Hepatitis C: Clinical Vignettes

Hepatitis B Vaccination in Hep C

o hep C patients have same response rate to Hep B vaccination as normals
o there is no change in HCV RNA levels in hep C patients during vaccination for Hep B
o the ALT levels may actually decrease during the vaccination period
o hep B vaccination is safe and immunogenic in patients with chronic hep C

Durability of a sustained response

o Interferon treatment for hep C has now been used for almost 10 years
o patients who responded to interferon (negative HCV RNA and normal ALT 6 months post therapy) have a good outcome in a 10 year follow-up and rarely recur or progress to cirrhosis

Extrahepatic manifestations associated with hep C

o 38% of all patients with hep C will have some extrahepatic manifestation
o some of the manifestations are laboratory findings only
o patients should only be treated for extrahepatic manifestations if they are symptomatic
o some of these extrahepatic manifestations are:
路 arthralgia 19%
路 xerostomia 12%
路 xeropthalmia 10%
路 sensory neuropathy 9%

o Auto-antibodies are common
o auto-immune associations should only be treated if symptomatic
o treatment of hep C may increase the activity of other auto-immune diseases
o some of the more frequent auto-antibodies are:
o anti-nuclear antibodies 41%
o rheumatoid factor 38%
o anti-cardiolipin 27%
o anti-thyroid 13%
o anti-smooth muscle 9%
o connective tissue disease has been noted in 14% of persons with hep C

Pruritis in liver disease

o pruritis can occur in any type of liver disease if there is a cholestatic element
o pruritis does occur in some patients with hep C
o simple measures such as lukewarm baths and topical creams may be helpful
o management is divided into “first line” and “second line” drugs

First line drugs are:
o Bile acid sequestrants = cholestyramine
路 dose is 4 grams up to four times a day
路 dose must be separated time wise from other medications
路 extra vitamins and calcium should be given if dosing is prolonged
o Antihistamines
路 action mainly by their sedating properties
路 hydroxyzine, 25-50mg orally every 6 hours as necessary
o Ursodeoxycholic Acid
路 use in hep C not well studied
路 some previous studies suggested may potentiate the benefits of interferon
路 may occasionally exacerbate the pruritis

Second line drugs are:
o Rifampicin at a dose of up to 10mg/kg/day
路 must watch for side effects
路 mechanism of action not known
o Opoid Receptor Antagonists – naltrexone orally
路 effective in up to 50% of persons resistant to other therapies
o Ultraviolet light is used in primary biliary cirrhosis but not in hep C

Efficacy of treatment in hep C relative to the presence of fibrosis or cirrhosis

o earlier studies suggested cirrhotic patients should not be treated because of the low response rate
o recent studies suggest that compensated cirrhosis is not a contraindication
o sustained response rates are not statistically different between non-fibrotics, fibrotics and cirrhotics as measured by the HCV RNA
o patients with cirrhosis may have a persistent elevation of ALT after the HCV RNA is negative
liver fibrosis normal ALT after therapy
no fibrosis 90%
bridging fibrosis 71%
cirrhosis 67%

Hepatitis C virus clearance improves quality of life

o quality of life assessments after treatment showed patients with a sustained virologic response
(negative HCV RNA) had improvenents over non-responders in 4 areas:
路 vitality
路 social functioning
路 general health distress
路 chronic hep C specific health-distress scale

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