Development of severe alcohol related liver disease over four decades in Iceland: impact of increased access and use of alcohol

OBJECTIVE

Limited data exist on the association between per capita alcohol consumption and incidence of alcohol related liver disease (ARLD). The aims were to analyse this relationship and assess prevalence of ARLD in Iceland and among patients treated for alcohol use disorder (AUD) and its impact on outcomes.

METHODS

A retrospective study on all patients diagnosed with severe ARLD: alcohol related cirrhosis (ARC) and alcohol related hepatitis (ARH) in Iceland 1984-2020. Medical records were scrutinized for clinical features, severity of ARLD, proportion undergoing treatment for AUD, data on abstinence and long-term outcomes.

RESULTS

A total of 314 patients, males 76%, median age 56 years, fulfilled the predetermined criteria for ARLD. Median MELD was 17, 73% with Child-Pugh B/C and 70/314 (22%) who had ARH. Incidence of ARLD increased from 0.77 cases per 100 000 inhabitants annually 1984-2000 to 6.1 per 100 000 in 2016-2020. Per capita alcohol consumption increased from 4.3 Liters to 7.5 L in in the same time periods. Overall 220/314 (70%) with ARLD had undergone treatment for AUD. Of all individuals who had AUD treatment during the study period (n = 21.845), 1% were diagnosed with ARLD. Patients who underwent treatment for AUD after the ARLD diagnosis had better prognosis than those who had treatment prior to ARLD diagnosis (hazard ratio 2.5 [95% CI 1.3-5.0]).

CONCLUSIONS

The incidence of ARLD increased 8-fold during the study period coinciding with 74% increase in per capita alcohol consumption. Patients with prior diagnosis of AUD had worse prognosis that needs special attention.

Genetic diversity fuels gene discovery for tobacco and alcohol use

Tobacco and alcohol use are heritable behaviours associated with 15% and 5.3% of worldwide deaths, respectively, due largely to broad increased risk for disease and injury1-4. These substances are used across the globe, yet genome-wide association studies have focused largely on individuals of European ancestries5. Here we leveraged global genetic diversity across 3.4 million individuals from four major clines of global ancestry (approximately 21% non-European) to power the discovery and fine-mapping of genomic loci associated with tobacco and alcohol use, to inform function of these loci via ancestry-aware transcriptome-wide association studies, and to evaluate the genetic architecture and predictive power of polygenic risk within and across populations. We found that increases in sample size and genetic diversity improved locus identification and fine-mapping resolution, and that a large majority of the 3,823 associated variants (from 2,143 loci) showed consistent effect sizes across ancestry dimensions. However, polygenic risk scores developed in one ancestry performed poorly in others, highlighting the continued need to increase sample sizes of diverse ancestries to realize any potential benefit of polygenic prediction.

Multi-trait genome-wide association study of opioid addiction: OPRM1 and beyond

Opioid addiction (OA) is moderately heritable, yet only rs1799971, the A118G variant in OPRM1, has been identified as a genome-wide significant association with OA and independently replicated. We applied genomic structural equation modeling to conduct a GWAS of the new Genetics of Opioid Addiction Consortium (GENOA) data together with published studies (Psychiatric Genomics Consortium, Million Veteran Program, and Partners Health), comprising 23,367 cases and effective sample size of 88,114 individuals of European ancestry. Genetic correlations among the various OA phenotypes were uniformly high (rg > 0.9). We observed the strongest evidence to date for OPRM1: lead SNP rs9478500 (p = 2.56 × 10-9). Gene-based analyses identified novel genome-wide significant associations with PPP6C and FURIN. Variants within these loci appear to be pleiotropic for addiction and related traits.

HIGH RATE OF HCV REINFECTION AMONG RECENTLY INJECTING DRUG USERS: RESULTS FROM THE TRAP HEP C PROGRAM - A PROSPECTIVE NATIONWIDE, POPULATION-BASED STUDY

BACKGROUND

The Treatment as Prevention for Hepatitis C program started in 2016 in Iceland, offering treatment with direct-acting antivirals to hepatitis C virus (HCV)-infected individuals. Reinfections through injection drug use (IDU) can hamper elimination efforts. We determined reinfection rates (RIR) of HCV among patients in the program.

METHODS

Clinical data were gathered prospectively. The study cohort consisted of HCV-cured patients with an estimated sustained virologic response between February 1st 2016 and November 20th 2018, with follow-up until November 20th 2019. The observation period and time until reinfection was estimated using a single random point imputation method coupled with Monte Carlo simulation. The RIR was expressed as reinfections/100 person-years (PYs).

RESULTS

640 treatments of 614 patients (417 males, mean age 44.3 years) resulted in cure, with 52 reinfections subsequently confirmed in 50 patients (37 males). Follow-up was 672.1 PYs with median time to reinfection of 231.7 days. History of IDU was reported by 523 patients (84.8%) and recent IDU with 220 (34.4%) treatments. Stimulants were the preferred injected drug in 85.5% of patients with history of IDU. The RIR was 7.7/100 PYs. Using multivariate Cox proportional hazards models for interval-censored data, age (HR 0.96, 95% CI 0.94-0.99) and recent IDU (HR 2.91, 95% CI 1.48-5.76) were significantly associated with reinfection risk.

CONCLUSIONS

The RIR is high in a setting of widespread stimulant use, particularly in young people with recent IDU. Regular follow up is important among high-risk populations to diagnose reinfections early and reduce transmission.

Cascade of care during the first 36 months of the treatment as prevention for hepatitis C (TraP HepC) programme in Iceland: a population-based study

BACKGROUND

WHO has set targets to eliminate hepatitis C virus (HCV) infection as a global health threat by 2030 through a 65% reduction in HCV-related deaths and 80% reduction in HCV incidence. To achieve these goals, WHO set service coverage targets of 90% of the infected population being diagnosed and 80% of eligible patients being treated. In February, 2016, Iceland initiated a nationwide HCV elimination programme known as treatment as prevention for hepatitis C (TraP HepC), which aimed to maximise diagnosis and treatment access. This analysis reports on the HCV cascade of care in the first 3 years of the programme.

METHODS

This population-based study was done between Feb 10, 2016, and Feb 10, 2019. Participants aged 18 years or older with permanent residence in Iceland and PCR-confirmed HCV were offered direct-acting antiviral (DAA) therapy. The programme used a multidisciplinary team approach in which people who inject drugs were prioritised. Nationwide awareness campaigns, improved access to testing, and harm reduction services were scaled up simultaneously. The number of infected people in the national HCV registry was used in combination with multiple other data sources, including screening of low-risk groups and high-risk groups, to estimate the total number of HCV infections. The number of people diagnosed, linked to care, initiated on treatment, and cured were recorded during the study. This study is registered with ClinicalTrials.gov, NCT02647879.

FINDINGS

In February, 2016, at the onset of the programme, 760 (95% CI 690-851) individuals were estimated to have HCV infection, with 75 (95% CI 6-166) individuals undiagnosed. 682 individuals were confirmed to be HCV PCR positive. Over the next 3 years, 183 new infections (including 42 reinfections) were diagnosed, for a total of 865 infections in 823 individuals. It was estimated that more than 90% of all domestic HCV infections had been diagnosed as early as January, 2017. During the 3 years, 824 (95·3%) of diagnosed infections were linked to care, and treatment was initiated for 795 (96·5%) of infections linked to care. Cure was achieved for 717 (90·2%) of 795 infections.

INTERPRETATION

By using a multidisciplinary public health approach, involving tight integration with addiction treatment services, the core service coverage targets for 2030 set by WHO have been reached. These achievements position Iceland to be among the first nations to subsequently achieve the WHO goal of eliminating HCV as a public health threat.

FUNDING

The Icelandic Government and Gilead Sciences.

A large-scale genome-wide association study meta-analysis of cannabis use disorder

BACKGROUND

Variation in liability to cannabis use disorder has a strong genetic component (estimated twin and family heritability about 50-70%) and is associated with negative outcomes, including increased risk of psychopathology. The aim of the study was to conduct a large genome-wide association study (GWAS) to identify novel genetic variants associated with cannabis use disorder.

METHODS

To conduct this GWAS meta-analysis of cannabis use disorder and identify associations with genetic loci, we used samples from the Psychiatric Genomics Consortium Substance Use Disorders working group, iPSYCH, and deCODE (20 916 case samples, 363 116 control samples in total), contrasting cannabis use disorder cases with controls. To examine the genetic overlap between cannabis use disorder and 22 traits of interest (chosen because of previously published phenotypic correlations [eg, psychiatric disorders] or hypothesised associations [eg, chronotype] with cannabis use disorder), we used linkage disequilibrium score regression to calculate genetic correlations.

FINDINGS

We identified two genome-wide significant loci: a novel chromosome 7 locus (FOXP2, lead single-nucleotide polymorphism [SNP] rs7783012; odds ratio [OR] 1·11, 95% CI 1·07-1·15, p=1·84 × 10-9) and the previously identified chromosome 8 locus (near CHRNA2 and EPHX2, lead SNP rs4732724; OR 0·89, 95% CI 0·86-0·93, p=6·46 × 10-9). Cannabis use disorder and cannabis use were genetically correlated (rg 0·50, p=1·50 × 10-21), but they showed significantly different genetic correlations with 12 of the 22 traits we tested, suggesting at least partially different genetic underpinnings of cannabis use and cannabis use disorder. Cannabis use disorder was positively genetically correlated with other psychopathology, including ADHD, major depression, and schizophrenia.

INTERPRETATION

These findings support the theory that cannabis use disorder has shared genetic liability with other psychopathology, and there is a distinction between genetic liability to cannabis use and cannabis use disorder.

FUNDING

National Institute of Mental Health; National Institute on Alcohol Abuse and Alcoholism; National Institute on Drug Abuse; Center for Genomics and Personalized Medicine and the Centre for Integrative Sequencing; The European Commission, Horizon 2020; National Institute of Child Health and Human Development; Health Research Council of New Zealand; National Institute on Aging; Wellcome Trust Case Control Consortium; UK Research and Innovation Medical Research Council (UKRI MRC); The Brain & Behavior Research Foundation; National Institute on Deafness and Other Communication Disorders; Substance Abuse and Mental Health Services Administration (SAMHSA); National Institute of Biomedical Imaging and Bioengineering; National Health and Medical Research Council (NHMRC) Australia; Tobacco-Related Disease Research Program of the University of California; Families for Borderline Personality Disorder Research (Beth and Rob Elliott) 2018 NARSAD Young Investigator Grant; The National Child Health Research Foundation (Cure Kids); The Canterbury Medical Research Foundation; The New Zealand Lottery Grants Board; The University of Otago; The Carney Centre for Pharmacogenomics; The James Hume Bequest Fund; National Institutes of Health: Genes, Environment and Health Initiative; National Institutes of Health; National Cancer Institute; The William T Grant Foundation; Australian Research Council; The Virginia Tobacco Settlement Foundation; The VISN 1 and VISN 4 Mental Illness Research, Education, and Clinical Centers of the US Department of Veterans Affairs; The 5th Framework Programme (FP-5) GenomEUtwin Project; The Lundbeck Foundation; NIH-funded Shared Instrumentation Grant S10RR025141; Clinical Translational Sciences Award grants; National Institute of Neurological Disorders and Stroke; National Heart, Lung, and Blood Institute; National Institute of General Medical Sciences.

2895. Threats to Successful Elimination of Viral Hepatitis: Results from the Nationwide Treatment as Prevention for Hepatitis C (TraP HepC) Program in Iceland

Background

The main driver of the Hepatitis C virus (HCV) epidemic in most western countries is injection drug use (IDU) among people who inject drugs (PWID). Iceland has provided unrestricted access to direct-acting antiviral agents (DAA) to all HCV-infected patients in the country covered by national health insurance, by a program entitled Treatment as Prevention for Hepatitis C (TraP HepC) from 2016 and is on track to become among the first to achieve the WHO goals of eliminating HCV as a public health threat.

Methods

We analyzed data regarding testing for HCV, incidence of IDU, prevalence of HCV viremia among PWID, drug use in the community and trends in homelessness prior to and during the first 24 months of TraP HepC to monitor outcomes and identify new or persistent challenges.

Results

Intensity of nationwide testing for HCV increased by 22% in 2016, 60% in 2017, and 81% in 2018 compared with previous years (P < 0.001). During 2016–2018 the incidence of new injection drug use, as surveyed among those admitted for addiction treatment increased by 48%. The total number of PWID admitted annually with HCV viremia however remained relatively stable during the entire period (2010–2018). The prevalence of HCV viremia among people recently injecting drugs admitted for addiction treatment however dropped from 48.7% to 16.2% in 2017, and to 10.2% in 2018 (P < 0.001). Analysis of data regarding stimulant use, as measured by drug levels in wastewater shows an almost threefold increase of amphetamine and an eightfold increase in cocaine levels during 2016–2018 compared with 2015. Concurrently, the number of homeless has doubled. Two years into TraP HepC > 80% of the estimated total HCV-infected population were started on their first course of DAAs. By intention to treat analysis, the cure rate was 92.4% among patients without history of IDU in the past 6 months, compared with 82.9% among active IDU (P = 0.0006); those with history of recent IDU were more likely to discontinue (P < 0.0001). Homelessness carried the highest relative risk (RR) of treatment failure (RR = 2.4, P = 0.008), mostly due to discontinuation.

Conclusion

Iceland is on track to eliminate HCV, but challenges such as increasing drug use in the community and homelessness need to continuously monitored and addressed; they may jeopardize the success of elimination efforts.

Disclosures

All Authors: No reported Disclosures.

Genome-wide association study implicates CHRNA2 in cannabis use disorder

Cannabis is the most frequently used illicit psychoactive substance worldwide; around one in ten users become dependent. The risk for cannabis use disorder (CUD) has a strong genetic component, with twin heritability estimates ranging from 51 to 70%. Here we performed a genome-wide association study of CUD in 2,387 cases and 48,985 controls, followed by replication in 5,501 cases and 301,041 controls. We report a genome-wide significant risk locus for CUD (P = 9.31 × 10^-12) that replicates in an independent population (P_replication = 3.27 × 10^-3, P_{meta-analysis} = 9.09 × 10^-12). The index variant (rs56372821) is a strong expression quantitative trait locus for cholinergic receptor nicotinic α2 subunit (CHRNA2); analyses of the genetically regulated gene expression identified a significant association of CHRNA2 expression with CUD in brain tissue. At the polygenic level, analyses revealed a significant decrease in the risk of CUD with increased load of variants associated with cognitive performance. The results provide biological insights and inform on the genetic architecture of CUD.

Association studies of up to 1.2 million individuals yield new insights into the genetic etiology of tobacco and alcohol use

Tobacco and alcohol use are leading causes of mortality that influence risk for many complex diseases and disorders1. They are heritable2,3 and etiologically related4,5 behaviors that have been resistant to gene discovery efforts6-11. In sample sizes up to 1.2 million individuals, we discovered 566 genetic variants in 406 loci associated with multiple stages of tobacco use (initiation, cessation, and heaviness) as well as alcohol use, with 150 loci evidencing pleiotropic association. Smoking phenotypes were positively genetically correlated with many health conditions, whereas alcohol use was negatively correlated with these conditions, such that increased genetic risk for alcohol use is associated with lower disease risk. We report evidence for the involvement of many systems in tobacco and alcohol use, including genes involved in nicotinic, dopaminergic, and glutamatergic neurotransmission. The results provide a solid starting point to evaluate the effects of these loci in model organisms and more precise substance use measures.

928. Major Decrease in Prevalence of Hepatitis C Viremia in Key Populations following the Second Year of Treatment as Prevention for Hepatitis C (TraP HepC) Program in Iceland

Background

Hepatitis C Virus (HCV) commonly affects people who inject drugs (PWID) and/or with history of injection drug use (IDU). They are also disproportionately represented in addiction treatment centers and the penitentiary system. In order to curtail spread of HCV it is therefore important to approach these groups. PWID and prisoners have been prioritized in the TraP HepC program. The impact can thus be assessed by monitoring HCV prevalence at sentinel sites, such as addiction hospitals and prisons.

Methods

TraP HepC offers direct-acting antiviral agents (DAAs) to all HCV patients in Iceland, starting in January 2016. HCV PCR is performed at the end of treatment and 12 weeks later (SVR12). PWID and prisoners are monitored for reinfection and retreated if needed. We compared the prevalence of HCV viremia among PWID admitted for treatment at Vogur addiction hospital and inmates of the penitentiary system, before and after 2 years of TraP HepC.

Results

Two years into the program 667 patients had been evaluated of which 632 were initiated on their first course of DAAs and 7 were pending, representing 80% of the estimated total patient population. Of those who completed first treatment according to guidelines the SVR12 is 95.5%. Drop-out from first treatment was 8.2%; nevertheless, the SVR12 was &gt;40% and most of the remaining viremic patients completed or are undergoing retreatment. In 2012–2015, prior to TraP HepC the prevalence of HCV viremia among actively injecting PWID admitted for addiction treatment was 47.9%, dropping to 39.8% in 2016 and 16.2% in 2017 (P &lt; 0.001). Likewise, the prevalence of viremia among patients with history of IDU but not recently injecting fell from 27.4% (2012–2015) to 19.8% in 2016 and 4.1% in 2017 (P &lt; 0.001). The prevalence of viremia among inmates of the penitentiary system was 29% prior to initiation of TraP HepC, dropping to 7% in 2017 (P &lt; 0.01). These results are not explained by declining IDU in the community.

Conclusion

On a population level the domestic transmission of HCV can be reduced by DAAs when combined with other efforts. Two years into the TraP HepC program the prevalence of viremia among two of the most important drivers of the epidemic has been markedly reduced. The program is ongoing, with further emphasis on increased intensity of screening, retreatment and harm reduction.

Disclosures

All authors: No reported disclosures.

Lifetime alcohol intake and pattern of alcohol consumption in patients with alcohol-induced pancreatitis in comparison with patients with alcohol use disorder

OBJECTIVE

To examine lifetime drinking patterns in men and women with alcohol-induced pancreatitis (AIP) in comparison with patients with alcoholic use disorder (AUD) without pancreatic disease.

METHODS

Alcohol consumption patterns were assessed using a validated questionnaire, the Lifetime Drinking History (LDH), during an outpatient visit. Patients diagnosed with AIP were matched for gender and age (+/- 5 years) with patients with AUD in addiction treatment.

RESULTS

A total of 45 patients with AIP (35 males, 10 females) and 45 AUD patients were included. Alcohol consumption patterns were not significantly different between males and females with AIP and those with history of acute AIP and chronic pancreatitis (CP). Alcohol consumption patterns of AIP and AUD patients were similar in terms of onset age and duration of alcohol consumption, lifetime alcohol intake and drinks per drinking day. A higher proportion of binge drinking was found among patients with AUD than those with AIP (median 1.00 vs. 0.94, p = .01). Males with AUD had lower onset age (15 vs. 16 years, p = .03), higher total amount of spirits (35520 vs. 10450 drinks, p = .04) and higher proportion of binge drinking (1.00 vs. 0.97, p = .01) than males with AIP, whereas females with AIP and AUD had similar drinking patterns.

CONCLUSIONS

Alcohol drinking patterns and lifetime drinking history was similar in patients with AIP and patients with AUD. Males with AIP had lower total amount of spirits and lower proportion of binge drinking than those with AUD, suggesting the idiosyncratic etiology of AIP.

Treatment as Prevention for Hepatitis C (TraP Hep C) - a nationwide elimination programme in Iceland using direct-acting antiviral agents

A nationwide programme for the treatment of all patients infected with hepatitis C virus (HCV) was launched in Iceland in January 2016. By providing universal access to direct-acting antiviral agents to the entire patient population, the two key aims of the project were to (i) offer a cure to patients and thus reduce the long-term sequelae of chronic hepatitis C, and (ii) to reduce domestic incidence of HCV in the population by 80% prior to the WHO goal of HCV elimination by the year 2030. An important part of the programme is that vast majority of cases will be treated within 36 months from the launch of the project, during 2016-2018. Emphasis is placed on early case finding and treatment of patients at high risk for transmitting HCV, that is people who inject drugs (PWID), as well as patients with advanced liver disease. In addition to treatment scale-up, the project also entails intensification of harm reduction efforts, improved access to diagnostic tests, as well as educational campaigns to curtail spread, facilitate early detection and improve linkage to care. With these efforts, Iceland is anticipated to achieve the WHO hepatitis C elimination goals well before 2030. This article describes the background and organization of this project. Clinical trial number: NCT02647879.

Polygenic risk scores for schizophrenia and bipolar disorder associate with addiction

We use polygenic risk scores (PRSs) for schizophrenia (SCZ) and bipolar disorder (BPD) to predict smoking, and addiction to nicotine, alcohol or drugs in individuals not diagnosed with psychotic disorders. Using PRSs for 144 609 subjects, including 10 036 individuals admitted for in‐patient addiction treatment and 35 754 smokers, we find that diagnoses of various substance use disorders and smoking associate strongly with PRSs for SCZ (P = 5.3 × 10⁻⁵⁰–1.4 × 10⁻⁶) and BPD (P = 1.7 × 10⁻⁹–1.9 × 10⁻³), showing shared genetic etiology between psychosis and addiction. Using standardized scores for SCZ and BPD scaled to a unit increase doubling the risk of the corresponding disorder, the odds ratios for alcohol and substance use disorders range from 1.19 to 1.31 for the SCZ‐PRS, and from 1.07 to 1.29 for the BPD‐PRS. Furthermore, we show that as regular smoking becomes more stigmatized and less prevalent, these biological risk factors gain importance as determinants of the behavior.

Lifetime drinking history in patients with alcoholic liver disease and patients with alcohol use disorder without liver disease

OBJECTIVE

To determine the differences in lifetime alcohol intake (LAI) and drinking patterns between patients with alcoholic liver disease (ALD) and alcohol use disorder (AUD) without notable liver injury and between males and females with ALD.

METHODS

Alcohol drinking patterns were assessed using the Lifetime Drinking History (LDH) a validated questionnaire, during an outpatient visit. Patients with AUD, currently in addiction treatment, were matched for gender and age (±5 years) with the ALD group.

RESULTS

A total of 39 patients with ALD (26 males and 13 females; median age 58) and equal number of AUD patients were included (median age 56 years). The onset age for alcohol drinking and duration of alcohol consumption was similar in ALD and AUD. The number of drinking days was higher in women with ALD than in women with AUD: 4075 [(3224-6504) versus 2092 (1296-3661), p = .0253]. The LAI and drinks per drinking day (DDD) were not significantly different between patients with ALD and AUD. Females with ALD had lower LAI than males with ALD: 32,934 (3224-6504) versus 50,923 (30,360-82,195), p = .0385, fewer DDD (p = .0112), and lower proportion of binge drinking as compared to males with ALD (p = .0274).

CONCLUSIONS

The total LAI was similar in patients with ALD and AUD. The number of drinking days over the lifetime was associated with the development of ALD in females. Females with ALD had significantly lower alcohol consumption than men with ALD despite similar duration in years of alcohol intake which supports the concept of female propensity of ALD.

Treatment as Prevention for Hepatitis C (TraP HepC). A Real-world Experience from the First 12 Months of a Nationwide Elimination Program in Iceland

Background

Hepatitis C virus (HCV) infection is associated with significant morbidity and mortality. Iceland, an island with a population of 330,000 has a HCV seroprevalence of 0.3% and an estimated total of 800–1000 patients. There is good access to health care among people who inject drugs (PWID) and Iceland thus serves as an ideal setting for a proof of concept intervention, aiming for elimination of the disease as a public health threat. If elimination is to be achieved PWID, who are key drivers of transmission, need to be a focus of treatment scale up.

Methods

All patients in the country infected with HCV were offered direct-acting antiviral agents (DAAs) starting in 01/2016. The regimens are chosen according to national guidelines; SOF/LDV +/−RBV through October 2016 and SOF/VEL +/− RBV thereafter. People with recent injection drug use (IDU), prisoners and patients with advanced liver disease are prioritized. PWID receive additional support to facilitate compliance. Various strategies are employed to enhance case detection and harm reduction. The goal is to initiate treatment for every patient in Iceland within 36 months (end-2018), aiming for elimination of domestic transmission of HCV.

Results

Twelve months after launching the nationwide program 527 patients had been evaluated, 53–66% of the estimated total patient population. The mean age is 42 years (range, 17–70 years, 2 males to every female). The reported main route of infection was IDU (90%). At the time of evaluation, 33% reported recent (within 6 months) IDU, 6% were homeless, and 5% in prison. Stimulants were the preferred IV drug among 84% of PWID but opiates by only 14%; overall 15% were receiving opiate substitution therapy (OST). During the first 12 months of the study period treatment with DAAs was initiated in 480 patients and 322 were scheduled to complete protocol. Drop-out rate is 6.5%. Sustained virological response at 12 weeks (SVR12) for the entire group, including patients who dropped out or are lost to follow-up is 90%. It is significantly lower among the homeless (60%) and active IDU (83% vs. 93%, P = 0.007).

Conclusion

A relatively large proportion of HCV infected patients in the community, including people actively injecting drugs, can be initiated on treatment in a short period of time. Current drug use does not preclude treatment success.

Disclosures

M. Gottfredsson, Gilead: Grant Investigator and Scientific Advisor, Consulting fee and Research support; Astellas: Consultant, Speaker honorarium

The effect of reducing levels of cat allergen (Fel d 1) on clinical symptoms in patients with cat allergy

BACKGROUND

Treatment of cat allergy normally entails removal of the cat from the household, but cat owners are often unwilling to part with their pets, despite clinically relevant allergies.

OBJECTIVE

To determine whether levels of Fel d 1 can be reduced without removal of the cat and whether this will affect symptoms of cat allergy.

METHODS

Cat-allergic patients underwent randomization to either a group instructed in environmental control (EC) and a group with unchanged environment (UE). Dust samples were obtained and settled Fel d 1 measured by enzyme-linked immunosorbent assay. Patients recorded daily nasal inspiratory flow rates. At baseline, 3 months, and 8 months, patients underwent symptom evaluation.

RESULTS

Eighteen patients were randomized to the EC group and 22 to the UE group; the final number completing the study was 31, 15 in the EC group, and 16 in the UE group. At 8 months, home Fel d 1 levels had diminished to 6.8% of baseline levels in the EC group, whereas no reduction in levels was noted in the UE group. In the EC group, significant improvements were found in nasal inspiratory flow rate and symptoms compared with the UE group. Patients did not have difficulties adhering to EC measures.

CONCLUSION

A decrease in the allergen load was found in the EC group, which had a significant effect on symptoms of nasal allergy.

Would you consider prescribing syringes to injection drug users? Addiction Medicine Conference Survey

In order to assess attitudes and practices of physicians regarding prescribing syringes to injection drug users (IDUs) to prevent disease transmission, a survey was conducted at the 2000 ASAM Conference. Of 497 physicians, 104 responded, representing 30 states and 3 countries. Seventy-eight percent provided care for IDUs. Only 2% had prescribed syringes to IDUs for safer injection of illegal drugs. Nineteen percent had prescribed syringes to diabetic patients whom they believed would use the syringes for injecting illegal drugs. Overall, 61% of physicians (74% of internists, 37% of psychiatrists) (p = 0.04) would consider prescribing syringes to IDUs. Prescribing syringes to IDUs can be part of a comprehensive approach to preventing spread of HIV and other infections, decreasing complications of syringe reuse, and bringing IDUs into medical and substance abuse treatment. The majority of physicians surveyed expressed interest in prescribing syringes. Psychiatrists may be less willing to do so.

Prescribing syringes to prevent HIV: a survey of infectious disease and addiction medicine physicians in Rhode Island

This article describes the assessment of physicians' attitudes and practices regarding prescribing syringes to injection drug users (IDUs). A brief, anonymous, self-administered questionnaire was sent to all Infectious Disease and Addiction Medicine specialists in Rhode Island. Of 49 eligible physicians, 39 responded (response rate 80%). Most (95%) indicated that there is a legitimate medical reason for IDUs to obtain sterile syringes. Many (71%) agreed that they would prescribe syringes to prevent disease in IDUs if it were clearly legal to do so. We can conclude that physician syringe prescription to IDUs may be an acceptable supplement to existing HIV prevention strategies.