Hepatitis C

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:

American Liver Foundation
Centers for Disease Control
The Hepatitis Foundation International
Roche (maker of Pegasys and Copegus)
Schering (maker of Peg-Intron and Rebetol)