Hepatitis C: Treatment: Side Effects of Treatment

The present accepted treatment for hep C is combination with interferon plus Ribavirin:

o Combination therapy is marketed as Rebetron* (a recap of dosage is as follows)
o Dose of ribavirin is determined by weight:
– weight under 75 kg the dose is 1000 mg/day in divided dose twice daily
– weight over 75 kg the dose is 1200 mg/day in divided dose twice daily

o Dose of ribavirin may have to be reduced because of hemolysis:
– dose reduction required in 19 to 25% of patients
– decrease to 600 mg/day if Hgb below 10 gm%
– decrease to 600 mg/day in patients with a stable cardiac history who have a fall in Hgb over 2 gm
– if Hgb falls below 8.5 gm the ribavirin should be discontinued

o Ribavirin should be stopped if creatinine increases

o Dose of interferon usually 3 million units three times a week:
– if platelets below 80,000 initial dose may be 2 million units three times a week and may be increased if platelets remain adequate

o Dose of interferon may have to be reduced because of thrombocytopoenia:
– if platelets fall below 50,000 dose should be reduced to 1.5 million units three times a week
– if platelets fall below 40,000 dose interferon should be stopped

o Dose of interferon may have to be reduced if WBC falls:
– if WBC below 1,500 decrease to 1.5 million units three times a week
– if WBC below 1,000 interferon should be stopped

Fatigue is a common complaint on treatment:

o fatigue may be significant during the first two to three weeks of therapy,
o fatigue may also become a problem after 6 months of therapy,
o patients should be encouraged to be active rather than inactive,
o exercise dose not make hepatitis C worse or treatment less effective,
o adequate rest with planned activity or exercise are best,
o milk thistle may make some patients feel better.

Weight loss occurs frequently with treatment:

o weight loss is usually due to decreased intake,
o weight loss usually occurs maximally during the first 2 to 3 months of therapy,
o patients should be encouraged to eat well balanced meals and snacks may be necessary.

Fever, rigors, headache and muscle aches are common:

o these side effects are most marked during the first 2 to 3 weeks but may persist, o acetaminophen, 1000 mg/day may be used to decrease side effects, o ketoprofen or ibuprofen may be used for headaches and muscle aches.

Psychiatric disorders may occur in up to 36% of patients:

o insomnia is common, sleeping medication may help
o irritability is common, may increase with time and occur in up to 36% of patients,
– patient self recognition of the problem is important
– family support and understanding is very helpful
– coping mechanisms may be required
– anxiety may be treated with benzodiazepines
o depression may occur in 11 to 30% of patients:
– depression may occur later during treatment
– patients and physicians must be aware of the possibility
– anti-depressants may help but take time to work, counselling is recommended
– patients with previous clinical depression/suicide may require treatment discontinuation

Shortness of breath is seen in up to 14% of patients:

o shortness of breath may be from anemia and this must be monitored for (see above)
o in patients with normal Hgb, pulmonary function is usually normal in spite of symptoms
o a non-productive cough may also occur
o chest pain is not usually a feature

Hair loss may occur in up to 30% of patients:

o usually manifested as increased loss when combing
o baldness is extremely rare
o hair loss ceases and hair returns following treatment
o treatment is not usually altered because of hair loss

Pruritis, rash, exacerbation of psoriasis or lichen planus may occur:

o these are usually treated symptomatically
o topical steroids may be required for lichen planus or psoriasis

Local skin irritation at the injection site may occur:

o this may decrease with time
o changing site of injection is important
o local topical therapy (creams, ointments) is of little value

There are many other less frequent but potentially serious side effects that must be monitored for.

There have been enquiries as to when to refer patients for treatment:

The following are guidelines:

Patients
* with confirmed hep C = antibody to hep C positive and HCV RNA positive by PCR,
* with serum ALT, AST over 1.5 times normal,
* with no ongoing major depression,
* with compensated liver disease,(no ascites, variceal bleeds or hepatic encephalopathy),
* without evidence of ongoing alcohol or drug abuse,
* with no serious systemic disease.

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