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Treatment of HCV
Jorge Mera, MD, FACPDirector, Infectious DiseasesCherokee Nation
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¡Rationale and goals for the universal need of HCV treatment
¡Describe FDA approved antivirals used in HCV treatment, their strengths and weaknesses
¡ Interpret decision trees to determine treatment options
OBJECTIVESTreatment
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GOAL OF TREATMENT
“The goal of treatment of HCV-infected persons is to reduce all-cause mor tality and liver-
related health adverse consequences, including end-stage liver disease and hepatocellular
carcinoma, by the achievement of virologic cure as evidenced by an SVR”
SVR: sustained virological response hcvguidelines.org
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30
20
10
00 1
Non-SVR
SVR
P<.001
2 3 4 5 6 7 8 9 10Time (years)
Perc
ent
All-Cause Mortality
International, multicenter, long-term follow-up study from 5 large tertiary care hospitals in Europe and Canada. Patients with chronic HCV infection started an interferon-based treatment regimen between 1990 and 2003 (n=530).van der Meer AJ, et al. JAMA. 2012;308:2584-2593.
SVR WAS ASSOCIATED WITH REDUCED LONG-TERM RISK OF ALL-CAUSE MORTALITY IN AN
INTERNATIONAL, MULTICENTER STUDY
Treatment
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WHY DO WE NEED TO TREAT HCV
¡SVR (cure) of HCV is associated with: •70% Reduction of Liver Cancer•50% Reduction in All-cause Mortality•90% Reduction in Liver Failure
L o k A . N E J M 2 0 1 2 ; G h a n y M . H e p a t ol 2 0 0 9 ; V a n d e r M e e r A J . J A M A 2 0 1 2
Treatment
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767,000
407,000
651,000
63,000
317,000
154,000198,000
31,0000
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
Liver-related Death
HCC Decomp. Cirrhosis
Liver Transplants
Dis
ease
Bur
den
(201
5–20
50)
No TreatmentPre-DAA EraDAA Era
6
HCV-ASSOCIATED DISEASE BURDEN (2015–2050)
50–70% reduction in HCV-associated disease burdenChhatwal et al. AASLD 2015 Abstract 104
Treatment
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IMPACT OF TREATMENT COMPARED TO OTHER COMMON DISEASES
¡ HCV cirrhosis risk = 40% over 30 years¡ Hepatocellular carcinoma (HCC) risk in HCV
Cirrhosis = 17% over 5 years¡ When we cure 30 patients with HCV we wil l prevent:
§ 12 cases of HCV related cirrhosis§ 2 case of HCV related HCC
If we treat 104 patients with hypercholesterolemia with statins (For 5 years), we wil l prevent 1 f irst t ime
heart attack and ¾ of a stroke
www.thennt.com
Treatment
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Ribavirin
NS4ACore E1 E2 NS2 NS4BNS3 NS5A NS5B
Daclatasvir (DCV)Ledipasvir (LDV)Ombitasvir (OMV)Elbasvir (ELB)Velpatasvir (VEL)
NS5AReplication
Complex Inhibitors
Boceprevir (BOC)Telaprevir (TVR)Simeprevir (SMV)Paritaprevir (PTV)Grazoprevir (GRZ)
NS3Protease Inhibitors
Protease
DIRECT ACTING ANTIVIRAL AGENTS (DAAS):KEEPING THEM STRAIGHT
Sofosbuvir (SOF)
Dasabuvir(DSV)
NS5BNUC
Inhibitors
NS5BNon-NUC Inhibitors
p7
PolymeraseNon-Enzyme
Target
Treatment
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HCV THERAPIES - DAAS
Medication NS5B NS5A Inh NS3 PI Other
Sovaldi® sofosbuvir
Harvoni® sofosbuvir ledipasvir
Epclusa® sofosbuvir velpatasvir
Zepatier® elbasvir grazoprevir
Viekira Pak®
dasabuvir ombitasvir paritaprevir ritonavir
Daklinza® daclatasvir
Olysio® simeprevir
Ribavirin ribavirin
Treatment
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HCV TREATMENT BY GENOTYPE
Medication GT1 GT2 GT3 GT4
Sovaldi® X X X XHarvoni® X XEpclusa® X X X XZepatier® X XViekira Pak®
XDaklinza® X X X XOlysio® XRibavirin X X X X
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¡ NS5B nucleotide inhibitor ¡ Few drug interactions¡ Genotypes 1 ,2,3,4¡ Contraindicated in
patients with GFR < 30¡ Most common reported SE
§ Headache§ Fatigue (with ribavirin)
¡ Pangenic in combination§ Not used as monotherapy
SOFOSBUVIR (SOVALDI®)
Sovaldi® [package insert]. Gilead Sciences, Foster City, CA
Treatment
SE: Side Effects
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¡ Once daily single oral tablet¡ Genotype 1 and 4¡ Minimal DDIs, no food ef fect¡ 8 week treatment available
§ Naïve/Non cirrhotic/VL < 6 million
¡ Do not use in patients with GFR < 30
¡ Avoid use with anti acids § May use with 20 mg of omeprazole
if necessary
LEDIPASVIR/SOFOSBUVIR(HARVONI®)
LDVNS5A inhibitor
SOF - NS5B nucleotide polymerase inhibitor
Approved: Oct 10, 2014
Harvoni® [package insert]. Gilead Sciences, Foster City, CA
Treatment
DDI: Drug-Drug Interactions
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¡ Once daily single oral tablet
¡ Minimal DDIs, no food ef fect
¡ Genotype 1 ,2,3,4
¡ Do not co-administer with PPI§ If medically necessary, take Epclusa
with food 4 hours before omeprazole 20 mg
¡ Do not use in patients with GF<30
VELPATASVIR/SOFOSBUVIR(EPCLUSA®)
VELNS5A inhibitor
SOF - NS5B nucleotide polymerase inhibitor
Approved: June 28, 2016
Epclusa® [package insert]. Gilead Sciences, Foster City, CA
Treatment
DDI: Drug-Drug Interactions
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¡ Includes 3 d i rect acting antiv i rals and r i tonavi r, tr ip le therapy o r PrOD§ Ombitasvir, paritaprevir, dasabuvir
¡ Ritonavi r (No HCV activ i ty )§ Used to boost the paritaprevir
¡ Genotype 1 and 4¡ Administer o ra l ly twice a day with
food¡ Many pharmacologica l interactions¡ GT1a requires addition o f RBV¡ May use with GFR < 30
OBV/PTV/R AND DSV(VIEKIRA PAK)
VIEKIRA PAK [package insert]. North Chicago, IL: AbbVie Inc. FDA approval Dec 19, 2014
2 tablets of ombitasvir/paritaprevir/ ritonavir (12.5/75/50 mg) combination tablet every am 1 dasabuvir 250 mg tablet every am and pm
Treatment
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¡Extended Release§All 3 tablets at the same time§Take with food
Same precautions as Viekira Pak
§Do not split, crush or chew
§Alcohol should not be consumed within 4 hours of taking VIEKIRA XR
OBV/PTV/R AND DSV XR(VIEKIRA XR)
Treatment
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¡ NS5A inhibitor ¡ High barrier to resistance¡ Once daily oral tablet
§ In combination with sofosbuvir¡ With or without food¡ Genotype 1 ,2,3,4¡ May use with antiacids
DACLATASVIR (DAKLINZA)
No DDIs: 60 mg once dailyDDIs with strong CYP3A inhibitors: 30 mg once dailyDDIs with moderate CYP3A inducers: 90 mg once daily
Daklinza [package insert]. Princeton, NJ: Bristol-Myers Squibb Company DDI: Drug-Drug Interaction
Treatment
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¡ Genotypes 1 and 4¡ Elbasvir/Grazoprevir
§ NS5A inhibitor - NS3/4A protease inhibitor
¡ Oral and once dai ly¡ Must perform resistance
testing in genotype 1A§ If resistance present must add Ribavir in and
extend therapy from 12 to 16 weeks
¡ DO NOT use in advanced liver disease (Child Pugh B or C
¡ May use with GFR < 30 ml/min¡ May use in Dialysis¡ May use with PPI
ELBASVIR/GRAZOPREVIRZEPATIER
FDA-approved Jan 28, 2016
Treatment
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¡ 55 year old HCV posit ive male with a hx of IVDU 10 years ago
¡ Genotype 1a¡ VL 2.4 mill ion/ML¡ Treatment naïve¡ Fibrosis Stage F0-F1¡ Labs: GFR of 65 ml/min, Hg 13 Platelets 245¡ Other medical condit ions
§HTN on amlodipine
¡ What are your options?
CLINICAL CASE #1Treatment
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Antacids§aluminum hydroxide§magnesium hydroxide
¡Separate administration by four hours
H2RAs§ famotidine§ ranitidine
¡Administer concurrently or 12 hours apart
¡Not to exceed doses >40 mg famotidine twice daily
SOFOSBUVIR/LEDIPASVIR (H AR V O N I )
AND ACID SUPPRESSING AGENTS
Harvoni® [package insert]. Gilead Sciences, Foster City, CA
Treatment
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¡Consider discontinuation of acid suppression therapy if patient is able to tolerate¡ Reduce PPI by 50% per week to lowest dose, then
discontinue to minimize rebound acid hypersecretion
¡If you have to use a PPI and Harvoni is the best option ¡Administer simultaneously on an empty stomach§Only doses < omeprazole 20 mg§Pantoprazole mg ≠ omeprazole mg
SOFOSBUVIR/LEDIPASVIR (H AR V O N I )
AND PROTON PUMP INHIBITORS
Harvoni® [package insert]. Gilead Sciences, Foster City, CA
Treatment
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Treatment
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¡ 65 year o ld HCV posi tive female with a hx o f a post par tum blood transfusion 40 years ago
¡ Genotype 1a¡ VL 8 .8mil lion/ML¡ Treatment naïve
§ Fibrosis Stage F3-F4§ No history of
§ Esophageal varices/ encephalopathy or ascitis§ Labs: GFR of 28 ml/min, Hg 13 Platelets 109§ Other medical conditions
§ Barrett's esophagus (on omeprazole 40 mg once a day)
¡ What are your options?
CLINICAL CASE # 2Treatment
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¡ Genotypes 1 and 4¡ Elbasvir/Grazoprevir
§ NS5A inhibitor - NS3/4A protease inhibitor
¡ Oral and once dai ly¡ Must perform resistance
testing in genotype 1A§ If resistance present must add Ribavir in and
extend therapy from 12 to 16 weeks
¡ DO NOT use in advanced liver disease (Child Pugh B or C
¡ May use with GFR < 30 ml/min¡ May use in Dialysis¡ May use with PPI
ELBASVIR/GRAZOPREVIRZEPATIER
FDA-approved Jan 28, 2016
Treatment
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¡ 73 year old HCV posit ive male with no risk factors§ Genotype 2§ VL 3.4 million/ML§ Treatment naïve§ Fibrosis Stage F3-F4§ History of ascites§ Labs: GFR of 69 ml/min, Hg 13.4, Platelets 88§ Other medical conditions
§ Prediabetes/40 pack/year smoking/HTN on amlodipine Hypercholesteremia on atorvastatin
¡ What are your options?
CLINICAL CASE # 3Treatment
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Do I need any workup before I start Ribavirin?What are his Drug - Drug Interactions with Epclusa?
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¡ Once Daily Single Oral Tablet¡ Minimal DDIs, no food ef fect¡ Genotype 1 ,2,3,4¡ Do not co-administer with PPI
§ If medically necessary, take Epclusawith food 4 hours before omeprazole 20 mg andOnly doses < omeprazole 20 mg
¡ Do not use in patients with GFR < 30
VELPATASVIR/SOFOSBUVIR(EPCLUSA®)
VELNS5A inhibitor
SOF - NS5B nucleotide polymerase inhibitor
Approved: June 28, 2016
Epclusa® [package insert]. Gilead Sciences, Foster City, CA
Treatment
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¡ Administration§ Weight-based dosing (Twice daily)
§ 1000 mg if > 75 kg§ 1200 mg if ≥ 75 kg
§ Take evening dose (8 hours apart) in the afternoon to keep from disturbing sleep
¡ Pregnancy category X§ Contraindicated in pregnant women or male partners of pregnant
women§ Use 2 effective forms of contraception during treatment and for at
least 6 months after completion of therapy (both male and female patients)
RIBAVIRIN (RBV)
LexiComp
Treatment
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¡ Adverse Events§ Headache§ Fatigue§ Nausea§ Insomnia§ Depression
¡ Lab abnormalities:§ Hemolytic anemia
§ Decrease ribavirin dose by 200 mg daily for a 2g or more drop in HgB
¡ Monitoring RBV§ CBC & CMP§ At baseline, weeks 2 and
4, as clinically indicated§ TSH at week 12§ Preexisting cardiac issue
¡ Ophthalmic exam§ Preexisting opthalmic
disorders¡ HCG
§ At baseline§ Monthly during treatment
and for 6 months after treatment
RIBAVIRIN Treatment
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WHO TO TREAT, AND WHEN?WHO TO PRIORITIZE?
¡ Who to treat?§All patients with chronic HCV should be treated, unless:
§ Life expectancy is < 1 year that cannot be remediated by treating HCV or liver transplantation (AASLD)
§ Uncontrolled comorbidities that can cause HCV treatment discontinuation (Dr. Mera’s Opinion)
¡ When to Prioritize§ Limited resources for medication procurement§ Limited clinical capacity to treat
Treatment
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¡ Pr io ri tize treatment only i f l imited by cl in ica l capaci ty§ Decompensated cirrhotic§ Non decompensated cirrhotic first, then F3, F2, F0-F1§ HCV related nephropathy/vasculitis§ PWID
WHO TO PRIORITIZE
AASLD/ IDSA HCV Guidelines
Highest Priority for Treatment Owing to Highest Risk for Severe Complications
Strength of Recommendation
Advanced fibrosis (Metavir F3 or F4) Class I, Level A
Organ transplant Class I, Level B
Type 2 or 3 essential mixed cryoglobulinemia with endo organ manifestations (vasculitis)
Class I, Level B
Proteinuria, nephrotic syndrome, or MPGN Class IIa, Level B
Dr. Mera’s Opinion
Treatment
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SPECIAL TREATMENT CONSIDERATIONS
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¡ Most anti convulsants are contraindicated§ Due to decreased antiviral levels
¡ Regimens with protease inhibitors tend to have more drug interactions§ PrOD (Viekira Pak) (has 2 PI), Simeprevir (Olysio)
elbasvir/grazoprevir (zepatier)
¡ Daclatasvir ( Da kli nza) has numerous DDI and may need dose adjustment
¡ Sofosbuvir/velpatasvir ( Epc lusa) and sofosbuvir/ledipasvir( Harvoni )
§ Decreased absorption with anti acids specially Proton Pump Inhibitors
SPECIAL TREATMENT CONSIDERATIONSDRUG-DRUG INTERACTIONS
Treatment
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¡Renal Impairment: §elbasvir/grazoprevir (Zepatier) is approved in ESRD
and dialysis§PrOD (Viekira Pak) is approved with CrCl <30
¡Hepatic Impairment (Child Pugh B/C): §PrOD (Viekira Pak) (has 2 PI), Simeprevir (Olysio)
elbasvir/grazoprevir (zepatier) are contraindicated§May require addition of ribavirin or treatment
extension
SPECIAL TREATMENT CONSIDERATIONSRENAL AND HEPATIC IMPAIRMENT
Treatment
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¡ Genotype 1a
§Will require Ribavirin if PrOD (Viekira Pak) is used§May treat for 8 weeks with sofosbuvir/ledipasvir
(Harvoni) if viral load is < 6 million, treatmentenaïve and non cirrhotic
§ If elbasvir/grazoprevir (zepatier) is used resistance testing needed
¡ Genotype 2 and 3§ Sofosbuvir/velpatasvir (Epclusa) is first line therapy but
PPI use and low GFR are a problem
SPECIAL TREATMENT CONSIDERATIONSGENOTYPES
Treatment
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SPECIAL TREATMENT CONSIDERATIONSHEPATITIS B STATUS
Treatment
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¡ Genotype¡ Vira l load fo r GT1a (< 6 mi l l ion ?)¡ Liver Fibrosis Staging
§ Cirrhosis vs no Cirrhosis§ If Cirrhotic
§ Compensated vs Decompensated
¡ Previous treatment status ¡ Kidney function
§ CrCl < or > 30 § Dialysis
¡ Drug interaction check§ Anti seizure meds, PPI, etc.
¡ Check Hepati tis B status to monito r reactivation
SUMMARY:WHAT DO YOU NEED TO KNOW TO SELECT
THE BEST TREATMENT OPTION
Treatment
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WHAT NOW?
Join the ECHO Community and start Paving the Road to HCV Elimination in Native America
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TELEMEDICINE IMPROVES ACCESSBY USING TECHNOLOGY TO BRIDGE DISTANCE
Specialist
Primary Care Clinician OR Patient
Treatment
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THE ECHO MODEL IMPROVESCAPACITY AND ACCESS SIMULTANEOUSLY
Treatment
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Treatment
MOVING KNOWLEDGE INSTEAD OF PATIENTS
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Treatment SHARING EVIDENCE BASED BEST MEDICAL PRACTICES
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• Professional interaction with colleagues with similar interest‒ Less isolation with improved recruitment and retention
• A mix of work and learning • Obtain HCV certification • Access to specialty consultation with GI, hepatology,
psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator
Benefits to Rural CliniciansTreatment
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¡ Qual i ty and Safety¡ Rapid Learning and best-practice d issemination¡ Reduce var iations in care¡ Access fo r Rura l and Underserved Patients, reduced
d isparities¡ Workforce Tra ining and Force Multipl ier¡ De-monopolize Knowledge¡ Improving Pro fessional Satisfaction/Retention ¡ Supporting the Medical Home Model¡ Cost E ffective Care- Avo id Excessive Testing and Travel¡ Prevent Cost o f Untreated Disease (e.g. : l i ver transplant o r
d ia lysis)¡ Integration o f Publ ic Health into treatment paradigm
Benefits of ECHO® model to Health System
Treatment
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IMPACT OF ECHO IN CNHS HCV PROGRAM
050
100150200250300350400
cumulative
Interferon-free all-oral DAA introduced
Interferon and ribavirin free all-oral DAA introduced
HCV ECHO Program Introduced
HCV Elimination Program Started
Num
ber o
f pat
ient
sTreatment
CNHS: Cherokee Nation Health Services
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¡http://www.hcvguidelines.org/
¡http://www.hepatitisc.uw.edu/§On-line curriculum on liver disease and HCV, includes clinical studies, clinical calculators, slide lectures
¡ECHO guidelines
HELPFUL RESOURCES
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1 . “ H C V E p i d em iolo gy i n t h e U n i t e d S t a t es. ” H e pa t i t i s C o n l i ne . U ni vers i t y o f W a s hi ngt o n. h t t p :/ / www.h epa t i t i s c.u w .ed u/ . A c c ess ed 1 0 A p r i l 2 0 1 6 .
2 . C e n t e rs f o r D i s ea se C o n t ro l a n d P re ven t ion ( C D C ) . ” P eo ple B orn 1 9 4 5 - 1 9 6 5 & H e p a t i t i s C ” . 3 1 M a y , 2 0 1 5 W e b . A c c es sed 1 0 A p r i l 2 0 1 6 .
3 . W o r l d H e a l t h O r gan iz a t ion ( W H O) . “ H e pa t i t i s C ” M e d ia C e n t re , F a ct S h e et # 1 6 4 , J u l y 2 0 1 5 , W e b . A c c e s s ed 1 0 A p r i l 2 0 1 6 .
4 . H C V G u i d a n ce : R e c om m en da t ion s f o r T e s t in g , M a n ag i ng , a n d T r e at in g H e p at i t i s C . h t t p :/ / hc vgu ide l in es.o rg
5 . M a y l i n S , e t a l . E r ad ica t io n o f h e p a t i t i s C v i r us i n p a t ien t s s u c c ess f ul l y t re at ed f o r c h ron ic h e pa t i t i s C . G a s t r oe nt er o lo gy . 2 0 0 8 ; 1 3 5 ( 3 ) :8 2 1 -8 2 9
6 . S i n g a l A G , e t a l . A S u s t ain ed V i r al R e s po ns e I s A s so ci at ed W i t h R e d uc ed L i v er - Re l at ed M o rbid i t y a n d M o r t al i t y i n P a t ie nt s W i t h H e pa t i t i s C V i r us . C l i nic al G a s t roen t ero logy a n d H e p at o log y. 2 0 1 0 ; 8 ( 3 ) : 2 8 0 - 2 8 8
7 . M o r g a n T R , e t a l . O u t co m e o f S u s t ain ed V i ro lo g ic al R e sp ond ers w i t h H i st o log ica l l y A d van c ed C h r on ic H e p a t i t i s C . H e pa t olo gy. 2 0 1 0 ; 5 2 ( 3 ): 8 3 3 -8 4 4
8 . K w o n g A D , e t a l . C u r ren t O p in P h arm ac olo gy. 2 0 0 8 ; 8 ( 5 ) : S 2 2 - 3 1¡ L y K N , e t a l . R i s in g m o r t al i t y a s s oc ia t ed w i t h h e p at i t i s C v i r u s i n t h e U n i t e d S t at e s,2 0 0 3 – 2 0 1 3 .
C l i n i c al I n f ec t iou s D i s ea ses B r i e f R e po r t . P u bl i sh ed 1 7 M a r c h 2 0 1 6 . 1 . S o v a l d i® [ p a ck ag e i n se r t ]. G i lea d S c i en ce s, F o st e r C i t y , C A2 . H a r v o ni ® [ p a ck age i n ser t ] . G i l ead S c i enc es , F o st er C i t y , C A3 . V i k e i ra P a k [ p ac ka ge i n s er t ] . N o r t h C h i c ago , I L : A bb Vie I n c.4 . D a k l i n z a [ p a c ka ge i n s er t ] . P r i nc et on , N J : B r i s t o l -Mye rs S q u ib b C o m pa ny5 . L e x i c o m p O n l in e , H u d so n, O h i o : L e x i - Co m p, I n c . ; 2 0 1 6 ; A c c e ss ed 1 J a n u a ry 2 0 1 6 .6 . N A T A P C o n f ere nc e R e po r t . h t t p:/ / www.n at a p.o rg/ 2 0 1 5 / AAS L D/ AAS L D _ 1 6 8 .ht m . A c ce ss ed 1 7 J a nuary
2 0 1 6 .7 . P r o j ec t E C H O. U ni vers i t y o f N e w M e xi co . h t t p:/ / ech o.u nm . edu /8 . T h e N N T . S t a t in D r u gs G i ven f o r F i v e Y e ar s f o r H e ar t D i s ea se P rev en t ion .
h t t p :/ / www. t h enn t . c om / nn t / st a t ins - f or - hea r t -di sea se -pre ven t ion -w i t h ou t -pr io r -h ear t - di s eas e/ . A c c e s s ed 1 7 J a n u a ry 2 0 1 6 .
REFERENCES
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ECHO DECISION TREES
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