Showing posts with label Questions About HCV. Show all posts
Showing posts with label Questions About HCV. Show all posts

Friday, December 3, 2010

Answered: Thirty Eight Questions About Hepatitis C

Part Four: Questions About Hepatitis C

Peppermint Patti’s FAQs in English (v. 10.1, 2015)
PEPPERMINT PATTI’s FAQs come out every year or two. Version 10.1 (2015, English) is 150 pages of answers to the questions most frequently asked (plus many less-frequently asked) about hepatitis C. It contains information about the hepatitis C virus (HCV), its treatment, and related complications.

Saturday, November 6, 2010

Hey,I Have Questions About Cirrhosis And My Liver......

Part One: Hey, Can I Get Hepatitis C From.....?
Part Two: Hey, I Have A Question About HCV Tests
Part Four: Answered: Thirty Eight Questions About Hepatitis C

Part Three: Hey, I Have Questions About Cirrhosis And My Liver......

Q-Isn’t it true that the liver can regenerate and does this mean I can get better on my own?
A-Your body can replace old liver cells, called hepatocytes, with new ones. This means that your liver can recover from minor stresses and strains. However, over time damage can cause fibrous scar tissue. This changes the structure of the liver and cannot be repaired. This is why it is so important to spot liver problems before the damage builds up and becomes irreversible.

Q-When does a doctor think liver enzymes readings are cirrhosis?
Wanted to see if anyone knew what liver enzyme reading ast/alt would concern a dr to the point to refer for a biopsy?
A-Doctors don't generally make a diagnosis of cirrhosis based solely on liver enzymes, which are not a reliable indicator of liver damage, i.e. a person can have end-stage liver disease and normal liver enzymes, or a healthy liver and elevated enzymes. While elevated liver enzymes indicate activity going on in the liver, they don't paint the whole picture, nor do they identify a specific liver problem, as many things can account for the elevation. Further, the doctor will also consider: How high are the enzymes? Was it a sudden one-time spike, or have they been up in the 100s over a period of time?

If elevated for a long time, have they remained steady around that level, or have they been steadily increasing? It's important to provide the doctor with a full (honest) history to determine whether there are risk factors for liver disease. Patient history, symptoms, and blood count are among the indicators (as well as enzymes & biopsy) that will help a physician assess liver damage. Liver biopsy remains the "gold standard" of evaluating the liver's condition. However, biopsy isn't always necessary, nor is it always 100% accurate, due to sampling error.

Generally, biopsy is only done to provide additional information that can't be assessed or confirmed through non-invasive measures - information that would help identify a specific liver disease or make a difference in determining a course of treatment. If non-invasive measures do suggest advanced disease (cirrhosis), the doctor may decide against doing a biopsy due to risk. So, in answer to your question, liver disease is complex, and assessing damage isn't as simple as a single test result, i.e. there isn't a liver enzyme level that prompts referral for biopsy, and biopsy isn't always needed to determine that someone has cirrhosis.

Q-Do high liver enzymes indicate serious liver damage?
A-Despite what one might expect, high levels of liver enzymes (transaminases - AST and ALT) in the blood don’t always reveal just how badly the liver is inflamed or damaged. This is an extremely important point to keep in mind. The normal ranges for AST and ALT are around 0 to 40 IU/L and 0 to 45 IU/L respectively. (IU/L stands for international units per liter and is the most commonly accepted way to measure these particular enzymes.) But someone who has an ALT level of 50 IU/L is not necessarily in better condition than someone with an ALT level of 250 IU/L! This is because these blood tests measure inflammation and damage to the liver at an isolated point in time. For instance, if the liver is inflamed on the day that blood was drawn—let’s say if a patient consumes an alcoholic drink a few hours prior to blood being drawn—the levels of the transaminases may be much higher than if the alcohol had not been consumed. Following the same reasoning, if the liver was damaged years before—by excessive alcohol use—the results of a blood test done today may be normal, but a damaged liver may still be present.

Q-What About My Diet ?
A- Cirrhosis refers to the replacement of damaged liver cells by scar tissue. Too much scarring prevents blood flow through the liver. This causes even more damage and loss of liver function. Cirrhosis can hinder the body's use of nutrients and can lead to malnutrition.

Many patients with cirrhosis tend to hold onto (or retain) water. This often is shown first by swelling in the ankles, particularly after walking. The swelling may move up the legs to the abdomen. Water buildup in the abdomen is called "ascites" (pronounced "ah-si-teez").

Sodium (salt)Too much sodium (or salt) in the diet can make the situation worse, because sodium encourages the body to retain water. Your doctor will tell you if you need to limit sodium in your diet. Usually this means restricting sodium intake to about 2,000 mg a day or less.

If you need to restrict sodium, here are some tips that can help:

Avoid salty foods, salt in cooking, and salt at the table. Anything that tastes salty (such as tomato sauce, salsa, soy sauce, canned soups) probably has too much salt. Spice things up with lemon juice or herbs, instead of salt. Fresh foods usually are a better bet than processed foods.

Read food labels when shopping. Check the amount of sodium in the foods you are buying.
Avoid fast-food restaurants. Most fast foods are very high in sodium.

Go easy on meats, especially red meats, which are high in sodium. When possible, consider vegetarian (meat-free) alternatives.

A dietitian can inform you about other products, such as antacids, that also contain lots of sodium.

The more fluid you retain, the greater your need to avoid salt. Your doctor may prescribe diuretics ("water pills") to help you urinate more. But all the water pills in the world won't help if you eat salty foods, such as anchovy pizzas.

Calories and protein
People with cirrhosis may need more extra calories and protein. They may lose their appetite and experience nausea, vomiting, and severe weight loss. This can lead to shortage of the minerals calcium and magnesium (signs include muscle cramps, fatigue, weakness, nausea, and vomiting), or a shortage of zinc (signs include reduced ability to taste, changes in taste).

It can help to eat small, frequent meals (4 to 7 times a day), including an evening snack. Your doctor even may recommend high-nutritional supplement drinks, such as Ensure or Boost.

When the scarring from cirrhosis prevents blood from passing through the liver, pressure increases in the veins entering the liver. This is called portal hypertension. The body is forced to reroute the blood away from the liver and into the general blood circulation. This causes large blood vessels, called "varices," to form.

Because the rerouted blood bypasses the liver, it contains high levels of amino acids, ammonia, and toxins that normally would have been handled by the liver. When these substances reach the brain, they can cause confusion and temporary loss of memory (a condition called "hepatic encephalopathy").

Amino acids and ammonia come from protein in the diet. Some evidence shows that patients with cirrhosis do better when they get their protein from vegetables (such as beans, lentils, and tofu) and from dairy products (eggs, milk, yogurt) instead of from meats.

Doctors can prescribe a syrup called Lactulose to push food through the bowels more quickly. This way, less food is absorbed, the liver has less work to do, and fewer toxins make their way to the brain.

Avoid eating raw oysters or other raw shellfish. Raw shellfish can harbor bacteria (Vibrio vulnificus) that cause severe infections in people with cirrhosis.

Diet For People With Cirrhosis
If your condition has progressed to cirrhosis there are additional considerations you will need to make in your diet to support your liver, learn more here.  For support visit; I Help C - Your Best Friends Guide to Hepatitis C and Cirrhosis

Q-Can antidepressants raise liver enzymes?
A-While SSRIs are considered to be safe for people with liver disease, they can increase liver-related blood tests. However, other causes of liver elevations need to be looked for as the SSRI may or may not be the cause, for example, thyroid disease can also sometimes cause elevations in liver enzymes.

Q-Can prescription medicines, common pharmacy medicines, herbal remedies and illegal drugs affect my liver disease?.
A-Yes. Most drugs (whether prescription, legal or illegal) are processed and broken down by the liver. In people with liver disease where the liver is already under strain, the extra work in breaking down drugs can be dangerous. Make sure all the health professionals (such as your GP, dentist and pharmacist) know about your liver disease before you are given or buy medicines from them. Even common tablets such as aspirin can be dangerous to people with liver problems. Herbal remedies and illegal drugs are a particular risk, as they are not regulated and can contain impurities that cause liver damage. If in doubt, speak to your liver specialist before taking any medicines or drugs.

The following are some tips for managing your medication:

To avoid potentially life-threatening complications, you should talk to your doctor or pharmacist about all medications or supplements - pharmaceutical and herbal - that you are taking or thinking of taking.

Always read the instructions, and never take more than the recommended dose. Taking more than is recommended of any medication could potentially cause harm to the liver.

NEVER mix medication with alcohol. Alcohol only increases the risk of possible liver damage. Acetaminophen can be especially toxic when combined with alcohol.

Consult your doctor about acetaminophen if you have liver disease.

Avoid certain herbal supplements as well as certain vitamins in high doses as they have the potential to cause damage to the liver. Kava, kava kava, comfrey, chaparral, jin bu huan, kombucha tea, pennyroyal, skullcap and shou-wu-pian all may be toxic to the liver.

High doses of vitamins E, K - and especially vitamins A and D - also may be harmful.

Take acetaminophen and all other pain relievers only when really necessary.

Q -What about using Milk Thistle ?
A Laboratory studies suggest that milk thistle may benefit the liver by protecting and promoting the growth of liver cells, fighting oxidation (a chemical process that can damage cells), and inhibiting inflammation. Study results from small clinical trials on milk thistle for liver diseases have been mixed; however, most of these studies have not been rigorously designed, or they have looked at various types of liver diseases—not just hepatitis C. High-quality, well-designed clinical trials have not proven that milk thistle or silymarin is beneficial for treating hepatitis C. The HALT-C study mentioned above found that silymarin use by hepatitis C patients was associated with fewer and milder symptoms of liver disease and somewhat better quality of life, but there was no change in virus activity or liver inflammation

Q-Can I use supplements?
A- In general it is important to keep in mind that excessive doses of iron , vitamin A and niacin have been found to be toxic to the liver. Thus, individuals with liver disease are generally advised to avoid these supplements. And, since osteoporosis ( a disease characterized by reduced bone mass resulting in an increased risk for bone fractures), is common to many liver diseases, it is a good idea for all people with chronic liver disease to take a calcium supplement. Calcium supplementation should be limited to no more than 1000 to 2000 milligrams per day and should be taken with a vitamin D supplement ( which is usually included in the calcium tablet). Since stomach acid is needed to properly absorb calcium, antacids, such as Tums, which reduce stomach acid, are poor sources of calcium. Finally. individuals suffering from ascites- a complication of cirrhosis resulting in an abnormal accumulation of fluid in the abdomen, need to limit their intake of sodium. For every gram of sodium consumed, the accumulation of 200 milliliters of fluid results. The lower the consumption of sodium in the diet, the better controlled this excessive fluid accumulation is. For people with ascites, sodium intake should be restricted to under 1,000 milligrams per day and preferably under 500 milligrams. This goal is difficult, yet attainable.

Iron and Hepatitis C :The liver plays an important role in the metabolism of iron since it is the primary organ in the body that stores this metal. The average American diet contains about 10- 20 mg of iron. Only about 10% of this iron is eliminated from the body. Patients with chronichepatitis C sometimes have difficulty excreting iron from the body. This can result in anoverload of iron in the liver, blood, and other organs. Excess iron can be very damaging to the liver. Studies suggest that high iron levels reduce the response rate of patients with hepatitis C to interferon. Thus, patients with chronic hepatitis C whose serum iron level is elevated, or who have cirrhosis, should avoid taking iron supplementation. In addition, one should restrict the amounts of iron rich foods in their diet, such as red meats, liver, and cereals fortified with iron, and should avoid cooking with iron coated utensils.

Healthcare professionals strongly advised not to take megavitamin therapy or to use nutritional products bought in special stores or by catalogue without consulting your doctor. Some dietary supplements can harm your liver. A few that have caused problems are cascara, chaparral, comfrey, kava, and ephedra.

Learn more by reviewing the following Herbal Glossary available at HCV Advocate: This glossary describes various herbs — the safety concerns, interactions with other medications and potential harms to The goal of the herbal glossary is to help people make an informed decision and stay safe. Note: be sure to inform your medical provider if you are taking any herbs or supplements.

Q-I have cirrhosis what can I take for joint pain ?
A-Acetaminophen is the recommended medication for relieving minor aches, pains, and headaches in people with liver disease. In small doses (less than 4 grams per day, or eight pills taken over a twenty-four hour period of time) acetaminophen is quite safe for the liver—unless combined with alcoholic beverages. (Note: each acetaminophen tablet or pill typically contains 500 milligrams of acetaminophen.) Be careful about mixing Tylenol® with other products that contain acetaminophen. By taking more than one pain reliever at a time, you may accidentally take more acetaminophen than is safe.

Q-What is acetaminophen?
A: Acetaminophen (pronounced: a∙seet·aminofen), is an active ingredient found in many OTC and prescription medicines to help relieve pain and reduce fever.It is also found in combination with other active ingredients, called combination medicines, which treat conditions such as:

symptoms of colds and flu

Medicines containing acetaminophen are available in many forms, including drops, syrups, capsules, and pills. Many people call OTC acetaminophen by a brand name, Tylenol. Others may know Percocet or Vicodin, which are prescription brand names that contain acetaminophen and other active ingredients to help relieve pain.You might see acetaminophen abbreviated as “APAP” on prescription medicines. In other countries, acetaminophen may have a different name. For example, acetaminophen is known as paracetamol in the United Kingdom.

Acetaminophen, supplements and other medications may trigger drug-induced liver injury
November 30, 2016
Download Full Text Article @ AACN Advanced Critical Care
About 46 percent of persons with acute liver failure in the United States have liver damage associated with acetaminophen, making it the most common cause of DILI. Since acetaminophen is often an ingredient in over-the-counter and prescription pain medications, patients may take higher doses than needed.

Liver disease and acetaminophen: can you take it safely?
June 2016
Doctors often tell patients with liver disease that they shouldn't use acetaminophen, a common over-the-counter pain reliever found in Tylenol and many other cold and flu medications. Acetaminophen is broken down by the liver and can form byproducts that are toxic to the liver, so this warning is not completely without merit.

But take it from a hepatologist, acetaminophen is the best option for pain relief for people with liver disease.

Acetaminophen is a “dose-dependent hepatotoxin,” which means that its toxic effects on the liver are related to the amount taken. If anyone takes too much, even those with healthy livers, it will reliably cause an acute injury to the liver. In fact, acetaminophen is the most common cause of acute liver failure in the United States, accounting for almost half of all cases.

The good news is that liver injury can be avoided by limiting the amount of acetaminophen taken each day to 3,000 mg for most people and 2,000 mg for those with chronic liver disease. Staying within these limits will generally prevent liver injury. But the toxic byproducts can accumulate, so it’s best not to take acetaminophen every day.
Continue reading....

Why acetaminophen is the 'most common cause of liver injury' in Canada
Sep 16, 2016
Health Canada's new labelling rules for acetaminophen are not strict enough, and the extra-strength products should be removed from store shelves, some doctors say. Acetaminophen is one of the most widely used pain and fever relievers in Canada and worldwide. It is safe if used properly, but too much can be dangerous, particularly over time.
"It is the most common cause of liver injury. Period. Full stop," said  Dr. Michael Rieder, a pediatric clinical pharmacologist at Western University in London, Ont.

Acetaminophen-induced acute liver injury, acute liver failure occurs more in women
May 23, 2016
​SAN DIEGO —  Despite increased rates of acetaminophen-induced acute liver injury and acute liver failure than male counterparts, women did not experience poorer survival outcomes related to these conditions, according to findings presented at Digestive Disease Week 2016.

AASLD-What Patients Need to Know about Acetaminophen
Hepatitis C Review - Acetaminophen -Tylenol
Q-Can liver cysts cause abdominal pain?
A-Simple liver cysts — fluid-filled cavities in the liver — usually cause no signs or symptoms and need no treatment. However, they may enlarge enough to cause pain or discomfort in the upper right part of the abdomen.

Most liver cysts can be detected on ultrasound or computerized tomography (CT) scans. When needed, treatment may include drainage or removal of the cyst.

The cause of simple liver cysts isn't known, but they may be present at birth (congenital). Rarely, liver cysts may indicate a serious, underlying condition such as:

Polycystic liver disease, an inherited disorder
Echinococcus infection, a parasitic infection
Liver cancer

Q- What is a hemangioma ?
A- Hemangioma (he-man-jee-O-muh) is a noncancerous (benign) mass that occurs in the liver. A liver hemangioma is made up of a tangle of poorly formed blood vessels. Liver hemangioma is sometimes called hepatic hemangioma or cavernous hemangioma.

Most cases of liver hemangioma are discovered during a test or procedure for some other condition. Most people who have a liver hemangioma never experience signs and symptoms and never need treatment.

While it may be unsettling to know you have a mass in your liver, even if it's a benign mass, there's no evidence that an untreated liver hemangioma can lead to liver cancer.

Q-What is the most common benign liver tumors?
A-Hemangiomas are the most common benign tumors of the liver.The name hemangioma derives from the fact that these tumors are filled with heme (blood). They have no malignant potential and may occur in a person with or without underlying liver disease. Hemangiomas occur in the liver in approximately 10 percent of the population, and are usually detected by chance during a sonogram or CT scan performed for the evaluation of an unrelated medical condition. Hemangiomas are more common in women, but can also be found in men, and can occur at any age.

Typically, an individual who harbors a liver hemangioma will not even be aware of it, as these tumors are usually asymptomatic. Some researchers believe that excess estrogen can cause hemangiomas to grow. In fact, growth of hemangiomas has been observed in some women during pregnancy, and in others while taking birth control pills. Furthermore, these people may be at increased risk for rupture. Although the effect of estrogen on hemangiomas is not conclusive, it is advisable for people with hemangiomas to stay off birth control pills and all other forms of estrogen replacement.

In the United States, metastatic tumors are the most common malignancies that occur in the liver. A metastatic liver tumor is a cancer that originally started in an organ other than the liver (known as the primary organ), and then spread to the liver.

Q-Why does my liver hurt ?
A-When diagnosed with hepatitis, patients often expect to feel pain over the liver. And, in fact, many people with chronic hepatitis do experience abdominal pain or discomfort over the liver. Others state that although they do not actually experience pain, they do feel a vague sense of “fullness”, or an “awareness”, of the liver. However, patients who report these symptoms to the doctor, will likely be informed that the liver itself does not typically cause pain or discomfort. Abdominal pain and/or pain over the liver (known as right upper quadrant pain), in people with liver disease may have many causes. This type of pain should not automatically be attributed to a liver disorder – other causes should be investigated. In fact, abdominal and right upper quadrant pain is rarely due to chronic liver disease.Right upper quadrant pain, when due to the liver, occurs most commonly in the acute stages of liver disease, (inflammation of the liver that lasts less than six months), or during a flare - up of a chronic liver disease. In these circumstances, the cause of this pain is due to acute inflammation, irritation, and distention of the liver’s surface. Otherwise, the liver is rarely tender.

Gallstones often occur in individuals with liver disease, especially those with cirrhosis. Other risk factors for gallstones include female gender, obesity, a family history of gallstones, multiple pregnancies, rapid weight loss, and biliary tract narrowing (known as biliary strictures). The typical pain from gallstones is a right upper quadrant discomfort that usually lasts from a half hour to six hours before abating. Pain is usually severe and usually recurs. This pain often radiates to the shoulder or back, and is usually accompanied by nausea and vomiting. Diagnosis of gallstones is typically made by obtaining an abdominal sonogram.Liver cancer may also cause abdominal or right upper quadrant pain. People with a history of chronic hepatitis B or C, and those with cirrhosis due to any chronic liver disease are at risk for developing liver cancer, (also known as hepatocellular carcinoma, (HCC) or hepatoma).

HCC is one of the most common cancers in the world, with its greatest frequency occurring in Asia and Africa. Although its rate of occurrence has been rising over the past twenty years in the United States, it is still uncommon, accounting for only 0.5 to 2 percent of all cancers. The cause of this rise has been linked to the prevalence of chronic hepatitis C in the United States.

Stomach disorders, such as peptic ulcer disease (PUD) and gastritis (inflammation of the stomach lining) often cause abdominal pain in people with liver disease. An upper endoscopy (a procedure wherein a flexible tube with a light at the end is inserted down the esophagus into the stomach and first part of the small intestine) is typically performed in order to diagnose these stomach disorders. During an upper endoscopy, a biopsy is usually taken of the lining of the stomach for Helicobacter pylori, a bacteria which may cause gastritis and ulcers. These stomach ailments are readily treatable with medications known as proton-pump inhibitors, such as Prevacid, Nexium, Protonix or Aciphex, either alone, or in combination with antibiotics, depending upon the precise diagnosis.

Other causes of abdominal and right upper quadrant pain which should be investigated in people with liver disease, include inflammation of the pancreas a condition known as pancreatitis, which may occur with increased frequency in those who drink excessive alcohol, and scar tissue from prior abdominal surgery known as adhesions.

If one experiences abdominal pain along with distention and swelling of the abdomen, ascites must be considered as a cause. Ascites is characterized by accumulation of fluid in the peritoneal cavity – the space between the abdominal organs and the skin, and is the most common complication of cirrhosis. When this is accompanied by a fever and severe abdominal pain, an infection of this fluid should be suspected. This is a serious medical condition known as spontaneous bacterial peritonitis (SBP), and requires immediate hospitalization and treatment.

However, abdominal distention and pain occurring in patients with liver disease may be due to less serious ailments than ascites. For example, abdominal distention and discomfort can result when the digestive tract fills with gas. When this happens, one may experience the sensation of being bloated. This type of abdominal distention may be due to impaired or inadequate absorption known as malabsorption or digestion, known as maldigestion, of certain foods which can be associated with certain liver disorders. This is a controllable condition, and may be treated by the avoidance of specific foods, for example milk-products or wheat (gluten) products

Q- Why does my spleen hurt?
A- Spleen is an important organ of the lymphatic system. It is found on the left upper side of the abdomen, between the 9th and 12th rib. The primary function of the spleen is to produce lymphocytes and plasma cells, which are used in humoral and cellular immune defense. Approximately half of the body’s monocytes are stored in this organ. These cells can easily transform into macrophages and dendritic cells, and assist in wound repair. Additionally, the spleen filters the blood and removes all the unwanted materials like cell debris and microorganisms as bacteria, viruses and fungi.

Furthermore, it monitors the red blood cells, eliminating those that are abnormal, damaged or too old to function properly. It also serves as a storehouse for various elements of the blood like platelets and white blood cells. In the absence of the spleen, the body becomes susceptible to diseases caused by bacteria and protozoa, and responsiveness to certain vaccines also decreases.

Whenever the normal functioning of the body is hampered by disorders like cancer, anemia, malaria, tuberculosis, amyloidosis, cirrhosis, hepatitis and the like, the spleen becomes hyperactive, and starts entrapping and storing a large number of blood cells and platelets. As the result, the platelet and blood cell count in the bloodstream begins to fall dramatically. Due to entrapment, the spleen grows in size, and as it grows, it traps in more and more blood cells and platelets. Eventually the overgrown spleen starts capturing and destroying the normal blood cells together with the abnormal ones. These blood cells and platelets clog the spleen and interfere with its normal function.

The characteristic symptom of spleen enlargement is severe pain in the abdomen and back. At times, the pain shoots up to the left shoulder. This happens when certain parts of the spleen begin to bleed and die due to inadequate supply of blood. The enlarged spleen also starts pressing the stomach, which leads to the feeling of fullness after eating a small amount of food or even without eating anything. Furthermore, as too many blood cells and platelets have been removed from the bloodstream, the body’s immune response begins to dwindle, symptoms of anemia emerge, and normal blood clotting process is also slows down.

In this era of personalized medicine, it is necessary to stratify different risk groups among patients with cirrhosis. As recently proposed, a revised staging of cirrhosis should start with its main classification of compensated and decompensated cirrhosis, 2 separate entities with different prognostic significance. Decompensated cirrhosis is defined by the presence of complications that are mostly secondary to portal hypertension: Ascites, variceal hemorrhage, and/or hepatic encephalopathy....

Q-What is cirrhosis ?
A-Cirrhosis is a description of the extent of scarring of the liver. With cirrhosis, scarring or fibrosis has advanced to the extent that the structure of the liver is altered: the usual smooth texture of the liver starts to become nodular and lumpy. Nodules are areas of liver cells that have become cut off from the rest of the liver by circular bands of scarring with liver cells unsuccessfully trying to regenerate inside the bands. The free flow of blood throughout the liver starts to be compromised.

Q-What are some symptoms of early cirrhosis?
A-Many people with cirrhosis have no symptoms in the early stages of the disease. However, as the disease progresses, a person may experience the following symptoms:

loss of appetite
weight loss
abdominal pain and bloating when fluid accumulates in the abdomen
spiderlike blood vessels on the skin

Q- What is compensated cirrhosis ?
A-Compensated cirrhosis means that the liver is still able to cope with or compensate for the damage and carry out most (sometimes all) of its functions. Cirrhosis, as with fibrosis, ranges from mild (at the beginning) to moderate and severe. Severe cirrhosis can then progress to decompensated cirrhosis.

** For people with Hepatitis C it is important to remember the disease progression is not linear; that is, the process speeds up so it is critical for people to take the necessary steps to make sure that they are receiving the appropriate medical care, which may include HCV therapy to help slow down or stop the disease progression process.

Q-What is decompensated cirrhosis ?
A- Decompensated cirrhosis means that the liver is extensively scarred and unable to function properly. People with decompensated cirrhosis eventually develop many symptoms and complications that can be life threatening.

Q- When does the liver stop working ?
A-The liver can still function with up to 80 percent deterioration. According to the Hepatitis C Trust, 80 to 90 percent of the liver becomes permanently damaged before decompensated occurs.

Q-Can a person have ascities and not have decompensated cirrhosis?
A- While the presence of ascites usually stems from decompensated cirrhosis, there are other causes of ascites, unrelated to liver disease - such as kidney failure, heart failure or ovarian cancer. Veno-occlusive disease can also cause ascites in people who do not have decompensated cirrhosis. In this disease, the hepatic vein becomes clogged, blocking off the blood supply to the liver resulting in ascites. The pyrrolizidine alkaloids which are ingredients of some herbal teas, such as Comfrey tea have been associated with veno-occlusive disorder. Many herbal preparations that contain a mixture of herbs include comfrey, but due to the lack of labeling regulations of herbal products, comfrey may or may not be listed as an ingredient on these products.

Q-Why is my urine a dark color ?
A-Brown urine can be a danger sign of liver disease, according to the University of Maryland Medical Center. Jaundice is often the first sign of liver disease, causing dark urine and yellowed eyes and skin. Cirrhosis, hepatitis, pancreatic cancer, pancreatitis, bile duct cancer and alcoholic liver disease all cause dark urine. Other symptoms of liver disease include an enlarged abdomen, disorientation, easy bruising or bleeding, nausea, loss of appetite and fatigue. Liver disease is a life-threatening disorder.

Q- What happens as liver function decreases?
A-As liver function decreases, fewer proteins such as albumin are produced resulting in fluid accumulation in the legs (edema) or abdomen (ascites). Individuals with cirrhosis may bleed and bruise easily due to a decrease in proteins required for blood clotting. Some people may even experience intense itching due to products that are deposited in the skin.

Q-What problems are associated with the later stages of cirrhosis, or in decompensated cirrhosis?
A-Complications can include:

• Hardening of the Liver due to dying liver cells can be felt on examination.
• As liver disease progresses there is bone mass and density loss.
• A damaged liver is unable to regulate the production and breakdown of some female and male hormones. In women this can cause menstrual irregularities, and in men, gynecomastia (breast enlargement).
• Impaired Mental Status is due to many factors. Toxic substances that are usually filtered by the liver reach the brain. Symptoms of encephalopathy include personality changes, changes in sleep patterns, sluggish movements, drowsiness, confusion, stupor, and coma.
• Itching (pruritus) can develop that can be debilitating. The cause of pruritus is believed to be caused by impairment or failure of bile flow complicated by jaundice.
• Kidney function deteriorates in someone with decompensated cirrhosis, contributing to fluid retention(ascites, edema) and various kidney disorders.
• People with hepatitis C who develop cirrhosis are at risk for liver cancer.
• Muscle wasting can result from the liver’s inability to metabolize proteins, which can make a person with cirrhosis more prone to bone fractures.
• A combination of factors such as portal hypertension,low albumin levels and kidney dysfunction produce an accumulation of fluid in the body. Ascites is the accumulation of fluid in the abdominal cavity. Edema is the accumulation of fluid in the extremities, especially the feet and legs
• Bleeding problems (coagulopathy) develop as the liver
• The spleen stores red and white blood cells and platelets. An enlarged spleen develops due to blood being forced into it when portal hypertension develops. An enlarged spleen loses its ability to store red and white blood cells, and platelets.
• Scar tissue in the liver restricts the flow of blood and leads to portal hypertension resulting in complications such as ascites, spontaneous bacterial peritonitis, varices and other potentially life-threatening complications.
• Spontaneous Bacterial Peritonitis is a condition caused when the body’s natural bacteria enters the ascites fluid causing severe infection.
• The veins in the stomach, esophagus and rectum become so stretched and dilated (due to portal hypertension) that a condition called varices develops which can lead to internal bleeding.

Q-What is hepatic encephalopathy?
A-Hepatic encephalopathy (HE) is a disorder of mental activity, neuromuscular function and consciousness that occurs as a result of either chronic or acute liver failure. This complex neuropsychiatric syndrome is primarily caused by metabolic abnormalities. The syndrome may occur spontaneously or be induced by some precipitating factor and may be reversible, either by improvement in liver function, correction of the precipitating factors or the administration of therapy. However, HE can eventually lead to coma and especially in acute liver failure, may be fatal.

Q-What are the different types of hepatic encephalopathy?
A-Acute or subacute encephalopathy - is generally rapidly progressive over the short course and is a complication of acute liver disease. This type of HE most often occurs in patients with acute fulminant viral hepatitis, toxic hepatitis and Reye's syndrome and is a sign of terminal liver failure.

Acute or subacute recurrent encephalopathy - more than one episode of HE in a patient with chronic disease with cirrhosis, with periods in between without any observable HE.

Specific precipitating factors can usually be identified in association with the recurrent episodes. Even though coma may develop, it is rarely fatal. Chronic recurrent encephalopathy - multiple recurrences of observable HE, requiring continuous therapy to decrease or prevent the development of symptoms during intervening periods.

Usually this type of HE is found in patients who are cirrhotic with an extensive portal collateral circulation with shunts either surgical or spontaneously evolving.

Chronic permanent encephalopathy or myelopathy - permanent neurological abnormalities unresponsive to therapy and forming part of the spectrum of acquired hepatocerebral degeneration and may include a myelopathy. This condition is very rare.

Q-What are the symptoms of hepatic encephalopathy?
A-There are four different stages of symptoms that can occur. The abnormalities that reflect mental and personality changes are distinguished from those reflecting neuromuscular functions.

In Stage 1, the symptoms include mild confusion, short attention span, nightmares and poor night time sleep with daytime sleepiness, restlessness, depression, aimless wandering, anxiety and irritability.
In Stage 2, the mental and personality changes include obvious drowsiness, obvious personality change, gross impairment of ability to do mental tasks, slow response, disobedience, sullenness and disorientation for time and place.
In Stage 3, the symptoms include bizarre behavior, occasional fits of rage, confusion, speech that is incomprehensible, paranoia and anger.
In Stage 4, coma is either responsive or unresponsive.

Q-How is hepatic encephalopathy diagnosed?
A-The diagnosis of HE is made primarily by recognition of neuropsychiatric changes occurring in a patient with known liver disease. In a patient with cirrhosis, whose liver disease has been followed for some time, the diagnosis becomes readily apparent with development of several of the symptoms mentioned above. When confronted with a patient who presents with an encephalopathy or a patient known to have a history of previous or current liver disease and who has neurological impairment, it is very important that attention should be paid to neurological symptoms such as personality changes, hypersomnia, reversal of sleep pattern, presence of precipitating factors such as gastrointestinal bleeding, use of sedative hypnotic drugs, etc. The presence of a flapping tremor is also an important physical finding in a patient with HE. There is no specific diagnostic test, improvement with treatment is the usual method of diagnosis.

Q-What is the treatment for hepatic encephalopathy?
A-The most important aspect of management is the prompt recognition and correction of precipitating factors, when possible. These factors include kidney failure, use of sedatives or narcotics, GI bleeding, hypokalemia/alkalosis, dietary protein increase, infection, constipation and exacerbation of liver disease. The importance of recognizing and correcting any precipitating factors in patients with HE cannot be overemphasized. Every patient with alcoholic cirrhosis and presumed HE should receive thiamine upon admission to hospital.

Additional therapeutic measures include dietary protein restriction and lactulose and occasionally additional neomycin or metronidazole therapy. The use of L-Dopa or bromocriptine is reserved for patients who do not respond to more conventional therapies, even though, in general, these two therapies are not effective in most patients.

Patients with chronic encephalopathy are encouraged to eat vegetable rather than animal protein. Branched-chain amino acid (BCAA) therapy, administered either orally or intravenously, remains the most controversial treatment. Available data about BCAA are conflicting and do not support its routine use. Newer therapies include lactilol, a disaccharide compound quite similar to lactulose. It is reported to be as effective as lactulose or neomycin but is associated with a decreased incidence of severe diarrhea and other side effects. In many patients with chronic liver disease, liver transplantation entirely reverses HE. Thus, liver transplantation may be considered in some patients with hepatic encephalopathy.

Q-What treatments are used to fight liver cirrhosis?
A-Treatments of cirrhosis are aimed at stopping or delaying the disease progress, minimizing liver cell damage and reducing complications. When cirrhosis is caused by alcohol, the patient must stop drinking to halt the progression of the disease. Cirrhosis caused by viral hepatitis may be treated with antiviral drugs to reduce liver cell injury. Medications can be given to control the symptoms of cirrhosis. For example, drugs called "diuretics" are used to remove excess fluid and to prevent edema and ascites from recurring. Combined diet and drug therapy can improve altered mental function. For instance, decreasing dietary protein results in less toxin formation in the digestive tract. Laxatives, such as lactulose, may be given to help absorb toxins and speed their removal from the intestines. A serious consequence of cirrhosis may be bleeding as a result of portal hypertension. Medications, such as beta blockers, may be prescribed to reduce portal hypertension.

Even when complications develop, they can usually be treated. If the patient bleeds from the varices of the stomach or esophagus, the doctor can inject these veins with a sclerosing (hardening) agent administered through a flexible tube (endoscope) that is inserted through the mouth and esophagus. Rubber bands can also be placed around the veins through the endoscope. In critical cases, a liver transplant or a portacaval shunt, which relieves the pressure in the portal vein and varices, may be necessary.

Q-What are varices?
A-Normally, blood from the intestines and spleen is brought to the liver through the portal vein. In people with severe liver damage (cirrhosis) however, the normal flow of blood through the liver is blocked. This can lead to swelling of the liver and potentially the spleen. Blood from the intestines is then rerouted around the liver through small vessels primarily in the stomach and esophagus. Some of these blood vessels become quite large and swollen (varices). These varices may rupture due to high blood pressure (portal hypertension) and thin vessel walls, causing bleeding in the upper stomach or esophagus.

Q-What is a portal systemic shunt?
A-In cases where severe bleeding occurs, surgical shunt procedures may be used to improve the flow of blood through the varices and to stop bleeding and relieve pressure in these swollen blood vessels.

Introduced in 1945, the portal shunt (portal systemic shunt) was the first definitive form of therapy used for patients who had bled from varices. The procedure involves the surgical joining of two veins, the portal vein and the inferior vena cava, to relieve pressure in the portal vein that carries blood into the liver.

Q-Who qualifies for this procedure?
A-Elective portal shunt surgery is performed in only a relatively small number of patients who bleed from esophageal varices. About one-fourth have severe, uncontrollable bleeding requiring emergency surgery.

Q-Is the portal systemic shunt still performed?
A-The shunt operation virtually eliminated recurrent bleeding from varices but its use declined in the 1970's for two major reasons. One was the frequency of encephalopathy (dysfunction of the brain) as a complication. The other was the failure of controlled clinical trials to establish a statistically significant advantage in survival for patients treated with shunts, over those treated with nonsurgical therapy. The failure of portal shunts to enhance survival, reflected the associated complications of encephalopathy and post shunt failure.

Q-What is a distal splenorenal shunt (DSRS)?
A-This operation was devised to preserve the flow of blood through the portal vein to the liver, while decompressing varices in the stomach and esophagus by joining the splenic vein to the left kidney vein. Studies comparing portal systematic shunts with DSRS, found similar rates of overall mortality and cumulative survival. DSRS had a higher operative mortality but a lower rate of encephalopathy afterwards. Also, patients with alcoholic cirrhosis do poorly with DSRS compared to nonalcoholic cirrhotic patients.

Q-What is endoscopic therapy?
A-Endoscopic therapy is a way of reducing variceal bleeding without surgery. In one procedure called endoscopic sclerotherapy, a flexible endoscope is used to inject diluted mixtures of sclerosing (hardening) solutions into the esophageal varices. Another technique called variceal banding, involves placing rubber bands around the veins through the endoscope.

What are the relative advantages and disadvantages of endoscopic therapy over surgical shunts?

The major merit of endoscopic therapy is that it is relatively easy to apply and can be administered at many primary care hospitals. It is commonly used in the initial management of patients with cirrhosis and variceal bleeding. However, patients experiencing gastric (stomach) variceal bleeding, hypertensive gastritis bleeding or repeated esophageal variceal bleeding following endoscopic therapy, should be treated surgically. In this combination, initial endoscopic therapy and selective shunt surgery may significantly improve survival in patients with variceal bleeding.

Q-What is a transjugular intrahepatic portal-systemic shunt (TIPS)?
A-An important recent advance has been the development of the transjugular intrahepatic portal-systemic shunt (TIPS). TIPS is performed by radiologists using only a local anesthetic and a sedative. A long needle is inserted via the jugular vein in the neck, advanced into a hepatic vein and then into a large branch of the portal vein in the liver. Using an inflatable balloon-tipped catheter tube, the section between the portal vein branch and the hepatic vein is widened and then kept open (stented) with a cylindrical wire-mesh stent.

Q-What are the advantages and disadvantages of TIPS?
A-The major advantages of TIPS are that it dispenses with the need for a general anesthetic and a major surgical procedure, both of which are often poorly tolerated by patients with cirrhosis. Another advantage of TIPS is that it reduces ascites (accumulation of fluid in the abdomen) while the DSRS does not. It has been used successfully to treat severe ascites that no longer respond to the use of drugs (diuretic) to reduce the amount of fluid. TIPS is a valuable innovation but it is not without its hazards. Although the direct mortality from TIPS complications is relatively low (less than 5%), this is true only in the hands of experienced radiologists in specialized centres. Approximately one quarter of patients develop encephalopathy after TIPS and these shunts frequently narrow or block up, requiring additional interventional procedures. In the setting of life-threatening bleeding that cannot be controlled by endoscopic therapy, TIPS is probably the ideal shunt procedure if it is readily available. In patients with portal hypertension who have failed treatment with endoscopic therapy and are candidates for liver transplantation in the near future, TIPS is not the preferred type of shunt. The presence of a surgical shunt makes transplant surgery more difficult and may therefore result in an increased risk of complications following liver transplantation. In patients who have recurrent bleeding in spite of endoscopic therapy and whose liver function is good, DSRS may be preferable in the elective or non-emergency setting. Appropriate clinical comparisons between TIPS, DSRS and endoscopic therapy are not yet available and will help to further clarify the place of TIPS in the management of variceal bleeding.

Q-What is ascites and what causes it?
A-When fluid accumulates in the abdominal cavity, it is called ascites. Cirrhosis of the liver is the most common cause of ascites but other conditions such as heart failure, kidney failure, infection or cancer can also cause ascites.

Q-How common is ascites in people with cirrhosis?
A-Ascites is common in people with cirrhosis and it usually develops when the liver is starting to fail. In general, the development of ascites indicates evidence of advanced liver disease and patients should be referred for consideration of liver transplantation.

Q-What causes ascites in patients with cirrhosis?
A-Ascites is caused by a combination of elevated pressure in the veins running through the liver (portal hypertension) and a decrease in liver function caused by scarring of the liver.

Q-What are the symptoms of ascites?
A-Most patients who develop ascites notice abdominal distension and rapid weight gain. Some people also develop swelling of ankles and shortness of breath.

Q-How is ascites diagnosed?
A-Depending on how much fluid is present in the abdomen, ascites may be diagnosed by your doctor on physical examination but is usually confirmed by tests such as ultrasound or CT scan of the abdomen. In the majority of patients, your doctor will recommend that a small needle be inserted through the abdominal wall (after local anesthesia) to remove fluid to be examined in the laboratory. This test is called a paracentesis. The fluid removed will be examined for signs of infection or cancer and to determine the cause for the fluid accumulation.

Q-Is ascites a dangerous sign?
A-Yes. The development of ascites generally suggests that the liver is not working well. The survival rate 5 years after ascites develops is only 30-40% and it is important that you and your doctor discuss a referral to a liver specialist and a liver transplant center.

Q-What are the complications of ascites?
A-Abdominal pain, discomfort and difficulty breathing: These may occur when too much fluid accumulates in the abdominal cavity. This may limit your ability to eat, ambulate and perform activities of daily living.

Infection: This is called spontaneous bacterial peritonitis (SBP) and it usually causes abdominal pain, tenderness, fever or nausea. If this is not promptly diagnosed or treated, a patient may develop kidney failure, severe infection in the blood stream or mental confusion. The diagnosis is generally made by taking a sample of the fluid from your abdominal cavity as described above. This infection can be treated with intravenous antibiotics, and after recovery, patients will require long term treatment with antibiotics to prevent SBP from recurring.

Ascites related hernias: Elevated intra-abdominal pressure can lead to the development of umbilical (around the bellybutton) and inguinal (groin) hernias that can cause abdominal discomfort. Surgical repair is generally avoided unless there is severe pain suggesting the intestines or tissue may be pinched or twisted along with a persistent bulge from the hernia. Surgeons who have experience in treating patients with cirrhosis should perform the operation.

Fluid may get into the chest: This is called hepatic hydrothorax and abdominal fluid fills your lung cavities (mostly on your right side).

Q-How best to treat ascites?
A-The most important step to treat ascites is to strictly reduce your salt intake. Your doctor may advise you to limit your salt intake to 4-5 grams per day (2,000 mg of sodium) or less. As it can be difficult to determine the salt content of various foods, it is generally recommended that a patient with ascites see a nutritionist (dietician) for advice about various foods to avoid. Patients may use salt substitute but it is essential to choose one without potassium because the potassium levels can increase with certain medications to treat ascites. It is important to discuss with your doctor or the dietician which salt substitute you are planning to use.

Most often, patients will require water pills (diuretics) to treat ascites. Your doctor will choose appropriate doses of water pills such as spironolactone (Aldactone) and/or furosemide (Lasix). As these water pills can cause problems with your electrolytes (levels of sodium, potassium, chloride, and bicarbonate in the blood stream), your doctor will need to monitor your blood levels closely. It is important to realize that taking water pills is not a substitute for reducing your salt intake, as water pills will work only when they are taken together with restricted salt intake.

Checking your body weight daily on a scale and contacting your physician whenever there is a gain of more than 10 lbs (or greater than 2 lbs per day for 3 consecutive days) is a good strategy for better management of ascites.

When fluid accumulation cannot be treated optimally with water pills and salt restricted diet, patients may require a large amount of fluid be removed (paracentesis) for relief of symptoms. Your doctors may also discuss with you other procedures such as having a radiologist place a shunt within the liver (called TIPS) to prevent significant fluid accumulation from ascites. As mentioned, patients with ascites have a serious health risk and are often evaluated for liver transplantation.


Sunday, October 24, 2010

Part Two: Hey, I Have A Question About HCV Tests And My Liver

Part Two: A digest of questions most often asked by patients
.Q Why do most persons remain chronically infected with HCV?

A A person infected with HCV mounts an immune response to the virus, but replication of the virus during infection can result in changes that evade the immune response. This may explain how the virus establishes and maintains chronic infection.

Q In A HCV Blood Test what does an indeterminate result mean?
A It means a laboratory could not confirm the presence of Hepatitis C antibodies in a particular blood sample. It could mean that an individual may be in the process of converting from being negative to being positive. It could also be due to other medical factors. In either case, it is recommended that the individual be re-tested.

Q Under what circumstances is a false-positive anti-HCV test result likely?
A False-positive anti-HCV tests appear more often when persons at low risk for HCV infection (e.g., blood donors) are tested. Therefore, it is important to confirm a positive anti-HCV test with a supplemental test, such as RIBA (recombinant immunoblot assay), as most false positive anti-HCV tests are reported as negative on supplemental testing.

Q Under what circumstances might a false-negative anti-HCV test result occur?
A Persons with early HCV infection might not yet have developed antibody levels high enough that the test can measure. In addition, some persons might lack the (immune) response necessary for the test to work well. In these persons, further testing such as PCR for HCV RNA may be considered.
Q What exactly is "active" hepatitis C?
A What a great question! You've hit on something that would seem straightforward, but in truth, the terms used to describe hepatitis have changed over the years as our knowledge has evolved and our technological capacity has progressed.

I am sure you do not want to hear a discussion of all these issues. Suffice it to say that when health care workers use the term "active hepatitis," they are referring to ongoing inflammation in the liver. This is usually accompanied by increased liver enzyme levels and specific findings that go along with inflammation on the liver biopsy. Hence, "active hepatitis" may be a finding noted on liver biopsy as well.

Q: What is hep C RNA and PCR?
A: These are the names of two tests for the hepatitis C virus. While hepatitis C screening tests detect antibodies produced in response to the hepatitis C virus, the hep C RNA and PCR tests detect the virus itself in the blood.

Q What does it mean when your viral load increases over the course of a year or two? Mine went from 4K to 8K. Took treatment twice.
A Viral load does not indicate disease severity. So the fact that your viral load has gone up does not indicate that your liver disease is worse, or that your disease is progressing. In studies where researchers took blood from people with HCV very frequently, it was found that the amount of virus in the blood fluctuates by huge numbers over time (and even within a single day). In short, what does it mean that your HCV viral load went from 4K to 8K? Based on all the evidence available, it indicates nothing of clinical relevance that you should be concerned about.

Q My HCV antibody test is reactive while the PCR test is undetectable. Is that cause for alarm?
A The most common explanation for this finding is that a person has been exposed to the hepatitis C virus at some point (hence the reactive antibody test), but has since cleared the virus (the reason the PCR test result is undetectable). A much less likely reason for these findings would be that the virus level is indeed too low to be picked up by the PCR test (different tests are more or less sensitive to low levels of the virus).
The best way to address this is by talking with your doctor, who knows your past medical history, past test results, and other issues that may influence your test results

Q I have recently been diagnosed with hep C type 1B. I went to a gastro doctor who says he won't treat me because my count is only 5000. Should I make an appointment with an infectious disease doctor? I want to try to get it out of my system before it grows more. I am so weak, I sleep most of the day and always feel sick. How come I feel so sick if my count is so low?
A Your hepatitis C viral load does not reflect the severity of your disease. It also does not predict the progression of hepatitis C disease. You didn't mention whether you had a liver biopsy. The liver biopsy will give you and your doctor information about how much damage has occurred in the liver as a result of having the hepatitis C virus. This is an important consideration in deciding whether treatment is indicated. You clearly describe that you are not feeling well. Your thought to talk with another doctor may be a good option if you feel your other doctor is not responding to your needs. It is your decision, of course. Whether you decide to go back and see your current doctor again or decide to see someone else, it is important to have a partnership with your doctor wherein you are working together to help you feel better.

Should I seek to have the most sensitive PCR test ?

Q I completed peginterferon/ribavirin therapy 4 1/2 years ago and just tested negative again for the virus. The test that was done was at the level of 50 parts per million. But a newer and more expensive test, not covered by insurance, can detect 5 parts per million. Could I still have the virus at extremely low levels and, if so, what are the chances it's still doing any damage? Should I seek to have the most sensitive test done next year?
A I do understand your concern, but after testing repeatedly undetectable for 4 1/2 years, the possibility of you still having the virus at levels consistently lower than the lower limit of detection of the test is extremely remote. I cannot say it is absolutely, positively impossible - but pretty close. Should you have the more sensitive test? I cannot answer that for you. I would urge you to talk with your doctor about this, but also do some personal reflection. If nothing short of the most sensitive test can put your mind at ease, then perhaps that is the best course of action for you. Best to you.

Q Can persons become infected with a different strain of HCV after they have cleared the initial infection?
A Yes. Prior infection with HCV does not protect against later infection with the same or different genotypes of the virus. This is because persons infected with HCV typically have an ineffective immune response due to changes in the virus during infection. For the same reason, no effective pre- or postexposure prophylaxis (i.e., immune globulin) is available.

Q Can superinfection with more than one genotype of HCV occur?
A Superinfection is possible if risk behaviors (e.g., injection drug use) for HCV infection continue, but it is believed to be very uncommon.

Q What can a person with chronic hepatitis C do to take care of his or her liver?
A People with chronic hepatitis C should be monitored regularly by an experienced doctor. They should avoid alcohol because it can cause additional liver damage. They also should check with a health professional before taking any prescription pills, supplements, or over-the-counter medications, as these can potentially damage the liver. Check with his or her doctor about getting vaccinated against hepatitis A and hepatitis B.

Q I have hepatitis C. Would injections of B-12 be helpful for extreme fatigue?
A Dr. Lyn Patrick, a naturopathic physician and contributing author to the book Hepatitis C Choices provided the following response to this question on vitamin B-12.
There are many possible reasons for fatigue in hepatitis C: nutrient deficiencies that can occur in late stage cirrhosis;thyroid disorders such as autoimmune thyroiditis (where the immune system attacks the thyroid gland) or hypothyroidism (lowered production of thyroid hormones); anemia that may result from standard treatment with ribavirin or from the chronic infection itself. In addition, people with hepatitis C can have other health problems unrelated to hepatitis C that may cause or contribute to fatigue.

Although a vitamin B-12 deficiency can occur coincidentally along with any of the above, simply taking B-12 would not correct the other causes of fatigue. In late stage disease, any of the fat-soluble vitamins (A,D,E, or K) can become deficient as the liver loses its ability to store these nutrients, something we depend on for adequate stores in the body.

It is very important to have blood work and any other appropriate medical tests done to determine the cause of the fatigue so it can be properly treated. Since vitamin B-12 is nontoxic, supplementing your diet with a B-12 is not dangerous, but not everyone can absorb B-12 from a pill or from food. Injections may be necessary in certain situations, but that must be determined by your doctor.

The bottom line here is that the cause of the fatigue must be determined before it can be treated.

Q I heard that vitamin A is bad for the liver. I have hepatitis C with cirrhosis. Should I avoid vitamin A and foods that contain vitamin A?
A Vitamin A,like all vitamins, is necessary for good health. Some vitamins are stored in the fat of the body (vitamins A, D, E and K) and can become toxic if taken in high doses over a prolonged period of time.

While it is not necessary to avoid a daily multivitamin or foods that contain vitamin A, extra amounts of vitamin A (above the recommended daily allowance) should be avoided to prevent overload and toxic complications.

Always talk with your doctor before taking any new medication or supplement to be sure it is safe for you. Even over-the-counter products can be hazardous in certain circumstances.

Q What about using Milk Thistle ?

A Laboratory studies suggest that milk thistle may benefit the liver by protecting and promoting the growth of liver cells, fighting oxidation (a chemical process that can damage cells), and inhibiting inflammation. Study results from small clinical trials on milk thistle for liver diseases have been mixed; however, most of these studies have not been rigorously designed, or they have looked at various types of liver diseases—not just hepatitis C. High-quality, well-designed clinical trials have not proven that milk thistle or silymarin is beneficial for treating hepatitis C. The HALT-C study mentioned above found that silymarin use by hepatitis C patients was associated with fewer and milder symptoms of liver disease and somewhat better quality of life, but there was no change in virus activity or liver inflammation.

Q How long does the hepatitis C virus survive outside the body?
A The hepatitis C virus can survive outside the body at room temperature, on environmental surfaces, for at least 16 hours but no longer than 4 days.
How should blood spills be cleaned from surfaces to make sure that hepatitis C virus is gone?
Any blood spills -- including dried blood, which can still be infectious -- should be cleaned using a dilution of one part household bleach to 10 parts water. Gloves should be worn when cleaning up blood spills.

Doctors - Can you tell me about Fibroscan?
Q I have heard from other Heppers that it is better than a liver biopsy and shows so much more. Is this still in the testing phase or is it possible to find a hospital to do it? Do you know if insurances (medicare) would pay for it? It seems so good, not to have the invasiveness of a biopsy. I am so interested in this. Will you please give me you thoughts and ideas on this? And if there is anyway you know how I can find a facility in my area that is doing it? I'm in the Treasure Coast of Fla and very close to South Fla.

A Fibroscan is a non invasive imaging study that evaluates the degree of liver stiffness, or scaring, known as fibrosis. It does this by determining the speed of sound waves through the liver utilizing a sonogram. Similar to blood tests such as Fibrotest and fibrosure, the fibroscan works well in determing the 2 extremes of liver disease - minimal or no scarring from cirrhosis. It does not work so well in evaluating moderately damaged livers and this scan is not yet approved in the U.S. Liver biopsy, while not perfect, still remains the gold standard for determining the stage of liver disease

Liver Biopsy
Q: I probably got Hep C 32 years ago, but just learned of it now at age 56. My gastro doctor says my blood tests are normal including tumor marker and he feels no swelling of liver. Left the decision up to me, but think I might not need a liver biopsy. What do you think?
A: In the absence of cirrhosis, the only way to determine with certainty how much scarring has occurred in the liver because of chronic hepatitis C infection is to perform a liver biopsy. Blood tests and tumor markers can be normal even the presence of significant liver scarring.

Q I just found out I have hep c. Most websites say you need a biopsy. My GI doctor looked at my family doctor's blood tests from me, felt of my stomach, and said I am ready for treatment. How can that be?

A You are correct, in most cases, a liver biopsy is recommended - but not always. The reason to do the liver biopsy is to see how much scarring (fibrosis in doctor-speak) has taken place in the liver because of the hepatitis C. For many people, a liver biopsy is the only way to find out this information. But in some cases, the doctor can tell how much scarring has taken place from the results of blood tests and feeling the liver. I do not know if this is the situation with you, but it may be - and if that's the case, not doing a liver biopsy would be in line with what most doctors would recommend. I would urge you to talk this over with your doctor to find out why he/she is not recommending a liver biopsy for you.

Q I have had hepatitis C for at least 15 years (that I know of). I had a check-up last week and my doctor scheduled me for an ultrasound to check for liver cancer. I have not had any new symptoms, and feel normal - so why does my doctor think I need to be checked for liver cancer? This has me worried.
A Long-standing hepatitis C infection increases a person's risk of liver cancer. While the vast majority of people with hepatitis C will never develop liver cancer, the increased risk for the disease is why doctors screen for it.
Liver cancer, like most other cancers, causes no symptoms early on. People with early stage liver cancer feel well. Symptoms usually do not develop until the liver cancer has become advanced and is much more difficult to treat.
While any cancer screening test tends to cause concern, try to take comfort in the fact that your doctor is being thorough in checking you periodically for liver cancer.

Mother being exposed to HEPATITIS C

Q My mom is a nurse and she said she got someone's blood on her finger (around the cuticle area too) for like 5 minutes and didn't know it at first. The person had Hepatitis C. And now she's very paranoid and worried. She has really dry hands and fingers, so she thinks there was a cut there and she may have Hepatitis C now.
A The incubation period for hepatitis C ranges from 15 to 150 days with the average around 50 days. You didn't mention how long ago this exposure was. I assume you mean she knows the patient had hepatitis C and worries because she came in contact with the blood when not wearing gloves. If this is a particular patient and she knows she had not previously been infected with hepatitis C, she can be tested now and maybe even repeat the test at 150 days after the exposure. If she shows no hepatitis C by then she can assume she was not infected.

Q: Does it take 2 to 6 months for hepatitis c to be come noticeable?
A: People who become infected with the hepatitis C virus are often unaware that they've been infected for up to 10, even 20 years because there are no initial symptoms.
If your question has to do with how long after a potential exposure to the virus would someone test positive, that is a different time frame.

After a potential or known exposure (blood-to-blood contact with another person known to have the hepatitis C virus or who may have hepatitis C), it is recommended that testing for the hepatitis C antibody be performed at 4 to 6 months after the exposure OR that testing for the hepatitis C virus itself (a test often called an HCV PCR or hepatitis C viral load test) be performed 4 to 6 weeks after the potential exposure.

Q: Could my boyfriend have given me hep C sexually?

A: Evidence indicates that hepatitis C can be spread by sexual intercourse, although this appears to be quite uncommon. Hepatitis C is spread by blood-to-blood contact. If your sexual practices involve blood-to-blood contact, precautions should be taken to protect yourself.

Q Is the sperm from a father with hepatitis C infectious to the baby if conception occurs?
A There is no evidence that the semen from a man with hepatitis C can infect the baby if conception occurs. The only known risk of passing on hepatitis C to a newborn is when the mother has hepatitis C. The virus can be passed from mother to baby at the time of delivery, but this is uncommon.

Q If my partner has HCV and we are trying to get pregnant but have had two misscarriage, is it due to the fact that he has HCV and my body is rejecting the pregnancy?
A Your partner having HCV does not affect your ability to get pregnant and does not cause miscarriage. Talk with your obstetrician/gynecologist about this problem to see if there are factors at play in the miscarriages that can be corrected.

After being clear for 6 months can you drink

Q This is an odd question, but after being cleared with no sign of HCV, is it possible to start drinking beer again?

A This answer is dependent upon multiple factors, such as gender, degree of liver scarring, general health,and other factors. In general, if cirrhosis is present one should continue to avoid all alcohol, even if the cause of cirrhosis was HCV.

Q How does alcohol effect the progression of hep C?
A The combination of alcohol and chronic hepatitis C is a dangerous one. The two in combination cause more liver damage than either one would alone. If you have hepatitis C, you should not consume any alcohol. If you are drinking and are having trouble stopping, please read the chapter on Alcohol and Hepatitis C in "Hepatitis C Choices" on this Internet site. It's free - and what you read there will give you more detailed information about this issue along with resources for help, should you need it.

Eradicated Hep C Still Dangerous?

Q If someone claims to have had "eradicated" Hep C for a number of years, is there a possibility, however remote, that that person could infect someone close to them such as a husband or wife? Is it true that this person could unexpectedly see a relapse in his or her condition, even after years of remission?
A The chance of relapse - i.e. a return of the HCV virus, after 6 months of discontinuation of therapy and the HCVRNA is still undetectable ( LESS THEN 5-10 IU/dL) is so rare that the medical community is now comfortable telling patients that they are cured. This means that you are not contagious to others by any meansIt is important to remember two things.1. HCVAb - hepatitis C antibody will remain positive - this does not mean that you are infectious to others, but it does mean that you will not be able to donate blood or organs in typical situations2. If you have cirrhosis, you are still at risk for liver cancer and liver failure.

Q Is it possible to get over hepatitis C ?
A Yes, approximately 15%–25% of people who get hepatitis C will clear the virus from their bodies without treatment and will not develop chronic infection. Experts do not fully understand why this happens for some people

Q I am going on a rafting trip this summer with some friends. Most of the people on that will be on the trip know that I have hepatitis C - but not all. Should I tell the trip leader ahead of time that I have hepatitis C?
A The decision about whether to disclose to those who do not already know you have hepatitis C is a personal one. Regardless of what you decide, everyone (including you) should familiarize themselves ahead of time with how to practice "universal precautions" in the event of an emergency. Universal precautions are intended to prevent the spread of all blood-borne infections (including hepatitis C). If everyone on your trip knows and practices universal precautions, the risk of blood-borne infection transmission is extremely remote (even in an emergency situation).


Q I was also dx with Fatty Liver. First found out about my liver being fat about 7 years ago when I was about 40 lbs lighter and in much better shape. Now after quitting smoking over a year ago and the extra weight I've gained b/c of quitting, I'm wondering how much weight will I have to lose to not have the fatty liver along with my Hep C?
A Once a fatty liver shows up by imaging studies - such as a sonongram, it means that at least 30% of your liver is laden with fat. This is very unhealthy for your liver and impacts your likelihood of curing HCV with antiviral treatment. You are to be congratulated for discontinuing cigarette smoking, and weight gain is a very common consequence.In addition to a healthy weight-lose diet and exercise program, studies have demonstrated that the following vitamins may be helpful in treating fatty livers - Vitamin E, Betaine, Vitamin C, Vitamin D. Of course, prior to starting any new diet/vitamins/ and exercise/ you must check with your personal physician, as he/she knows the details of your history best.In specific answer to your question, I actually researched and published on this issue over 2 decades ago- and found that losing 10% of your current body weight will significantly impact the amount of fat on your liver.Extensive details on nutrition and hepatitis can be found in my book and my website

SSRI antidepressants and elevations in liver function tests
Q Is there a relationship between SSri antidepressant medications and elevations in SGPT and Sgot blood tests? Oddly enough my sister also has benign thyroid nodules that increase in size when on these antidepressants. Is there another safer form of antidepressants that treat depression and not effect LFTests? Her GGT was 278 and Sgot was 200. Thanks
A While SSRIs are considered to be safe for people with liver disease, they can increase liver-related blood tests. However, other causes of liver elevations need to be looked for as the SSRI may or may not be the cause, for example, thyroid disease can also sometimes cause elevations in liver enzymes

Q I have hep C. Is it okay for me to use Prozac?
A Studies have shown that, overall, Prozac can be taken safely in someone with hepatitis C. Be sure your liver doctor knows you're taking Prozac and is monitoring you for any changes in your liver as well as any symptoms of new or worsening depression.

Q Is it safe to continue taking medical marijuana after being diagnosed with hepatitis C?
A Frequent marijuana smoking (daily in one study) has been found in some studies to cause more rapid progression of the disease in the liver. If possible, it is best to avoid anything that may complicate or accelerate the progression of the disease. I urge you to talk with your doctor to see if there may be other alternatives that would make it possible for you to stop using medical marijuana in order to protect your liver from possible damage related to its use.

Q I have read that the estrogen hormone in females help protect the liver from hep C. At 50 years old and having hep C for 32 years, should I take hormone replacement therapy to help protect my liver against further damage from hep C?
A While there is some evidence that naturally occurring estrogens may play a role in slowing the rate of progression of hepatitis C-related liver damage, hormone replacement therapy (HRT) is not recommended as a way to protect the liver from HCV-related damage. As I'm sure you're aware, HRT is associated with certain health risks of its own.

Q How serious is HCV infection?
A Many people with HCV infection will never develop symptoms. Ten to 20 percent of HCV-infected persons will go on to develop cirrhosis (scarring of the liver). Less than 5% will actually die of HCV. The good news is that new treatments to cure HCV infection are becoming available.

Q Does chronic Hepatitis C affect only the liver?
A A small percentage of persons with chronic HCV infection develop medical conditions due to Hepatitis C that are not limited to the liver. These conditions are thought to be attributable to the body's immune response to HCV infection. Such conditions can include
Diabetes mellitus, which occurs three times more frequently in HCV-infected persons
Glomerulonephritis, a type of kidney disease caused by inflammation of the kidney

Essential mixed cryoglobulinemia, a condition involving the presence of abnormal proteins in the blood

Porphyria cutanea tarda, an abnormality in heme production that causes skin fragility and blistering

Non-Hodgkins lymphoma, which might occur somewhat more frequently in HCV-infected persons

Q What Is Fibrosis ?A When the hepatitis C virus enters theliver cell it uses the chemicals in the cell to multiplyand make more copies of itself. Eventually the newviruses are released back into the bloodstream. Duringthe process it kills the liver cell it has invaded. Itis at this point that the body’s immune system sendschemicals to the liver cells to try to repair the damage,but something goes wrong – the area around the livercell becomes inflamed and irritated.

Eventually, thearea around the cell is surrounded by a type of tissuethat may eventually form light scarring. As more andmore liver cells are destroyed by the hepatitis C virus,the scarring starts to spread and it connects with otherdamaged and scarred cells.After many years of infection the liver can be so damagedthat it can not perform all of the functions to keepus healthy. The light to medium scarring of the liver iscalled fibrosis.

The liver is also called a “non-complainingorgan” so most people who develop fibrosis do notknow that there is damage occurring.After a period of time (usually many years) the fibrosiscan become so severe that it spreads and connects toother liver tissue and forms extensive scarring. Thisis called cirrhosis.

There are two types of cirrhosis– compensated and decompensated. Compensated cirrhosismeans that the liver is heavily scarred but canstill perform most of the functions that keep peoplehealthy. Decompensated cirrhosis means that the liveris so scarred that blood can not flow through it whichcauses the liver function to break down. When it reachesthis stage there are many conditions and symptoms thatcan occur.

Q What are my chances of developing cirrhosis or other complications?
A Only about 20 percent of people with hepatitis C develop cirrhosis of the liver, and of those, only about one in four develops complications from cirrhosis. So overall, only about 5 percent of all people with hepatitis C develop cirrhosis complications.

It’s been estimated that the number of people with cirrhosis and complications will increase by about 600 percent over the next 10 years. That’s not because more people are getting hepatitis C — the incidence of the virus has actually been going down since the United States started screening donor blood in 1992. The reason for the increase in complications now is that cirrhosis generally takes 30 or 40 years to develop (although alcohol use can accelerate it). The millions of Americans who contracted the virus in the ’60s, ’70s and ’80s, before we knew how it was transmitted, are just now starting to develop the complications that take decades to develop.

Q How do you manage cirrhosis and its potential complications?
A In terms of monitoring, people who are experiencing complications from hepatitis C should see their primary care provider every two to three months, and their gastroenterologist every four to six months. The primary care provider will reassess symptoms and check lab work. The gastroenterologist will adjust medications and screen for complications. Screenings should include a liver ultrasound twice a year to check for signs of cancer, and an upper endoscopy once a year to monitor for a complication of cirrhosis called varices — enlarged veins in the digestive tract that can cause bleeding.

In terms of treatment, the complications may vary widely from one patient to the next, so each person’s management regimen is highly individualized.

Q Does everyone with hepatitis C eventually develop liver cancer?
A No — in fact, most don’t. Only people who develop cirrhosis as a complication of hepatitis C have a higher risk of developing liver cancer. About 20 percent of people with hepatitis C develop cirrhosis — advanced liver scarring caused by decades of inflammation. Of those who do develop cirrhosis, about 20 percent eventually develop liver cancer. So overall, among all people with hepatitis C, the chance of developing liver cancer at some point in your life is about 4 percent.

Liver Cancer After Treatment For Hepatitis C
November 23, 2016
A collection of 2016 articles retrieved online from press releases, conferences (The Liver Meeting® 2016 and the International Liver Congress 2016) and peer-reviewed journals featuring long-term risk for liver cancer in those who were cured of Hepatitis C.

December 2016
The following article appeared in the December print edition of HCV NEXT, published online at Healio; Screening for HCC in the Post-SVR12 Setting

Q What makes some people with hepatitis C more or less likely to get liver cancer?A If you don’t develop cirrhosis, then you are at no higher risk of liver cancer than the general public. Having cirrhosis is what raises the risk, so anything that increases your risk of developing cirrhosis will also increase your risk of developing liver cancer.
Alcohol consumption is the key risk factor here. People with hepatitis C should not drink alcohol, since it can accelerate liver damage. Certain prescription and non-prescription drugs also can damage the liver, so people with hepatitis C should review their medications with their physician to make sure they aren’t taking anything that could put further stress on their liver. Finally, smoking increases the risk of all cancers, including liver cancer, so people with hepatitis C should not smoke.

Q How does hepatitis C lead to liver cancer?A Hepatitis C inflames the liver, and over the course of many years, this inflammation can lead to scarring. Most people with hepatitis C never experience significant scarring or complications, but about 20 percent develop cirrhosis, which is advanced scarring throughout the liver.
Because hepatitis C is a slowly progressive virus, it can take 30 or 40 years for cirrhosis to develop. Meanwhile, the liver is resilient — when damage occurs, the liver goes to work to regenerate itself. We believe that cancer occurs during this ongoing cycle of injury and regeneration. The more cells the liver regenerates, the higher the chances that a mutation will occur in one of those cells, and it’s these mutations that can lead to hepatocellular cancer.

Q Is there a way to screen people with hepatitis C to check for liver cancer?A Yes. Ultrasound is the main screening tool used to check for tumors in the liver. Ultrasound is non-invasive and can detect tumors when they are quite small.

Q Should everyone with hepatitis C get ultrasound screenings?
A Since liver cancer is a complication of cirrhosis, people who don’t have cirrhosis don’t need to be monitored closely for liver cancer. But people who do have cirrhosis should definitely get regular ultrasound screenings to check for liver tumors.

Q How often should a person with cirrhosis get screened for liver cancer?A At the Providence Liver and Pancreas Clinic, we recommend that people with cirrhosis get an ultrasound screening twice a year. The more vigilant you are about getting these screenings regularly, the better your chances of catching cancer early, when treatment is most likely to be successful.

Q Are there any symptoms of liver cancer that a person should watch for?A Liver cancer usually doesn’t present any outward symptoms in its early stages, which is why regular screening is so important. Signs of advanced liver cancer may include pain, tenderness or a lump on the upper right side of the abdomen; enlargement of the abdomen; jaundice (yellowing of the skin and whites of the eyes); easy bruising or bleeding; nausea; fatigue; loss of appetite; unexplained weight loss; or pain around the right shoulder blade.

Q Is hepatitis C curable?A When a health care provider prescribes antiviral therapy for a person infected with hepatitis C virus, one of the goals is to reduce the person’s viral load (the amount of the virus present in the blood) to undetectable. If there is no measurable virus repeatedly in these people, they are considered to be “sustained viral responders”. Should treated individuals continue to be virus-free after repeat blood tests after two, three, five, and eight or more years, then specialists consider these people to be cured of hepatitis C.

2016Physicians and HCV: Don't Be Afraid to Say 'Cure'
Direct-acting antivirals (DAAs) in the treatment of hepatitis C virus (HCV) have changed the face of hepatology forever.

The miracle drugs have provided a cure for upwards of 95 percent of individuals involved in clinical trials for medications such as Sovaldi and Harvoni. Yet even with these astounding medical advances, patients still fear the worst when faced with an HCV diagnosis.

In an interview with CURE Hepatitis C, Donald Jensen, M.D., recently retired professor of Medicine and Director of the Center for Liver Diseases at the University of Chicago Medical Center, shared his thoughts on why physicians and specialty pharmacists alike need to work to ease patients’ minds and assure them that there is a cure to the disease.

Dr. Jensen makes special efforts with his patients to educate them more about their infection. In addition to providing them with informational websites such as the American Liver Foundation (ALF) web site and the Centers for Disease Control and Prevention (CDC) web site, he allows patients to email him directly with information they have found online so that he may check the validity before using it as a reference.

“A lot of physicians don’t give their patients their email address. They don’t want patients to have their email address … because then they become legally liable for information that they transmit,” Dr. Jensen said. “I’ve never been really concerned about that. It’s counseling that I’m doing, I’m not telling them what treatment to do or that sort of thing. It’s more helping them with educational information.”

With the amount of misinformation circulating about HCV, it makes sense to provide patients with that extra care. In fact, many patients are told by their referring physicians that they have a death sentence upon diagnosis, according to Dr. Jensen, which is severely misguided.

In addition to being told that they are going to die from their liver disease, patients are also led to believe there is no cure for HCV.

“[DAAs] represent a cure for hepatitis C and that’s an important message that we need to get out. This is a curable disease. It can prevent other complications down the road, or most of the complications down the road, if someone is cured of their disease,” Dr. Jensen said. “For years, we as physicians avoided the ‘cure’ word and used ‘sustained response,’ and sustained response is not the same as cure. It does not connote the same information that cure does.”

Dr. Jensen is a huge advocate of physicians using the word “cure” in relation to HCV rather than sustained virologic response (SVR).

“I think we need to say [cure], not only to reassure the people who have had a sustained response, but also to encourage people that haven’t yet been treated to undergo treatment,” Dr. Jensen noted. “If they don’t think it’s a curable disease, they’re going to say, ‘well why should I get tested? Why should I get treated?’ I think using the ‘cure’ word right up front is very important.”

Dr. Jensen even went so far as to organize a reception at the University of Chicago for patients who were cured between the years of 2011 and 2013. Forty-two patients attended the reception and some even gained enough courage to speak about their disease despite the stigma attached to it.

Out of that reception evolved a web site authored by Dr. Jensen that serves as a patient portal for sources of information regarding HCV, and that discusses the importance of “cure” when speaking about HCV treatment.

However, even with existing cures available, patients still struggle to access curative medicines because of the high price tag that accompanies drugs like Harvoni and Sovaldi. Dr. Jensen suggests a possible solution to this issue.

“The role of specialty pharmacies to take over a middleman role to try and negotiate to get some access to these medications through their insurance provider, I think has been very important,” he said. “They always had a role in hepatitis C therapy even with interferon, but I think their role is even bigger now because there are far more patients being treated now than there were in the interferon days. I think specialty pharmacy becomes very important in helping to negotiate for coverage and access to treatment.”

In addition to the high cost of treatment, there exist restrictions by Medicaid regarding coverage for hepatitis C treatments only for the very sickest of patients, making access even more difficult.

“Sometimes letters from [physicians] can help in arranging coverage for treatment, but the big trend that we never ever faced before is this access to care,” Dr. Jensen said. “It’s really unconscionable; we have a treatment that cures hepatitis, that can prevent cirrhosis, prevent liver cancer, prevent the need for liver transplant in millions of patients, and yet to be denied access to that medicine because it’s too expensive is really a shame on both the pricing by the pharmaceutical industry as well as by the insurance and government agencies that are legislating the restrictions.”

The high cost of medication has also changed the patient-physician dynamic, according to Dr. Jensen. Prior to this trend, physicians never got more involved in a patient’s treatment than prescribing medication.

“A doctor never got involved much more in the price of the medicines or in the negotiating to get treatment, except on rare conditions for very experimental therapies,” Dr. Jensen explained. “So I think this for us is sort of a new experience for there to be this issue of pricing of medications and astounding copays that patients would sometimes have to pay out of their own pocket for these medicines. I think for us as physicians this is sort of a new era for us to be dealing with negotiating payment for medications.”

Additionally, the astronomical pricing of medications make patient adherence to treatment difficult. However, Dr. Jensen’s practice has a special policy in place where nurses follow up with patients regularly, even after treatment has ended, to make sure patients are following doctor’s orders, remaining adherent to medication, and sustaining a virologic response well after treatment has ended.

But Dr. Jensen commends HCV patients for being generally adherent despite the multitude of factors that could prevent it. He explains that HCV patients are motivated individuals who are pretty good about taking their medicines, not unlike HIV patients who have similar adherence behaviors.

Patients with HCV do have a great reason to remain adherent to their regimen. The medication is proven to be a cure in many cases, has limited side effects, and provides patients with an avenue to a healthier life. Dr. Jensen assures his patients that the new treatments are tolerable and will provide them with a cure.

“I think first they should know that the treatment is simple and highly effective and really free of major side effects,” Dr. Jensen said. “For the most part I’m really telling them how easy this therapy potentially really is. And I’m telling them how important it is that they take their medicine on a daily basis, that they don’t miss doses.”

Dr. Jensen is positive about the cure for hepatitis C, and says that the possibility for eradication is clear in our future.

“It turns out we probably don’t need to treat everybody, and we can probably still get to a state by 2030 where we reduced significantly the prevalence of hepatitis C, as well as the morbidities associated with hepatitis C (liver cancer, cirrhosis and need for liver transplant) by 2030, even if we treat a significant percentage of those who have hepatitis C and not necessarily everybody,” Dr. Jensen said.

But Dr. Jensen also cautions that this projection comes with a stipulation. If the population of young injection drug users in the United States decreases, then hepatitis C may have a better chance at being fully eradicated. But if the problem of injection drug use continues to grow, the possibility of eradication may turn out to be a pipe dream.

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