Heavy Drinking and Chronic Hepatitis C

Questioning How Much Alcohol Is Safe

Chronic hepatitis C and heavy alcohol abuse increase the chance of developing advanced liver disease, including cirrhosis and hepatocellular carcinoma (a form of liver cancer). Both of these conditions compound each other's effects, leading to the development, progression, and worsening of liver disease.

Whisky in two glasses and bottle on a wooden table background.
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On its own, heavy alcohol intake can lead to a form of non-viral hepatitis called alcoholic hepatitis. When paired with viral hepatitis (in the form of either hepatitis B or hepatitis C), the impact on the liver can be exponentially increased.

Hepatitis C has also been found to be more common in people with a history of alcohol abuse than among non-drinkers. While the reasons for this are not entirely clear, we do know two things:

  • That alcohol and injecting drug use are strongly linked,
  • and
  • That injecting drug use remains the predominant mode of hepatitis C transmission in the U.S.

These associations highlight the need for people who have chronic hepatitis C, to avoid alcohol intake whether symptomatic or not, as well as the need to consider alcohol use when starting a hepatitis C virus (HCV) prevention strategy, particularly among injecting drug users and other high-risk groups.

Learn more about the risks associated with alcohol use and hepatitis C below.

Increased Risk of Cirrhosis

There is little doubt that people with chronic hepatitis C who drink alcohol have a higher chance of developing cirrhosis. From an epidemiological point of view, more than 90% of heavy drinkers (roughly defined as women who have more two drinks per day and men who have more than three drinks per day) will develop fatty liver disease. As many as 20% of them will develop liver cirrhosis within 10 to 20 years.

Hepatitis C infection runs a similar course, with 75% of infected persons developing chronic disease, while 15-20% will progress to advanced disease within 10 to 30 years.

The combination of these two factors speeds the process dramatically, as well as increasing the severity of liver damage—by some estimates, by as much as 200-300%. Furthermore, heavy alcohol users with HCV have a nearly 11-fold greater risk of developing cirrhosis than non-drinkers with HCV.

Increased Risk of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common form of liver cancer in the U.S., and one of the more common complications of chronic hepatitis C infection. The association between alcoholism and HCC is strong, with 80% of HCC cases being identified as heavy alcohol users.

The risk appears to increase with the amount a person drinks. One Italian study showed that the likelihood of HCC doubled when a person drank between 3.4 and 6.7 drinks per day. Similarly, studies have shown that heavy drinking can accelerate the development of HCC by as much as five years, resulting in larger tumors and far shorter survival times.

Reduced Effectiveness of Peginterferon-Based Therapies

While the drug peginterferon is used much less in modern HCV therapy, it is still common in cases where there has been previously failed treatment and/or a diagnosis of advanced liver disease. Ironically, it is often patients with a history of alcohol abuse who require peginterferon-based therapy.

Alcohol interferes with the efficacy of peginterferon, resulting in a 300% risk of viral rebound (i.e., the return of virus) after completion of therapy. Surprisingly, the risk of failure was seen to be the same between both light and heavy drinkers when compared to non-drinkers with HCV.

How Much Alcohol Is Safe?

So far it is unclear how long a person has to abstain from alcohol before the negative effects of alcohol abuse are reversed. It is for this reason that alcohol cessation (along with an alcohol treatment program, if needed) should be explored as part of a treatment plan for people with chronic HCV infection, particularly those diagnosed with compensated or decompensated cirrhosis.

Furthermore, people who need treatment with peginterferon are recommended to abstain for at least six months before starting treatment and are advised to abstain from further alcohol consumption for at least six months following the completion of therapy.

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By Charles Daniel
 Charles Daniel, MPH, CHES is an infectious disease epidemiologist, specializing in hepatitis.