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

1. First Steps:Understanding Hepatitis C and What You Can Do About It August 19, 2008

2. What is Hepatitis? • Inflammation of the liver • Causes • Viruses • Toxins • Genetic Disorders • Bacteria • Parasites • Unknown causes

3. Liver • Largest internal organ • Located on right side under rib cage • 3 lbs • Size of a football • Has over 500 vital functions

4. Liver Functions • Stores: vitamins, minerals, sugars • Produces: bile, cholesterol and lymph • Regulates: blood clotting, glucose, and hormone levels • Cleans: the blood from bacteria and toxins

5. Liver Functions - continued • Processes: food, alcohol and other drugs • Converts: food and drink into forms the body can use • Oxidizes: triglycerides to produce energy Basically, the liver processes everything we eat, drink, swallow, breathe and/or absorb! • Don’t gamble with your liver!

6. Hep-Trivia How many quarts of blood does the liver filter every minute? A. .5 quart B. 1 quart C.1.5 quarts

7. Hepatitis Language • Acute infection is when the infection is newly acquired • Chronic infection lasts 6 months or more and is usually life-long • Resolved or cleared infection occurs when the body has gotten rid of the infection

8. Viral Hepatitis • Hepatitis A (HAV) • Hepatitis B (HBV) • Hepatitis C (HCV)

9. Hepatitis A • Virus found in feces • Transmitted • Contaminated food and/or water • Direct contact with infected persons feces • Resolves-does not become chronic • Can lead to fulminant hepatitis with chronic liver disease

10. What can I do? • Prevent by hand washing • Vaccine available • Two doses over a six month period • Life-long

11. Hepatitis B • Blood, semen, vaginal and other body fluids • High sexual transmission • Perinatal • Percutaneous • Noninjection drug use • Chronic infection occurs in • 90% of infants infected at birth • 30% of children infected at age 1–5 years  • 6% of persons infected after age 5 years  • Death in 15%–25% of chronically infected

12. What can I do? • Avoid contact with body fluid • Use barrier methods • Use new needles, cookers, cottons, etc. • Use your own personal items, such as razors, toothbrushes, etc. • Vaccine available • Three doses within six months • Twinrix

13. Hepatitis C • Blood to blood transmission • Percutaneous • Non-injection drug use • Transfusions, organ transplants or blood products prior to 1992 • Perinatal • Low sexual transmission • Primarily causes damage to the liver • Often no symptoms • No vaccine available

14. Hepatitis C • Of 100 persons infected with HCV: • 85 (85%) may develop long term infection • 70 may develop chronic liver disease • 10-20 may develop cirrhosis • 1 - 5 may die from consequences of chronic liver disease

15. HCV Testing • HCV Elisa III (EIA) • Detects antibodies • Signal to Cut Off Ratio = 95% • RIBA HCV • Confirming anti-body test

16. HCV Testing • Viral Load • Amount of virus in per milliliter of blood • Copies or International units • Qualitative – presence of virus • Most sensitive • Quantitative – measure amount of virus • Some Quantitative are as sensitive as Qualitative

17. HCV Testing • Viral Load • Confirm active HCV infection • Confirm HCV medications are working • Does not correlate with disease progression! • May effect mother to child transmission

18. Liver Function Tests • ALT – (Alanine Aminotransferase) • most commonly used test for liver • Indication something is going on in liver • 30% of people with HCV have normal • Some people and populations have normal ALT’s but still have disease progression or damage • AST – (Aspartate Aminotransferase) • AP – (Alkaline Phosphatase) • GGT – (Gamma Glutamyl Transferase)

19. Liver Biopsy • Measures liver health • Measures scarring • Treatment decisions • Benchmark • Predictor of progression?

20. Fatigue Brain Fog Flu symptoms Muscle, joint, fever Itching Liver pain Loss of appetite Headaches Nausea/indigestion Depression Symptoms** **Symptoms do not correlate to disease progression

21. Hep-Trivia Which of these can be avoided by getting a vaccine? A. Hepatitis A B. Hepatitis B C. Hepatitis C

22. What can I do? • Refrain from shooting drugs • If you do, use new or sterile tools • Avoid contact with blood • Use your own personal items, such as razors, toothbrushes, etc. • Cover wounds and clean up blood spills promptly with bleach • Use barrier methods • Do not donate blood

23. Healthy Liver

24. Fibrosis: Light Scarring of the liver

25. Cirrhosis: Extensive scarring

26. Factors That Cause Progression • Alcohol consumption • Drug use • Acquired over age 40 • Males • Co-infected with HBV or HIV • Immune system is compromised • Steatosis

27. Liver cells on alcohol

28. Steatosis

29. No Association with Progression • Genotype • ALT • Viral load • Mode of transmission

30. What can I do? • Enroll in treatment • Talk to your doctor about your options • Disease Management • Keeping your liver healthy

31. Treatment • Only effective ~50% of time • Dependent upon individual • Genotype • Duration 6 – 12 months

32. Goals of Treatment • Clear virus • Improve inflammation • Improve liver health–scarring • Slow disease progression • Improve symptoms and quality of life • Put HCV behind them and move on with their life

33. Length of Treatment • Genotype 1 (12 months) • Genotype 2 (6 months) • Genotype 3 (6 months)

34. Response to Therapy • 12 Week Rule - decrease (2 log drop) or elimination of virus at week 12 is thought to be predictive of sustained virologic response • Example: 10,000,000 to 100,000

35. General Treatment Guidelines • Overall Health is Stable • Active HCV Infection • Elevated ALTs (exceptions) • Compensated liver disease

36. HCV Treatment & Substance Use History • General Guideline 6 months clean/sober? • No alcohol on treatment • Requires counseling on medication adherence • Key component – SUPPORT!

37. Contraindications to HCV Treatment • Pregnancy or patients unwilling or unable to practice two forms of birth control • Poorly controlled psychiatric disease • Poorly controlled coronary disease • Kidney or heart transplant recipient • Autoimmune Disorders • Cancer • Decompensated liver disease (research only)

38. Optimal Response to Treatment • Younger • Female • Low Viral load • Minimal Liver Damage • Genotype 2 or 3 • Lower Weight / BMI • Little or No Steatosis

39. Preparing for Treatment • Psychiatric Evaluation • Drug and/or Alcohol Evaluation • Ophthalmology Evaluation • Adherence Consultation • Side-Effect Consultation

40. Pegylated IFN and Ribavirin • Interferon plus ribavirin • Genotype 1: 42 to 46% • Genotype 2&3: 28 to 82%

41. Interferon Headaches Slight fever Fatigue Muscle/joint pain Nausea/vomiting Appetite/weight loss Depression/anxiety Skin irritation Ribavirin Increases side effects of interferon, especially fatigue Anemia Shortness of breath Birth defects Side-effects

42. Injections at bedtime Vary injection sites Low doses of pain relievers Drink lots of water Small frequent meals Moderate exercise Plenty of rest Support system Anti-depressants Managing Side-effects

43. Managing side-effects

44. Depression • Psychiatric symptoms require serious attention • Depression occurs in 35-57% of HCV patients before treatment • Increases in 20-30% of patients after starting treatment • Most common reason for stopping treatment

45. Neutropenia (low white blood cells) Neupogen Thrombocytopenia (low platelets) Anemia Procrit/ EPO Thyroid disease Depression / anxiety Treat with anti-depressants / anti-anxiety drugs General Health Monitoring Therapy – Potential Problems

46. Disease Management • Get vaccinated (A & B) • Avoid alcohol • Lowers immune response • Helps HCV replicate • Lowers treatment response • Monitor disease through doctor • Lab tests: Decisions should not be based upon one lab

47. Disease Management • Be cautious about all drugs, vitamins and herbs • Your liver processes everything • Avoid nicotine, caffeine, drugs, chemicals

48. Lifestyle Management • Eat a healthy diet • Emphasize fruits, vegetables, whole grains and fat-free/low-fat dairy • Avoid fatty foods • Avoid mega vitamins or supplements • Moderate exercise

49. Lifestyle Management • Drink before you become thirsty • #1 factor for fatigue is dehydration • 2% drop in body water can trigger short-term memory function, decreased concentration • Limit caffeinated beverages/sugar beverages • Keep water around • Sip throughout day, easier to absorb

50. Support Groups • Informational • Speakers • Emotional • People with HCV • 12 step programs • Focus on different aspects of recovery