Primary Care Consultation Request
Initiation of Hepatitis C Treatment in Victoria
Alfred Hospital Liver Clinic (Gastroenterology) Fax: (03) 9076 2194
Alfred Hospital Infectious Diseases Fax: (03) 9076 6528
Austin Health Liver Fax: (03) 9496 2097
Box Hill Hospital Liver and Hepatitis Clinics Fax: (03) 9895 4852
St Vincent's Hospital Melbourne Liver & Hepatitis Clinic Fax: (03) 9231 3596
The Royal Melbourne Hospital Liver Clinic Fax: (03) 9342 7848
Victorian Infectious Diseases Service – Infectious Hepatitis Clinic Fax: (03) 9342 7277
Western Health Hepatitis Clinic Fax: (03) 8345 7212
Note: All fields below are mandatory
ATTENTION OF Dr (if known):
GP DETAILS
Name: Treating Doctor.Name Provider No: Treating Doctor.Provider Number
Address: Treating Doctor.Full Address
Phone: Treating Doctor.Phone Fax: Treating Doctor.Fax Email: Treating Doctor.E-mail
PATIENT DETAILS
Name: Patient Demographics.Full Name UR No (if known): UR
Date of Birth: Patient Demographics.DOB Gender: Patient Demographics.Gender
Pregnant or nursing female*: Pregnant/Nursing
FibroScan Date: FibroScan
Median Liver Stiffness (kPa): kPa
Is it >12.5?* kPa >
APRI Score: APRI http://www.hepatitisc.uw.edu/page/clinical-calculators/apri
Date: Date of last APRI
IQR/med (%): IQR/med
Result: IQR/med
Is it >1.0?*: IQR/Med Result
* If ANY apply, please refer to a specialist for clinical review
Hepatitis C History Intercurrent Conditions
Likely year of acquisition: Acquisition Diabetes: Diabetes
Year of chronic hepatitis C Diagnosis: Chronic Hep C Obesity (BMI>30): BMI
Known Cirrhosis*: Cirrhosis Immunosuppressed: Immuno
Hepatic Decompensation (ascites, encephalopathy, variceal bleeding)*: Hepatic Decomp Hepatitis B*: Hep B
Any previous treatment with Direct Acting Antivirals for HCV: Direct Antivirals HIV*: HIV
* If ANY apply, please refer to a specialist for clinical review Alcohol >40g/day: Alcohol
LABS (OR ATTACH COPY OF RESULTS
Test Result Date Test Result Date
HCV Genotype: HCV Genotype HCV INR: INR INR
Viral Load: Viral Load Viral Creatinine: Creatinine Creatinine
ALT: ALT ALT eGFR: eGFR eGFR
AST: AST AST Hb: Hb Result Hb Result
Total Bilibrubin: Total Bilbrubin Bilbrubin Platelets: Platelets Platelets
Albumin: Albumin Albumin ß HCG: B HCG B HCG
DRUG INTERACTIONS AND COUNSELLING
I have entered current medication (prescription and over-the-counter) and proposed treatment regimen according to genotype into http://www.hep-druginteractions.org/ and assessed outputs.
Recommend printing and attaching the outputs.
NB: Current GP practice software is NOT sufficient for assessing these potential drug interactions. Complementary and alternative medicines should already be ceased and therefore not entered.
Yes o No o
On no Medication o
Amiodarone at any time in last 3 months: Yes o No o
*If hep-drug interactions chart RED or AMBER please await specialist response
Cease ALL non-traditional (complementary and alternative) medicines during treatment: Yes o No o N/A o
Contraception education given (males and females): Yes o No o N/A o
Management of this patient will be according to Australian Recommendations for the Management of HCV infection consensus statement 2016 https://www.asid.net.au/documents/item/1208 Yes o No o
HCV INTENDED TREATMENT REGIMEN (for patients with NO CIRRHOSIS)
Regimen Genotype Duration Please tick
Sofosbuvir + ledipasvir 1 8 weeks o
1 12 weeks o
Sofosbuvir + daclatasvir 1 12 weeks o
3 12 weeks o
Sofosbuvir + ribavirin 2 12 weeks o
Paritaprevir + ritonavir + ombitasvir + dasabuvir 1b 12 weeks o
Paritaprevir + ritonavir + ombitasvir + dasabuvir + ribavirin 1a 12 weeks o
Monitoring of patients on treament - see https://www.asid.net.au/documents/item/1208, https://melbourne.healthpathways.org.au, https://www.hepvic.org.au/
Alcohol and other drugs (AOD Support ) - see http://www.directline.org.au/, http://www.vaada.org.au/wp-content/uploads/2014/09/VIC-AOD-Catchment-Intake-and-Assessment-details.pdf and
https://www2.health.vic.gov.au/alcohol-and-drugs/aod-treatment-services/pathways-into-aod-treatment/aod-telephone-online-services