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HEPV-L's HEPATITIS C FAQ v2.0
October 21,
1997
HealthBann Plus Banner Exchange Member
October 21, 1997
This FAQ is dedicated to the memory of David H. Kehrer, LTC John Heintz
(Peters) and his wife Patricia Heintz (Peters), Dr. Horst Irmler, and Daniel
Bodiford.
PART 0: ADMINISTRIVIA
0.01 Introduction
0.02 Disclaimer
PART I: THE BASICS
I.0.1 What is Hepatitis?
I.0.2 What Happens in the Body?
I.0.3 What
is the Incubation Period?
I.0.4 How Does Hepatitis C Usually Begin?
I.0.5 What Are the Different Types of Hepatitis?
I.0.6 What is the
Function of the Liver?
I.0.7 Hepatitis C (HCV)
I.0.7a When was Hepatitis
C Discovered?
I.0.8 Who Gets Hepatitis?
I.1.0 How is it Transmitted?
I.1.0a How is it NOT Transmitted?
I.1.1 HCV and Blood
Transfusion
I.1.2 HCV and Intravenous Drug Use
I.1.3 HCV and IV
Immunoglobulin
I.1.4 Neonatal Transfer of HCV
I.1.5 Other Means of HCV
Transmission
I.1.5a Sexual Transmission
I.1.5b Occupational Exposure
(Health Care Workers)
I.1.5c Toothbrushes/Razors/Nail Clippers
I.1.5d
Hemodialysis
I.1.6 Highly Speculative Modes of Transmission
I.1.6a Tears,
Saliva, Urine, Other Body Fluids
I.1.6b Cat Scratches
I.1.6c
Mosquitoes
I.1.6d Alternative Medical Procedures
I.1.6.e Household
Transmission
I.1.6f Other
I.1.6g Is HCV Anything Like HIV?
I.1.7
Prevention
I.1.7a When and How Long Can it be Spread?
I.1.7b How Can the
Spread of HCV be Prevented?
I.1.7c Cleaning Up Blood Spills
I.1.7d What
to do in Case of an Accidental Needlestick
I.1.8 Who Should I Tell?
I.1.9
Can You Get Hepatitis More Than Once?
I.1.10 Vaccines
PART II: MEDICAL ISSUES
II.0.1 How Do I Find Good Medical Care for Hepatitis
II.0.2 Hepatologists
and Gastroenterologists
II.1.0 How is it Diagnosed?
II.1.1 Antibody
Tests
II.1.2 What is a PCR?
II.1.2a What is a Genotype?
II.1.3 Is it
Possible the Test Could be Wrong?
II.2.0 Biopsy
II.2.0a What is a Liver
Biopsy
II.2.0b What Are the Dangers of Liver Biopsy?
II.2.0c Will it
Hurt?
II.2.1 Chronic Active and Chronic Persistent
II.2.2 What Are the
Main Symptoms of HCV?
II.2.2a Fatigue
II.2.2b Right-Side Pain
II.2.2c
Loss of Libido
II.2.2d Red Palms
II.2.2e Nausea
II.2.2f Brain Fog
(Confusion/Forgetfulness)
II.2.2g Itching
II.2.2h Vision
Problems
II.2.2i Dizziness
II.3.0 It's Not All In Your Head!
II.3.1
What is the Evolution of the Disease?
II.4.0 What Other Medical Problems Are
Related to HCV?
II.4.0a Cryoglobulinemia
II.4.0b Thyroid and Autoimmune
Problems
II.4.0c Rheumatoid Arthritis-Like Symptoms
II.4.0d Fibromyalgia
II.4.0e Dermatological Manifestations
II.4.0f Porphyrins
II.4.0g
Lichen Planus
II.5.0 Cycles and Flareups
II.6.0 Should I be Vaccinated
Against Other Types?
II.7.0 HCV and Women's Concerns
II.7.1 How Does HCV
Relate to Pregnancy?
II.8.0 How Does HCV Affect Children?
II.9.0 What
Are the Different Clinical Indications?
II.9.1 Elevated Liver
Enzymes
II.9.2 Jaundice
II.9.3 Hepatomegaly/Splenomegaly
II.9.4 Spider
Nevi
II.9.5 Ascites
II.9.6 Portal Hypertension/Varices
II.9.7 Hepatic
Encephalopathy
II.9.8 Cirrhosis
II.9.9 Fulminant Hepatitis
II.9.10 Does
HCV Increase the Likelihood of Cancer?
II.10.0 How Many of Us Are There?
PART III: TREATMENT (Conventional Medicine)
III.1.0 Interferon
III.1.0a When is Interferon Treatment Not Indicated?
III.1.0b Interferon "Breakthrough" and "Non-Response"
III.2.0 Iron
Reduction Therapy
III.3.0 Ribavirin
III.3.1 Interferon and Ribavirin
Combined
III.3.2 Consensus Interferon
III.3.3 Alferon
III.3.4
Lymphoblastoid Interferon
III.3.5 Protease Inhibitors
III.3.5 Interferon
and GM-CSF - Combined
III.4.0 Amantadine
III.5.0 Ofloxacin
III.6.0
Thymosin
III.7.0 Cyclosporine Therapy
III.8.0 Reticulose
III.9.0
Transplant
III.10.0 Others
PART IV: TREATMENT (Alternative Medicine)
IV.0.1 Acupuncture
IV.0.2 Chiropractic
IV.0.3 Energy Healing
IV.0.4
Reflexology
IV.0.5 Homeopathy
IV.1.0 Herbal Treatments and
Vitamins
IV.1.1 Kombucha Tea
IV.1.2 Reishi/Shitake Mushrooms
IV.1.3
Dandelion
IV.1.4 Milk Thistle
IV.1.5 Artichoke
IV.1.6 Licorice
Root
IV.1.7 Spirulina
IV.1.8 Garlic
IV.1.9 Thymic Factors
IV.1.10
Vitamin C
IV.1.11 Vitamin B12
IV.1.12 Vitamin E
IV.1.13 Natural
Interferon Boosters
IV.1.14 Other Herbs or Vitamins
IV.2.0
Exercise
IV.3.0 Stress Management
IV.4.0 Positive Attitude
IV.5.0 Tai
Chi/Chi Kung/Yoga/Meditation
IV.6.0 Other Ways to Keep Yourself Healthy
PART V: NUTRITION
V.1.0 What Should I Do About Nutrition?
V.1.1 Foods to Avoid
V.2.0
Nutrition and Cirrhosis
V.3.0 Coffee, Tea, Caffeine and Other
Stimulants
V.4.0 Salt
PART VI: DRUGS AND ALCOHOL
VI.1.0 Alcohol
VI.2.0 Tobacco
VI.3.0 Marijuana
VI.4.0 What are the
Effects of Recreational Drugs?
VI.4.1 Intravenous Drug Use
Precautions
VI.4.2 Cleaning Fits
VI.4.3 Methadone
PART VII: HOW CAN HCV AFFECT MY EMOTIONAL LIFE?
VII.1.0 How is Depression Related to Hepatitis?
VII.1.1 Mood
Changes
VII.1.2 Dealing with a Chronic Disease
VII.1.3 Dealing with a
Lower Level of Energy
VII.1.4 Irritability
VII.1.5 How Can HCV Affect My
Sex Life?
VII.1.6 Helping a Friend with Hepatitis C
VII.1.6a What Can I
Say?
VII.1.6b What *Shouldn't* I Say?
PART VIII: LIVING WITH HCV
VIII.1.0 Life Problems Created by HCV
PART IX: DEALING WITH INTERFERON THERAPY
IX.1.1 Hair Loss
IX.1.2 Nausea
IX.1.3 Fatigue
IX.1.4 Importance of
Water
IX.1.5 Timing of Injections
IX.1.6 Injection Hints
IX.1.7 Needle
Size
IX.1.8 Help! I Think I Hit a Vein!
IX.1.9 What to do When You Can't
Afford the Interferon
PART X: WHERE DO WE GO FROM HERE?
X.1.0 Long-Term Prognosis (Am I Going to Die?)
X.2.0 Current Research,
Testing, New Drugs
PART XI: EMPLOYMENT AND DISABILITY
XI.1.0 Income Security: Job and/or Disability Benefits
XI.1.1 How Do I
Handle Problems About My Job?
XI.1.2 Problems in Seeking Disability
Benefits
XI.1.3 Applying for SSI/SSDI
PART XII: IMPORTANT INFORMATION
XII.1.0 What Else is Important to Know About HCV?
XII.1.1 HCV Information
Resources
XII.1.2 National (USA)
XII.1.3 Canada
XII.1.4 Australia/New
Zealand
XII.1.5 Great Britain
XII.1.6 Germany
XII.1.7 Local (USA)
Associations and Support Groups
XII.1.8 HCV Resources on the Internet and
Usenet
XII.1.9 Bibliography: Suggested Reading
XII.1.10 Newsletters,
Magazines and Videos
APPENDIX A: Where to Get the Current Version of the FAQ
APPENDIX B: Common Abbreviations and Medical Terms
APPENDIX C: Some Recommended World Wide Web Sites
===============================================================
Subject: Part 0: Administrivia
NOTICE: It has come to my attention that there is currently an
unauthorized version of this FAQ being distributed under the name "HEPV-L's and
HEP C's Hepatitis C FAQ v1.01 April 04, 1997". This version has had additions
and unsubstantiated and unauthorized information, and an additional author's
name added to it. As of this date (October 21, 1997) the current version of the
FAQ is v2.0 and contains no reference to a group calling themselves HEP-C. If
you see a pirated version of the FAQ, please write to me at
clotho@bellatlantic.net and let me know where you saw it.
Subject: 0.00 Copyright
The HEPV-L FAQ is copyright (c) 1996-98 by Patricia Johnson on behalf of the HEPV-L Internet Mailing List. Permission is granted to redistribute or quote this document for non-commercial purposes provided that you include an attribution to HEPV-L, the contact address of clotho@bellatlantic.net or HEPVL-REQUEST@MAELSTROM.STJOHNS.EDU, the FAQ's version number and date, and at least two locations from which a current version of this FAQ may be retrieved (see Appendix 1). For any other use, permission must be obtained in writing from Patricia Johnson (clotho@bellatlantic.net).
This is a document whose development is in progress. Please make comments to help improve it. Please send suggestions for additions, corrections, or changes privately to the author (Patricia Johnson) at address: clotho@bellatlantic.net
If you want your contribution to be anonymous, please state so.
============================================================
HEPV-L is a list devoted to people with chronic hepatitis, and related liver diseases. Its address is HEPV-L@MAELSTROM.STJOHNS.EDU. Subscribe by addressing a message to:
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-------------
0.01 INTRODUCTION
This document answers
frequently asked questions (FAQ) about Hepatitis C Virus, (HCV), its treatment,
and related complications. This FAQ is not comprehensive, and there will be
further FAQs describing other types of hepatitis (viral - A,B,D,E,G, Autoimmune,
toxic) and related liver disorders and complications, as well as treatments,
electronic resources and other specialized topics sometime in the near future.
These related FAQs will likely be found near where you have found this one.
-----------
0.02 DISCLAIMER
The information
presented in this document was written and developed by patients and members of
the HEPV-L mailing list. It represents an informal catalog of accumulated
knowledge by people who for the most part are not medical professionals. As this
file is developed further, we hope to include references and citations which
will document more of the statements that are made here. Much of the information
contained in this FAQ was compiled from the varied and personal experiences and
opinions on the HEPV-L mailing list. As useful as this information may be, it
must not be considered medical advice, and must not be used as a substitute for
medical advice. And as always, don't forget to use your common sense. It is
important that anyone who has, or thinks they may have, hepatitis should consult
with a licensed health care practitioner who is familiar with liver disease.
=============================================================
PART I - THE BASICS
I.0.1 WHAT IS HEPATITIS?
Hepatitis is an
inflammation of the liver. "Hepato" is Greek for "liver," and "itis" means
"inflammation." The different types of hepatitis are caused by different things,
but they all produce inflammation of the liver. Viral hepatitis refers to
several common contagious diseases caused by viruses that attack the liver. The
most important types of viral hepatitis are hepatitis A, hepatitis B, and
hepatitis C. Newly discovered forms of viral hepatitis also include hepatitis D,
E, and G. Non-viral forms of hepatitis can be caused by toxic agents (drugs or
chemicals), alcohol, or autoimmune processes. Another form of hepatitis is toxic
hepatitis. Toxic hepatitis can be caused by viruses or by liver damage due to
toxic substances. Toxic hepatitis is a deterioration of the liver cells caused
by chemicals, alcohol, drugs, and industrial compounds. Alcohol abuse is a
common cause of toxic liver damage.
---
I.0.2 WHAT HAPPENS IN THE BODY?
The
hepatitis A and E viruses first enter the gut and begin reproducing. They spread
to the liver and multiply in liver cells. Hepatitis B, C, D, and G enter the
bloodstream; when they pass through the liver, they enter liver cells and begin
to reproduce. The body attacks the infected cells, which causes the liver to
become inflamed. In hepatitis B infection, the liver usually repairs itself,
leaving antibodies to the surface antigen, which shows that the infection
occurred, but that the body defeated it.
When someone catches the hepatitis C virus, their body produces antibodies to
try to destroy it. More often than not, the antibodies fail to identify the
hepatitis C virus properly. The infection then remains long-term. Most infected
people don't know they have the virus. This is because for some people there
will be no symptoms and for others, symptoms may take an average 13 years to
develop. Some people may have hepatitis C for 20 years or more before finding
out.
The way that hepatitis affects people is different for different people. Some are not affected by the condition, but others are affected very badly.
It currently seems that if 100 people catch hepatitis C:
- 15-20 people will get rid of it within 2-6 months (much like we get rid of a flu virus)
- 60 people will have a long-term infection that may cause no problems or may cause levels of liver damage ranging from mild to serious.
- 20-25 people will have a long-term infection that leads to serious liver damage after 20 years. Of these people, 10-15 will remain stable and the other 10 will progress to liver failure or liver cancer after another 5-10 years.
Hepatitis C infection doesn't always make people sick. When someone does get
sick, symptoms take a long time to develop (approximately 13 years). Symptoms
often stay at a certain level and don't always get worse. They can come and go
with no real pattern.
Some people with chronic infection don't have any noticeable liver damage or symptoms. These people remain well, but *they are infectious and should take care to reduce any risk of transmitting the virus to others.*
---
Data on the clinical course of HCV is limited because the onset of
infection often goes unrecognized, and the early course of the disease is
indolent and protracted in many individuals. Prospective cohort studies are few,
typically small, include relatively few subjects whose date of infection can be
well documented, (e.g. blood transfusion recipients and victims of accidental
needle sticks), and have relatively short followup. The natural history of
disease appears to differ according to geography, alcohol use, virus
characteristics, (e.g., genotype, viral load), coinfection with other viruses,
and other unexplained factors. - National Institutes of Health Statement on
Hepatitis C 1997
---
I.0.3 WHAT IS THE INCUBATION PERIOD?
The
incubation period (the amount of time that elapses between infection and the
development of symptoms) varies for the different hepatitis viruses. Hepatitis A
and E may develop as few as two weeks after exposure, but usually appear after
four weeks. For hepatitis B and C it may take up to six months before symptoms
develop. (The average incubation period is two to three months for hepatitis B
and six to nine weeks for hepatitis C.) In experiments on chimpanzees, hepatitis
D developed two to ten weeks after infection.
---
After initial exposure, HCV RNA can be detected in blood in 1-3 weeks.
Within an average of 50 days (range 15-150 days), virtually all patients develop
liver cell injury, as evidenced by elevation of serum alanine aminotransferase
(ALT). The majority of patients are asymptomatic and anicteric. Only 25-35
percent develop malaise, weakness, or anorexia, and some become icteric.
Fulminant liver failure following HCV infection has been reported but is a rare
occurrence. Antibodies to HCV (anti-HCV) almost invariably become detectable
during the course of illness. Anti-HCV can be detected in 50-70 percent of
patients at the onset of symptoms and in approximately 90 percent of patients in
3 months after onset of infection. HCV infection is self-limited in only 15
percent of cases. Recover is characterized by disappearance of HCV RNA from
blood and return of liver enzymes to normal. - National Institutes of Health
Statement on Hepatitis C 1997
---
I.0.4 HOW DOES HEPATITIS C USUALLY
BEGIN?
For a slight majority of patients, the illness begins
suddenly as though one had come down with the flu. Except that this "flu"
doesn't seem to completely go away. For many other patients, the onset appears
gradually over a long period of time. Infants and young children often have no
symptoms at all.
Many other symptoms may also be present, however they will typically be different among different patients. These include: fatigue, low-grade fever, headaches; slight sore throat, loss of appetite, nausea, vomiting, sensitivity to light, and stiff or aching joints. Many people develop a pain in the right side, over the liver area. The urine may become dark brown, and the feces may be pale. In severe acute infections, some people may develop jaundice in which the skin and whites of the eyes become yellowish.
The degree of severity can differ widely among patients, and will also vary over time for the same patient. Severity can vary between getting unusually fatigued following stressful events, to being totally bedridden and completely disabled. The symptoms have a tendency to wax and wane over time.
---
I.0.5. WHAT ARE THE DIFFERENT TYPES OF HEPATITIS?
The different types of VIRAL hepatitis are:
A (formerly called infectious hepatitis),
B (serum
hepatitis),
C ( formerly called non-A, non-B hepatitis),
D
(delta hepatitis),
E (transmitted through the feces of an infected
person)
Cryptogenic (or Non-A,B,C,D,E,G)
G (a virus
transmitted through infected blood products)
More hepatitis viruses are
being discovered, but may be less common.
Other viruses, such as Yellow
Fever, Epstein-Barre virus, Cytomegalovirus, as well as parasites and bacteria,
can cause hepatitis as a secondary effect.
Other types of non-viral hepatitis are: Autoimmune, Wilson's disease, hemochromatosis, drug or chemical induced, alcoholic hepatitis.
---
I.0.6 WHAT IS THE FUNCTION OF THE
LIVER?
The liver:
* Stores iron reserves, as well as vitamins and minerals
* Makes bile to help digest food
* Detoxifies poisonous chemicals, including alcohol, beer, wine, and drugs - prescribed and over-the-counter as well as illegal substances. Acts as a filter to convert them to substances that can be used or excreted from the body
* Converts food we eat into stored energy, and chemicals necessary for life and growth
* Makes your blood
* Manufactures new proteins
* Makes clotting factors to help blood clot
* Removes poisons from the air, exhaust, smoke and chemicals we breathe.
* Manufactures and exports important body chemicals used by the body. One of these is bile, a greenish-yellow substance essential for the digestion of fats in the small intestine.
---
I.0.7 HEPATITIS C VIRUS (HCV)
HCV is a
form of hepatitis caused by an RNA virus of the Flaviviridae family that targets
the liver. HCV accounts for the majority of the hepatitis cases previously
referred to as non-A, non-B hepatitis, and is responsible for 150,000 to 250,000
new cases of hepatitis each year. The virus, which typically has a six to
nine-month incubation period, presents symptoms such as: fatigue, nausea, loss
of appetite, dark urine, and jaundice; and if left untreated can lead to liver
cancer and death. According to a recent report by a committee sponsored by the
National Institutes of Health, nearly four million individuals in the U.S. are
infected with HCV. The report also noted that treatment of the disease with
current drugs is disappointing and estimated that the number of U.S. deaths
caused by HCV will triple in the next 10-20 years.
---
I.0.7a WHEN WAS THE HEPATITIS C VIRUS DISCOVERED?
In 1987, Michael Houghton and colleagues at Chiron Corporation in
California discovered part of the genetic material of HCV using molecular
recombinant technology. This discovery allowed the development of tests to
detect specific antibodies. The first enzyme immunoassay (EIA) test made
available in 1989 employed only a single recombinant protein to detect
antibodies and produced a significant proportion of both false positive and
false negative results. An antibody test that could be used to increase the
safety of the blood supply and of transplantable organs and tissues was
available by 1990. In mid-1995 the hepatitis C virus was seen for the first time
ever by scientists with the aid of an electron microscope. It is a linear
single-strand RNA (ribonucleic acid) virus 40-50 nanometers in size. It is
covered with a lipid envelope and is encased with glycoprotein peplomers or
"spikes".
---
I.0.8 WHO GETS HEPATITIS?
People who
have ever had blood transfusions or blood products before screening was
introduced (1990), and people who have ever shared injecting equipment for drugs
should be tested for the hepatitis C virus. Other people who should consider
having the test done are those who have been tattooed, had body piercing or a
needlestick injury. People with abnormal liver function tests with no apparent
cause would also benefit from having a hepatitis C antibody test.
Healthcare workers who perform "exposure prone procedures" should also be tested.
Hepatitis C currently causes between 150,000 and 250,000 new cases of chronic infection in the United States each year. Hemophiliacs and intravenous drug users are at the greatest risk, but anyone, of any status or age, and in any walk of life, is at risk for acquiring the hepatitis C virus. Researchers have found that many people infected with hepatitis C don't even know it. From 20 to 40 percent of patients in inner-city hospitals are infected, as are 80 percent of intravenous drug users.
---
I.1.0 HOW IS IT
TRANSMITTED?
"Relax...you have cooties...but they aren't as bad
as you are imagining." - Cindy Torchin <cindyt@cpcug.org>, Listowner
HEPV-L
---
Most people with hepatitis C contracted it either through a blood
transfusion or receiving a blood product (plasma, etc.) that was contaminated
with hepatitis C, or by sharing needles with intravenous drug users that were
infected with hepatitis C. Prior to 1990 blood could not be screened for HCV.
Thanks to HCV testing with modern sensitive methods, the risk of acquiring
hepatitis C from blood transfusion is now less than 1%. The other people who
acquire hepatitis C include health care and laboratory workers that may get
stuck with an infected needle or instrument, people receiving medical/dental
procedures, people receiving hemodialysis, body piercing, sharing razors,
toothbrushes, nail clippers or people who have had tattoos or manicures that
were performed with poorly sterilized equipment. Infected mothers can pass the
virus to the fetus in utero but this occurs less than 1% of the time. It may
occur more readily if the mother is also infected with the human
immunodeficiency virus (HIV) that causes AIDS.
Cases of hepatitis C with no evidence of exposure through blood transfusions, needle sticks or needle sharing are called "sporadic". How these individuals became infected is unknown.
Forty percent of all cases of hepatitis C were contracted through unknown means by people who have are in no current risk category. What this means is that we are *all* at risk for contracting hepatitis C.
---
1.1.0a HOW HCV IS *NOT* TRANSMITTED
1.
The hepatitis C virus is NOT airborne.
2. It is NOT spread by:
a. sneezing and coughing
b. holding hands
c. kissing
d. using the same toilet
e. eating food prepared by someone with HCV
f. holding a child in your arms
g. swimming in the same pool
3. The virus IS in the blood of an infected person.
4. Hepatitis C can be spread by using something with infected blood on it
such as:
a. razors, nail clippers or scissors
b. tooth brushes and water pics
c. tattoo or body piercing needles
d. illicit IV drug needles and paraphenalia (cottons, spoons, etc.)
e. tampons or sanitary napkins
5. The virus must enter the body through the skin or mucous membrane.
---
I.1.1 HCV AND BLOOD TRANSFUSIONS
Anyone who received a blood transfusion or a blood product before 1992 is
considered to be in a high risk group. Chance of infection by transfusion today
is said to be 0.12%. Blood banks began screening donors for certain markers as
early as 1986. In May 1990, screening tests for the hepatitis C virus came into
use, and the risk is now thought to be one in 3,300 units of blood, or 0.12% for
the typical recipient of a transfusion. - California at Berkeley Wellness
Letter, May 1993
HCV acquired through blood transfusion tends to be more severe than through
other modes of transmission.
- In a group of patients seen at a referral center, chronic post-transfusion hepatitis C infection was a progressive disease and, in some patients, led to death from either liver failure or hepatocellular carcinoma - N Engl J Med 1995;Vol 332, Iss 22:1463-1466
---
I.1.2 HCV AND INTRAVENOUS DRUG
USE
Investigators at Johns Hopkins report that injection drug
users are at high risk for contracting hepatitis B and C, and that many contract
hepatitis B or C within the first year of IV drug use.
Dr. David Vlahov and colleagues studied 716 volunteers who had been injecting for six years or less. Seventy-seven percent of them were infected with HCV and 65.7% were infected with HBV. Roughly 20% were HIV-positive. Hepatitis C was more prevalent among those who reported injection drug use for less than four months than among those who reported injecting drugs for 9 to 12 months. - Am J Pub Health 1996;86:642-646.
---
I.1.3 HCV AND IV IMMUNOGLOBULIN
(GAMMAGARD/POLYGAM/FACTOR D)
Contaminated batches of Gammagard
and Polygam, drugs used in intravenous immunoglobulin therapy, may have caused
thousands across the U.S. to contract the hepatitis C virus. Many of those
infected by Gammagard were children. Gammagard is primarily used to boost a
patient's immune system. Many women in Ireland were infected through the use of
contaminated Factor D after childbirth.
Patients who received immunoglobulin therapy with Gammagard should contact their doctor immediately to have liver function tests performed.
---
I.1.4 NEONATAL TRANSFER OF
HCV
Physicians are not very concerned about hepatitis C
transmission during birth, and many HCV positive women have given birth to
children who were HCV negative. The likelihood of transmission from breast milk
is also very small for both HCV and HBV.
Physicians do not advise against breastfeeding.
Neonatal transfer among women infected with the hepatitis C virus has been
reported in 5% of pregnancies, but can be as high as 25% if the mother is also
HIV positive. Japanese studies, (where a much more severe HCV genotype is
prevalent) showed that only 6% of the babies born to HCV positive mothers
contracted hepatitis C. Many showed antibodies at birth, but were clear of the
virus by 18 months. This is not the case if the transmission is simultaneous
with HIV or HBV infection, of if the mother is infected by multiple strains of
hepatitis C virus.
Mother-to-baby transmission of HCV may be increased if the mother is also infected with HIV or HBV or has a high titer of HCV in the blood. In the latter circumstance, Japanese researchers have estimated that the risk of transmission can be approximately 10%.
---
Full recovery from perinatal hepatitis C virus infection is rare, as
chronic hepatitis generally develops even in children with prolonged intervals
of remission. - "Natural History of Perinatal HCV Infection," Clinical
Infectious Diseases, July 1996;23:47-50
---
According to an abstract by V. Papaevangelou from the 35th Interscience Conference on Antimicrobial Agents and Chemotherapy, "Mother-to-Infant Transmission of Hepatitis C in Children Born to Mothers Coinfected with HIV and HCV," the rate of HCV vertical transmission was not affected by the mode of delivery (vaginally or by C-section).
---
Recent technological advances have led to the development of several
types of invasive procedures in the fetus principally for the diagnosis and
management of fetal disorders. There is probably a small but finite risk of
transmission of maternal viral infections such as human immunodeficiency virus,
hepatitis B and C, cytomegalovirus and herpes simplex during invasive
procedures. - "Risk of Fetal Infection from Invasive Procedures," Journal of
Hospital Infection 1997 Mar;35(3):169-173
---
I.1.5 OTHER MEANS OF HCV
TRANSMISSION
Like hepatitis B, hepatitis C is spread through
exposure to blood from an infected person, such as through a blood transfusion
or sharing needles. There is no evidence that the hepatitis C virus can be
transmitted by casual contact, through foods or by coughing or sneezing.
---
I.1.5a SEXUAL TRANSMISSION
The risk of
sexual transmission of hepatitis C virus has not been thoroughly investigated
but appears to be minimal. Some studies have shown no risk of passing hepatitis
C on to a sexual partner, others have shown only a very low risk. The United
States Centers for Disease Control and Prevention (CDC) do not recommend a
change in sexual practices for those engaged in a long-term relationship with
one sexual partner. However, people with acute illness and multiple sexual
partners may be at greater risk and should use condoms to reduce the risk of
acquiring or transmitting hepatitis C as well as other sexually transmitted
infections. The risk is increased if the HCV positive partner is
immunocompromised because the virus titer in the blood may be increased under
those circumstances. Sex during the menstrual period should be avoided, due to
the blood contact at that time. There is also some speculation about the
possibility of transmission piggybacked on the genital herpes virus through
genital lesions.
---
The reason that many studies say "multiple sexual partners" when
referring to the risk of sexual transmission of HCV, is because people who have
multiple sexual partners have a greater risk of contracting other sexually
transmitted diseases which can cause open sores and lesions. And with those open
sores and lesions you are at greater risk for blood contact. Also, it is thought
that the hepatitis C virus tends to "piggyback" on the herpes virus, and if you
have herpes you are at much greater risk of contracting or transmitting the
virus.
---
According to a report in the Archives of Internal Medicine, sexual
transmission of HCV occurs at a rate of about 1% per year in at-risk partners,
and shows that periodic serum immune globulin prophylaxis for sexual partners is
protective.
Transmission of the virus "...occurred only in partners of HCV-infected
patients with active liver disease," the researchers report. They add an
"intriguing" finding that patients who became infected during the study were
older and had longer relationships with their partners compared with those who
did not become infected. - Arch Intern Med 1997;157:1537-1544
---
I.1.5b OCCUPATIONAL EXPOSURE (HEALTH CARE WORKERS)
Occupational exposure to HCV is possible in any occupation in
which there is exposure to possibly infected blood, (i.e., nurses and
phlebotomists through needle sticks, emergency medical technicians through blood
at accident scenes, etc.). The risk of HCV infection following a needlestick
injury with HCV-contaminated blood may be as high as 10%. Nonetheless, the risk
of occupational transmission of HCV to Health Care Workers is far less than that
of HBV.
---
Needlestick accidents pose a varying rate of transmission, from 0% in
81 Spanish patients followed for 12 months by radioimmunoblot assay II up to as
high as 10% in other studies using detection by PCR. This rate is lower than
that of HBV (7% to 30%) but is higher than HIV (0.5%). The resultant hepatitis
seems to be mild, transient, and less likely to evolve into a chronic hepatitis.
This may reflect a low virus load or different HCV strains. There is no evidence
to date to support the use of antiviral therapy for acute exposures. -
"Recent Developments in Viral Hepatitis", Current Opinions in
Gastroenterology, 1994
---
I.1.5c TOOTHBRUSHES/RAZORS/NAIL
CLIPPERS
It is possible for toothbrushes, razors, nail clippers,
tweezers and similar personal care items to come in contact with infected blood.
Therefore, sharing of these items is not recommended.
---
I.1.5d HEMODIALYSIS
Hepatitis C viral
infection is a common infection in hemodialysis units, according to a report by
Dr. Brian J.G. Pereira of Tufts University in the the January 25, 1996 edition
of Family Practice News.
Dr. Pereira points to data from eight studies that indicate a 16% prevalence rate of infection in nearly 2,500 dialysis patients without a history of blood transfusion - a rate "considerably higher" than that seen in the general population.
---
I.1.6 HIGHLY SPECULATIVE MODES OF TRANSMISSION OF
HCV
The following are considered highly speculative because either
no studies have been done, conflicting studies have been done, or there is
scientific reason to believe this is not a mode of transmission, but there still
is no conclusive study to rule it out.
---
I.1.6a TEARS, SALIVA, URINE, AND OTHER BODY FLUIDS
Body fluids from 14 patients with chronic hepatitis C were
analyzed for the presence of hepatitis C viral RNA using the polymerase chain
reaction. ...The hepatitis C viral genome was not detected in any saliva or
semen sample. These findings suggest that body fluids of patients with chronic
hepatitis C are rarely, if ever, contaminated with the hepatitis C virus. This
may help to explain the infrequent transmission of this disease by sexual or
close physical contact. - "Absence of hepatitis C viral RNA from saliva and
semen of patients with chronic hepatitis C", Fried MW; Shindo M; Fong TL; Fox
PC; Hoofnagle JH; Di Bisceglie AM, Gastroenterology 102: 1306-8 (1992)
---
Previous studies have provided conflicting results on the presence of
hepatitis C virus-RNA in saliva. In this study, 23 (62%) of 37 patients tested
positive for hepatitis C virus-RNA in saliva, using polymerase chain reaction
analysis. A slightly greater proportion had a sporadic rather than a parenteral
origin of chronic hepatitis C. These results provide a biological basis for
saliva as a possible source of hepatitis C virus (HCV) infection, but do not
necessarily imply transmission by this route. - "Detection of HCV-RNA in
saliva of patients with chronic hepatitis C", P. Couzigou, L. Richard, F. Dumas,
L. Schouler & H. Fleury, Gut 34:S59-60 (1993)
---
We conclude that HCV RNA is present in the saliva of approximately
half of patients with acute and chronic hepatitis C, and the presence of HCV RNA
correlates with HCV viremia. The efficiency of HCV transmission is low among
spouses. - "Hepatitis C virus RNA in saliva of patients with posttransfusion
hepatitis and low efficiency of transmission among spouses", J. T. Wang, T. H.
Wang, J. C. Sheu, J. T. Lin & D. S. Chen, Department of Internal Medicine,
National Taiwan University Hospital, Taipei, Republic of China.
---
For up to 20 to 40% of patients chronically infected with hepatitis C
virus (HCV), the mode of transmission is still unknown. We demonstrate that tear
fluid contains HCV RNA-carrying material with the properties of infectious virus
and conclude that smear infection with tear fluid may play a role in HCV
transmission. - "Tear fluid of hepatitis C virus carriers could be
infectious", H. H. Feucht, B. Zollner, M. Schroter, H. Altrogge & R. Laufs,
J Clin Microbiol 33: 2202-2203 (1995)
---
I.1.6b CAT SCRATCHES
It is unknown if
the hepatitis C virus can be transmitted via cat's claws if the cat scratches
one person and immediately scratches another.
---
I.1.6c MOSQUITOS
Researchers have
determined that the hepatitis C virus is not transmitted by mosquitos. There is
a lack of epidemiological or physical evidence that it is mosquito-borne and
experiments to see any HCV replication in mosquito cells have failed.
There are two ways that mosquitos can transmit illness to humans. These are "mechanical transmission" in which a small amount of blood may be present on the mosquito's feeding spike. This type of transmission does not occur with serious human diseases such as HCV, HBV, or HIV. The second way mosquitoes transmit disease is called "biological" transmission. Studies show that mosquitoes can swallow viruses into their middle gut, but once there the virus dies and is digested in the same way we digest food - by breaking it down using acid.
---
I.1.6d ALTERNATIVE MEDICAL
PROCEDURES
Some cases may be related to the use of poorly
sterilized needles by medical practitioners in some countries as well as folk
medicine and cultural practices that involve skin piercing.
Alternative medical procedures involving invasive medical procedures, particularly those performed in non-medical settings, or involving autologous blood (such as the ozone-enrichment of blood) may transmit the hepatitis C virus. ref: "Transmission of Hepatitis C by Ozone Enrichment of Autologous Blood," Lancet, 1996;347:541).
---
I.1.6.e HOUSEHOLD TRANSMISSION
Household
transmission of hepatitis C is rare. It can occur where blood-to-blood contact
happens. This could involve your blood spills coming into contact with someone's
open cut, or to a lesser extent, the sharing of razor blades, toothbrushes and
sharp personal grooming aids. It is advisable to wipe up blood spills with paper
towels and bleach, and to keep razors and toothbrushes separate from those
belonging to other family members.
---
I.1.6f OTHER
A proportion of HCV
infected individuals do not fall into any currently recognized risk group. It is
thought that some of these cases may have had exposure to injected drugs many
years ago which they have forgotten or are unwilling to discuss.
---
I.1.6g IS HCV ANYTHING LIKE HIV?
Yes
and No. HIV and HCV are both RNA viruses. That is both use RNA to carry their
genetic code until they find a yummy host! However, these viruses belong to two
entirely different families. Sort of like whales and humans are both mammals,
but boy what a difference. They have completely different strategies for
replication and for survival.
HIV is a retrovirus, and once the virus is in a human cell it copies itself
to DNA and migrates into the cell nucleus and integrates into the host genome
and is then copied everytime the cell copies it's own DNA. Retro meaning it
reverts to a DNA virus once it is in the cell. Other retro viruses are HTLV
viruses like some types of leukemia.
HCV is a flavivirus. It is related to yellow fever and dengue fever viruses.
It replicates by making positive and negative RNA strands and does not make DNA
or integrate into the host genome.
There are lots of other structural and envelope differences between these two, but the main point is that HIV and HCV are NOT very similar at all--except they both completely screw up the immune system and there is no known cure.
---
I.1.7 PREVENTION
Prevention: avoid risk behaviors. Shots of gamma globulin after a person has been stuck with a needle do not seem to work. There are no current HCV vaccines. With screening of the blood supply, the risk of HCV infection from a transfusion has dropped from 10% (1970's) to less than 1%. "Prevention, Diagnosis, and Management of Viral Hepatitis", AMA
---
I.1.7a WHEN, AND FOR HOW LONG, IS A PERSON ABLE TO
SPREAD THE HEPATITIS C VIRUS?
Some people carry the virus in their
bloodstream and may remain contagious for years. The disease may occur in the
acute form and be followed by recovery, but the majority of the cases become
chronic and cause symptoms for years.
---
I.1.7b HOW CAN THE SPREAD OF HEPATITIS C BE PREVENTED?
People who have hepatitis C should remain aware that their blood
and possibly other body fluids are potentially infective, even when the person
carrying the virus is asymptomatic. Care should be taken to avoid blood exposure
to others by sharing toothbrushes, razors, needles, etc. Infected people must
not donate blood, plasma or semen, and should inform their dental or medical
health providers so that proper precautions can be followed.
---
I.1.7c CLEANING UP BLOOD SPILLS
A 10%
bleach (soak for 30 minutes) should be used on all contaminated surfaces. There
is no proof that this KILLS everything, but you can't autoclave the world. There
are also chemical disinfectants containing phenols and other very expensive
ingredients, but for home use bleach is the best we have. Bleach can be VERY
VERY corrosive on some surfaces..so be careful what you slop it on.
---
Pure H2O Bio-Technologies Inc. is currently working on a new germ killing liquid that kills bacteria and some viruses, including hepatitis C .
---
I.1.7d WHAT TO DO IN CASE OF AN ACCIDENTAL NEEDLESTICK
Because there is no effective neutralizing antibody or vaccine
for preventing hepatitis C virus (HCV) transmission, HCV can be transmitted to
health care workers through accidental needlesticks. In a study reported in the
journal Clinical Infectious Diseases, after the clinical onset of acute
hepatitis, two health care workers who had sustained accidental needlesticks
were treated with interferon (total dose, similar to 300 megaunits). Neither
individual developed chronic hepatitis. This finding raises the possibility that
treatment with low-dose interferon following an accidental needlestick may be
beneficial, even when it is started after the clinical onset of hepatitis. -
"Early Therapy with Interferon for Acute Hepatitis C Acquired Through a
Needlestick." Clinical Infectious Diseases, May 1997;24(5):992-994.
---
I.1.8 WHO SHOULD I TELL?
If you have
hepatitis C, you are under no legal obligation to tell others. It is up to you
to decide whether to tell anyone of your hepatitis C status. Some people, (and
unfortunately some health care providers also) may have judgmental attitudes or
unnecessarily exaggerated fears of infection. People should carefully consider
who they inform, in light of possible discrimination. How people might have
caught the virus is not important. Those who have the hepatitis C virus are
covered by anti-discrimination laws.
---
I.1.9 CAN YOU GET HEPATITIS MORE THAN
ONCE?
Once you completely recover from hepatitis A or B you can't
get it again, although in some people the condition becomes chronic and can last
their whole lives. But since there are at least five different viruses that
cause hepatitis, you can get one of the others (though not D if you are immune
to B). Becoming infected with B and C at the same time may actually cause a much
more severe, dangerous case of hepatitis. A person who has recovered from a case
of viral hepatitis could also develop hepatitis again due to other causes, such
as alcohol or drugs.
If you have had hepatitis C and clear the virus, you *can* become infected with it again. Because there are so many different genotypes of hepatitis C, and because the virus mutates so rapidly, natural immunity is not developed. Studies with chimpanzees have shown that after resolution of an acute hepatitis C infection, rechallenge with the same strain of HCV causes reinfection.
---
I.1.10 VACCINES
Chiron is preparing to
begin clinical trials for a hepatitis C vaccine. Preclinical results have shown
promise for this vaccine in preventing HCV disease. If effective, trials will
require at least five years to complete.
---
Studies of laboratory animals suggest that protective immunity against
the hepatitis C virus may not develop: Animals that have recovered from HCV
infection have developed hepatitis again after rechallenge with infected
material. Another potential obstacle comes from evidence that more than a
half-dozen strains of HCV may exist. One strain may predominate in a particular
geographic region. Furthermore, different strains are likely to exhibit
differing virulence. - Hepatitis C & E: How Much of a Threat? (Special
Issue: Emerging Infectious Diseases). Brown, Edwin A. Patient Care. May 15 1994,
v28, n9, p105(8)
---
PART II: MEDICAL ISSUES
---
II.0.1 HOW DO I FIND GOOD MEDICAL CARE FOR HEPATITIS?
It is very important to find a health practitioner who is
familiar with this illness. The symptoms of hepatitis can be mimicked by other
illnesses (autoimmune illnesses, cancer, chronic fatigue syndrome, lupus,
arthritis, etc.), and if you in fact have another illness that is not properly
diagnosed, you may be losing out on getting treatments that might be effective
for you.
It is still an uphill struggle to find a doctor who is experienced in
diagnosing and treating hepatitis C. Hepatologists specialize in diseases of the
liver, and would be your best choice in physicians, followed by a
gastroenterologist (a digestive disease specialist) or an infectious disease
specialist. If there is a hepatitis support group nearby, they would be an
excellent source of advice in identifying local doctors who may be familiar with
hepatitis, or you can contact the American Liver Foundation (ALF) for a list of
doctors near you. The best way to identify local support groups is to contact
one of the national organizations. If there are no hepatitis knowledgeable
doctors in your area and you wish to find an out-of-town specialist, you may
read about such specialists from time to time in the newsletter of one of the
national organizations.
If your own doctor is sympathetic but not knowledgeable, you might gather together some medical articles on hepatitis and hepatitis treatments and encourage your doctor to study them.
---
II.0.2 WHAT IS THE DIFFERENCE BETWEEN A
GASTROENTEROLOGIST AND A HEPATOLOGIST?
A hepatologist specializes
in treating liver disease. A gastroenterologist does guts, essentially. I
recommend finding a hepatologist, as they are more likely to be on top of the
latest information concerning treatment of hepatitis C.
---
II.1.0 HOW IS IT DIAGNOSED?
While the
newer HCV antibody tests are better; false positive results still occur, and
further testing should be used to confirm the antibody test. Abnormal liver
function tests (LFTs) suggest chronic disease, but there is no correlation
between the level of the liver function tests and how severe the disease is. A
liver biopsy is the best way to identify liver inflammation or early cirrhosis.
Before 1990 doctors could diagnose HCV only by ruling out other possibilities
(thus the old name for HCV "non-A, non-B hepatitis). Hepatitis C antibodies may
not develop for two to six months after infection, so only two-thirds of
patients who go to the doctor with possible hepatitis C infection can be
diagnosed with blood tests. Diagnosis may have to exclude other possible causes
such as HAV, HBV, cytomegalovirus, Epstein-Barre virus infection, as well as
nonviral liver problems such as fatty liver, or alcohol or drug-related
diseases.
Follow-up blood tests are very important in order to determine if the disease has become chronic. The blood tests for antibodies are usually repeated three and six months after the original illness.
---
Diagnosis is most commonly made after detecting an antibody to a
portion of HCV in the blood. This indicates that the person was exposed to the
virus and that their immune system made an antibody. The test can show false
positive reactions and therefore confirmation is necessary by finding evidence
that the Hepatitis C virus is actually in the blood using the polymerase chain
reaction (PCR), an extremely sensitive test for viral RNA.
---
II.1.1 ANTIBODY TESTS
Antibody tests indicate whether the body has been exposed to the virus and
has produced antibodies to fight it. They do not determine whether or not
someone still has the virus, or how long they've been infected.
II.1.2 WHAT IS A PCR?
Polymerase Chain Reaction (PCR) . HCV PCR tests are a newly developed test
that came onto the market in late 1994. HCV PCR tests look for the presence of
the virus. Information gained from the HCV PCR can be useful in interpreting
unclear antibody test results. The HCV PCR cannot tell how long someone has been
infected.
Basically, your blood sample is broken up and certain parts are "fed" to
E.coli bacteria, which grow real fast. When there are enough of them, they are
put into the "bacteria-matic". Then that stuff is separated, and the remains are
x-rayed, producing that pretty sheet of stripes that you see in cops and robbers
shows and the OJ trial.
There are two sets, one side is the control, which is a known HCV, the other side is you. If they match you have the virus.
---
There are 3 major tests for HCV.
1) The ELISA test detects antibody to the virus.
2) The RIBA test is the
confirmatory test for HCV.
3) The Quantitative HCV PCR test, which measures
the amount of virus circulating in a person's blood stream.
---
II.1.2a WHAT IS A GENOTYPE?
Our genotype does
not change. Genotypes are as follows: 1a, 1b, 1c, 2a, 2b, 2c, 3a, 3b, 4, 5 and
3a has the highest response rate to interferon, and people with this genotype
are generally younger in age and usually IV drug users.
---
II.1.3 IS IT POSSIBLE THE TEST COULD BE WRONG?
Antibody tests are usually positive or negative, but sometimes
they come back unclear. Tests that come back positive are redone to confirm they
are right. Unclear results are repeated and if still unclear, different types of
blood tests are done. If you get a positive test result and have no risk
background (for example, blood transfusions or injecting drug use) it's a good
idea to check with your doctor to make sure that the blood laboratory double
checked the result by using confirmatory tests.
---
II.2.0 BIOPSY
If viral hepatitis
infection occurs, it may resolve on its own or become chronic. However, patients
with chronic hepatitis often do not experience symptoms. On the other hand,
others complain of excessive fatigue, weakness, and a reduced capacity for
exercise.
Since liver damage may occur even in asymptomatic cases (no patient complaints), it is important to perform a biopsy and determine whether there is ongoing liver damage. As chronic hepatitis progresses, damage to liver cells may impair liver function. The biopsy of the damaged liver indicates the degree of cellular necrosis (death of liver cells), inflammation (cellular infiltration and swelling), and scarring (scar tissue beginning to replace functioning liver cells). - "Understanding Chronic Hepatitis" - Schering - 10/92 INH-001/17098403
---
II.2.0a WHAT IS A LIVER BIOPSY?
Liver
biopsy is a diagnostic procedure used to obtain a small amount of liver tissue,
which can be examined under a microscope to help identify the cause or stage of
liver disease.
The most common way a liver sample is obtained is by inserting a needle into
the liver for a fraction of a second. This can be done in the hospital with a
local anesthetic, and the patient may be sent home within 3-6 hours if there are
no complications.
The physician determines the best site, depth, and angle of the needle
puncture by physical examination or ultrasound. The skin and area under the skin
is anesthetized, and a needle is passed quickly into and out of the liver.
Approximately half of individuals have no pain afterwards, while another half
will experience brief localized pain that may spread to the right shoulder.
Patients are monitored for several hours after a biopsy to make sure serious bleeding has not occurred. Some patients occasionally have a sudden drop in blood pressure after a biopsy that is caused by a "vagal" reflex and not by blood loss; this is caused by sudden irritation of the peritoneal membrane. The characteristics that distinguish this from a bleeding event are: 1) slow pulse rather than rapid, 2) sweating, and 3) nausea.
---
II.2.0b WHAT ARE THE DANGERS OF LIVER
BIOPSY?
The risk of a liver biopsy is minimal. The primary risk
is bleeding from the site of needle entry into the liver, although this occurs
in less than 1% of patients. Other possible complications include the puncture
of other organs, such as the kidney, lung or colon. Biopsy, by mistake, of the
gallbladder rather than the liver may be associated with leakage of bile into
the abdominal cavity, causing peritonitis. Fortunately, the risk of death from
liver biopsy is extremely low, ranging from 0.1% to 0.01%.
A biopsy should not be done if: 1) you have taken aspirin in the last 5-7 days, 2) the hemoglobin is below 9-10 grams/dl, 3) the platelets are below 50,000-60,000, or 4) the prothrombin time INR is above 1.4. Those with bleeding disorders such as hemophilia which can be temporarily corrected with transfused clotting factors can be biopsied safely.
---
II.2.0c WILL IT HURT?
Most doctors will
not do percutaneous needle liver biopsies under anesthesia. This is because the
liver is directly under the diaphram and moves as you breathe. When the needle
is inserted through the skin and body wall, the liver must not be moving or else
there is danger of a laceration. To keep the liver from moving, the patient has
to stop breathing momentarily. Doctors prefer to have you alert and following
directions, but if you are very anxious you may want to ask for a sedative to
help you relax.
The injections of the local anesthetic and the actual puncture of the liver
capsule itself can be a little painful for some people, but it only takes a
second and is over very quickly. Other people feel no pain at all, and don't
even realize it's over with until the doctor tells them they're finished.
Occasionally there will be a small to moderate amount of pain afterwards. If you find that you are uncomfortable, your doctor will generally prescribe a light painkiller immediately after the biopsy. The pain may be well away from the biopsy site, possibly in the pit of your stomach or typically in the right shoulder. The liver itself has no pain-sensing nerve fibers, but a small amount of blood in the abdominal cavity or up under the diaphram can be irritating and painful. Very occasionally, small adhesions (scar tissue) may form at or near the biopsy site, and can cause a chronic pain that persists near the liver area after the biopsy.
---
II.2.1 CHRONIC PERSISTANT OR CHRONIC ACTIVE - WHAT'S
THE DIFFERENCE?
Hepatitis C is considered to be "chronic" if it
has persisted for longer than 6 months. The term "Chronic Persistent" used to be
used to define hepatitis which persisted for longer than 6 months, but which was
not currently causing active damage to the liver. The term "Chronic Active" was
used to define hepatitis which persisted for longer than 6 months, and which was
actively destroying the liver. The differentiation between "persistant" and
"active" is not commonly used any more, with the assumption being that if the
virus exists, it is causing damage whether it is moving quickly or not.
---
About 85 percent of HCV-infected individuals fail to clear the virus
by 6 months and develop chronic hepatitis with persistent, although sometimes
intermittent viremia. This capacity to produce chronic hepatitis is one of the
most striking features of HCV infection. The majority of patients with chronic
infection have abnormalities in ALT levels that can fluctuate widely. About
one-third of HCV patients with chronic infection have persistently normal serum
ALT levels. Antibodies to HCV or circulating viral RNA can be demonstrated in
virtually all patients with chronic HCV hepatitis.
Chronic HCV is typically an insidious process, progressing, if at all, at a
slow rate without symptoms or physical signs int eh majority of patients during
the first two decades after infection. A small proportion of patients with
chronic HCV hepatitis - perhaps less than 20 percent - develop nonspecific
symptoms, including mild intermittent fatigue and malaise. Symptoms first appear
in many patients with chronic HCV hepatitis at the time of development of
advanced liver disease.
Although patients wtih HCV infection and normal ALT levels have been referred to as "healthy" HCV carriers, liver biopsies can show histological evidence of chronic hepatitis in many of these patients. - National Institutes of Health Consensus Statement on Hepatitis C 1997
---
II.2.2 WHAT ARE THE MAIN SYMPTOMS OF HEPATITIS
C?
Acute hepatitis C is almost indistinguishable from acute
hepatitis B infection. Patients with acute hepatitis C are frequently
asymptomatic (meaning that they have no symptoms), even when liver tests are
abnormal. - "Hepatitis C & E: how much of a threat?" Special Issue:
Emerging Infectious Diseases, Brown, Edwin A., May 15 1994, v28, n9,
p105(8)
Soon after contracting the infection many people have a flu-like illness with
fatigue, fever, muscular aches and pain, nausea and vomiting. About 10% of
patients become jaundiced (their skin turns yellow). Generally these symptoms
resolve and the patient has no symptoms of liver disease for many years.
Symptoms may occur from two weeks to six months after exposure but usually
within two months.
What are the symptoms of chronic infection and cirrhosis? The symptoms of chronic infection range from no symptoms at all, to gradually progressive fatigue and lack of energy, to complete debility. The effects of the virus vary widely between individuals.
The symptoms of cirrhosis include progressive fatigue, jaundice (yellow skin), icterus (yellow eyes), dark urine (the color of cola), abdominal swelling, muscle wasting, itching, disorientation and confusion, loss of appetite, and easy bruisability.
---
In an informal survey of hepatitis C symptoms, Scott Warren
<swarren@idir.net> polled 50 people on the HEPV-L list and compiled the
following results:
FATIGUE, WEAKNESS, TIREDNESS - 72%
JOINT, MUSCLE PAINS - 52%
MEMORY
LOSS, MENTAL CONFUSION - 50%
SKIN PROBLEMS-DRY\ITCHY\RASHES\SPOTS -
44%
DEPRESSION, ANXIETY, IRRITABILITY, ETC - 44%
INDIGESTION, NAUSEA,
VOMITING, GAS - 34%
SLEEP DISTURBANCES - 32%
PAIN OR DISCOMFORT IN ABDOMEN
- 32%
CHILLS, SWEATING, HOT \ COLD FLASHES - 26%
EYE OR EYESIGHT PROBLEMS
- 24%
SENSITIVITY TO HEAT OR COLD - 22%
NO SYMPTOMS - 20%
VERTIGO,
DIZZINESS, COORDINATION - 18%
FLU LIKE SYMPTOMS - 18%
HEADACHES -
18%
URINARY PROBLEMS, ODOR, COLORATION - 16%
FEVER - 16%
SLOW HEALING
AND RECOVERY - 14%
SUCCEPTIBILITY TO ILLNESS \ FLU - 14%
WEIGHT GAIN,
WATER RETENTION - 10%
MENSTRUAL PROBLEMS - 10%
APPETITE \ WEIGHT LOSS -
8%
SWELLING OF STOMACH, LEGS OR FEET - 8%
ORAL, OR MOUTH SORES \ PROBLEMS
- 8%
EXCESSIVE BLEEDING - 4%
---
II.2.2a FATIGUE
The main symptom of most
people with hepatitis C is chronic fatigue, ranging from simply getting tired
easily to extreme, debilitating fatigue.
---
II.2.2b UPPER RIGHT QUADRANT (URQ) PAIN (SIDE
PAIN)
Even though the liver itself contains no nerve endings, and
does not feel pain, many people with HCV experience a pain on the upper right
side of their body, just beneath the ribs. This is thought by some to be
"referred pain" from the swelling of the liver capsule due to the disease
process. This pain may also be referred to the right shoulder or to the back
between the shoulder blades.
---
II.2.2c LOSS OF LIBIDO
Many hepatitis C
patients find that they are no longer interested in sex. This tends to be
especially true for those undergoing interferon treatment. This is not
necessarily directly related to the hepatitis, but is most likely due to the
stress, discomfort and exhaustion caused by the struggle with a chronic illness.
---
II.2.2d RED PALMS
Red palms can occur in
any chronic liver disease and are not specifically caused by the virus. The
cause for the redness is unknown, but it's speculated that it may involve upset
hormone metabolism or microcirculatory changes.
---
II.2.2e NAUSEA
A few of the more popular
nausea aids are chewing candied ginger, putting a (small) drop of peppermint oil
on the end of your tongue, eating small frequent meals, dry crackers and weak
tea, and popsicles.
---
II.2.2f BRAIN FOG
This is the mental
fuzziness and forgetfulness that some people experience. It's not the same as
encephalopathy, and seems to occur in all stages of the illness. Some people
have found taking CoEnzyme Q10, also known as CoQ10, to be helpful (2 30mg
capsules per day). Another listmember recommends taking Gingko Biloba.
---
II.2.2g ITCHING
The build-up of
bilirubin in the skin may cause itching. Itching can be treated with
antihistamines, or cholestyramine (which binds bile in the intestines). Actigall
and Questran are two drugs reported to help with this problem.
---
II.2.2h VISION PROBLEMS
Some hepatitis
patients complain of blurring vision, and dry eyes. This can be especially true
while undergoing interferon treatment.
---
II.2.2i DIZZINESS
Some people have found
that wearing "Sea Bands" helps with their dizziness. Sea Bands are elastic bands
that can be bought, usually in sporting goods stores, which press against
pressure points in the wrist. They were designed for use in seasickness.
---
II.2.2j DRY MOUTH
There are two products
(mouthwash and toothpaste) by the name of Biotene, which are designed to help
with the problem of a dry mouth and gum problems as a result of medication use.
Several listmembers have reported great relief by using these products.
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II.3.0 IT'S NOT ALL IN YOUR HEAD!
Some
doctors (but thankfully fewer than there used to be) insist on believing that
HCV usually has no symptoms, and dismiss the patient's complaints as being "all
in their head". Some HCV+ patients have been treated for depression for many
years before their actual diagnosis of HCV was uncovered. Much is still unknown
about the hepatitis C virus, and many physicians have not had much experience
treating it. Many doctors are not yet familiar with the research which
legitimizes the various symptoms which go along with this virus.
Emerging illnesses such as HCV typically go through a period of many years before they are accepted by the medical community, and during that interim time patients who have these new, unproven symptoms are all too often dismissed as being "psychiatric cases". This has been the experience with HCV as well.
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II.3.1 WHAT IS THE EVOLUTION OF THE
DISEASE?
Three out of four people infected with hepatitis C - not
50%, as once thought - will remain infected for life. Up to half of those people
will develop cirrhosis, scarring of the liver, and up to 10,000 will die this
year, say doctors and disease trackers meeting in San Diego. The latest findings
are sobering because about 1.4% of the U.S. population is infected with the
virus - "Hepatitis C Chronic 75% of the Time", USA Today, 05-15-1995
---
At least 50-80% of people infected with HCV will develop chronic
hepatitis; ultimately, 20-30% of those will progress to cirrhosis. Another
20-30% may develop chronic HCV infection without abnormal elevations of liver
enzymes in the blood. - "Prevention, Diagnosis, and Management of Viral
Hepatitis", AMA
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II.4.0 WHAT OTHER MEDICAL PROBLEMS CAN BE RELATED TO
HCV?
Chronic hepatitis C infection occasionally causes problems
for parts of the body beyond the liver. The organs most often affected include
the blood vessels, skin, joints, kidneys, and thyroid gland. If chronic
hepatitis C infection causes liver cirrhosis (severe scarring of the liver
rarely caused by hepatitis C), many problems may arise from the cirrhosis, per
se. Potential problems from cirrhosis include fluid accumulation in the abdomen,
bleeding into the stomach, jaundice, confusion, poor blood clotting, and
susceptibility to infection.
---
Hepatitis has so many symptoms that it's easy to ascribe all new
anomalies to this disease. But HCV patients are not exempt from getting other
illnesses also, therefore it is important to regularly monitor your health and
to consult with your doctor about the changes as they progress.
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II.4.0a CRYOGLOBULINEMIA
One-third to
one-half of people with chronic hepatitis C infection have cryoglobulinemia
(antibodies in the bloodstream attached to the hepatitis C RNA that happen to
solidify when cold). Hepatitis C is recognized as the most common cause of mixed
cryoglobulinemia. Most of the people with cryoglobulinemia from hepatitis C have
had their hepatitis for a long time or have cirrhosis. People with higher
concentrations of hepatitis C RNA in their blood do not seem to have a higher
risk of having cryoglobulinemia. Usually the cryoglobulins are in low
concentration and cause no symptoms. About twenty-percent of people with
hepatitis C and cryoglobulinemia have symptoms. Symptoms most often associated
with cryoglobulinemia include mild fatigue, joint pains, or itching.
Occasionally, people with cryoglobulinemia develop vasculitis (inflammation of the blood vessels) which can cause purpura (purple skin lesions), Raynaud's phenomenon (the hands turn white, then blue, and then red from constriction and subsequent dilation of the blood vessels), or numbness in the hands and feet. The presence of cryoglobulinemia does not effect people's response to interferon. In fact, some people with vasculitis have improvement in the vasculitis as their liver tests improve on interferon.
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II.4.0b THYROID AND AUTOIMMUNE
PROBLEMS
Chronic hepatitis C infection is also associated with
many autoimmune diseases (where the body develops antibodies which attack parts
of itself). For example, about one-tenth of people with chronic hepatitis C
infection (more often in women and older people) have antibodies to the thyroid
gland, one-half of whom may develop hypothyroidism (an underactive thyroid
gland).
Additionally, interferon therapy causes hypothyroidism or hyperthyroidism (an overactive thyroid gland) in about one-tenth of those treated. People with hypothyroidism may suffer from fatigue poor memory, weakness, constipation, weight gain, muscle cramps, intolerance to cold, hoarse voice, coarse skin, and brittle hair. People with hyperthyroidism may suffer from anxiety, insomnia, weakness, diarrhea, weight loss, intolerance to heat, velvet-like skin, and brittle nails. Hypothyroidism can be treated with thyroid hormone pills. Hyperthyroidism can be treated with pills that block thyroid hormone synthesis. If the thyroid gland dysfunction is from interferon treatment and is caught early, the thyroid gland will return to normal once interferon is stopped.
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II.4.0c RHEUMATOID ARTHRITIS-LIKE
SYMPTOMS
Hepatitis C infection can present with rheumatic
manifestations indistinguishable from rheumatoid arthritis. The predominant
clinical findings include palmar tenosynovitis: small joint synovitis, and
carpal tunnel syndrome. Risk factors such as transfusions and IV drug abuse or a
history of hepatitis or jaundice should be included in the history of present
illness of any patient with acute or chronic polyarthritis or unexplained
positive RF. In such patients, gammaglutamyl aminotransferase, serologic studies
for hepatitis C, and other tests appropriate for chronic liver disease should be
performed. - " Journal of Rheumatology, June 1996;23(6):979-983.
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II.4.0.d FIBROMYALGIA
Fibromyalgia is
the name for a condition that typically includes widespread muscle pain, fatigue
and abnormal sleep patterns. Until a few years ago, doctors called the condition
fibrositis or muscular rheumatism and believed that for the most part, the
condition was "all in the patient's head". Today, fibromyalgia is recognized by
medical organizations as a genuine and serious problem.
The symptoms of fibromyalgia typically include pain in many muscles, and
around ligaments and tendons, persistent fatigue, waking up feeling tired even
after a full night's sleep, headaches, bouts of constipation and diarrhea,
abdominal pain, painful menstrual periods, sensitivity to cold, numbness or
tingling, and difficulty exercising.
Symptoms vary widely among patients and tend to wax and wane over time. An
illness, injury, cold weather or emotional stress may trigger a fibromyalgia
episode or make ongoing symptoms worse.
A study at the Oregon Health Sciences University and Portland Adventist
Hospital suggests hepatitis C may trigger fibromyalgia ("Fibromyalgia: A
prominent feature in patients with musculoskeletal problems in chronic hepatitis
C, A report of 12 patients," by A. Barkhuizen, G.S. Schoepflin, and R.M.
Bennett, Journal of Clinical Rheumatology, Vol. 2, No. 4, August 1996) .
This study is the first to show a link between the two illnesses.
It was determined that the between the hepatitis C virus and fibromyalgia
followed three distinct patterns:
In nine patients, fibromyalgia developed as a long-term complication of the
hepatitis, arising on average 13.4 years after the virus was acquired.
In two patients, fibromyalgia arose simultaneously with the hepatitis C
infection.
In one patient, pre-existing fibromyalgia was significantly worsened by the
hepatitis C.
It is unknown why the hepatitis C virus and fibromyalgia may be linked, but
the authors suggest that hepatitis C causes chronic activation of the immune
system that leads to muscle aching, fatigue, mental changes, sleep
abnormalities, and alterations of the neuroendocrine system.
The patients with both hepatitis C and fibromyalgia could be distinguished from most other patients with fibromyalgia alone because they had symptoms unusual to fibromyalgia. These symptoms included synovitis (inflammation of the membrane around a joint, bursa, or tendon) and vasculitis (inflammation of a blood or lymph vessel). In addition, laboratory findings pointed to a disease process other than fibromyalgia.
---
II.4.0e DERMATOLOGICAL
MANIFESTATIONS
The main dermatologic disorders in HCV infection
include (1) vasculitis (mainly cryoglobulin-associated vasculitis, the cause of
which is HCV in most cases, and, possibly, some cases of polyarteritis nodosa);
(2) sporadic porphyria cutanea tarda; (3) cutaneous and/or mucosal lichen
planus; and (4) salivary gland lesions, characterized by lymphocytic
capillaritis, sometimes associated with lymphocytic sialadenitis resembling that
of Sjoegren's syndrome.
Hepatitis C virus is the cause of, or is associated with, various dermatologic disorders. In patients with such disorders, HCV infection must be sought routinely because antiviral therapy may be beneficial in some of them. - Arch Dermatol. 1995; 131:1185-1193
---s
II.4.0f PORPHYRIA CUTANEA TARDA
(PCT)
Porphyrins are a group of compounds that are mainly
synthesized in the bone marrow. They play an important role in many chemical
reactions in the body, e.g. with proteins to build hemoglobin. They are later
converted to bile pigments mainly in the liver. Porphyrinuria increase of
porphyrins in the urine) may be caused by chronic liver diseases. Hepatitis C is
a major cause of porphyria throughout the world and may cause many symptoms,
including excess blood iron - important in conjunction with an interferon
therapy (since elevated blood iron seems to reduce the effect of interferon).
Porphyria cutanea tarda is a rare deficiency of a liver enzyme essential for cellular metabolism. The enzyme deficiency may cause sun exposed skin to blister, ulcerate, turn dark, or bruise. Hair may increase on the forehead, cheeks, or forearms, and the urine may turn pink or brown. It now appears that hepatitis C is the most common trigger of porphyria in people who are predisposed. Topical sunscreens do not prevent the skin lesions. Avoidance of alcohol and removal of iron by repeated phlebotomy (blood removal) or taking medication that binds to iron sometimes helps. Chloroquine (an anti-malaria drug), which removes a toxic by-product of the enzyme deficiency, may help, as well.
---
II.4.0g LICHEN PLANUS
Occasionally,
people with chronic hepatitis C develop a skin condition called lichen planus.
It is a grouping of small, itchy, irregular, flat-topped reddened bumps. The
bumps often have a network of very fine gray lines on their tops. The bumps show
up most often on the wrists, shins, lower back, or genitals. Lichen planus also
frequently occurs in the mouth, where it looks like a white, net-like plaque. It
sometimes shows up as mouth ulcers and can be treated with a steroid mouth rinse
called Dexamethasone Elixir or Nystatin tablets.
---
II.5.0 CYCLES AND FLAREUPS
Hepatitis
flareups tend to occur in cycles, where for a while you may feel pretty good,
then bad (maybe days to weeks for each period), then good again. It can be
frustrating to obtain some relief, but then not know whether you have recovered
or if you are merely between cycles.
Some people claim that they begin to feel better in the Spring, then start to feel worse again in August/September, with a low point usually around November/December.
---
II.6.0 SHOULD I BE VACCINATED AGAINST OTHER TYPES OF
HEPATITIS?
Patients with chronic hepatitis C who are at risk for
hepatitis B should be offered vaccination during their first contact with
healthcare professionals, according to a report from Great Britain's University
of Cambridge. ("Prospective Study of Hepatitis B Vaccination in Patients with
Chronic Hepatitis C," British Medical Journal, May 25, 1996;312:1336-1337).
Chronic hepatitis C (HCV) infection is estimated to occur in between 70- and 92 percent of intravenous drug users. These IV drug users are also at risk for parenterally or sexually transmitted hepatitis B. Coinfection with hepatitis B virus (HBV) may accelerate underlying liver damage due to hepatitis C.
---
II.7.0 HCV AND WOMEN'S CONCERNS
Women
can be affected by hepatitis C in a different way from men. This is possibly due
to hormonal effects and liver damage.
MENSTRUATION: The hormonal effects of HCV can involve menstrual
irregularities, particularly if you are experiencing significant hepatitis C
symptoms. It is important that your general health is checked as well as your
hepatitis C monitored. Tampons and sanitary napkins should be secured in plastic
bags before going into the trash.
BIRTH CONTROL: If you are experiencing significant hepatitis symptoms,
using the estrogen-based contraceptive pill may be inadvisable. In these cases,
the progesterone-only pill or Depo-Provera may be preferable.
HORMONE REPLACEMENT THERAPY: If you have severe hepatitis symptoms you may need to discuss with your doctor whether hormones should be used for menopausal symptoms. If this is the case, external vaginal creams and skin patches are probably better than pills.
---
Dysfunctional uterine bleeding and premature menopause, and most any
other sort of hormonal aberration is pretty common with chronic liver disease.
The liver processes these hormones, and they tend to not get processed properly
when the liver is damaged.
---
While on interferon therapy, many woman find that they come down with
one yeast infection after another, due to the immunosuppression.
---
Waste paper products (napkins and tampons) which have been exposed to
blood should be securely wrapped and disposed of in a safe manner. A 10% bleach
(soak for 30 minutes) should be used on all contaminated surfaces, and in the
laundry for clothing and linens which have been exposed to blood.
---
Sexual intercourse during your period is *not* safe.
---
II.7.1 PREGNANCY AND BREASTFEEDING
A
substantial proportion of pregnant women with hepatitis C virus infection have
circulating HCV RNA, even when they are asymptomatic, according to a report from
Italy. Researcher A. Floreani and colleagues noted, however, that these women do
not have an increased risk of obstetric complications and that pregnancy does
not appear to induce symptomatic liver disease. - "Obstetrics (HCV);
Circulating HCV RNA Does Not Increase Pregnancy Complications", Hepatitis
Weekly, June 24, 1996
If a baby is born to an HCV+ mother and its blood was tested at birth for
hepatitis C antibodies, the test would come back positive. This is because the
baby has some of its mother's antibodies. These antibodies clear naturally over
time. A test at 12 months usually confirms a toddler has the virus.
BREASTFEEDING: The hepatitis C virus has not been found in samples of breastmilk taken from HCV+ women. Transmission risk via breastmilk is therefore very unlikely. There are many advantages to breastfeeding. Breastfeeding mothers should check their nipples before each feed and avoid breastfeeding if they are cracked or bleeding.
---
Circulating HCV RNA does not increase pregnancy complications. A
substantial proportion of pregnant women with hepatitis C virus infection have
circulating HCV RNA, even when they are asymptomatic, however, these women do
not have an increased risk of obstetric complications and that pregnancy does
not appear to induce symptomatic liver disease. "There is no risk to the outcome
of pregnancy in an anti-HCV positive pregnant mother. The majority of pregnant
women have normal transaminase levels during the course of pregnancy, although a
substantial proportion have circulating HCV RNA. Pregnancy does not induce a
deterioration of liver disease, and HCV infection does not increase the risk of
obstetric complications." - - "HCV Infection in Pregnancy," British Journal
of Obstetrics and Gynecology, 1996;103:325- 329
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II.8.0 HOW DOES HCV AFFECT
CHILDREN?
Children with chronic hepatitis cannot be treated simply
like miniature adults. Specific issues and questions need to be addressed when
dealing with the pediatric age group.
Pediatric patients are less likely than adults to have symptoms of infection
with hepatitis C, leaving the viruses undetected and possibly unknowingly
spread. According to information available on the natural history of HCV, the
percentage of children who become chronic and the long-term outcomes are similar
to the percentage of adults. Children who are chronic carriers of HCV have
normal growth patterns.
Liver biopsy appears to be less valuable in children than adults. Chronic
hepatitis rarely progresses to cirrhosis in children. In 16 HCV children
followed for up to 14 years, encephalopathy (mental confusion), ascites (swollen
stomach), or bleeding did not develop. The lack of cirrhosis in children with
HCV is consistent that a time period of 10 to 20 years or more is required for
cirrhosis to occur. Hepatocellular carcinoma occurs very rarely in the pediatric
group.
Few studies exist examining interferon use in children with chronic HCV,
however a recent study in Hepatology suggests that interferon therapy may be
beneficial The rates of initial and long-lasting response were higher in the
study than those observed in adults treated with standard schedules. Possible
explanations include the shorter time of infection in children, and that most
have a mild form of liver disease. The results of this study are encouraging,
according to the researchers, but more investigation needs to be conducted.
Many questions still remain about chronic hepatitis C in children. Further studies need to be done to determine the disease's course and progress as well as the role of interferon treatment.
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II.9.0 WHAT ARE THE DIFFERENT CLINICAL INDICATIONS OF
HCV?
---
II.9.1 ELEVATED LIVER ENZYMES
There are
two general categories of "liver enzymes." The first group includes the alanine
aminotransferase (ALT) and the aspartate aminotransferase (AST), sometimes
referred to as the SGPT and SGOT. These are enzymes that are indicators of liver
cell damage. The other frequently used liver enzymes are the alkaline
phosphatase and gamma-glutamyltranspeptidase (GGT and GGTP) that indicate
obstruction to the biliary system, either within the liver or in the larger bile
channels outside the liver.
The ALT and AST are enzymes that are located in liver cells and leak out and make their way into the general circulation when liver cells are injured. The ALT is thought to be a more specific indicator of liver inflammation, since the AST may be elevated in diseases of other organs such as heart disease or muscle disease. ALT and AST are often used to monitor the course of chronic hepatitis and the response to treatments, such as prednisone and interferon. The alkaline phosphatase and the GGT are elevated in a large number of disorders that affect the drainage of bile, such as a gallstone or tumor blocking the common bile duct, or alcoholic liver disease or drug-induced hepatitis, blocking the flow of bile in smaller bile channels within the liver. The alkaline phosphatase is also found in other organs, such as bone, placenta, and intestine. For this reason, the GGT is utilized as a supplementary test to be sure that the elevation of alkaline phosphatase is indeed coming from the liver or the biliary tract. In contrast to the alkaline phosphatase, the GGT tends not to be elevated in diseases of bone, placenta, or intestine. Mild or moderate elevation of GGT in the presence of a normal alkaline phosphatase
is difficult to interpret and often caused by changes in the liver cell enzymes induced by alcohol or medications, but without causing injury to the liver.
---
II.9.1a ELEVATED ALFHA-PHETOPROTEIN
LEVELS
It is fairly common for alfa-phetoprotein markers to be
elevated in patients with hepatitis C. Alfaphetoprotein is a marker for tumors,
but unless your numbers are extremely high (for example, in the hundreds), there
is no need for alarm. Your doctor will probably want to perform further studies,
such as an ultrasound or CT scan, just to be on the safe side
--
II.9.2 JAUNDICE
Jaundice (yellow skin)
may appear as a symptom occasionally, but is most common during an acute attack.
Jaundice is caused by the buildup of bile pigment that is passed by the liver
into the intestines. This same bile buildup can also cause intense itching.
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II.9.3 HEPATOMEGALY, SPLENOMEGALY
Some
people experience a swelling of the liver (hepatomegaly) or the spleen
(splenomegaly) as a result of hepatitis.
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II.9.4 SPIDER NEVI
Spider nevi are small
capillaries that are seen on the surface of your skin. Branches form (grow) from
the one capillary and it can either look like a small red spider or a splat
(kind of like a squashed spider). They are also referred to as spider angiomas.
If you have less than 10 that can be considered normal, more than that and it's
an indication of chronic liver disease. They can be found only above the waist,
usually on the chest, upper arms, shoulders, face, neck and upper back.
---
II.9.5 ASCITES
Occurring in cirrhosis,
the accumulation of fluid in the abdominal cavity, or ascites, is related to
portal hypertension, significant reduction in serum albumin, and renal retention
of sodium. The volume of abdominal ascites in adults with cirrhosis may reach
levels as great as 10 to 12 liters (10.6 to 12.7 quarts). Ascitic fluid may
accumulate in the scrotum and in the chest cavity, where its presence, combined
with the upward pressure on the diaphragm from the abdominal fluid, may severely
affect breathing. Appetite also is often reduced by the abdominal
distention.
Ascites are treated by the removal of enough fluid directly from the abdomen by needle puncture to ease discomfort and breathing. Patients are placed on diets low in salt, and they are given diuretic drugs to increase the output of water by the kidneys. If these measures do not control massive ascites, ascites can be drained internally into the general venous blood system by running a plastic tube from the abdominal cavity, under the skin of the chest, into the right internal jugular vein of the neck (peritoneovenous shunt of LeVeen).
---
II.9.6 PORTAL HYPERTENSION /
VARICES
Sometimes occurring in cirrhosis, portal hypertension is
the increased pressure in the portal vein and its tributaries resulting from
blockages to the blood flow into the liver. It is usually caused by the scarring
processes of cirrhosis. The increased pressure causes varices, or dilations of
the veins leading into the portal vein. When varices are located in superficial
tissues, they may rupture and bleed profusely. Two such locations are the lower
esophagus and the perianal region.
Esophageal varices are likely to bleed most heavily, and this bleeding is frequently associated with the onset of hepatic encephalopathy or coma. Because of their location at the lower end of the esophagus or the upper portion of the stomach, bleeding from varices is often difficult to control. If variceal bleeding persists, surgical formation of a shunt, or artificial passageway, from the portal vein to an abdominal vein may be done.
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II.9.7 HEPATIC ENCEPHALOPATHY
Hepatic
encephalopathy refers to the changes in the brain that occur in patients with
advanced acute or chronic liver disease. If liver cells are damaged, certain
substances that are normally cleansed from the blood by the healthy liver are
not removed (mainly ammonia, or possibly certain fatty acids). A patient with
chronic hepatic encephalopathy may develop progressive loss of memory,
disorientation, untidiness, and muscular tremors, leading to a form of chronic
dementia. The ingestion of protein invariably aggravates these symptoms.
The treatment of hepatic encephalopathy involves, first, the removal of all drugs that require detoxification in the liver and, second, the reduction of the intake of protein. Restricting the amount of protein in the diet will generally lower the levels of amino acids and ammonia in the bloodstream and brain. Most physicians advise their patients with this condition to eat only about 40 grams of protein a day, and will prescribe lactulose or neomycin to lower amino acid production. Non-meat proteins, such as those found in vegetables and milk, are also recommended. Certainamino acids are used in treatment, since they are considered less likely to cause mental impairment. A dietary supplement rich in these amino acids is used at many liver treatment centers.
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II.9.8 CIRRHOSIS
When chronic diseases
cause the liver to become permanently injured and scarred, the condition is
called cirrhosis. The scar tissue that forms in cirrhosis harms the structure of
the liver, blocking the flow of blood through the organ. The loss of normal
liver tissue slows the processing of nutrients, hormones, drugs, and toxins by
the liver. Also slowed is production of proteins and other substances made by
the liver.
People with liver cirrhosis may develop many problems beyond the liver. When
the liver is scarred, the blood cannot easily get through the liver, and backs
up under higher than normal pressure (portal hypertension). This often causes
ascites, which is yellow fluid that leaks out of the bloodstream into the
abdominal cavity.
If the ascites becomes tense, it can cause an umbilical hernia (a protruding
belly button). The backed-up blood also often creates varices, in which the
pressure causes the blood vessels around the esophagus to burst causing
significant blood loss. Varices can be treated with beta blockers, or can be
obliterated using endoscopically-placed rubber bands or injections of liquid
that cause the varices to scar. If endoscopy fails to stop bleeding, a TIPS
(transjugular intrahepatic portosystemic shunt) can be created by inserting a
short metal mesh tube through a neck vein into the liver and connecting the
portal vein in the liver to a regular vein in the liver. Another alternative is
to surgically redirect some of the blood flow around the liver.
People with cirrhosis sometimes may develop jaundice (a yellowing of the
whites of the eyes or the skin) due to an accumulation of bilirubin in the
blood. If the bilirubin is excreted in the urine, the urine may turn dark.
People with cirrhosis are also at risk for hepatic encephalopathy, which is
fatigue or confusion caused by ammonia and other products of protein digestion
which are inadequately cleared from the bloodstream by the liver.
People with cirrhosis often bruise easily because the liver manufactures reduced amounts of clotting factors. Additionally, platelets may be lower than normal in the circulation if the spleen is enlarged. A spleen enlarged from portal hypertension may hold onto too many platelets.
---
Chronic HCV infection leads to cirrhosis in at least 20 percent of
patients within 2 decades of the onset of infection. Cirrhosis and end-stage
liver disease may occasionally develop rapidly, especially among patients with
concomittant alcohol use. - National Institutes of Health Consensus Statement
on Hepatitis C 1997
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II.9.9 FULMINANT HEPATITIS
In very rare
cases hepatitis symptoms develop quickly and become very severe. This less
common form of hepatitis is called fulminant hepatitis or fast-progressing
hepatitis, and it requires prompt medical attention. It can be fatal in up to 70
to 80 percent of cases. The kidneys may fail, and the liver shrinks as cells are
killed. The person may fall into a coma and die. Fulminant liver failure
following HCV infection has been reported but is a rare occurrance.
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II.9.10 DOES HCV INCREASE THE LIKELIHOOD OF CANCER?
Chronic infection by HCV is associated with an increased risk of
liver cancer. The prevailing concept is that hepatocellular carcinoma (HCC)
occurs against a background of inflammation and regeneration associated with
chronic hepatitis over the course of approximately 3 or more decades. Most cases
of HCV-related HCC occur in the presence of cirrhosis. The risk for a person
with chronic HCV hepatitis developing HCC appears to be 1-5 percent after 20
years, with striking variations in rates in different geographic areas of the
world. Once cirrhosis is established, the rate of development of HCC is 1-4
percent per year. - National Institutes of Health Consensus Statement on
Hepatitis C 1997
---
Chronic infection with hepatitis C virus (HCV) is regarded as a risk
factor for hepatocellular cancer, mostly in patients with liver cirrhosis. We
looked for HCV genomes in the livers of patients with hepatocellular cancer who
did not have cirrhosis to see whether HCV was directly oncogenic. Cancerous and
non-cancerous liver tissue, and serum samples from 19 patients negative for
hepatitis B surface antigen were analysed by polymerase chain reaction for the
presence of HCV genome, HCV replication, HCV genotyping, and HBV genome. 13 of
19 patients were HCV RNA-positive in cancerous and non-cancerous liver tissue; 8
of 17 tested were anti-HCV positive. Among the 13 HCV RNA-positive patients, 11
had genotype 1b and 2 had genotype 2a. 7 of 13 serum samples were HCV RNA
positive. 7 of 19 patients were HBV DNA positive in cancerous and non-cancerous
liver tissue, 5 of them anti-HBc positive. 4 patients were both HCV RNA and HBV
DNA positive and 3 were both HCV RNA and HBV DNA negative. The results provide
evidence for the association of HCV, mostly genotype 1b, with hepatocellular
cancer without the intermediate step of cirrhosis. - "HCV-associated liver
cancer without cirrhosis", De Mitri MS; Poussin K; Baccarini P; Pontisso P;
D'Errico A; Simon N; Grigioni W; Alberti A; Beaugrand M; Pisi E; et al,
Department of Internal Medicine, University of Bologna, Italy, Lancet 345: 413-5
(1995)
---
Previously, we reported the high prevalence of hepatitis C virus (HCV)
infection in patients with oral cancer or oral lichen planus in Kyushu, Japan.
We now report a 61-year-old man with chronic hepatitis C and no oral lesions who
developed oral cancer 6 months after interferon therapy (interferon alpha, 6
million units (MU) daily for 2 weeks and then 3 times a week for 14 weeks). This
case emphasizes the need for periodic oral cavity examinations of hepatitis C
patients and contributed to the investigation of oral cancer and HCV. - "Oral
cancer and hepatitis C virus (HCV): can HCV alone cause oral cancer?--a case
report." Kurume Medical Journal, 1996 Vol 1, Issue 43, pp 97-100
---
It is thought that treatment with interferon reduces the risk of later
developing liver cancer. "The low incidence of hepatocellular carcinoma in
patients treated with interferon suggests that interferon may prevent the
development of hepatocellular carcinoma." - "Risk Factors and the Effect of
Interferon Therapy in the Development of Hepatocellular Carcinoma," Journal of
Gastroenterology and Hepatology 1997 Feb;12(2):149-155
---
An association between chronic hepatitis C infection and non-Hodgkin's
lymphoma has been reported. " HCV Infection and Extrahepatic Malignancies,"
Journal of Clinical Gastroenterology 1997 Mar;24(2):87-89
---
II.10.0 HOW MANY OF US ARE
THERE?
Hepatitis C accounts for 20% of community-acquired
hepatitis in the US. Approximately 200 case of hepatitis C are reported in New
York State each year. -- "Prevention, Diagnosis, and Management of Viral
Hepatitis", AMA
Each year, 150,000 new cases of hepatitis C infection occur in the United
States. -- " Hepatitis C & E: how much of a threat?" Special Issue:
Emerging Infectious Diseases, Brown, Edwin A., May 15 1994, v28, n9,
p105(8)
The (US) Center for Disease Control and Prevention, estimates that at least 17 1/2 million people (in the US) are living with chronic hepatitis C infections and as many as 150,000 Americans are newly infected with hepatitis C each year.
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PART III - TREATMENT (Conventional Medicine)
A number of new therapies for
hepatitis C are emerging in clinical practice. Combination approaches of
Interferon and Ribavirin are currently being tested and will likely prove to be
beneficial. Within two to three years we expect to see a whole new class of
drugs which will be oral, have low toxicities, and improved efficacy. These
drugs will likely need to be taken lifelong and may need to be taken in
combination with each other as is currently the case in HIV disease. -
"Emerging Therapies for HCV," - Scripps Clinic and Research Foundation, Liver
Disease Study Group
---
III.1.0 INTRON A (INTERFERON ALPHA 2B, RECOMBINANT)
Interferon is a genetically engineered product originally
licensed in 1986 to treat hairy cell leukemia. It is a copy of a protein found
naturally in low levels in the human body. It was OK'd by (US) FDA Feb. 25,
1991, to treat hepatitis C. The product, alpha interferon, is the first
effective treatment against this form of hepatitis, which affects an estimated
150,000 Americans each year.
According to the manufacturer's (Schering-Plough) literature for using
Interferon in the treatment of Hepatitis C: 3 million units per dose 3 times a
week Interferon has an effective cure rate of about 25% .
Besides hairy cell leukemia and hepatitis C, alpha interferon is licensed for treatment of AIDS-related Kaposi's sarcoma and genital warts. Schering-Plough Corporation of Kenilworth, N.J., which markets a version of the product under the trade name Intron-A, received approval for the product's use for hepatitis.
---
Treatment: Interferon has been approved for chronic HCV. Patients are
selected for therapy on the basis of persistently abnormal liver function
(blood) tests, rather than on the presence or absence of symptoms. It's not
known what should be done for patients with mild chronic HCV infection; since
some patients with mild disease can go on to develop cirrhosis, a trial of
therapy with interferon is usually recommended. It's recommended that such
patients be referred to specialists with knowledge in liver disease
(gastroenterologist/hepatologists). -- "Prevention, Diagnosis, and Management
of Viral Hepatitis", AMA
About half of patients treated with interferon respond, with better blood tests and better liver biopsies. Half the patients who respond relapse once the interferon is stopped. -- "Prevention, Diagnosis, and Management of Viral Hepatitis", AMA
---
Alpha interferon seems to work better the sooner it is used after
infection. However, in many cases of hepatitis C the symptoms get worse again
when the treatment is stopped. In one study, half of the chronic hepatitis C
sufferers who had responded to alpha interferon had a relapse within six months
after treatment stopped. Thus only 25 percent of HCV patients respond favorably
without relapsing.
The average six months of injections three times a week are expensive ($75 a
week). Many patients also suffer side effects, such as flulike symptoms, a
reduction in the number of disease fighting white blood cells, and a decreased
number of platelets in the blood. (Platelets are needed for blood clotting.)
Factors most closely associated with response to interferon are: 1) absence of fibrosis or cirrhosis in the pretreatment liver biopsy; 2) HCV genotype other than 1; 3) lower RNA levels in the blood (e.g., less than 2 million/ml); and 4) shorter duration of infection (which often isn't known).
---
III.1.0a WHEN IS INTERFERON TREATMENT NOT INDICATED?
Patients with chronic hepatitis B or C, with fluid in the abdomen
ascites), bleeding from dilated veins in the esophagus (variceal bleeding), or
mental confusion (encephalopathy) should be treated only in a clinical trial.
Others not suitable for treatment are those with symptomatic heart, lung or
kidney disease, with human immunodeficiency virus (HIV) infection or organ
transplant recipients on prednisone, cyclosporine and FK-506 and patients on
antidepressants or with a history of suicide attempts. Interferon should not be
given to women considering pregnancy, nor to the intended father. Patients with
active substance abuse (alcohol or illegal drugs) should not be offered this
therapy. - "Interferon Treatment for Hepatitis B and C Fact Sheet", American
Liver Foundation
---
III.1.0b INTERFERON "BREAKTHROUGH" AND
"NON-RESPONSE"
Recombinant interferon alfa
(r-IFN alpha 2) has been shown to normalize the aminotransferase levels in
approximately 50% of patients with chronic hepatitis C virus (HCV). Few patients
experience a relapse during the eatment, in spite of a complete initial response
(breakthrough). Continued treatment with r-IFN alpha 2, even at higher doses,
did not restore the previous response in any patient. All of them were then
switched to natural lymphoblastoid IFN, and this rapidly restored a complete
response in all of the patients. - "Breakthrough during recombinant interferon
alfa therapy in patients with chronic hepatitis C virus infection: prevalence,
etiology, and management." - Hepatology Vol. 21 no. 3 pp. 645-9 1995 Mar
---
A report in the Archive of Virology 1997 ;142(3):535-544 suggests that
an inapparent coinfection of the hepatitis B virus (HBV) along with the
hepatitis C virus may be implicated in cases of resistance to interferon
treatment. In addition, HBV replication may persist in patients in whom HCV
replication was inhibited by interferon treatment.
---
III.2.0 IRON REDUCTION THERAPY
A new
study published in the fall issue of American Journal of Gastroenterology, Vol
89, No. 7, suggests that using "Iron Reduction Therapy" along with interferon
can result in an effective cure rate in the area of 75-80% and that adding
cytokines and antivirals such as ribavirin can improve effectiveness even
further. The theory behind this is that viruses need iron to replicate, and by
reducing the hepatic iron in the liver you prevent them from replicating. It
should be noted that this new procedure is not yet FDA approved and is still in
the early trial stages.
---
Iron is an element required for replication of virtually all virulent
microorganisms. Reducing the amount of iron helps to limit the replication of
the hepatitis C virus. The role of iron influencing the natural history of viral
hepatitis was reported in a study more than 15 years ago (Blumberg BS,
Lustbader ED, Whitford PL. "Changes in serum iron levels due to infection with
hepatitis B virus." Proc Natl Acad Sci USA 1981;78:3222-4). In this study it
was observed that patients with hepatitis B viral infection with higher serum
iron or ferritin levels had greater likelihood of development of chronic
infections than those with lower levels, who more often resolved their
infections spontaneously.
Increases in levels of serum ferritin, iron, and transferrin saturation also have been noted with high frequencies in patients with chronic hepatitis C,2 and the higher levels have, in general, been associated with lesser likelihood of response to interferon therapy.
Complete responders to interferon have, on average, lower hepatic iron
concentrations than do noncomplete responders.
In a report by Hayashi and colleagues ("Improvement of serum aminotransferase levels after phlebotomy in patients with chronic active hepatitis C and excess hepatic iron." Am J Gastroenterol 1994;89:986-8) it was reported that iron reduction alone, by repeated venesection (bloodletting), led to significant improvement in serum alanine aminotransferase (ALT) levels in chronic hepatitis C.
---
III.3.0 RIBAVIRIN
Many hepatitis C
patients show a clear-cut biochemical response to ribavirin, with a lowering of
liver enzyme levels. However, the ribavirin does not clear circulating hepatitis
C virus RNA and relapses occur after they discontinue taking the drug.
---
III.3.1 INTERFERON AND RIBAVIRIN -
COMBINED
Over the past year, clinical trials of interferon-alpha
and ribavirin have been underway. Schering-Plough Corporation (the manufacturers
of Intron A - interferon alfa-2b) recently announced the results from two Phase
III clinical studies showing that Intron A plus oral ribavirin combination
therapy versus Intron A alone resulted in a 10-fold increase in the number of
patients showing eradication of detectable hepatitis C virus in patients who had
relapsed after prior alpha interferon treatment. Based on these results,
Schering-Plough hopes to file a New Drug Application with the Food and Drug
Administration by the end of this year.
---
III.3.2 LOW DOSE ORAL INTERFERON AND HIGH DOSE
INJECTABLE INTERFERON - COMBINED
According to a news release from
Amarillo Biosciences, Inc, dated May 12, 1997, a study is commencing to test low
dose oral interferon alpha as a combination treatment with high dose injectable
interferon alpha in hepatitis C patients in Canada and Mexico. The company has
compiled preliminary data indicating that pretreatment with low dose oral
interferon alpha preconditions patients to respond better to injectable
interferon alpha. A clinical trial will be conducted with Dr. Elliott Alpert of
Montreal as the principal investigator and another hepatitis expert located in
Mexico as co-investigator. The study is expected to eventually enroll 180
patients and could take 2-3 years to complete.
---
III.3.2 CONSENSUS INTERFERON
(INFERGEN)
Consensus interferon, or CIFN, is a synthetic form of
one type of interferon. Created by Amgen scientists, the drug has undergone
extensive clinical testing for treating hepatitis C, cirrhosis and a form of
cancer.
---
According to the NIH Consensus Development Conference on Management of
Hepatitis C 1997:
Consensus interferon at a dose of 9 ug administered tiw for 24 weeks is safe
and effective for the treatment of chronic HCV infection in interferon-naive
patients and results in a sustained HCV RNA response rate of 12 percent.
When compared to with MU (15 ug) IFN alfa-2b, 9 ug CIFN may result in higher
sustained HCV RNA response rates in patients with genotype 1 and in patients
with high pretreatment viral loads.
In patients failing prior CIFN or IFN alfa-2b therapy, retreatment with a higher dose of CIFN (15 ug) for 24 weeks results in sustained HCV RNA response rates in 8 percent of nonresponders and 32 percent of relapsers and is well tolerated.
---
III.3.3 NATURAL SOURCE INTERFERON ALPHA-N3 - HUMAN
LEUKOCYTE-DERIVED (ALFERON)
Alferon, produced by Interferon
Sciences Inc., is an injectable, natural-source, multispecies alpha interferon
produced from human peripheral blood leukocytes which is currently in clinical
trials for the treatment of hepatitis C. The preliminary results of the trials
are encouraging and further studies are planned. It is thought that the chance
of "breakthrough" is less when using natural source interferon, than with the
standard interferon alpha 2b preparation. If the results at the end of clinical
trials are favorable, the company intends to seek FDA approval of Alferon N
Injection for the treatment of hepatitis C by the end of the third quarter 1998.
---
III.3.4 ROFERON (INTERFERON ALPHA 2A,
RECOMBINANT)
---
III.3.4 LYMPHOBLASTOID INTERFERON (WELFERON,
OMNIFERON)
---
III.3.5 PEGYLATED INTERFERON (PEG-INTRON
A)
PEG-Intron A is a modified form of Schering-Plough's Intron A
(interferon alfa-2b, recombinant), developed by Enzon, Inc. to have
longer-acting properties. Currently in Phase III clinical trials, PEG-Intron A
is administered once a week, compared to the normal dosage of 3 times a week for
Intron A.
---
III.3.6 INTERFERON AND GM-CSF -
COMBINED
Effects of granulocyte/monocyte colony stimulating factor
(GM-CSF) have generally been disappointing: it is expensive, poorly tolerated,
and without beneficial effect except perhaps in a rare patient who develops
severe neutropenia due to interferon, in whom GM-CSF may permit continuation of
higher doses of interferon.
---
An open label trial of GM-CSF plus high-dose interferon (IFN) alpha 2b
was performed in 16 patients with chronic hepatitis C, who either failed to
clear virus with 6 months of daily high-dose IFN (5 MU daily) therapy (n = 22)
or were considered untreatable because of advanced disease and leukopenia (n =
2). The dose of GM-CSF used was 500 mu g subcutaneously twice weekly, The dose
of IFN used was 5 MU daily, Both agents were administered for 4 months. Five of
the 16 hepatitis C virus patients responded to combined therapy having
previously failed IFN therapy alone. No such differences for responders and
non-responders were seen with the hepatitis C virus patients, These data suggest
that the combination of GM-CSF and IFN may be more effective at achieving viral
clearance than IFN alone. - "A Preliminary Experience with GM-CSF Plus
Interferon in Patients with HBV and HCV Resistant to Interferon Therapy,"
Journal of Viral Hepatitis 1997 ;4:101-106
---
III.3.7 BETA INTERFERON,
RECOMBINANT
According to a report in the Journal of Interferon and
Cytokine Research 1997 Jan; 17(1):27-30, the intramuscular administration of
interferon-beta (IFN-beta) at a dosage of 6 million units three times per week
for 6 months was evaluated in 90 patients included in a multicenter, randomized,
controlled trial for the treatment of chronic hepatitis C. At the end of the
study, the researchers concluded that intramuscular IFN-beta at the dosage used
has little efficacy in the treatment of chronic hepatitis C.
---
While the efficacy of beta-intereron has been proven to be ineffective
when administered intramuscularly, a study reported at the 1996 Annual AASLD
conference ("Therapy of Chronic Hepatitis C Non-Responders to
Alfa-Interferon: A Preliminary Report of Intravenous Natural
Beta-Interferon") reports that beta-interferon has been proven to be
efficacious when administered by intravenous infusion, and that intravenous
beta-interferon can be a well tolerated effective treatment for patients with
chronic hepatitis C non-responders to [alpha]-IFN.
---
Another study reported at the 1996 Annual AASLD conference
("Analysis of Amino Acid Residues 2209 to 2248 of NS5A of HCV-1b in Relation
to the Response to Interferon Beta Therapy"), suggests that some HCV
patients with genotype 1b who have a mutant type of the NS5A2209-2248 gene are
sensitive to interferon beta therapy regardless of lower doses and shorter
treatment periods compared to interferon alpha. HCV-1b patients with the
intermediate or the wild type of the NS5A2209-2248 gene are resistant to
interferon beta therapy.
---
III.4.0 URSODEOXYCHOLIC ACID
(ACTIGALL)
Ursodeoxycholic acid (UDCA) has been used in chronic
liver diseaes and can limit hepatocyte injury. The various mechanisms of action
of this hydrophilic bile acid include direct cytoprotection, detergent action on
dysfunctional microtubules, immunomodulation and induction of hypercholeresis.
It has recently been used in the management of chronic hepatitis, cirrhosis,
post liver transplant rejection, graft -versus-host disease and acute viral
hepatitis, where it not only relieves symptoms of cholestasis but also arrests
ongoing hepatocyte necrosis.
According to a study reported at the American Gastroenterology Association Digestive Disease Week meeting in Washington in May 1997 (Treatment of chronic hepatitis C with interferon with or without ursodeoxycholic acid: a randomized prospective trial), combination therapy with UDCA plus interferon was no more effective than interferon monotherapy in inducing a biochemical response in previously untreated patients with chronic hepatitis C. UDCA was, however, useful in prolonging the sustained biochemical response of IFN therapy in this small pilot study
-
III.5.0 HYPERICIN (VIMRx, HIFRITZEN)
A new
drug discovered by Israeli scientists Professor David Lavi, formerly the
director of Organic Chemistry Department at the Weizmann Institute and his son,
Dr. Gad Lavi, a senior lecturer at N.Y.U., is in the second stage of clinical
testing in humans with AIDS and hepatitis and the reports are very promising.
The new drug neutralizes viruses like hepatitis C as if it were an antibiotic,
according to Dr. Lavi. The drug is produced from a plant that grows primarily in
Europe and North American and is called Hifritzin. It is claimed the active
substances in the drug neutralizes the virus and causes it to lose its power to
attack healthy cells in the body. - The Jewish Free Press, Friday March 7,
1997
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III.6.0 THYMOSIN
Thymosin alpha 1 is a
protein produced by the human body, the cow and others which is supposed to
enhance the immune system. It is associated with the thymus gland, which shrinks
as we get older - yet has important role in immunity. There are over the counter
products which take raw cow thymus - dry - defat - and process the gland in
tablet form which some claim when taken causes the human body to increase
natural production of "thymosin alpha 1". Dr. Burgstiner in Savannha, Georgia,
believes he cured himself of hepatitis B by using this formula (telephone
912-355-5755). That preparation is called "Thymic Fractions" and is produced by
a company in California called Bio-Naturals at 800-991-7990. The reference to
Dr. Burgstiner can be found in Naomi Judd's book " Love Can Build A Bridge"
paperback edition - Pages (480-482) Dr. Burgstiner believes that this
preparation must be taken with vitamins to act as coenzymes in order to be
effective.
There is also a synthetic "thymosin alpha 1" being produced by a company called SciClone Pharmaceuticals - Telephone - 415-358-1446 available only in trials - It is given intravenously and has been - and is currently being studied for use in treating hepatitis B and C - in hepatitis B the results have been promising - and it is now being studied in combination with interferon.
---
III.6.1 THYMOSIN AND INTERFERON
COMBINATION
In November 1996, SciClone Pharmaceuticals, Inc.
commented on results from a randomized, placebo-controlled, double-blind phase
III study in chronic hepatitis C patients receiving a combination therapy of
thymosin alpha 1 and interferon alpha-2B. A life-table analysis showed almost
50% of the 65 patients had complete normalization of ALT in the thymosin
combination treated group and in less than 20% of the interferon-only treated
group. The study showed a statistically significant reduction in ALT levels in
the combination group and significant complete normalization of ALT levels, as
compared to the interferon only and placebo groups. Also observed were
significant early virologic response in patients treated with combination
therapy when compared to the interferon arm."
---
III.7.0 NAC
In chronic hepatitis C, oxidative stress increases and plasma and liver GSH
concentrations decrease. Oral NAC ( 1800 mg/d), although having little effect
alone, tends to enhance the response to interferon.
According to a report in the Journal of Interferon Research (13:279-282 1993), In interferon-unresponsive patients, the addition of 600 mg tid of oral N-acetyl cysteine (NAC), a glutathione precursor, resulted in a steady decrease of ALT values in all patients, with complete normalization in 41% of cases after 5-6 months of combined therapy. The authors conclude that NAC enhanced the response to interferon in chronic hepatitis C, and suggest that further studies were needed to determine whether antioxidant therapy would be useful in conjunction with interferon treatment of hepatitis C.
---
III.8.0 PROTEASE INHIBITORS
HCV protease
is one of the proteins that catalyze critical steps in the viral life cycle of
hepatitis C. Recent efforts have focused on the molecular mechanism of hepatitis
C replication as this has proven to be a successful approach in the treatment of
HIV. The combination of HIV protease inhibitors and nucleoside analogs have been
the first major breakthrough in the treatment of AIDS. There are similarities
between the HIV and hepatitis C viruses as they are both RNA viruses which have
a tendency to mutate. The HIV protease inhibitors are aspartate proteinases
whereas the HCV protease is serine-based. This makes it unlikely that any of the
current drugs being used for HIV would be effective in patients with hepatitis
C.
Particular attention is being focused on the NS3 protease domain of the hepatitis C virus as this is an enzyme considered essential for replication of the hepatitis C virus. Recently the crystal structure of the hepatitis C virus NS3 protease domain was reported by two separate groups in the journal, Cell. This will no doubt lead to rapid development of protease inhibitor drugs by a number of biotechnology and pharmaceutical companies who are racing to accomplish this. Other logical targets for inhibition are the NS3 helicase and the NS5b polymerase enzymes as these are also essential for viral replication. It is likely that a number of inhibitor drugs will reach clinical testing phase in the next 18 to 36 months. (As of yet there are no protease inhibitors in clinical trials.) - "Emerging Therapies for HCV," - Scripps Clinic and Research Foundation, Liver Disease Study Group
---
Shering-Plough has signed an agreement with Corvas International to
collaborate on research to seek orally bioavailable inhibitors of a key protease
necessary for hepatitis C virus replication.
---
III.4.1 RIBOZYME GENE THERAPY
Ribozymes
are enzymes which have the ability to cause a catalytic cleavage of a targeted
RNA. Ribozymes directed against the hepatitis C virus RNA have been developed
which have the ability to destroy the virus' replicative material. Although
these compounds have been produced using recombinant bench techniques they have
not yet been proven safe or effective in vivo. It is anticipated that these
compounds may have unpredictable and non-specific effects on other cells and
therefore may be potentially toxic. More work is needed on these drugs before
they will reach the clinic. - "EMERGING THERAPIES FOR HCV," From the Scripps
Clinic and Research Foundation, Liver Disease Study Group
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III.4.2 ANTISENSE BASED
THERAPIES
Antisense drugs are large, highly charged molecules
which form DNA-RNA or RNA -RNA hybrids with the target RNA receptor. In the case
of hepatitis C this hybrid would form with the hepatitis C RNA which is the
viral replicative material. This occurs by simple Watson-Crick base pairing.
Once an anti-sense DNA hybrid has been formed it inactivates the viral
replication process. - "Emerging Therapies for HCV," - Scripps Clinic and
Research Foundation, Liver Disease Study Group
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III.7.0 AMANTADINE
Amantadine (trade
name Symmetrel) is a drug commonly used in the treatment of Parkinson's disease,
and for the prophylaxis and treatment of illness caused by the influenza A
virus. It is thought to prevent viral uncoating and thus viral multiplication.
Amantidine was recently tested in patients with HCV, and clinical trials will be
beginning soon.
---
(From the 96th annual meeting of the American Gastroenterological
Association, Digestive Disease Week , San Francisco, CA, May 21, 1996)
Dr. J.P. Smith presented the results of a recent trial of the antiviral
agent, amantadine hydrochloride, in patients with chronic hepatitis C infection
who had previously failed to respond to interferon alpha-2b. Twenty-two patients
were treated with orally administered amantadine HCl, 100 mg twice a day, for 6
months. These same patients served as their own controls during two intervals of
no treatment (24 months before and 12 months after previous treatment with
interferon) and during interferon therapy. Twenty of the 22 patients completed
the 6-month study of amantadine.
Thirty percent of those patients completing the study demonstrated a complete
response to therapy as demonstrated by the normalization of serum alanine
aminotransferase (ALT) levels. Forty percent of the patients achieved a partial
response (defined as a reduction in ALT of greater than 50%), and 30% failed to
respond to amantadine therapy. Responders and partial responders maintained
therapeutic benefits 6 months after treatment was stopped.
Two patients were discontinued from the study as a precaution due to
cardiac-related side effects. Two patients reported difficulty concentrating,
two patients reported constipation, and one experienced insomnia, but none of
these patients discontinued the study. There was no observed decrease in WBC
levels, nor was there any detrimental effect on the bone marrow attributable to
treatment with amantadine.
Dr. Smith noted that the comparative costs of therapy at the Hershey Medical
Center were $120 for 6 months of therapy with amantadine HCl vs $3,000 for
interferon.
As shown by this study in 20 patients, amantadine HCl (which has the additional benefit of being taken orally vs by subcutaneous injection for interferon) may prove to be a useful alternative to interferon in treating patients with chronic hepatitis C. - "Treatment of Chronic Hepatitis C with Amantadine", J. P. Smith, The M. S. Hershey Medical Center, Pennsylvania State University Hershey, PA
---
III.8.0 OFLOXACIN
On the basis of the
recent report on the antiviral effects of ofloxacin (OFLX) which is
antibacterial drug, a study was designed to test the efficacy of OFLX in
combination with interferon by a open clinical trial method. Analysis of HCV-RNA
titer revealed that it decreased markedly after the beginning of combination
therapy. HCV-RNA titer became negative in 8 cases of 11, and in 1 of 8 patients
HCV disappeared by OFLX. However, the effects of OFLX were not monitored by
HCV-RNA titers. ALT normalised rate at the end of the study in group I and group
III (control) were 87.5% and 69.0% respectively, which differences were not
statistically significant. The results of the trial indicate that the
combination therapy of interferon and ofloxacin may be a possible strategy for
the treatment of type C hepatitis. - "Combination therapy of interferon and
ofloxacin in patients with chronic type C hepatitis", Takada N.; Yamazaki Y.;
Sato T.; Furukawa T.; Matsuzaki H.; Shimada K.; Iwasaki K.; Furube M.; Tomioka
H., Japanese Pharmacology and Therapeutics (Japan), 1995, 23/SUPPL. 3
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III.9.0 CYCLOSPORINE THERAPY
Interferon
therapy is of proven efficacy in chronic hepatitis C, but it is not universally
effective and is often limited by side effects. Cyclosporine A (CsA) is a potent
immunosuppressant widely used in organ transplantation. We conducted a pilot
study to determine whether CsA therapy could affect aminotransferase activity
and hepatitis C virus RNA levels in patients with chronic hepatitis C. The
findings suggest: that CsA,