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Rethinking strategies to control hepatitis B and hepatitis C
Editorial
Institute of Medicine
Rethinking strategies to control hepatitis B and hepatitis C
For the Institute of Medicine’s report see http://www.iom.edu/ Reports/2010/Hepatitis-andLiver-Cancer-A-National-Strategyfor-Prevention-and-Control-ofHepatitis-B-and-C.aspx
Hepatitis B and hepatitis C viruses are common, infecting about 500 million people worldwide. Often asymptomatic, the disease might not be noticed until complications, such as hepatocellular carcinoma, develop. Hepatitis B can be prevented by vaccination, and simple precautions reduce infection from both viruses. But this knowledge has not been translated into decreased incidence in the USA. The Institute of Medicine investigated why not in Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C published on Jan 11. The report describes poor engagement between providers of fragmented services and communities at risk of hepatitis B or C: ethnic minorities, indigenous peoples, users of illicit drugs, prison inmates, and immigrants from hepatitis B-endemic countries. As a result, opportunities for education, prevention, detection, and treatment are missed. A broader, holistic, and more aggressive approach is recommended, beginning with active surveillance targeting communities at risk, whose members are under-represented in traditional samples.
Primary care physicians and obstetric staff show poor knowledge of hepatitis B and C, as do many people at risk of infection. Thus the benefit of immunisation is lost by delayed vaccination of infants born to infected mothers, and by lack of awareness in adults at risk. Educational outreach is needed for health and social workers, as well as people at risk. Better contact with groups at highest risk could be achieved by collaboration with other agencies. Because 30% of people with acute hepatitis B had previously been treated for a sexually transmitted disease, and a similar proportion had been imprisoned, sexual health clinics and correctional facilities offer innovative settings for education and testing. Hepatitis B and C are more prevalent and infectious than HIV but, cloaked by stigma and ignorance, they have not received commensurate attention or funding. The Institute of Medicine’s report challenges health workers to use existing tools more effectively and imaginatively, so that outcomes and quality of life for people with hepatitis B or C can be improved. ■ The Lancet
Prescribing medicines: size matters
iStockPhoto
The printed journal includes an image merely for illustration
See Viewpoint page 248
172
Doctors prescribing commonly used medicines to adults often have the option of scored tablets and preparations of different tablet strengths so that they can best treat their patient’s presenting condition, for example, 250 mg or 500 mg for most oral antibiotics and some analgesics. But do current restricted tablet strengths for common medicines provide optimum treatment for patients? According to principles of pharmacokinetics and pharmacodynamics, varying patient factors, such as liver and renal function, age, and sex need to be taken into account when prescribing. Consideration of body size is routine practice in some specialties, such as oncology, where treatment with toxic agents is common, and paediatrics, where dose is affected by size and maturity. In a Viewpoint in The Lancet today, Matthew Falagas and Drosos Karageorgopoulous make a strong case for varying antibiotic regimens according to bodyweight. Many medical disorders can lead to increasing or decreasing bodyweight and in view of the growing obesity epidemic in some countries and rising rates of undernutrition in others, it follows that taking a patient’s bodyweight
into account makes pharmacological and clinical sense. Adjusting drug doses according to body weight might not only be more clinically effective, but also be more tolerable for patients since they might have fewer side-effects. If bodyweight is to become a major consideration in clinical treatment, could similar drug-dosing principles be applied to all medicines, not just toxic agents and anti-infective agents? Relevant randomised controlled trials are needed to adequately answer this question. Doctors might be willing to implement the practice of adjusting treatment for an individual’s body weight if robust clinical trials showed benefits to their patients. Since doctors often prescribe via computer, appropriate algorithms could easily be incorporated—as in paediatric practice, in which dose adjustment can be made fairly easily by the use of liquids and solutions. Such forms of treatment are often expensive and have a limited shelflife, so if evidence pointed to the therapeutic advantages of dose adjustment per bodyweight, a wider range of tablet strength options would need to be widely available: good for pharmaceutical business perhaps? ■ The Lancet www.thelancet.com Vol 375 January 16, 2010
Institute of Medicine
Rethinking strategies to control hepatitis B and hepatitis C
For the Institute of Medicine’s report see http://www.iom.edu/ Reports/2010/Hepatitis-andLiver-Cancer-A-National-Strategyfor-Prevention-and-Control-ofHepatitis-B-and-C.aspx
Hepatitis B and hepatitis C viruses are common, infecting about 500 million people worldwide. Often asymptomatic, the disease might not be noticed until complications, such as hepatocellular carcinoma, develop. Hepatitis B can be prevented by vaccination, and simple precautions reduce infection from both viruses. But this knowledge has not been translated into decreased incidence in the USA. The Institute of Medicine investigated why not in Hepatitis and liver cancer: a national strategy for prevention and control of hepatitis B and C published on Jan 11. The report describes poor engagement between providers of fragmented services and communities at risk of hepatitis B or C: ethnic minorities, indigenous peoples, users of illicit drugs, prison inmates, and immigrants from hepatitis B-endemic countries. As a result, opportunities for education, prevention, detection, and treatment are missed. A broader, holistic, and more aggressive approach is recommended, beginning with active surveillance targeting communities at risk, whose members are under-represented in traditional samples.
Primary care physicians and obstetric staff show poor knowledge of hepatitis B and C, as do many people at risk of infection. Thus the benefit of immunisation is lost by delayed vaccination of infants born to infected mothers, and by lack of awareness in adults at risk. Educational outreach is needed for health and social workers, as well as people at risk. Better contact with groups at highest risk could be achieved by collaboration with other agencies. Because 30% of people with acute hepatitis B had previously been treated for a sexually transmitted disease, and a similar proportion had been imprisoned, sexual health clinics and correctional facilities offer innovative settings for education and testing. Hepatitis B and C are more prevalent and infectious than HIV but, cloaked by stigma and ignorance, they have not received commensurate attention or funding. The Institute of Medicine’s report challenges health workers to use existing tools more effectively and imaginatively, so that outcomes and quality of life for people with hepatitis B or C can be improved. ■ The Lancet
Prescribing medicines: size matters
iStockPhoto
The printed journal includes an image merely for illustration
See Viewpoint page 248
172
Doctors prescribing commonly used medicines to adults often have the option of scored tablets and preparations of different tablet strengths so that they can best treat their patient’s presenting condition, for example, 250 mg or 500 mg for most oral antibiotics and some analgesics. But do current restricted tablet strengths for common medicines provide optimum treatment for patients? According to principles of pharmacokinetics and pharmacodynamics, varying patient factors, such as liver and renal function, age, and sex need to be taken into account when prescribing. Consideration of body size is routine practice in some specialties, such as oncology, where treatment with toxic agents is common, and paediatrics, where dose is affected by size and maturity. In a Viewpoint in The Lancet today, Matthew Falagas and Drosos Karageorgopoulous make a strong case for varying antibiotic regimens according to bodyweight. Many medical disorders can lead to increasing or decreasing bodyweight and in view of the growing obesity epidemic in some countries and rising rates of undernutrition in others, it follows that taking a patient’s bodyweight
into account makes pharmacological and clinical sense. Adjusting drug doses according to body weight might not only be more clinically effective, but also be more tolerable for patients since they might have fewer side-effects. If bodyweight is to become a major consideration in clinical treatment, could similar drug-dosing principles be applied to all medicines, not just toxic agents and anti-infective agents? Relevant randomised controlled trials are needed to adequately answer this question. Doctors might be willing to implement the practice of adjusting treatment for an individual’s body weight if robust clinical trials showed benefits to their patients. Since doctors often prescribe via computer, appropriate algorithms could easily be incorporated—as in paediatric practice, in which dose adjustment can be made fairly easily by the use of liquids and solutions. Such forms of treatment are often expensive and have a limited shelflife, so if evidence pointed to the therapeutic advantages of dose adjustment per bodyweight, a wider range of tablet strength options would need to be widely available: good for pharmaceutical business perhaps? ■ The Lancet www.thelancet.com Vol 375 January 16, 2010