First Steps:First Steps:Understanding Hepatitis C and Understanding Hepatitis C and What You Can Do About ItWhat You Can Do About It

August 19, 2008August 19, 2008

What is Hepatitis?What is Hepatitis?

Inflammation of the liverInflammation of the liver– CausesCauses

VirusesViruses ToxinsToxins Genetic Disorders Genetic Disorders BacteriaBacteria ParasitesParasites Unknown causesUnknown causes

LiverLiver

Largest internal organLargest internal organ Located on right side under rib Located on right side under rib

cagecage 3 lbs3 lbs Size of a footballSize of a football Has over 500 vital functionsHas over 500 vital functions

Liver FunctionsLiver Functions

Stores: vitamins, minerals, sugarsStores: vitamins, minerals, sugars Produces: bile, cholesterol and Produces: bile, cholesterol and

lymphlymph Regulates: blood clotting, Regulates: blood clotting,

glucose, and hormone levelsglucose, and hormone levels Cleans: the blood from bacteria Cleans: the blood from bacteria

and toxinsand toxins

Liver Functions - Liver Functions - continuedcontinued Processes: food, alcohol and other drugs Processes: food, alcohol and other drugs Converts: food and drink into forms the body Converts: food and drink into forms the body

can use can use Oxidizes: triglycerides to produce energyOxidizes: triglycerides to produce energy

Basically, the liver processes everything we Basically, the liver processes everything we eat, drink, swallow, breathe and/or absorb!eat, drink, swallow, breathe and/or absorb!

Don’t gamble with your liver!Don’t gamble with your liver!

Hep-TriviaHep-Trivia

How many quarts of blood does the How many quarts of blood does the liver filter every minute?liver filter every minute?

A. A. .5 quart.5 quart

B. B. 1 quart1 quart

C.C. 1.5 quarts1.5 quarts

Hepatitis LanguageHepatitis Language

Acute infection is when the infection is Acute infection is when the infection is newly acquirednewly acquired

Chronic infection lasts 6 months or more Chronic infection lasts 6 months or more and is usually life-longand is usually life-long

Resolved or cleared infection occurs Resolved or cleared infection occurs when the body has gotten rid of the when the body has gotten rid of the infectioninfection

Viral HepatitisViral Hepatitis

Hepatitis A (HAV)Hepatitis A (HAV) Hepatitis B (HBV)Hepatitis B (HBV) Hepatitis C (HCV)Hepatitis C (HCV)

Hepatitis AHepatitis A

Virus found in fecesVirus found in feces TransmittedTransmitted

– Contaminated food and/or waterContaminated food and/or water– Direct contact with infected persons Direct contact with infected persons

fecesfeces Resolves-does not become chronicResolves-does not become chronic Can lead to fulminant hepatitis with Can lead to fulminant hepatitis with

chronic liver diseasechronic liver disease

What can I do?What can I do?

Prevent by hand washingPrevent by hand washing Vaccine availableVaccine available

– Two doses over a six month periodTwo doses over a six month period– Life-longLife-long

Hepatitis BHepatitis B

Blood, semen, vaginal and other body fluidsBlood, semen, vaginal and other body fluids High sexual transmissionHigh sexual transmission

– PerinatalPerinatal– PercutaneousPercutaneous– Noninjection drug useNoninjection drug use

Chronic infection occurs inChronic infection occurs in– 90% of infants infected at birth90% of infants infected at birth– 30% of children infected at age 1–5 years 30% of children infected at age 1–5 years – 6% of persons infected after age 5 years 6% of persons infected after age 5 years 

Death in 15%–25% of chronically infected Death in 15%–25% of chronically infected

What can I do?What can I do?

Avoid contact with body fluidAvoid contact with body fluid– Use barrier methodsUse barrier methods– Use new needles, cookers, cottons, Use new needles, cookers, cottons,

etc. etc. – Use your own personal items, such Use your own personal items, such

as razors, toothbrushes, etc.as razors, toothbrushes, etc. Vaccine availableVaccine available

– Three doses within six monthsThree doses within six months– TwinrixTwinrix

Hepatitis CHepatitis C

Blood to blood transmissionBlood to blood transmission– PercutaneousPercutaneous– Non-injection drug useNon-injection drug use– Transfusions, organ transplants or blood Transfusions, organ transplants or blood

products prior to 1992products prior to 1992– PerinatalPerinatal– Low sexual transmissionLow sexual transmission

Primarily causes damage to the liverPrimarily causes damage to the liver Often no symptomsOften no symptoms No vaccine availableNo vaccine available

Hepatitis CHepatitis C

Of 100 persons infected with HCV:Of 100 persons infected with HCV:– 85 (85%) may develop long term 85 (85%) may develop long term

infectioninfection– 70 may develop chronic liver 70 may develop chronic liver

diseasedisease– 10-20 may develop cirrhosis10-20 may develop cirrhosis– 1 - 5 may die from consequences of 1 - 5 may die from consequences of

chronic liver diseasechronic liver disease

HCV TestingHCV Testing

HCV Elisa III (EIA)HCV Elisa III (EIA)– Detects antibodiesDetects antibodies

Signal to Cut Off Ratio = 95%Signal to Cut Off Ratio = 95%

RIBA HCVRIBA HCV– Confirming anti-body test Confirming anti-body test

HCV TestingHCV Testing

Viral LoadViral Load– Amount of virus in per milliliter of bloodAmount of virus in per milliliter of blood

Copies or International unitsCopies or International units

– Qualitative – presence of virusQualitative – presence of virus Most sensitiveMost sensitive

– Quantitative – measure amount of virusQuantitative – measure amount of virus Some Quantitative are as sensitive as Some Quantitative are as sensitive as

QualitativeQualitative

HCV TestingHCV Testing

Viral LoadViral Load– Confirm active HCV infectionConfirm active HCV infection– Confirm HCV medications are Confirm HCV medications are

workingworking– Does not correlate with disease Does not correlate with disease

progression!progression!– May effect mother to child May effect mother to child

transmission transmission

Liver Function TestsLiver Function Tests

ALT – (Alanine Aminotransferase)ALT – (Alanine Aminotransferase)– most commonly used test for livermost commonly used test for liver– Indication something is going on in liverIndication something is going on in liver– 30% of people with HCV have normal30% of people with HCV have normal– Some people and populations have normal Some people and populations have normal

ALT’s but still have disease progression or ALT’s but still have disease progression or damagedamage

AST – (Aspartate Aminotransferase)AST – (Aspartate Aminotransferase) AP – (Alkaline Phosphatase)AP – (Alkaline Phosphatase) GGT – (Gamma Glutamyl Transferase)GGT – (Gamma Glutamyl Transferase)

Liver BiopsyLiver Biopsy

Measures liver healthMeasures liver health– Measures scarringMeasures scarring

Treatment decisionsTreatment decisions Benchmark Benchmark

– Predictor of progression?Predictor of progression?

Symptoms**Symptoms**

FatigueFatigue Brain FogBrain Fog Flu symptomsFlu symptoms

– Muscle, joint, Muscle, joint, feverfever

ItchingItching

Liver painLiver pain Loss of appetiteLoss of appetite HeadachesHeadaches Nausea/Nausea/

indigestionindigestion DepressionDepression

**Symptoms do not correlate to disease progression

Hep-TriviaHep-Trivia

Which of these can be avoided by Which of these can be avoided by getting a vaccine?getting a vaccine?

A.A. Hepatitis A Hepatitis A

B.B. Hepatitis B Hepatitis B

C.C. Hepatitis C Hepatitis C

What can I do?What can I do?

Refrain from shooting drugsRefrain from shooting drugs– If you do, use new or sterile toolsIf you do, use new or sterile tools

Avoid contact with bloodAvoid contact with blood– Use your own personal items, such as Use your own personal items, such as

razors, toothbrushes, etc.razors, toothbrushes, etc.– Cover wounds and clean up blood spills Cover wounds and clean up blood spills

promptly with bleachpromptly with bleach– Use barrier methodsUse barrier methods

Do not donate bloodDo not donate blood

Healthy Liver

Fibrosis: Light Scarring of the liver

Cirrhosis: Extensive scarring

Factors That Cause Factors That Cause ProgressionProgression Alcohol consumptionAlcohol consumption Drug useDrug use Acquired over age 40Acquired over age 40 MalesMales Co-infected with HBV or HIVCo-infected with HBV or HIV Immune system is compromisedImmune system is compromised SteatosisSteatosis

Liver cells on alcoholLiver cells on alcohol

Steatosis

No Association with No Association with ProgressionProgression GenotypeGenotype ALTALT Viral loadViral load Mode of transmissionMode of transmission

What can I do?What can I do?

Enroll in treatmentEnroll in treatment– Talk to your doctor about your Talk to your doctor about your

optionsoptions

Disease ManagementDisease Management– Keeping your liver healthyKeeping your liver healthy

TreatmentTreatment

Only effective ~50% of timeOnly effective ~50% of time– Dependent upon individualDependent upon individual– GenotypeGenotype

Duration 6 – 12 monthsDuration 6 – 12 months

Goals of TreatmentGoals of Treatment

Clear virusClear virus Improve inflammationImprove inflammation Improve liver health–scarringImprove liver health–scarring Slow disease progressionSlow disease progression Improve symptoms and quality of Improve symptoms and quality of

lifelife Put HCV behind them and move on Put HCV behind them and move on

with their lifewith their life

Length of TreatmentLength of Treatment

Genotype 1Genotype 1 (12 months)(12 months)

Genotype 2Genotype 2 (6 months)(6 months)

Genotype 3Genotype 3 (6 months)(6 months)

Response to TherapyResponse to Therapy

12 Week Rule - decrease (12 Week Rule - decrease (2 log 2 log dropdrop) or elimination of virus at week ) or elimination of virus at week 12 is thought to be predictive of 12 is thought to be predictive of sustained virologic responsesustained virologic response

– Example: 10,000,000 to 100,000Example: 10,000,000 to 100,000

General Treatment General Treatment GuidelinesGuidelines

Overall Health is StableOverall Health is Stable Active HCV InfectionActive HCV Infection Elevated ALTs (exceptions)Elevated ALTs (exceptions) Compensated liver diseaseCompensated liver disease

HCV Treatment & HCV Treatment & Substance Use HistorySubstance Use History General Guideline 6 months General Guideline 6 months

clean/sober?clean/sober? No alcohol on treatmentNo alcohol on treatment Requires counseling on Requires counseling on

medication adherencemedication adherence Key component – SUPPORT! Key component – SUPPORT!

Contraindications to Contraindications to HCV TreatmentHCV Treatment Pregnancy or patients unwilling or unable Pregnancy or patients unwilling or unable

to practice two forms of birth controlto practice two forms of birth control Poorly controlled psychiatric diseasePoorly controlled psychiatric disease Poorly controlled coronary diseasePoorly controlled coronary disease Kidney or heart transplant recipientKidney or heart transplant recipient Autoimmune DisordersAutoimmune Disorders CancerCancer Decompensated liver disease (research Decompensated liver disease (research

only)only)

Optimal Response to Optimal Response to TreatmentTreatment YoungerYounger FemaleFemale Low Viral loadLow Viral load Minimal Liver DamageMinimal Liver Damage Genotype 2 or 3Genotype 2 or 3 Lower Weight / BMILower Weight / BMI Little or No SteatosisLittle or No Steatosis

Preparing for Preparing for TreatmentTreatment Psychiatric EvaluationPsychiatric Evaluation Drug and/or Alcohol EvaluationDrug and/or Alcohol Evaluation Ophthalmology EvaluationOphthalmology Evaluation Adherence ConsultationAdherence Consultation Side-Effect ConsultationSide-Effect Consultation

Pegylated IFN and Pegylated IFN and RibavirinRibavirin Interferon plus ribavirinInterferon plus ribavirin

– Genotype 1: 42 to 46%Genotype 1: 42 to 46%– Genotype 2&3: 28 to 82%Genotype 2&3: 28 to 82%

Side-effectsSide-effects

InterferonInterferon– HeadachesHeadaches– Slight feverSlight fever– FatigueFatigue– Muscle/joint painMuscle/joint pain– Nausea/vomitingNausea/vomiting– Appetite/weight Appetite/weight

lossloss– Depression/anxietyDepression/anxiety– Skin irritationSkin irritation

RibavirinRibavirin– Increases side Increases side

effects of effects of interferon, interferon, especially fatigueespecially fatigue

– AnemiaAnemia– Shortness of Shortness of

breathbreath– Birth defects Birth defects

Managing Side-effectsManaging Side-effects

Injections at Injections at bedtimebedtime

Vary injection sitesVary injection sites Low doses of pain Low doses of pain

relieversrelievers Drink lots of waterDrink lots of water Small frequent Small frequent

mealsmeals

Moderate Moderate exerciseexercise

Plenty of restPlenty of rest Support systemSupport system Anti-depressantsAnti-depressants

Managing side-effectsManaging side-effects

DepressionDepression

Psychiatric symptoms require Psychiatric symptoms require serious attentionserious attention

Depression occurs in 35-57% of Depression occurs in 35-57% of HCV patients before treatmentHCV patients before treatment

Increases in 20-30% of patients Increases in 20-30% of patients after starting treatmentafter starting treatment

Most common reason for stopping Most common reason for stopping treatmenttreatment

Monitoring Therapy – Monitoring Therapy – Potential ProblemsPotential Problems Neutropenia Neutropenia (low white blood (low white blood

cells)cells)– NeupogenNeupogen

ThrombocytopeniThrombocytopenia (low platelets)a (low platelets)

Anemia Anemia – Procrit/ EPOProcrit/ EPO

Thyroid diseaseThyroid disease

Depression / Depression / anxietyanxiety– Treat with anti-Treat with anti-

depressants / depressants / anti-anxiety anti-anxiety drugsdrugs

General HealthGeneral Health

Disease ManagementDisease Management

Get vaccinated (A & B) Get vaccinated (A & B) Avoid alcohol Avoid alcohol

– Lowers immune responseLowers immune response– Helps HCV replicateHelps HCV replicate– Lowers treatment responseLowers treatment response

Monitor disease through doctorMonitor disease through doctor– Lab tests: Decisions should not be Lab tests: Decisions should not be

based upon one labbased upon one lab

Disease ManagementDisease Management

Be cautious about all drugs, Be cautious about all drugs, vitamins and herbsvitamins and herbs– Your liver processes everythingYour liver processes everything– Avoid nicotine, caffeine, drugs, Avoid nicotine, caffeine, drugs,

chemicalschemicals

Lifestyle ManagementLifestyle Management

Eat a healthy dietEat a healthy diet– Emphasize fruits, vegetables, whole Emphasize fruits, vegetables, whole

grains and fat-free/low-fat dairygrains and fat-free/low-fat dairy– Avoid fatty foodsAvoid fatty foods– Avoid mega vitamins or Avoid mega vitamins or

supplementssupplements Moderate exerciseModerate exercise

Lifestyle ManagementLifestyle Management

Drink before you become thirstyDrink before you become thirsty– #1 factor for fatigue is dehydration #1 factor for fatigue is dehydration – 2% drop in body water can trigger 2% drop in body water can trigger

short-term memory function, short-term memory function, decreased concentrationdecreased concentration

Limit caffeinated beverages/sugar Limit caffeinated beverages/sugar beveragesbeverages

Keep water aroundKeep water around Sip throughout day, easier to absorbSip throughout day, easier to absorb

Support GroupsSupport Groups

InformationalInformational– SpeakersSpeakers

EmotionalEmotional– People with HCVPeople with HCV

12 step programs12 step programs– Focus on different aspects of Focus on different aspects of

recoveryrecovery

SupplementsSupplements

Avoid large doses of vitamins or Avoid large doses of vitamins or supplementssupplements

General recommendation is multi-General recommendation is multi-vitamin with no ironvitamin with no iron

Always discuss supplements Always discuss supplements and/or herbs with medical and/or herbs with medical providerprovider

Medical CareMedical Care

Prepare for your appointmentsPrepare for your appointments– Write down questions based on Write down questions based on

prioritypriority– Describe symptomsDescribe symptoms– Discuss fears Discuss fears

and feelingsand feelings

Medical CareMedical Care

Bring health documents with youBring health documents with you– Save time and duplication by getting Save time and duplication by getting

recent records such as labs, special recent records such as labs, special tests, vaccinationstests, vaccinations

Write a brief health historyWrite a brief health history– Include details that would include Include details that would include

previous medical providers, other previous medical providers, other health conditions, family history of health conditions, family history of illnessillness

Medical CareMedical Care

If you don’t understand, ask againIf you don’t understand, ask again If tests are ordered, ask what If tests are ordered, ask what

they are for & they are for &

how they are how they are

administeredadministered

Medical CareMedical Care

Write down what was saidWrite down what was said Most people won’t remember Most people won’t remember

everythingeverything Take a friend or family member if Take a friend or family member if

you need helpyou need help

Hep-TriviaHep-Trivia

What is the most important thing What is the most important thing you can do when in the doctor’s you can do when in the doctor’s office?office?

A.A. Follow doctor’s instructions Follow doctor’s instructions

B.B. Be your own advocate Be your own advocate

C.C. Remember everything said Remember everything said

What can I do now?What can I do now?

Don’t rush into a treatment Don’t rush into a treatment decisiondecision

Do your homeworkDo your homework Discuss all options with medical Discuss all options with medical

providerprovider Take care of yourselfTake care of yourself

Love your liver and live longer!Love your liver and live longer!

ResourcesResources

Arizona Department of HealthArizona Department of Health– http://www.azdhs.gov/phs/oids/hepc/http://www.azdhs.gov/phs/oids/hepc/

index.htmindex.htm American Liver FoundationAmerican Liver Foundation

– http://www.liverfoundation.org/chapters/http://www.liverfoundation.org/chapters/arizona/resources/arizona/resources/

Hepatitis C Support ProjectHepatitis C Support Project– http://www.hcvadvocate.org/http://www.hcvadvocate.org/