Nurses need to be aware of when to refer patients to a specialist nurse for treatment
Citation: Botterill G (2016) Viral hepatitis: the clinical nurse specialist role. Nursing Times; 112: 15, 15.
Author: Gemma Botterill is hepatitis clinical nurse specialist, Queen Elizabeth Hospital, Birmingham.
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Viral hepatitis clinical nurse specialists treating patients with hepatitis C virus (HCV) have experienced a sharp increase in patient numbers due to new direct-acting anti-virals (DAAs) commissioned by NHS England (2015) and approved by the National Institute for Health and Care Excellence.
Starting treatment with DAAs requires careful education of patients and relatives about side-effects and different regimes. Missed doses may lead to treatment being abandoned. Before treatment can start, interactions between DAAs and concomitant medications must be checked.
A background in hepatology is needed when working with this group of patients to fully understand the disease pathway and educate them and their relatives. Patients may present with advanced cirrhosis of the liver and associated complications such as ascites (accumulation of fluid in the peritoneal cavity) requiring regular paracentesis (drainage) and treatment with diuretics, and oesophageal varices, which can bleed. Patients with cirrhosis may also experience hepatic encephalopathy resulting in episodes of confusion. Occasionally patients attend clinic with symptoms of pain and pruritus caused by cirrhosis, which can be helped with medication.
To educate patients and their relatives we have developed practice standards for each DAA regimen. These enable the CNS to ensure vital information is not missed.
Patients sign the practice standards at the end of the consultation to show they have understood the information and are happy to start treatment. This is filed and a copy sent to them so they can refer to it throughout their treatment.
When to contact the nurse specialist
- For further advice and education on hepatitis C virus (HCV)
- When patients are given a confirmed diagnosis of HCV. Patients need to be under the care of a hepatologist, especially if their health deteriorates
- If advice is needed on symptom management and further interventions
- When patients are known to have cirrhosis
- When patients who may not have cirrhosis show a keen interest in being treated. These patients may be eligible for treatment under new commissioning
- For advice on new treatments available – this is an exciting time in this area of medicine as there are many changes in the treatments that are available
- When meeting patients undergoing a treatment regime. There are many drug–drug interactions that must be checked before new medication is prescribed; this is particularly helpful for practice nurses
- For advice on public-health issues – this may apply to healthcare workers
- For information regarding HCV and pregnancy, although vertical transmission is very rare at <5%. Also for information about treatment while pregnant or for women wanting to start a family – there is no data showing what effect these medications may have on a unborn child
Guidance and resources
- National Institute for Health and Care Excellence guidelines and technology appraisal guidance
- Summary of product characteristics provide information about the treatments patients may be prescribed
- University of Liverpool’s online hepatitis C drug interaction checker
- NHS Choices guide to hepatitis C
- Hepatitis C Trust
- There are six main genotypes of hepatitis C virus (HCV). Different regimes are available for each, with more undergoing clinical trials or awaiting national guidance and NHS funding
- HCV is bloodborne and transmitted via infected blood. It is associated with drug use, high-risk sexual behaviour, infected blood transfusions pre-1991 in the UK, and medical treatment in countries where prevalence is high
- In the early stages, the virus causes inflammation, tenderness and fibrosis of the liver. There are often no symptoms for 20-30 years
- 10% of patients will clear HCV but 90% go on to have chronic HCV leading to liver cirrhosis
- HCV can be cured in over 90% of patients if an appropriate drug regimen is used