Treatment of hepatitis C in its early stages, when symptoms are milder and damage less well established, can be most beneficial for patients. Early treatment increases the chances of clearing the virus and where clearance is not achieved, suppressing the virus and delaying progression of the disease. Clinicians will therefore want to consider whether patients are suitable for treatment, rather than just regular assessment, taking into account all the relevant clinical and patient information. It should be noted that the National Institute of Clinical Excellence (NICE) has recommended treatment of active injecting drug users.
Current UK treatment guidelines from NICE for chronic hepatitis C now recommend a 24- or 48-week course of pegylated interferon plus ribavirin, as the treatment of choice. Using this combination therapy, sustained viral responses of around 40-50% have been reported in those with genotype 1 infections, and of around 75-80% for those with non-genotype 1 infections.
Previously interferon was used by itself, but treatment was only successful in a small proportion of people. For a few people who are unable to tolerate combination therapy, interferon on its own is sometimes beneficial.
Interferon
Interferon is a man-made drug which mimics the naturally occurring interferon produced as part of the body’s immune response to a viral infection. The aim of the drug is to prevent the virus from multiplyingand causing further liver damage. Pegylated interferon is a slow release version of the drug which only needs to be injected once a week. People learn to inject themselves after being carefully trained. The injection is sub-cutaneous (into the fat under the skin – as with skin popping).
Ribavirin
Ribavirin is also a man-made drug which is used against a range of different viruses. For hepatitis C treatment it is always used with interferon, never on its own. The drug is given in capsule form twice daily with the dose adjusted for the patient’s body weight.
Important:
Whilst taking ribavirin, and for six months after stopping treatment, it is vitally important for both men and women to use barrier contraception to ensure that pregnancy does not occur. Treatment can harm or even kill a foetus.
Side effects of interferon and ribavirin
Both interferon and ribavirin produce side effects in most people, especially in the early stages of treatment, although the severity varies from person to person. Side effects may include:
- flu-like symptoms
- fatigue
- headaches
- nausea
- anaemia
- depression
Occasionally there may be other side effects.
Some people who experience particularly bad side effects may be unable to tolerate a full dose or a full course of treatment. Because of the range of side effects, in particular anaemia, blood tests of various kinds are needed during treatment. It is important that regular appointments at the clinic are kept so that side effects and progress can be carefully monitored. The flu-like symptoms can often be relieved by taking paracetamol and many people find that they feel better after a few weeks.
Depression is a frequent side effect of interferon treatment and can have a substantial impact on a patient’s quality of life, their ability to tolerate treatment and their likelihood of completing the planned treatment course.
There have been a number of studies showing that anti-depressants can both treat and even prevent treatment-associated depression. Many treatment programmes now try and assess a patient’s risk of depression using scoring systems before and during treatment. Many anti-depressants have been used with recent studies looking at the newer rapid-onset drugs such as citalopram.
New drugs
The drugs Neupogen and Epoetin, currently licensed for use in cancer and renal therapies, are now being trialed in the hope that they may assist in the treatment of hepatitis C. They stimulate cell roduction in the blood, thereby boosting the immune system and helping to alleviate the symptoms of tiredness and lack of energy. These drugs have their own side effects and problems, and their long term safety is still not clear. They are not widely used in the UK as the benefits are not established.
Models of care
Most patients are being treated in hospital clinics. It may be possible in the future to treat some patients in GP surgeries or even at home, and some pilot schemes have been launched to assess the prospects of this.
Liver transplantation
For some people with cirrhosis who develop life-threatening complications, liver transplantation is a late stage option.
In over 60 to 80% of people who are desperately ill, this major surgical procedure is successful. The virus will infect the new liver and can sometimes cause severe disease after some years.
Complementary care
Complementary care means care that is complementary to orthodox (hospital or hepatology unit) medical treatment.
Many people with hepatitis C consider complementary care in addition to orthodox medical treatment. There are many forms such as massage, aromatherapy, reflexology, t’ai chi, and meditation.
Some people find these helpful in the relief of symptoms and/or as a way of combating side effects of treatment.
Traditional Chinese medicine, acupuncture and medical herbalism are other therapies which are sometimes considered by people who have hepatitis C. If anyone is considering complementary treatment as part of their care, it is important to be aware of the risks.
As with Western treatments, not all complementary therapies are safe or effective.
There have been a few cases of Chinese herbs causing liver damage and infected acupuncture needles causing hepatitis. Make sure the practitioner is registered and experienced in treating hepatitis C, just as one would check a Western doctor.
Diet
People with hepatitis C often ask if they should follow a special diet. For most people, particularly those who are well, the answer is no. Just like anybody else they should simply eat a well balanced diet with everything in moderation and no excesses.
This means eating regular meals, including plenty of fruit and vegetables (5 portions a day) and avoiding excessively fatty and high-sugar food.
Also, most people need two portions of food a day which provide a good source of protein such as meat, poultry, fish, eggs, nuts, pulses, beans, cheese, milk and milk products.
Eating a wide variety of different foods will help to ensure that meals are enjoyable as well as providing an adequate supply of vitamins and minerals. Vitamin supplements are not required by most people who are eating well.
However, people who are experiencing symptoms from hepatitis C may need further advice to help them eat well. Individual advice should be sought from a specialist, a GP or a registered dietician or nutritionist.
People on treatment may lose their appetite or experience nausea, vomiting or diarrhoea. They should consider vitamin supplements and eat nutrient-rich foods (e.g. bananas). Individuals experiencing persistent side effects should seek medical advice.
Alcohol
People with hepatitis C, whatever their situation, should not drink alcohol. Research has shown that alcohol aggravates hepatitis C infection, and progression from chronic hepatitis C to cirrhosis is hastened in those who drink alcohol.
Some key messages
- Active injecting drug users should seek regular HCV testing.
- People with an injecting history or who are living with someone who is HCV positive, should seek HCV testing.
- Everyone with hepatitis C should be seen regularly by a specialist (where possible) whether treatment is considered appropriate at present or not.
- Hepatitis C is one of the most recently discovered hepatitis viruses and there are some aspects of the disease that are still not fully understood.
- Knowledge and experience of the disease are increasing all the time so regular assessment is needed to be able to take advantage of new research, to detect whether liver damage is occurring or progressing and to decide if treatment is appropriate.
- Treatment for hepatitis C is improving rapidly with many promising new drugs in advanced stages of trials.