PLEASE SEND THIS HEPATITIS C REFERRAL TO FAX: 
(02) 8738 3094/ (02) 87386678 or EMAIL: 
SWSLHD-LiverpoolGastro@health.nsw.gov.au

Patient Name: ___________________
DOB: ___________
Ethnicity: ________     Country of Birth: ____________ 
Referring Practitioner:

(All patient information will be de-identified by the Project ECHO team )

Hepatitis C history:  

Tx naïve:   	Yes   ☐      No ☐

Other medical history: 

Social / psych / D&A history:

Contraception:       Yes  ☐       No  ☐

Medications (please avoid trade names for search):  

OST: 	 	   daily pick up ☐     takeaways ☐

Examination:

Treatment options (for treatment naïve patients)

Genotypes 1 to 6
Maviret (Glecaprevir 100mg / Pibrentasvir 40mg) 8wks for non-cirrhotic patients; 12 weeks for cirrhotic patients ( Child’s Pugh A only )

Epclusa (Sofosbuvir 400mg / Velpatasvir 100mg) 12 wks; eGFR >30 

Genotype 1
Harvoni (Sofosbuvir 400mg / Ledipasvir 90 mg) 12 wks; eGFR >30 

*See consensus guidelines for other patient groups (i.e. treatment experienced): http://hepcguidelines.org.au/ 

Investigations: (pls attach results)
1.	HCV Genotype / viral load
2.	LFT / EUC / FBC / AFP
3.	GFR (if <30 beware)
4.	HBsAg /sAg /cAb   HIV Ab
5.	Fibroscan/elastography: 
(>12.5 = cirrhosis)
6.	US liver/CT abdomen (esp if cirrhosis)
7.	APRI:            or  FIB4:  

Other Information / Comments:

If you need to discuss a case prior to the Project ECHO meeting call Quyen Trinh (Admin) on 02 8738 4074 or 
Melissa Bagatella (CNC) on 8738 3571 or 0408 968 191

TIPS TO ASSIST YOU
with this form and treatment work-up
HCV history: 
Likely cause/date of infection if known, diagnosis date, previous Rx or liver review

6 C’s checklist when assessing patients
Complications of HCV (liver, other)
Co-morbidities
Conflicting priorities 
Concomitant medications
Compliance
Contraception

Medication interactions: 
Include prescribed, over the counter, recreational and herbal preparations at:
http://hep-druginteractions.org/

Chronic liver disease signs: 
splenomegaly, shrunken liver, spider naevi, palmar erythema, peripheral oedema / ascites, jaundice, muscle wasting

APRI/FIB4 calculators - see
 www.hepatitisc.uw.edu/page/clinical-calculators
•	APRI  <1 negative predictive value 93%  for cirrhosis > 1 proceed to fibroscan or other
AST (IU/L) / AST ULN = 40(IU/L) /Platelet x 100
FIB4  <1.45 negative predictive value 90% for adv fibrosis/cirrhosis (Age x AST)/[Platelet x (√ALT)]
•	If APRI>1 or FIB 4 >1.45 proceed to Fibroscan ≥12.5kPa  =cirrhosis