Hepatitis C: Assessment for Treatment

Who should be treated?

Because:

  • the treatment for Hep C is less than 50% effective,
  • there may be side effects to the treatment,
  • ¬†the treatment is lengthy,
  • the treatment is expensive,
  • it is important to identify those patients who are suitable for treatment.

In assessing patients for treatment the following steps are important:

a. Confirm Hep C:
o Anti-Hep C, (ELISA then RIBA)
o HCV RNA

b. Confirm hepatitis:
o Ast, Alt over 1.5 times normal for 3 months
o liver biopsy showing interface hepatitis (piecemeal necrosis)

c. Determine length of time of infection if possible:
o potential last time of possible infection
o assess degree of progression over time

d. Rule out other types of liver disease:
o HBsAg = Hep B
o serum iron, iron binding = hemochromatosis
o ceruloplasmin = Wilson’s Disease
o alpha one antitrypsin = alpha one antitrypsin defiency
o anti-nuclear antibodies = auto-immune hepatitis
o anti-mitochondrial antibodies = Primary Biliary Cirrhosis

e. Assess for hepatic decompensation:
o history of varices, ascites, encephalopathy
o clinical assessment for portal hypertension
o clinical assessment for ascites
o protein electrophoresis (albumin and gammaglobulin)

f. Assess psychological history and status:
o history of depression
o history of suicidal thoughts or attempts
o previous treatments for psychological disease
o present emotional status

g. Assess for substance abuse and alcohol use:
o previous and present use of IV or illicit drugs
o previous and present alcohol use

h. Check for associated conditions: (see Volume 1 No.1) in particular:
– thyroid disease
– diabetes
– heart disease
– vasculitis

i. Check hematology:
– platelets
– hemoglobin
– WBC
– INR

j. Assess for any other systemic diseases
Contraindications to treatment:
o decompensated liver disease
o auto-immune hepatitis
o depression, bipolar disease, aggressive behaviour
o active bacterial infection
o ongoing alcohol use
o neutropoenia
o ongoing IVDU
o neutropoenia
o thrombocytopoenia (discussion following)
o auto-immune diseases
o anemia (discussion following)
o significant heart disease
o HIV if CD4 below 250
o serious systemic disease

Psychological status and treatment:

Interferon may cause depression, particularly in patients with a previous history. It may also cause anger, irritability and aggressive behaviour. The side effects of fever, chills, fatigue and muscle aches may be hard for some patients to tolerate. A careful emotional and psychological assessment of the patient along with a determination of his/her support systems is important before instituting therapy.

Thrombocytopoenia and treatment:

Thrombocytopoenia in Hep C is common. There are a number of causative factors. One may be splenomegaly, although a large spleen rarely causes a platelet count below 70-80,000. Another cause is auto-immune thrombocytopoenia which is common and causes platelets as low as 20-60,000. Interferon often causes platelets to fall, the average fall is 15%, sometimes it may be more. If platelets are too low (below 60,000) treatment may not be possible. It may be necessary to treat the auto-immune thrombocytopoenia first before starting interferon, or it may be necessary to start interferon at a low dose while monitoring platelets and increase the dose slowly if possible. Careful expert management is necessary.

The hemoglobin and treatment:

One of the main side effects of ribavirin is hemolysis which occurs in all patients to some extent and may be significant in some patients. A relatively normal hemoglobin is usually essential before treatment. Patients with any history of hemolysis or anemia must be carefully assessed. Angina may be significantly worsened by hemolysis.

Vocation and treatment: Because of the possible side effects of therapy, it is important to assess the patient’s vocation and the possible effect of interferon on such activities as:

o education – the ability to study, concentrate
o high risk employment – the ability to operate heavy equipment
o hours of work – the requirement for long shifts and inability to rest

Nutrition and treatment:

The average patient loses 15 pounds of weight on interferon treatment. A nutritional assessment before treatment and ongoing assessment is essential with nutritional support if necessary.

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