Heavy Drinking and Chronic Hepatitis C

It is well acknowledged that a person with chronic hepatitis C and a history of heavy alcohol abuse has an increased chance of developing the advanced liver disease, including cirrhosis and hepatocellular carcinoma (a form of liver cancer). Both of these conditions work together to effectively promote the development, progression, and severity of liver disease.

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 me 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 to address alcohol intake in all persons with chronic hepatitis C, whether symptomatic or not; and to address alcohol use whenever embarking upon an HCV prevention strategy, particularly among injecting drug users and other high-risk groups.

Among the risks associated with alcohol use and hepatitis C:

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 three drinks per day) will develop fatty liver disease, of which as many as 20% will develop liver cirrhosis within 10-20 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 10-30 years.

The combination of these two factors only speeds the process dramatically, as well as increasing the severity to the 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.

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. Even more so than liver cirrhosis, 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 the heavy drinking can accelerate the development of HCC by as much as five years, resulting in not only larger tumors but far shorter survival times.

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 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.

So far it is unclear how long a patient 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) be explored as part of a treatment plan for people with chronic HCV infection, particularly those with diagnosed with compensated or decompensated cirrhosis.

Furthermore, patients who require peginterferon are recommended to abstain for at least six months before start treatment and should be advised to abstain from further alcohol consumption for at least six months following completion of therapy.