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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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First steps understanding hepatitis c and what you can do about it l.jpg

First Steps:Understanding Hepatitis C and What You Can Do About It

August 19, 2008


What is hepatitis l.jpg
What is Hepatitis?

  • Inflammation of the liver

    • Causes

      • Viruses

      • Toxins

      • Genetic Disorders

      • Bacteria

      • Parasites

      • Unknown causes


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Liver

  • Largest internal organ

  • Located on right side under rib cage

  • 3 lbs

  • Size of a football

  • Has over 500 vital functions


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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


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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!


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Hep-Trivia

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

A. .5 quart

B. 1 quart

C.1.5 quarts


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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


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Viral Hepatitis

  • Hepatitis A (HAV)

  • Hepatitis B (HBV)

  • Hepatitis C (HCV)


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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


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What can I do?

  • Prevent by hand washing

  • Vaccine available

    • Two doses over a six month period

    • Life-long


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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


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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


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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


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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


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HCV Testing

  • HCV Elisa III (EIA)

    • Detects antibodies

      • Signal to Cut Off Ratio = 95%

  • RIBA HCV

    • Confirming anti-body test


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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


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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


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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)


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Liver Biopsy

  • Measures liver health

    • Measures scarring

  • Treatment decisions

  • Benchmark

    • Predictor of progression?


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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


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Hep-Trivia

Which of these can be avoided by getting a vaccine?

A. Hepatitis A

B. Hepatitis B

C. Hepatitis C


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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



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Fibrosis: Light Scarring of the liver


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Cirrhosis: Extensive scarring


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Factors That Cause Progression

  • Alcohol consumption

  • Drug use

  • Acquired over age 40

  • Males

  • Co-infected with HBV or HIV

  • Immune system is compromised

  • Steatosis




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No Association with Progression

  • Genotype

  • ALT

  • Viral load

  • Mode of transmission


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What can I do?

  • Enroll in treatment

    • Talk to your doctor about your options

  • Disease Management

    • Keeping your liver healthy


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Treatment

  • Only effective ~50% of time

    • Dependent upon individual

    • Genotype

  • Duration 6 – 12 months


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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


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Length of Treatment

  • Genotype 1 (12 months)

  • Genotype 2 (6 months)

  • Genotype 3 (6 months)


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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


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General Treatment Guidelines

  • Overall Health is Stable

  • Active HCV Infection

  • Elevated ALTs (exceptions)

  • Compensated liver disease


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HCV Treatment & Substance Use History

  • General Guideline 6 months clean/sober?

  • No alcohol on treatment

  • Requires counseling on medication adherence

  • Key component – SUPPORT!


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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)


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Optimal Response to Treatment

  • Younger

  • Female

  • Low Viral load

  • Minimal Liver Damage

  • Genotype 2 or 3

  • Lower Weight / BMI

  • Little or No Steatosis


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Preparing for Treatment

  • Psychiatric Evaluation

  • Drug and/or Alcohol Evaluation

  • Ophthalmology Evaluation

  • Adherence Consultation

  • Side-Effect Consultation


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Pegylated IFN and Ribavirin

  • Interferon plus ribavirin

    • Genotype 1: 42 to 46%

    • Genotype 2&3: 28 to 82%


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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


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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



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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


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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


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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


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Disease Management

  • Be cautious about all drugs, vitamins and herbs

    • Your liver processes everything

    • Avoid nicotine, caffeine, drugs, chemicals


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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


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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


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Support Groups

  • Informational

    • Speakers

  • Emotional

    • People with HCV

  • 12 step programs

    • Focus on different aspects of recovery


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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


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Medical Care

  • Prepare for your appointments

    • Write down questions based on priority

    • Describe symptoms

    • Discuss fears

      and feelings


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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


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Medical Care

  • If you don’t understand, ask again

  • If tests are ordered, ask what

    they are for &

    how they are

    administered


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Medical Care

  • Write down what was said

  • Most people won’t remember everything

  • Take a friend or family member if you need help


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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


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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!


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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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