Management of HCV

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The hepatitis C virus causes acute and chronic hepatitis C (HCV) infection, characterized by inflammation of the liver. Acute HCV typically resolves on its own and rarely results in liver failure. However, most HCV infections become chronic. Chronic HCV infection typically progresses over many years and can lead to complications including cirrhosis, hepatocellular carcinoma (liver cancer), and, ultimately, the need for a liver transplant.

How is chronic HCV infection managed?

The cornerstone of treatment for chronic HCV infection is antiviral drug therapy. In addition to drug therapy, management of chronic HCV should include a coordinated plan of care that consists of1:

  • Counseling and education
  • Dietary approaches
  • Symptom management
  • Medication and dietary supplements
  • Screening for HCV-related complications
  • Vaccination

Counseling and education

Learning that you have chronic HCV infection can be difficult. Even if you are asymptomatic, it can be frightening to learn you have an infectious disease that is serious and potentially life-threatening. Your doctor can guide you through the process of learning about HCV and provide valuable advice concerning the emotional and physical aspects of living with chronic HCV.

Counseling for chronic HCV infection should include basic education concerning how HCV can be transmitted. HCV is passed when infected blood gets into the bloodstream of someone who doesn’t have HCV. The most common way of getting HCV is by sharing needles, syringes, and anything associated with intravenous drug use. You can also get HCV if your blood comes into contact with infected blood, such as in a medical or occupational setting. Below are some other ways HCV can be transmitted:

  • HCV may be passed from mother-to-child during pregnancy and delivery.
  • Blood transfusions and organ transplantation prior to July 1992 were other common ways to become infected with HCV. However, accurate screening for HCV has made blood transfusions and transplants much safer and today, HCV is rarely transmitted via donated blood, tissue, or organs.
  • The risk of HCV transmission through sexual contact is generally low, especially for HIV-negative individuals. Certain sexual practices seem to increase risk for infection. These include unprotected receptive anal sex with multiple partners. The use of drugs and alcohol during sex is associated with increased risk for HCV transmission.
  • Other potential modes of transmission are sharing straws during nasal drug use, tattoos, body piercing, and long-term hemodialysis.

Hepatitis C counseling and education: how to avoid transmitting the virus

Household exposures
  • Risk of household transmission is low
  • Avoid sharing hygiene items, such as toothbrushes, other dental cleaning equipment, shaving equipment
  • Cover any bleeding wound to keep blood away from others
Drug Use
  • Avoid use of recreational drugs
  • If injection drug use continues, syringes, needles, and other paraphernalia assocaited with injection or inhaled drug use should not be reused or shared
  • Injection site should be cleaned with fresh alcohol swab
  • Syringes and needles should be discarded safely after one use
Sexual transmission
  • Risk of sexual transmission is low
  • Persons in long-term, monogamous relationship need not use barrier precautions
  • Persons not in long-term monogamous relationship should always practice safe sex
Organ, blood, semen donation
  • Persons with hepatitis C should not donate organs, blood, semen, tissue, or eggs

You should know that smoking cigarettes or marijuana may also harm the liver, especially if you have HCV. Being overweight or obese may increase your risk of liver damage. Ask your doctor about how you can lose weight and quit smoking.3,4

Your doctor should screen you for depression, both at diagnosis and at follow-up visits, especially after antiviral drug treatment is started.3 Screening for depression during antiviral treatment is important because certain HCV therapies are associated with significant psychiatric side effects including depression. These psychiatric side effects can affect 30% to 80% of people receiving these medications.5

To help you cope with the emotional and physical consequences of having chronic HCV, talk to your doctor about counseling and other support resources. Many people with chronic HCV infection find a patient support group useful.

Diet
Although no particular diet or pattern of eating has been shown to benefit a person with chronic HCV infection, there are some dietary factors that you may want to consider.

The most important dietary consideration is alcohol consumption. Most experts advise against drinking alcohol when you have HCV. Alcohol has been shown to promote the progression of chronic HCV. So, you should stop, or at least limit drinking alcohol.3 If stopping or reducing alcohol is difficult, talk to your doctor about getting help for this.

If you have HCV, one powerful step that you can take to protect your health is to make sure you are eating a healthy, well-balanced diet. Getting the nutrients you need on a daily basis and achieving and maintaining the proper body weight is an important key to maintaining your general health. The healthier you are, the better able you’ll be to meet the challenges posed by HCV. Before you make any change to your diet, including taking vitamins or supplements, check with your doctor first. This is especially important for a person with HCV, because the liver is directly involved in the metabolism of much of what we eat and drink. Some supplements, especially those containing certain herbs, can pose a danger to your liver. Additionally, if you have HCV, you should avoid certain foods that pose a risk to your liver, including raw or undercooked shellfish and wild mushrooms (those that are gathered by foraging).

The three main goals of your healthy eating plan should be to:

  • Maintain the proper balance between your energy needs and the calories you take in
  • Take in sufficient amounts of specific nutrients to prevent malnutrition
  • Supplement your diet as needed to prevent deficiencies in specific nutrients

Drinking two or more cups of caffeinated coffee daily may reduce your risk of cirrhosis, hepatocellular carcinoma (liver cancer), hospitalization, and death from chronic liver disease. Additionally, coffee consumption appears to increase HCV treatment cure rates (sustained virology response) if you are being treated with interferon in combination with ribavirin.3

Managing fatigue
Many people with HCV complain of feeling tired or fatigued.3 Fatigue is the most common HCV symptom. The first step in successfully managing fatigue is to understand its cause or causes. There are many different tools you can use to overcome fatigue, once you’ve figured out what’s causing it. For instance, if you’re fatigued because of poor sleep, your doctor may be able to offer you a medication that can help you sleep or offer you suggestions for improving your sleep. So, the first thing your doctor will do is to check to see if your fatigue is related to another condition, such as thyroid disease, diabetes, depression, or a blood abnormality, such as anemia.3

Learn more about managing fatigue

Medications and dietary supplements
The liver plays a central role in how we metabolize the drugs, herbs and supplements we take. People with HCV and normal liver function can take most medications that people without liver disease can. However, if you have cirrhosis, ask your doctor whether you should avoid or adjust the dose of any medications.

Acetaminophen (eg, Tylenol) in amounts above the prescribed dose can be toxic to the liver. HCV patients can take acetaminophen, but safe use depends on following strict recommendations. First, check all the medicines you are taking. Acetaminophen (sometimes listed as APAP) is added to over 600 prescription and nonprescription drugs. These include drugs for pain, sleep, colds, cough, sinus medications, etc. Liver experts do not agree on the maximum safe dose of acetaminophen for HCV patients with cirrhosis. However, they generally agree that patients with cirrhosis should not exceed 2000 mg (2 grams) of acetaminophen per 24 hours, taken in divided amounts. For example, if you take 2 tablets containing 325 mg of acetaminophen, 3 times a day (2 tablets x 325 mg = 650 mg per dose, taken 3 times in a day = 1950 mg), you are getting about the daily limit of 2000 mg. As for acetaminophen doses for HCV patients without cirrhosis, the recommendations vary between 2000 mg and 3000 mg daily.3

People with cirrhosis should avoid non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (eg, Advil), naproxen (eg, Aleve), and aspirin.

Screening for HCV-related complications
HCV infection increases risk for certain health conditions, especially cirrhosis. Your doctor will suggest regular screening for HCV-related conditions based on your current health status. Your doctor may want to check your vitamin D level and bone density. If you have cirrhosis, you will be monitored for esophageal varices, a condition involving enlargement of the veins in the lower esophagus that often affects people with liver disease. Your doctor will also monitor you for hepatic encephalopathy and hepatocellular carcinoma (liver cancer). Additionally, if you have HCV infection, you should be screened for depression, suicidal thoughts, and substance use (alcohol and drug) before starting and during antiviral drug therapy.3,6

Vaccination
If you have HCV, you should receive vaccinations against hepatitis A and hepatitis B if you are susceptible to these types of viral hepatitis. Flu shots are also recommended for patients with liver disease. Discuss immunization guidelines with your doctor to be sure that you are up-to-date with the latest recommendations.3,4

Antiviral drug therapy
Antiviral drug therapy is the cornerstone of treatment for chronic HCV infection. The goal of HCV treatment is to achieve a sustained virologic response (SVR). SVR is the medical term for eliminating HCV, sometimes also called virologic cure. SVR is the most important result in HCV treatment. SVR12 means that HCV is not detectable in the blood 12 weeks after treatment is completed. SVR24 means that HCV is not detectable in the blood 24 weeks after treatment is completed. If you achieve SVR24 following HCV treatment, you are considered cured. Although SVR24 is the key goal, most people with SVR12 will also achieve SVR24. Achieving SVR is associated with a very high likelihood (almost 100%) of being free of HCV. SVR is also associated with increased likelihood of survival, decreased risk for liver transplantation, hepatocellular carcinoma (liver cancer), and other types of liver complications. While SVR is important for all patients with HCV, if you have cirrhosis, SVR does not mean that you are cured of liver disease. You may be virologically cured, and still have cirrhosis.3

If you have chronic HCV infection, the decision to start antiviral drug therapy will depend on several factors. These include how quickly the disease is progressing, the stage of fibrosis, and consideration of the efficacy and tolerability of therapy. Generally, antiviral drug treatment is considered appropriate if you have3:

  • Confirmed chronic HCV (presence of HCV RNA)
  • Compensated liver disease (advanced liver disease that is stable)
  • Blood counts and other laboratory measures are favorable
  • No contraindications to treatment (this includes health conditions that prevent you from using recommended antiviral medications)

Additionally, other factors, including current alcohol and drug use, the presence of kidney disease, and whether you have had a liver transplant, may also affect the decision to start antiviral drug treatment. However, new HCV treatments with fewer side effects are making it possible to treat many of those who weren’t eligible for treatment in the past.

Choice of antiviral treatment. Your doctor will recommend an HCV treatment regimen depending on several factors, the most important being your HCV genotype. There are seven different HCV genotypes and many different subtypes. Different combinations of antiviral drugs are more successful than others at working against different genotypes.

Learn more about HCV genotypes

There are three types of medications currently used to treat HCV. They include:

Learn more about antiviral treatment for HCV infection

view references
  1. Bonis PAL, Chopra S. Patient information: HCV (Beyond the Basics). Di Bisceglie AM, Bloom A, eds. Accessed at: www.uptodate.com. 2014.
  2. Epidemiology of hepatitis C. US Department of Veteran Affairs. Available at: http://www.hepatitis.va.gov/provider/reviews/epidemiology.asp. Accessed on 073014.
  3. Chopra S. Overview of the management of chronic HCV infection. Di Disceglie AM, Bloom A, eds. Accessed at: www.uptodate.com. 2014.
  4. American Association for the Study of Liver Disease, Infectious Diseases Society of America. Recommendations for testing, managing, and treating HCV. Available at: http://www.hcvguidelines.org. Accessed April 24, 2014.
  5. Schaefer M, Sarkar R, Diez-Quevedo C. Management of mental health problems prior to and during treatment of HCV infection in patients with drug addiction. Clin Infect Dis 2013;57.
  6. Yee HS, Chang MF, Pocha C, et al. Update on the management and treatment of HCV infection: recommendations from the Department of Veterans Affairs HCV Resource Center Program and the National HCV Program Office. Am J Gastroenterol 2012;107:669-89.
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