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First Steps: Understanding Hepatitis C and What You Can Do About It. August 19, 2008. What is Hepatitis?. Inflammation of the liver Causes Viruses Toxins Genetic Disorders Bacteria Parasites Unknown causes. Liver. Largest internal organ Located on right side under rib cage 3 lbs

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what is hepatitis
What is Hepatitis?
  • Inflammation of the liver
    • Causes
      • Viruses
      • Toxins
      • Genetic Disorders
      • Bacteria
      • Parasites
      • Unknown causes
liver
Liver
  • Largest internal organ
  • Located on right side under rib cage
  • 3 lbs
  • Size of a football
  • Has over 500 vital functions
liver functions
Liver Functions
  • Stores: vitamins, minerals, sugars
  • Produces: bile, cholesterol and lymph
  • Regulates: blood clotting, glucose, and hormone levels
  • Cleans: the blood from bacteria and toxins
liver functions continued
Liver Functions - continued
  • Processes: food, alcohol and other drugs
  • Converts: food and drink into forms the body can use
  • Oxidizes: triglycerides to produce energy

Basically, the liver processes everything we eat, drink, swallow, breathe and/or absorb!

  • Don’t gamble with your liver!
hep trivia
Hep-Trivia

How many quarts of blood does the liver filter every minute?

A. .5 quart

B. 1 quart

C.1.5 quarts

hepatitis language
Hepatitis Language
  • Acute infection is when the infection is newly acquired
  • Chronic infection lasts 6 months or more and is usually life-long
  • Resolved or cleared infection occurs when the body has gotten rid of the infection
viral hepatitis
Viral Hepatitis
  • Hepatitis A (HAV)
  • Hepatitis B (HBV)
  • Hepatitis C (HCV)
hepatitis a
Hepatitis A
  • Virus found in feces
  • Transmitted
    • Contaminated food and/or water
    • Direct contact with infected persons feces
  • Resolves-does not become chronic
  • Can lead to fulminant hepatitis with chronic liver disease
what can i do
What can I do?
  • Prevent by hand washing
  • Vaccine available
    • Two doses over a six month period
    • Life-long
hepatitis b
Hepatitis B
  • Blood, semen, vaginal and other body fluids
  • High sexual transmission
    • Perinatal
    • Percutaneous
    • Noninjection drug use
  • Chronic infection occurs in
    • 90% of infants infected at birth
    • 30% of children infected at age 1–5 years 
    • 6% of persons infected after age 5 years 
  • Death in 15%–25% of chronically infected
what can i do12
What can I do?
  • Avoid contact with body fluid
    • Use barrier methods
    • Use new needles, cookers, cottons, etc.
    • Use your own personal items, such as razors, toothbrushes, etc.
  • Vaccine available
    • Three doses within six months
    • Twinrix
hepatitis c
Hepatitis C
  • Blood to blood transmission
    • Percutaneous
    • Non-injection drug use
    • Transfusions, organ transplants or blood products prior to 1992
    • Perinatal
    • Low sexual transmission
  • Primarily causes damage to the liver
  • Often no symptoms
  • No vaccine available
hepatitis c14
Hepatitis C
  • Of 100 persons infected with HCV:
    • 85 (85%) may develop long term infection
    • 70 may develop chronic liver disease
    • 10-20 may develop cirrhosis
    • 1 - 5 may die from consequences of chronic liver disease
hcv testing
HCV Testing
  • HCV Elisa III (EIA)
    • Detects antibodies
      • Signal to Cut Off Ratio = 95%
  • RIBA HCV
    • Confirming anti-body test
hcv testing16
HCV Testing
  • Viral Load
    • Amount of virus in per milliliter of blood
      • Copies or International units
    • Qualitative – presence of virus
      • Most sensitive
    • Quantitative – measure amount of virus
      • Some Quantitative are as sensitive as Qualitative
hcv testing17
HCV Testing
  • Viral Load
    • Confirm active HCV infection
    • Confirm HCV medications are working
    • Does not correlate with disease progression!
    • May effect mother to child transmission
liver function tests
Liver Function Tests
  • ALT – (Alanine Aminotransferase)
    • most commonly used test for liver
    • Indication something is going on in liver
    • 30% of people with HCV have normal
    • Some people and populations have normal ALT’s but still have disease progression or damage
  • AST – (Aspartate Aminotransferase)
  • AP – (Alkaline Phosphatase)
  • GGT – (Gamma Glutamyl Transferase)
liver biopsy
Liver Biopsy
  • Measures liver health
    • Measures scarring
  • Treatment decisions
  • Benchmark
    • Predictor of progression?
symptoms
Fatigue

Brain Fog

Flu symptoms

Muscle, joint, fever

Itching

Liver pain

Loss of appetite

Headaches

Nausea/indigestion

Depression

Symptoms**

**Symptoms do not correlate to disease progression

hep trivia21
Hep-Trivia

Which of these can be avoided by getting a vaccine?

A. Hepatitis A

B. Hepatitis B

C. Hepatitis C

what can i do22
What can I do?
  • Refrain from shooting drugs
    • If you do, use new or sterile tools
  • Avoid contact with blood
    • Use your own personal items, such as razors, toothbrushes, etc.
    • Cover wounds and clean up blood spills promptly with bleach
    • Use barrier methods
  • Do not donate blood
factors that cause progression
Factors That Cause Progression
  • Alcohol consumption
  • Drug use
  • Acquired over age 40
  • Males
  • Co-infected with HBV or HIV
  • Immune system is compromised
  • Steatosis
no association with progression
No Association with Progression
  • Genotype
  • ALT
  • Viral load
  • Mode of transmission
what can i do30
What can I do?
  • Enroll in treatment
    • Talk to your doctor about your options
  • Disease Management
    • Keeping your liver healthy
treatment
Treatment
  • Only effective ~50% of time
    • Dependent upon individual
    • Genotype
  • Duration 6 – 12 months
goals of treatment
Goals of Treatment
  • Clear virus
  • Improve inflammation
  • Improve liver health–scarring
  • Slow disease progression
  • Improve symptoms and quality of life
  • Put HCV behind them and move on with their life
length of treatment
Length of Treatment
  • Genotype 1 (12 months)
  • Genotype 2 (6 months)
  • Genotype 3 (6 months)
response to therapy
Response to Therapy
  • 12 Week Rule - decrease (2 log drop) or elimination of virus at week 12 is thought to be predictive of sustained virologic response
    • Example: 10,000,000 to 100,000
general treatment guidelines
General Treatment Guidelines
  • Overall Health is Stable
  • Active HCV Infection
  • Elevated ALTs (exceptions)
  • Compensated liver disease
hcv treatment substance use history
HCV Treatment & Substance Use History
  • General Guideline 6 months clean/sober?
  • No alcohol on treatment
  • Requires counseling on medication adherence
  • Key component – SUPPORT!
contraindications to hcv treatment
Contraindications to HCV Treatment
  • Pregnancy or patients unwilling or unable to practice two forms of birth control
  • Poorly controlled psychiatric disease
  • Poorly controlled coronary disease
  • Kidney or heart transplant recipient
  • Autoimmune Disorders
  • Cancer
  • Decompensated liver disease (research only)
optimal response to treatment
Optimal Response to Treatment
  • Younger
  • Female
  • Low Viral load
  • Minimal Liver Damage
  • Genotype 2 or 3
  • Lower Weight / BMI
  • Little or No Steatosis
preparing for treatment
Preparing for Treatment
  • Psychiatric Evaluation
  • Drug and/or Alcohol Evaluation
  • Ophthalmology Evaluation
  • Adherence Consultation
  • Side-Effect Consultation
pegylated ifn and ribavirin
Pegylated IFN and Ribavirin
  • Interferon plus ribavirin
    • Genotype 1: 42 to 46%
    • Genotype 2&3: 28 to 82%
side effects
Interferon

Headaches

Slight fever

Fatigue

Muscle/joint pain

Nausea/vomiting

Appetite/weight loss

Depression/anxiety

Skin irritation

Ribavirin

Increases side effects of interferon, especially fatigue

Anemia

Shortness of breath

Birth defects

Side-effects
managing side effects
Injections at bedtime

Vary injection sites

Low doses of pain relievers

Drink lots of water

Small frequent meals

Moderate exercise

Plenty of rest

Support system

Anti-depressants

Managing Side-effects
depression
Depression
  • Psychiatric symptoms require serious attention
  • Depression occurs in 35-57% of HCV patients before treatment
  • Increases in 20-30% of patients after starting treatment
  • Most common reason for stopping treatment
monitoring therapy potential problems
Neutropenia

(low white blood cells)

Neupogen

Thrombocytopenia (low platelets)

Anemia

Procrit/ EPO

Thyroid disease

Depression / anxiety

Treat with anti-depressants / anti-anxiety drugs

General Health

Monitoring Therapy – Potential Problems
disease management
Disease Management
  • Get vaccinated (A & B)
  • Avoid alcohol
    • Lowers immune response
    • Helps HCV replicate
    • Lowers treatment response
  • Monitor disease through doctor
    • Lab tests: Decisions should not be based upon one lab
disease management47
Disease Management
  • Be cautious about all drugs, vitamins and herbs
    • Your liver processes everything
    • Avoid nicotine, caffeine, drugs, chemicals
lifestyle management
Lifestyle Management
  • Eat a healthy diet
    • Emphasize fruits, vegetables, whole grains and fat-free/low-fat dairy
    • Avoid fatty foods
    • Avoid mega vitamins or supplements
  • Moderate exercise
lifestyle management49
Lifestyle Management
  • Drink before you become thirsty
    • #1 factor for fatigue is dehydration
    • 2% drop in body water can trigger short-term memory function, decreased concentration
  • Limit caffeinated beverages/sugar beverages
  • Keep water around
  • Sip throughout day, easier to absorb
support groups
Support Groups
  • Informational
    • Speakers
  • Emotional
    • People with HCV
  • 12 step programs
    • Focus on different aspects of recovery
supplements
Supplements
  • Avoid large doses of vitamins or supplements
  • General recommendation is multi-vitamin with no iron
  • Always discuss supplements and/or herbs with medical provider
medical care
Medical Care
  • Prepare for your appointments
    • Write down questions based on priority
    • Describe symptoms
    • Discuss fears

and feelings

medical care53
Medical Care
  • Bring health documents with you
    • Save time and duplication by getting recent records such as labs, special tests, vaccinations
  • Write a brief health history
    • Include details that would include previous medical providers, other health conditions, family history of illness
medical care54
Medical Care
  • If you don’t understand, ask again
  • If tests are ordered, ask what

they are for &

how they are

administered

medical care55
Medical Care
  • Write down what was said
  • Most people won’t remember everything
  • Take a friend or family member if you need help
hep trivia56
Hep-Trivia

What is the most important thing you can do when in the doctor’s office?

A. Follow doctor’s instructions

B. Be your own advocate

C. Remember everything said

what can i do now
What can I do now?
  • Don’t rush into a treatment decision
  • Do your homework
  • Discuss all options with medical provider
  • Take care of yourself
  • Love your liver and live longer!
resources
Resources
  • Arizona Department of Health
    • http://www.azdhs.gov/phs/oids/hepc/index.htm
  • American Liver Foundation
    • http://www.liverfoundation.org/chapters/arizona/resources/
  • Hepatitis C Support Project
    • http://www.hcvadvocate.org/
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