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HEPATITIS C
SOME THINGS YOU SHOULD KNOW…
What is Hepatitis C?
Hepatitis C is caused by an RNA virus that infects the liver. Chronic
infection, which occurs in about 90 percent of those exposed to the virus, can
lead to liver damage, cirrhosis and its complications, and even death. Almost
two million people in the United States are infected with the virus. Most people
with Hepatitis C have no symptoms. Their infection is usually detected by
abnormal blood tests.
How is Hepatitis C Spread?
Hepatitis C can be transmitted by administration of blood products obtained
from persons infected with the virus. Blood tests to detect hepatitis C became
available in 1989. Since that time, transfusion associated hepatitis has become
a rare event. Intravenous drug use and sharing needles is another common route
of infection. The exposure leading to infection may have occurred many years
ago. Health care workers who are exposed to blood are also at risk. Sexual
transmission is a rare event, and accounts for less than five percent of cases.
Household contacts of persons with Hepatitis C are at increased risk for
infection, although the mechanism is not always obvious. Sharing razor blades,
nail clippers, or toothbrushes that have been used by a person with Hepatitis C
increases the risk of infection. Kissing, hugging, or sharing eating utensils
does not. Rare cases of transmission from mother to infant may also occur. In
some cases the mode of transmission is not at all apparent. There is no evidence
that mosquitoes or other insects spread the disease.
What happens if I get Hepatitis C?
Some patients have a flu-like illness during the initial phase of the
infection. Jaundice and fever rarely occur in this setting. Occasionally, joint
and body aches and kidney disease may occur. Most people who become infected
with Hepatitis C have no symptoms at all. The infection may be present for many
years before it is ever detected. About 20% of patients with chronic Hepatitis C
will develop cirrhosis of the liver. Alcoholism and the presence of other
infections such as Hepatitis B may accelerate the progression to cirrhosis.
Chronic infection with Hepatitis C and the presence of cirrhosis increase the
risk of developing hepatoma or primary liver cancer.
It is important to remember that the majority of patients who are infected
with Hepatitis C do not develop cirrhosis or require liver transplantation.
What treatments are available?
Interferon in various forms is presently the most important drug for
treatment of Hepatitis C. Interferon is a naturally occurring substance that is
created by the body’s immune system to fight off viral infections. Even though
it helps eliminate the virus, interferon is responsible for many of the symptoms
that occur during a viral illness like the flu. These symptoms include
generalized aches, fever, headaches and fatigue.
Interferon alfa (Intron) was the first drug released for use. It required
injection three times a week. Long acting forms of interferon were created by
combining the drug with polyethylene glycol (PEG). This formulation can be given
once a week as the interferon is slowly released into the circulation. It is
also more effective against the virus since the drug is present in the body for
a longer time.
Ribavirin (Rebetol or Copegus) is an antiviral drug that is given in
combination with different types of interferon. The combination has proven to be
far more effective than interferon alone in completely eliminating the
infection. Ribavirin alone is not effective.
Currently, there are several FDA approved treatments for hepatitis C, and
all include various forms of interferon. These include Intron (alpha
interferon), Infergen (a synthetic interferon), Rebetron (combination of Intron
and Ribavirin), PEG Intron (long acting interferon), and Pegasys (peginterferon
alfa-2b) which is usually given with Copegus (Ribavirin).
Most treatment programs require administration of these drugs for six to twelve
months. Most patients are able to clear the infection during therapy. This is
termed a response. About fifty percent of patients have no detectable evidence
of infection one year after completing treatment. This is felt to represent a
cure of the Hepatitis C infection.
Who should be treated?
At this time, there is no reliable way to predict which patients are at risk
for progression to cirrhosis of the liver and severe liver disease. For this
reason, for most young people who have hepatitis C, we recommend treatment. It
is also advised in patients who have evidence of significant damage on liver
biopsy. If cirrhosis has already developed, treatment may prevent further
deterioration.
Who should not be treated?
Patients with severe cirrhosis or advanced liver disease may actually worsen
on treatment. These patients may need to be considered for liver
transplantation. People with severe depression or other psychiatric illness may
not tolerate treatment. Those with heart disease may have problems with chest
pain or heart failure if they become anemic on therapy.
What tests are Available for Detecting Hepatitis C?
The ELISA test for Hepatitis C Antibody detects the antibody to the virus.
It does not detect the virus itself, but only indicates that a person has had
exposure. About 90% of those exposed to the virus will have chronic infection.
Early forms of this test had a very high false positive rate. This means the
test was positive in people who did not really have the disease.
The polymerase chain reaction (PCR) assay detects the presence of the virus
itself. The test may also be used to determine how much virus is actually
present. This is termed the viral load. The PCR test is performed during
treatment to determine whether the virus is being cleared from the body.
Viral genotype is a test to determine the actual strain or type of virus
present. Different strains respond differently to treatment and this information
is often used to decide how long a course of treatment is needed.
How is treatment monitored?
Blood tests are done at regular intervals to monitor liver inflammation, and
to detect side effects of therapy. If side effects occur, dosages of the drugs
are usually lowered to a tolerable level, or other medications are given to
treat the side effects. Viral load is monitored to ensure that the patient is
clearing the virus. If the virus does not respond, a decision to stop treatment
may be necessary.
What do you have to do to get treated?
A liver biopsy is advised in almost all patients before beginning treatment
for Hepatitis C. The biopsy is used to accurately stage the disease. Staging
describes the amount of inflammation and damage in the liver. The presence or
absence of cirrhosis is also an important factor in predicting long-term
prognosis and response to treatment. Biopsy is also important to identify other
conditions such as autoimmune hepatitis that can be dramatically worsened by
administration of interferon.
Informed consent is mandatory. Anyone who wishes to be treated for Hepatitis
C must have a clear understanding of the potential risks and benefits, and
limitations of treatment. One must also agree to close medical follow-up and
monitoring so that treatment can be done as safely as possible. You will be
required to sign a detailed consent form agreeing to comply with the
requirements for treatment.
A stress test to detect heart disease, and a psychiatric evaluation are also
required before you will be started on treatment. Women are required to have a
pregnancy test.
What other health measures are important?
Patients infected with hepatitis C are at risk for other liver infections.
Vaccinations against Hepatitis A and B are strongly advised. Even though sexual
transmission is uncommon, safe sex is advised. There is no vaccine available for
Hepatitis C. Please ask your physician before taking any dietary supplements as
some of them can be harmful to your liver.
What are the Side Effects of Interferon Therapy?
Treatment for Hepatitis C can result in serious side effects. For this
reason, treatment must be closely monitored in order to minimize the impact and
risk to our patients. Periodic laboratory tests are necessary to detect side
effects and assess the effectiveness of treatment. These tests are not optional.
If you do not keep follow-up appointments and have blood tests done as ordered,
your treatment cannot be continued.
With careful management of side effects and adjustment of drug dosages,
more patients are able to finish the treatment and have a better chance of being
cured of the infection.
When interferon therapy is begun, many patients have symptoms that resemble
a flu-like illness, with fatigue, fever, headaches and muscle aches, loss of
appetite, and nausea. Most of these symptoms tend to diminish with continued
therapy, but fatigue may persist. Tylenol and other simple measures are very
helpful. Dose reduction may be needed. Mild dehydration commonly occurs with
therapy. It is important to make sure you take in enough fluids.
Other common side effects include:
Depression or other psychiatric conditions
Low platelet count (can affect blood clotting)
Low white blood count (weakens body’s defenses and increases risk of infection)
Anemia (most commonly with Ribavirin)
Pain or redness at injection site
Diarrhea
Nausea
Anxiety
Insomnia
Confusion
Temporary hair loss
Numbness of hands and feet
Less common side effects include:
Under or overactive thyroid
Damage to the retina (more likely in patients with diabetes and high blood
pressure)
Pneumonia
Abnormal chest x-ray
Abnormal heart rhythm
Liver injury
If anemia or low white blood count persists, referral to a hematologist may
be needed for administration of drugs such as Neupogen or Epogen to stimulate
blood production.
It is not known whether interferon can cause harm to pregnant women or the
unborn child. We do not advise treatment of pregnant women. Pregnancy tests are
recommended before starting treatment, as is effective contraception during
therapy. Men are advised against fathering children while on treatment. There
may be some impairment of fertility for men and women.
What are the side effects of Ribavirin therapy?
The most common side effect of Ribavirin is hemolytic anemia. This is
accelerated destruction of blood cells. It improves with reduction of dosage of
Ribavirin. Patients with cardiac disease may be at increased risk for angina or
even a heart attack or heart failure if they become severely anemic. A treadmill
or stress test may be advisable before beginning treatment if there is any
concern about heart disease.
Ribavirin is known to cause severe birth defects.
Birth control is an absolute must for women during treatment. Men are also
advised not to father children while on treatment.
Hepatitis C Support Group
Please see our web site for up to date information about a local Hepatitis C
support group.
Financial Assistance
Financial assistance with drug costs is available from the drug
manufacturers for eligible patients.
To Learn More
Excellent patient education information is available on the internet from
national professional organizations. Both online and printed materials are
available from several drug manufacturers.
Here are a few internet sites to help you get started.
Roche (maker of Pegasys and Copegus)
www.pegasys.com
Updated 2/24/2004
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