Alcohol Awareness Month: Dr. Galati Discusses

Tonight on Your Health First, I did a segment on alcohol use, and the ill effects on the body. This is information that needs to be shared with those closest to you. Unfortunately, not everyone is up to date on this information, and only after years of alcohol misuse and or abuse, do they come to terms with the damaging effects.

Read this recent article, and listen to the audio from the radio program tonight.

 

Dr. Joseph Galati and Your Health First: April 20, 2014-Alcohol Awareness Month Program Segment by Your Health First Radio on Mixcloud

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Hepatitis C, Liver Cancer, and Bad New for Patients: It’s Never Easy

Hepatitis C, Liver Cancer, and Bad New for Patients: It’s Never Easy

Liver Cancer Discussion with Dr. Joe Galati

Liver Cancer Discussion with Dr. Joe Galati

Primary liver cancer, or hepatocellular carcinoma, is a growing problem we face in the care of patients with chronic liver disease, especially hepatitis C. The number of new cases of liver cancer I see each week has grown steadily over the past 15 years. A lot of this has to do with the aging population of patients with hepatitis C. It is well known that the development of liver cancer is a function of time. The longer you liver with hepatitis C, the annual chance of developing cancer increases. The incidence of developing liver cancer is approximately 3-8% per year. Liver cancer is highest in those with cirrhosis; the risk of cancer in hepatitis C patients without cirrhosis is significantly reduced.

Over the years, we have developed a very good strategy to screen for liver cancer in those with hepatitis B and hepatitis C, as well as other causes of cirrhosis. The general strategy is to obtain an ultrasound of the liver along with a blood tumor marker, alphafetoprotein (AFP), every six months. Following these guidelines has shown to reduce death by 37%.

In practices with large numbers of patients with cirrhosis, keeping track of everyone that needs to be screened is a daunting process. Even with the use of electronic medical records, keeping up with everyone is difficult. Despite our best efforts, and alerting patients, they still need to go and have the scan performed, and get their blood work as scheduled. People are human, and they forget to get these tests done in a timely fashion. During tough financial times, patients ask me if they can extend the frequency of testing from every six months to 8-12 months. High deductibles, tuition bills, and other expenses take priority over these necessary scans. As I have said before, all I can do is encourage the patient, educate them on the importance of screening and early detection and cancer, and document it in their medical record. Unfortunately, I have seen cases where skipping required scans have resulted in the development of new, large cancers, that are not amendable to proper treatment.

Routine screening with AFP and ultrasound (or in certain cases MRI or CT scan), small liver cancers are detected. In the setting of cirrhosis, surgical resection is never routinely recommended, due to the high risk of precipitating progressive liver failure and death. Instead, local therapy applied to the tumor is preferred. The two most common therapies we use are radio-frequency ablation (RFA), and transarterial-chemoembolization (TACE). Collectively, these are referred to as loco-regional therapies. A review is available here. In both of these therapies, along with the local delivery of radiation, in the form of yttrium-90, focused treatment can be delivered right to the tumor, instead of a systemic method, which is given by mouth or vein, exposing the entire body to these medicines.

In addition to loco-regional therapy, liver transplantation is at the heart of therapy for hepatocellular carcinoma in patients with cirrhosis. To be considered for transplant, the size and location of the tumor needs to be within specific guidelines.

The Milan criteria state that a patient is selected for transplantation when he or she has:

  • one lesion smaller than 5 cm.
  • up to 3 lesions smaller than 3 cm.
  • no extrahepatic manifestations
  • no vascular invasion

With all of this said, we have:

a. Identified those patients with an increased risk of liver cancer (hepatitis C, hepatitis B, alcoholic cirrhosis, all other forms of cirrhosis).

b. Established a screening strategy (ultrasound and AFP every six months).

c. Understand the biology of these tumors, the doubling time and rate of growth.

d. Developed protocols for treatment (loco-regional therapies, sorafenib, liver transplant).

Unfortunately, this always doesn’t work out as planned.

Today, I had the unfortunate job of talking with a long-time patient of mine, and explaining to him that literally out of nowhere, a liver cancer developed, exceeding criteria for transplant, and that there appeared to be invasion of the tumor into his portal vein. This further complicated the options for him. He had always been compliant, getting scans and blood work in a timely fashion. His last MRI was a little less than 6 months ago. On review, no less that five times, with multiple sets of expert eyes, there was no indication that there was a tumor brewing at the last scan, that may have been missed. He had the best of technology scanning his liver.

The lessons here are important. Despite all parties doing their job in a diligent manner, bad things happen to good people. As a physician, I am reminded daily that I have little control in what happens to my patients. All of the science and technology cannot save everyone. The news I shared was devastating to him and his wife. He walked into my office this afternoon thinking that a transplant was needed, but left with the news that most good options had been lost. Keeping emotions at bay, I forged ahead to develop a credible plan “B”. In situations like this, physicians and all healthcare providers need to display empathy, rather than sympathy for our patients. I purposely did not discuss with them “survival”, or “how much time he had left”. Over the many years of listening to patients, the one thing that upsets patients more than anything else is a physician telling them, with authority, what their expected survival will be. In cases of clear-cut terminal illness, I will be more specific. These are cases where an amateur could see that a person was moments from death. Once you define length of survival in these early discussions mortality, more negative comes from it than good.

We did take the time to lay out a plan, one I believe can leave them with a sense that there will be options to try. At each turn, we can readjust our expectations. I do not feel I candy-coated the discussion.

After 25 plus years of delivering bad news to patients, it is never easy, and it pains me and my staff each and every time. We all take the time to get to know our patients, and their families. We become friends, and share laughs when we meet. Days like today suck for all of us.

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Childhood Obesity: New Research Released in New England Journal of Medicine

A new article in the NEJM sheds light on the origins of obesity. It seems obesity starts earlier than expected, and obese 5 year olds are at risk for life-long obesity.

Listen to Dr. Galati’s podcast here.

 

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New Hepatitis C Drug Sofosbuvir FDA Approved and Available Now.

Last Friday the FDA gave approval to Gilead approving their new HCV drug sofosbuvir, know as Solvadi.

The indication for the HCV drug is wider than ever before, opening the door to a much wider range of patients that can benefit from treatment. Know that it is available, feel free to contact us for a consultation at 713-794-0700 and talk with Lexa.

This short video explains some of the highlights of hepatitis C.

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New Gilead Drug Sovaldi FDA Approved: Improved Cure Rate Available

Yet another new drug to treat hepatitis C has been approved. The FDA announced the approval of sofosbuvir, commercially known as Sovaldi. Sovaldi is manufactured by Gilead.

More details on this new therapy will be added this weekend, so stay tuned. For an office evaluation and opinion if you are a candidate for these new hepatitis C therapies, call our office at 713-794-0700, and fill out this on-line form.

Look at our latest video on these new hepatitis C treatment. It will be update this weekend.

 

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New Hepatitis C Drug Approved: Janssen’s Hepatitis C Drug Simeprevir Now Available

This past week, the FDA gave approval to Janssen’s new drug to treat hepatitis C. Simeprevir, commercially know as OLYSIO, is the first new hepatitis C drug since the release of telapravir (Incevik) and boceprevir (Victrelis) in 2011. Simeprevir is a  NS3/4A protease inhibitor, used in combination with interferon and ribavirin.

The release of simeprevir marks the beginning of a new wave of direct acting antiviral agents against the hepatitis C virus. Additional drugs are set for FDA approval, including the Gilead drug sofosbuvir in early December 2013.

Most of the new hepatitis C drugs will have a number of features in common. These include:

  • Very high cure rate, in the 80-90% range – lower in null and non-responders
  • Less side effects
  • Shorter duration of treatment
  • Less pills to take each day
  • Cirrhosis reduces response rates
  • Less drug-drug interactions
  • Genotype 1 subtype differences exist

Looking at the dosing of simeprevir, I have attached the official product insert that describes how the drug will be doses. Several points to consider:

  • This is an interferon/ribavirin based therapy
  • Patients with genotype 1 need additional screening for the NS3 Q80K polymorphism
  • Those with this variant have a decreased response rate to the therapy, and should be considered for an alternative therapy
  • The initial dosing is 12 weeks of simeprevir with interferon and ribavirin, followed by an additional 12 or 36 weeks of interferon and ribavirin combination therapy.
  • There are drug-drug interaction which have to be monitored closely
  • FDA approval is for genotype 1 patients only

While the release of simeprevir is welcomed, it has not provided the proverbial “home-run” we have been looking for in our quest to cure hepatitis C. In well selected patients, achieving a better than 80% cure rate is available. The concerns I have relate to the Q80K polymorphism noted above. This will be an additional step required in screening our patients. Additionally, in patients with prior non-response or null responders, as well as those with cirrhosis, these patients will still require a full 48 week of interferon and ribavirin. One of the goals of the next generation of hepatitis C therapies is reduced interferon exposure, or complete elimination. Simeprevir does not fully meet this goal.

In the days to come, I will post additional information on sofosbuvir. For now, these are the highlights to consider (refer to this FDA document for additional details):

  • Sofosbuvir will likely receive FDA approval for Genotype 1,2,3, and 4 patients with hepatitis C
  • Interferon-free treatment in genotype 2 and 3 for 12 weeks
  • Sofosbuvir combined with interferon and ribavirin in genotype 1 and 4 for 12 to 16 weeks

This treatment strategy is far different than the simeprevir treatment noted above.

Looking further, we will eventually have all interferon-free protocols. It is anticipated that as additional new drugs are approved, they will be combined (example sofosbuvir and simeprevir), allowing us to treat a wide range of patients, safely, and with a cure rate many of us may have never envisioned 20 years ago.

For a consultation to see if you are a candidate for these new drugs, contact Lexa at our office at 713-794-0700 and visit our webpage for additional information.

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Colon Poop: Another Bad Colonoscopy Prep: Follow All Directions

From our YouTube page, another example of a poor bowel prep. This man did not fully follow the instructions. When going for a colonoscopy, follow all directions as given, or else you’ll have to repeat the colonoscopy which is no fun.

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Acetaminophen and the Liver: Dr. William Lee

Acetaminophen and the Liver: Dr. William Lee

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This morning, Dr. Will Lee from UT Southwestern, gave a magnificent talk on acetaminophen (Tylenol) toxicity, and acute liver failure (ALF).

Dr. Lee is an expert in this area, and has been studying acute liver injury for years. He and his colleagues have looked at acetaminophen toxicity nationwide, and have contributed greatly to our understanding. Some of the important take-home messages include the following:

•Suicide is a common problem associated with acetaminophen overdose

•Individuals with intentional overdose have more depression, are likely single, less likely working, and have problems with chronic pain

•Alcohol use increases the risk of liver toxicity, as well as the use of opioids

•The vast majority of patients recover from the liver injury

•Health care providers, usually in the ER, need to ask questions regarding possible unintentional overdose

•The FDA and other groups are limiting the availability of acetaminophen, hoping to stem availability and the risk of ALF

•Unfortunately, the number of ALF cases from acetaminophen toxicity is not reducing in numbers despite these efforts

For our patients and consumers, special care needs to be given to being aware of your acetaminophen intake, realize that less is better, avoid alcohol, and beware of OTC products that contains acetaminophen , potentially increasing the risk of inadvertent toxicity, ALF, and death.

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NASH and Fatty Liver Disease: Surgical Options

NASH and Fatty Liver Disease: Surgical Options

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Fatty liver disease is a hot topic here at the AASLD Annual Meeting. The complications of fatty liver including cirrhosis and liver cancer, and the central treatment strategy is weight loss. While bariatric surgery has been studies, presentations on less invasive therapies have been presented here at the meeting.

Early results of a number of studies looking at various endoscopic treatment options for treating obesity and nonalcoholic fatty liver disease (NAFLD) are promising, according to Barham Abu Dayyeh MD, MPH, Assistant Professor of Medicine, Mayo Clinic, Rochester, MN, who presented data on these options during the AASLD/ASGE Endoscopy Course on Friday.

Emerging endoscopic technologies have opened the door to using endoscopic approaches and devices to reproduce many of the anatomical alterations of bariatric surgery endoscopically and thereby contribute to the effective treatment of obesity and its associated disorders, researchers noted.

For those with fatty liver, the discussion with your doctor/surgeon has to now include less invasive therapies such as endoscopic procedures noted above.

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AASLD-TV: Spotlight Houston Methodist Liver Transplant Program

AASLD-TV: Spotlight Houston Methodist Liver Transplant Program

Dr. Ghobrial discusses the transplant program at Houston Methodist Center for Liver Disease and Transplantation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

At the annual meeting of the AASLD this year, AASLD-TV highlighted several top-rated liver programs from around the country, broadcasting these stories throughout the convention hall.

I am proud to post the Houston Methodist Center for Liver Disease and Transplantation video, highlighting both the people behind the program, including Dr. Barbara Bass, Dr. Osama Gaber, Dr. Mark Ghobrial, Dr. Howard Monsour, and Dr. Robert McFadden.

The video highlights the efforts we have put forth at Houston Methodist in the areas of liver cancer, cholangiocarcinoma (bile duct cancer), liver transplantation, and the care of patients with alcoholic liver disease.

Watch the video here.

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