have recently released evidence-based treatment recommendation guidelines. It is apparent that interferon-alpha continues to be a standard of care, with the new drugs added to this recognized regimen in order to shorten treatment and to boost efficacy. Clinical settings must continue to assess appropriateness for treatment, including current or recent psychiatric comorbidities, and must continue to closely monitor patients for the emergence of psychiatric side effects. The newly developed hepatitis C treatments may affect the metabolism of several categories of psychiatric drugs, and so drug-drug interactions must also be considered and monitored. With many promising drugs under development, an all-pill regimen, with no interferon-alpha and no ribavirin, may emerge in the near future. This will greatly change the challenge of treatment decision-making, and should expand the portion of patients able to successfully complete a treatment regimen. Core tip: Emerging hepatitis C treatment regimens, which include newer medications such as boceprevir, telaprevir, sofosbuvir, and simeprevir, hold promise to reduce the need for psychosocial screening and monitoring. Thus far, these medications do not seem to have the same psychiatric side effect profile as interferon-alpha.
    02/2015; 4(1):13-16. DOI:10.5501/wjv.v4.i1.13
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