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April 02, 2015
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What you need to know about Hepatitis C

By James D. Lomax, MD

Recently there has been increasing attention given to Hepatitis C in the print media because of new treatments available. Hepatitis C is not a newly discovered disease, but most of us are not aware of its potential to cause serious disease.

Hepatitis C (HCV) is an infectious viral illness that affects the liver primarily. It is estimated that 150-200 million people worldwide are infected with hepatitis C. In the United States, chronic hepatitis C infections are the most common causes of liver-related deaths and reasons for liver transplants.

Because there were blood tests developed in the 1970s for other types of viral hepatitis (A and B), it was obvious to doctors then that there was another type that accounted for a large number of liver infections. It was originally described in the medical literature as “non-A non-B.” There was finally a screening test developed in 1989 to accurately diagnosis this condition. HCV infects only humans and chimpanzees.

The complicating factor is that for most people with an active infection there are no symptoms. Chronic infection can lead to scarring of the liver and ultimately cirrhosis, but only after many years. Some people will progress from cirrhosis to liver failure, liver cancer, or life-threatening bleeding from varicose veins that develop in the stomach or esophagus.

The primary ways that people become infected are through intravenous drug use (needle sharing), blood transfusions and organ transplant not properly screened, or use of unsterilized surgical instruments, such as dental equipment or tattoo needles. For about 20% of infections, no source is identified. Health care workers are also at risk from needle punctures or sharp injuries (e.g. scalpel blades) when contaminated with blood from an infected patient.

Acute and Chronic Infections

Most people with new infections have no symptoms. Only 15% of people present with decreased appetite, fatigue, nausea, skin itching, muscle or joint pains, weight loss or jaundice or yellowing of the skin. This is different from other types of viral hepatitis in which the majority feels ill or has clinical signs such as fever or jaundice after being infected.

About 20% of people infected with HCV can resolve without treatment—usually in individuals who are young and female. About 80% of those exposed to the virus develop a chronic infection. Most people have minimal or no symptoms during the initial few decades of the infection until complications develop from extensive liver scarring or obstruction from cancer.

How is Hepatitis C Diagnosed?

The decision to order testing by the doctor is often because of elevated liver enzyme tests found in testing for other conditions, the presence of vague symptoms such as fatigue or developing a yellowing of the skin. Diagnosis is made by testing first for antibodies to HCV. These antibodies are screened by using an immunoassay test. If the results are positive they are confirmed by using a test called an immunoblot assay. If the immunoblot test is positive, a third test known as RNA polymerase assay is then performed which approximates the number of viral particles in the blood.

If there is a high viral load found, the doctor then sends a specimen for viral gene type testing. There are seven major gene types of HCV, which are numbered one through seven. In the United States 70% + of cases are caused by gene type one, 20% by type two and about 1% by each of the viral groups. The gene type of the HCV determines what type of treatment the person will be offered.

Another procedure that is done if there is suspicion of scarring is a liver biopsy. This will give the specialist a clear picture of the amount of scar formation in the tissue.

Treatment of HCV

Current treatment consists of a combination of two or more powerful immune modulating medications. Treatments consist of a combination therapy of pegylated interferon alpha and the antiviral drug ribavirin for a period of 24 or 48 weeks, depending on HCV gene type. This results in cure rates of between 70 and 80% for genotype 2 and 3, and 45 to 70% for other types. The downside of this treatment is that it is associated with many side effects, such as fatigue, headache, and diarrhea, and many people do not finish the entire treatment.

A new treatment recently announced in the New England Journal of Medicine describes a new drug combination that includes two non-interferon drugs (Ombitasvir and Dasbuvir) along with ribavirin that is used for only 12 weeks for type 1 infections and no evidence of cirrhosis. The data demonstrated that there is a 95%+ cure rate for this group. Because this is the most common gene type in the United States, it holds excellent promise for people with chronic hepatitis C.

This drug will be on the market soon, but with a significant price tag. When it becomes available it is estimated that it will be $1,000 per pill with a total cost of $150,000 for the 12-week treatment. It is unclear at this time whether all drug plans will cover these medications. However, if it prevents having to have a liver transplant or the person getting liver cancer, it may be money well spent by insurance companies.