How Hepatitis C Is Treated

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Hepatitis C (HCV) treatments are highly effective in curing chronic infections, with newer generation drugs improving cure rates even among those who have previously failed HCV therapy.

Typically, between 20 percent and 30 percent of HCV infections are spontaneously cleared with no medical intervention. Of the remaining 70 percent to 80 percent, the infection can progress over the course of decades and gradually damage the liver. About 10 to 20 percent of those infected develop serious conditions such as cirrhosisliver cancer, or end-stage liver failure requiring a liver transplant.

Prescriptions

The goal of hepatitis C treatment is to suppress the virus to the point where it becomes undetectable in blood samples. The amount of virus in the blood is referred to as the viral load. A viral load that remains undetectable is defined as a sustained virologic response (SVR).

Research has shown that people who maintain an SVR for 24 weeks following the completion HCV therapy have only a 1 percent to 2 percent chance of experiencing a return of the virus. An SVR-24 can reasonably be considered a "cure."

Even people unable to achieve an SVR-24 can benefit to do some degree. The reduction of viral activity confers to slower disease progression and a reversal of some of the liver scarring (fibrosis) associated with HCV infection.

Direct-Acting Antivirals (DAAs)

Direct-acting antivirals (DAAs) are a newer class of drug that achieves cure rates of up to 99 percent. The duration of treatment can run anywhere from 8 to 24 weeks, depending on the stage of the disease and the previous treatment history.

Compared to older generation drugs, DAAs have far fewer side effects and can even treat advanced liver disease. Some of newer combination DAAs can even treat all six major genetic strains (genotypes) of HCV.

The following DAAs have been approved by the FDA for the treatment of chronic hepatitis C infection:

  • Daklinza (daclatasvir): approved for HCV genotype 3. Taken as a daily tablet in combination with Sovaldi, Daklinza is not recommended if you have heart disease. 
  • Epclusa (sofosbuvir/velpatasvir): approved for all HCV genotypes 1, 2, 3, 4, 5, and 6. Taken as a daily tablet for 12 weeks.
  • Harvoni (sofosbuvir, ledipasvir): approved for HCV genotype 1. Taken as a daily tablet, often in combination with ribavirin. 
  • Mavyret (glecapravir, pibrentasvir): approved for all six HCV genotypes. Taken as a daily tablet with food. Works in as little as 8 weeks for newly treated patients and up to 16 for those who were previously treated.
  • Sovaldi (sofosbuvir): approved for HCV genotypes 1, 2, 3 and 4. Taken as a daily tablet with ribavirin or a combination of ribavirin and peginterferon. 
  • Vosevi (sofosbuvir, velpatasvir, voxilaprevir): approved for all six HCV genotypes. Taken a daily tablet with food for 12 weeks.  Used for people who previously failed on a sofosbuvir-based therapy.
  • Zepatier (grazoprevir + elbasvir): approved for HCV genotypes 1, 4 and 6, Taken as a daily tablet with or without ribavirin. 

A number of older medications, such as Olysio, Incivek, Technivie, Victrelis, and Viekira Pak, were voluntarily retired by the manufacturers because they were nowhere as effective as these newer generation drugs.

Peginterferon and Ribavirin

Peginterferon and ribavirin have long been considered the standard treatment for chronic HCV infection prior to the emergence of DAAs. While are they are no longer the backbone to HCV therapy, they are still considered important for people with advanced disease or as alternatives if DAAs are not effective.

The efficacy of peginterferon and ribavirin is aa high as 90 percent, which is not as high as that of the newer DAAs. Some DAAs are taken with ribavirin or peginterferon, particularly in advanced disease or if multiple treatment failures have occurred.

On the downside, peginterferon and ribavirin may cause side effects, sometimes severe. Common side effects include:

  • Anemia
  • Headaches
  • Irritability
  • Anxiety
  • Depression
  • Hair loss 
  • Itchiness
  • Skin rash
  • Insomnia
  • Fatigue
  • Joint pain
  • Muscle pain
  • Nausea and vomiting
  • Fever
  • Chills

Response to Antiviral Therapy

Your response to HCV therapy is evaluated during and after the completion of treatment and is defined by the following criteria:

  • Rapid viral response (RVR): an undetectable viral load after four weeks of treatment
  • Extended rapid viral response (eRVR): an undetectable viral load at 12 weeks following the initial RVR
  • Early viral response (EVR): an undetectable viral load or a 99 percent reduction in viral load by 12 weeks
  • End of treatment response (ETR): an undetectable viral load achieved at 12 weeks
  • Partial responder: achieves EVR, but is unable to sustain an undetectable viral load 24 weeks after therapy completion
  • Null responder: unable to achieve EVR by 12 weeks
  • Sustained viral response (SVR): able to sustain an undetectable viral load for 12 weeks (SVR-12) and 24 weeks (SVR-24) following completion of therapy

Surgery

Chronic hepatitis C infection may lead to end-stage liver disease in some people if left untreated. This is a life-threatening condition in which the liver is so damaged that it cannot function as it should. Surgical treatments for end-stage liver disease include symptomatic management and possibly a liver transplant. Examples include:

  • Esophageal banding: Esophageal varices, a complication of end-stage liver disease, is caused by the obstruction of blood flow to the liver, causing the swelling and bleeding of blood vessels in the esophagus. A procedure called banding can stop the bleeding by placing rubber bands on esophageal blood vessels.
  • Liver transplant: A liver transplant is considered the only viable treatment for end-stage liver disease. With that being said, HCV may recur if the recipient has not achieved SVR-24. A liver transplant is most often performed using a liver from a deceased donor. A partial liver from a living donor can also be used since the liver is one of the few internal organs able to fully regenerate, both in the donor and the recipient.

Hepatitis C Doctor Discussion Guide

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Lifestyle

If you have chronic hepatitis C infection, there are things you need to do to protect the liver as you await appropriate treatment:

  • Avoid alcohol. Heavy alcohol use can accelerate fibrosis and lead to decompensated cirrhosis (in which the liver damaged but still functioning) and compensated cirrhosis (where the liver is non-functional). While an occasional drink may not cause harm, you would be better served to stop drinking altogether since your liver will become progressively less able to metabolize alcohol. 
  • Avoid Tylenol. Several common medications are processed in the liver and may cause harm if you have hepatitis C. Most of these drugs require a prescription, so it is unlikely your doctor would prescribe them. On the other hand, some people will take Tylenol (acetaminophen) without realizing that the over-the-counter remedy can harm the liver. If a painkiller is needed, speak with your doctor about switching to a nonsteroidal anti-inflammatory drug like aspirin, Advil (ibuprofen), or Aleve (naproxen).
  • Manage your blood pressure. Liver failure may cause a condition called portal hypertension characterized by increased blood pressure in the liver. While portal hypertension is not directly related to your overall blood pressure, lowering your blood pressure (with exercise, weight loss, and medication) may help avoid complications in portal hypertension. 

Complementary Alternative Medicine (CAM)

Certain vitamin deficiencies are common in people with hepatitis C and are associated with a worsening of the disease. This is because the liver plays a central role in all metabolic processes in the body. This includes storing vitamins and certain minerals (like copper and iron) and releasing them into the bloodstream when needed.

When the function of the liver is compromised, you may need to take steps to supplement missing nutrients. Among these:

  • Vitamin D has long been considered a risk factor for liver disease progression. Vitamin D is a fat-soluble vitamin, meaning that it requires fats to be properly absorbed. If you have liver failure, your body will be less able to absorb vitamin D and will need supplements to maintain the recommended daily intake (RDI).
  • Vitamin A and vitamin E are also fat-soluble vitamins that may need supplementation if levels are especially low in the blood.

in addition to supplements, there are complementary therapies sometimes used to treat HCV infection. These need to be used with great caution since many are metabolized by the liver and can add to the inflammatory stress already placed on the liver. Few, if any, are strongly supported by research.

Among the remedies you may need to avoid if you have advanced liver disease:

  • Vitamin K may cause excessive blood clotting as the liver loses its ability to produce the proteins needed to regulate normal blood clotting.
  • Ginkgo biloba is an herb that can cause blood thinning and lead to severe hemorrhaging due to loss of normal clotting in people with liver failure.
  • Herbal remedies have long been associated with drug-induced liver injury and should only be used under the direct supervision of a liver specialist. 

Always advise your doctor about any medications you are taking, whether they are pharmaceutical, over-the-counter, recreational, or traditional.

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Article Sources

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