Hepatitis C--anything new in the last few years?

Factual Questions
1

It’s been a while since we had a thread on Hepatitis C. I’m interested in any recent advances in treatment, current medical wisdom on how asymptomatic people can stay that way, what sort of monitoring is suggested, and what advances are on the horizon.

Bonus question: A friend was recently diagnosed with HCV, though she had no symptoms (it was found during a blood test). She told the doctor (and I believe it’s true because I’ve known her for a long time) that she hadn’t ever used IV drugs or had a transfusion. She hasn’t had sex with a man since the mid-90’s. The doctor replied that “we don’t know how people get Hepatitis C. There are lots of other routes of transmission. Some people just get it and we don’t know how.” My friend came away from this with the feeling that this was code for “I believe that you’ve used IV drugs but I’m not going to argue with you.” I teach a course that includes HIV/HCV co-occurence, and so I’ve read a fair amount about that, but the list of Ways to Get HCV on reputable websites still pretty much looks like needles, transfusion, sex, or mom having had HCV at the time of one’s birth. Is this accurate or was this doctor being politic? I hate to teach my students inaccurate “facts,” and also I’d like to be helpful to my friend. [Friend is under medical care and this is not a request for medical advice.]

Thanks.

2

I’m going to a Hepatitis C update conference this Thursday. Ask me then.

But my current knowledge, which is still pretty up to date, includes the following:

Hepatitis C is a blood-borne pathogen, generally needing some type of blood contact to get it. Statistically, sharing IV needles still tends to be the the most common way, along with (for reasons unknown) sharing cocaine straws. Sexual transmission doesn’t seem to be nearly as common for Hep C as it is for Hep B or HIV.

But it seems 30% of the folks diagnosed with it don’t have any of the risk factors. :confused:

Most important part of living with Hep C: Don’t drink alcohol. The most horrendous cases I’ve seen (and I’ve seen LOTS and LOTS of cases) involve those who continued to drink on top of their Hep C. Otherwise, avoid drugs, watch the tylenol intake (some experts say up to 2 grams a day is safe, I tell my patients to really just try to avoid it), eat healthy, maintain an idea body weight, and avoid megavitamin supplements. Especially vitamin E, which was once felt to be helpful for Hep C but which now may actually cause more problems.

The mainstays of treatment are still injections of interferon and tablets of ribavirin. For Genotypes 1 & 4, this means 48 weeks of both (check the viral load at 12 weeks, if it hasn’t shown a 2 log decline, there’s no sense in continuing treatment). Cure rates for these genotypes I think are still under 40%.

For genotypes 2 & 3, 24 weeks of ribavirin and interferon seem to cure up to 75% of the cases.

Of course, genotype 1 is the more common.

More after my conference.

3

Thank you very much. I found a meta-analysis on Medscape that surveys unexplained routes of infection, which was useful. I’ll be very interested in hearing what you learn at your update conference.

4

Update conference info: Blood-borne (duh), not spread nearly as efficiently by sex as are Hep B and HIV, if the sex partner has it and one is monogamous & hetero, risk of acquiring it per year is about 0.6%. If not monogamous, goes up fairly significantly. If monogamous but Male with male sex, risk is higher, too. Female to female sexual transmission rate is not well defined.

IVDU still most common way of getting infection these days. Health workers have small but significant risk due to blood exposures.

Up to 44% of cases can’t be explained by typical risk factors (IVDU, MSM). But the harder one grills the patients, the smaller that “44%” number becomes. But even the most rigorous screens still have 10% of cases as ‘unexplained’.

20% of cases or less have symptoms during the acute infection. If the virus is treated during the acute infection, up to 98% cure rate is seen. People with symptomatic infections have a higher chance of clearing the virus on their own, too since the symptoms are generally due to a strong immune response.

Anywhere from 15-25% of folks clear it on their own within 6 months, usually in 3 months or less. If not cleared on its own by 6 months, it won’t generally be cleared without treatment.

If not treated, 20-25% will go on to have cirrhosis. Of those with cirrhosis, 4-6% go on to have liver cancer. One doesn’t see liver cancer arising from Hep C unless there is cirrhosis.

How to identify who will have cirrhosis: Tough to do. Some folks are rapid deteriorators (2-6 years), some intermediate (7-20years), some slow (20-50+ years). If one can identify when they got the infection that can help determine which category they are in. If the patient first did IV drugs in 2001 and liver biopsy this year shows bridging fibrosis (stage III), then he’s a rapid deteriorator. If he had a transfusion in 1979, and biopsy shows small portal fibrosis (Stage I), he’s a slow deteriorator, and probably doesn’t merit treatment.

Who to treat? Anyone with Stage II or worse on liver biopsy. Degree of inflammation (or Grade) doesn’t matter nearly as much. Except: Don’t treat chronic lung disease people, folks with decompensated cirrhosis, severe mental illness (they will get worse!), and be real careful with folks with significant cardiac dysfunction. Plus be ware of treating anyone else with a wide range of less common disease states.

Does genotype matter? Only in deciding what treatment to use. 1 and 4 get 48 weeks of pegylated interferon along with ribavirin, and 2 & 3 (more readily cureable) get interferon (pegylated or otherwise) and ribaviring for 24 weeks. Cure rate for genotype 2 is about 90%, for 3 it’s 80%. For type 1 it’s around 40-45%.

Genotype has no bearing on severity of disease or its course.

Genotype 1 and response to treatment: Need to see a 2 log drop after 12 weeks of treatment. Don’t get it, stop treatment! Need to see viral load drop to zero at 24 weeks also. If virus persists at all at 24 weeks, chance of cure very very low.

Goal of treatment: Viral elimination! Check for virus at end of treatment, and 6 months later. If not present 6 months later, consider a cure.

Treatment failure: Virus appears to be all gone at 48 weeks, but same infection back 6 months later. Consider retreatment, for longer period of time. How long? Good question. Perhaps 18 months to 2 years.

Seeing many folks now coming down with new Hep C infections after successful treatment for first infection! Frustrating!!! Usually IVDU’s who have not found recovery. Sometimes new infections from different sex partners.

A role for viral suppression? Some type 1s get viral reduction but not viral elimination by treatment. Is this desirable? Some think so, for folks with compensated cirrhosis. May keep them out of terminal liver failure and reduce chance of cancer. A study should be out in 18 months which may show if just suppressing the virus long-term (think years, with low dose peg-intron weekly but no ribavirin after the 48 weeks of treatment) reduces the risk of cirrhosis and/or liver cancer.

Consumption of alcohol or use of illicit drugs forbidden during active treatment, and failure to abide by this should be grounds to terminate treatment, because it lowers the effectiveness so much.

Treatment is still rough. Up to 30% dropout rate due to unacceptable side-effects. This drop-out rate can be decreased with vigorous use of meds to combat side-effects (erythropoeitin to fight anemia, neupogen to fight low white blood counts, analgesics for headaches, anti-depressants for depression, antinauseants for well, you know).

New therapies? Nothing to replace interferon yet. New classes of meds, protease, polymerase, synthetase inhibitors, are in clinical trials and look promising. They may end up being added as 3rd agents to interferon and ribavirin. Could end up replacing ribavirin. time will tell.

Hep C vaccine? Not on the horizon yet. Very difficult, same degree of difficulty as HIV vaccine. Prevention prevention prevention!!!

Now, ask me about chronic Hep B! (or better yet, wait a while before asking). We covered that today too. Far more complicated, yet simpler. Can’t cure it, not sure if suppressing virus is more helpful than harmful.

5

What you’ve said here doesn’t exclude the possibility of transmission via sex - has she been tested for HepC since that time in the mid-90s but prior to the test that caught the disease? Perhaps she’s in the intermediate or slow category.

6

I waited until late 2005 before doing my treatment, because when I was first diagnosed in the 1990s the only available treatment was crap and I was hoping something more effective would be discovered. Oh that it was, all right. :eek:

In only 3 months I got the viral load down to zero. My recent bloodwork, taken one year after the end of treatment, shows my liver enzymes still in the normal range. (Well, high normal, but still.) That means I really am cleared.

I nearly died from the ribavirin combo treatment, though. Twice. I consider it extremely dangerous in several ways, no one should attempt it without very careful health monitoring, both physical and psychological. The really dangerous side effects can hit suddenly without warning. I wonder if I was overdosing. The doctor should have caught that for me.

If I’d known what it was really going to be like before starting, I would have been too scared to attempt it. I’m not trying to scare anyone else out of it, because it did beat down the disease and I’m very happy about that. Just be extremely careful. I’d heard it was bad. No. It was a horrible fucking nightmare of Hell. And on top of it, the physician “care” was negligent. That made it more dangerous for me than it should have been. The only time I got Pitted was during the time of my treatment, which is actually not a coincidence. I lost several friendships during that time too. One of them, fortunately, is now fully renewed.

7

Thank you Qadgop, that was fantastic.

8

Qadgop, a million thanks. I’ll pass it on.

This could be possible. I’ll pass on the question. My impression is that she was never tested for HCV. She was in a monogamous relationship from the early 80’s to mid 90’s and had one brief relationship with a man for a few months in the mid-90’s. Since then she has been in a monogamous relationship with a woman. I’m sure she’d be thrilled to be in the “slow” category.

9

One is only considered ‘cleared’ if their viral load is still zero 6 months after the end of treatment. Liver enzymes (ALT is the best marker) range from normal to significantly evelated and back again over and over during the multi-decade chronic phase of the disease.

What was your last viral load, and how long after treatment was it?

Responding with a viral load of zero at 12 weeks into treatment generally results in a cure for 75% of patients after 48 weeks of treatment.

10

Also, about 10% of cases of Hep C can be tentatively traced to having had a surgical procedure. Probably due to being exposed to the blood of someone in the OR or caring for the patient during the early post-op period.

11

Running amok with rage is an all-too-common side effect. I wear a body alarm when seeing patients, just in case.

(Well, that’s not why I wear it. But after talking to a few of my patients during their treatment, I’m happy to have it).

12

Okay, more data. My friend has never had an HCV test before. In 2001 and 2002 her ALT and AST were in the normal range. Her earlier monogamous partner has since been tested and is negative. She had several surgeries as a kid in the late 50’s and her parent doesn’t know if she had transfusions or not. She had a surgery last year. Qadgop (and other doctors), is there a way to find out whether a hospital has had allegations or substantiated incidents of nosocomial transmission of HCV?

13

Her earlier ALTs being normal means little. She could have picked up the infection in the 1950’s, and be a slow progressor.

If she had surgery a year ago, it’s also possible that she picked it up then. But it would be difficult to demonstrate that, unless she still has tissue/blood in storage from that time. She could contact the hospital infection control RN and report her situation and see if that produces info, but it may not.

Frankly, the percentage of “unknown source of infection” (10-44% of caes) is so high that wanting to know definitively how one got it may just never be possible.

14

That’s an excellent point. My guess is that she’s more interested in trying to determine when she was infected so she’ll have some sense of how quickly she deteriorates, which might influence treatment decisions. That, of course, is between her and the hepatologist. I’ve suggested that in the absence of data, she tell people she acquired HCV from transfusions as a child. She had a negative experience with a nurse the other day that made her wonder if she’s being perceived as a drug user who lies. Certainly my father, who died of HCV, ran into that at times.

15

I hope I’m still in the window for posting this:

Hepatitis C drugs provide ‘cure’