Centerforce Hepatitis C-Infected Peer Health Educator Training

1. Centerforce Hepatitis C-Infected Peer Health Educator Training DAY 3

2. Day 3: Schedule

3. Module 7: Side Effects of Treatment By the end of this module, participants will have: • Learned the common side effects associated with the current treatments • Learned ways to manage those side effects 3

4. Side Effects of Treatment Most people on HCV treatment experience some side effects Side effects vary from person to person About 60% or more of people experience side effects Some people feel better on treatment Some people feel about the same *ALWAYS talk with your doctor about any side effects you may be experiencing while on treatment

5. Side Effects of Treatment Side effects vary in severity from mild to moderate to severe Side effects are usually worse during the first few weeks of treatment How long any one patient experiences side effects from treatment can be different for each person The benefits of treatment can outweigh the side effects Talk with your Doctor about what to expect from side effects

6. Some Common Side Effects of Interferon Flu-like symptoms Fatigue Muscle/joint pain Nausea and vomiting Fever Diarrhea (at high doses of treatment)

7. Alopecia (hair loss) Headaches Trouble Sleeping Short-tempered Feeling “down”, depressed, or sad Mania Anxiety Personality changes Some Common Side Effects of Interferon (cont’d)

8. Some possible side effects of Ribavirin Birth defects and miscarriages Anemia Rash (itching) Dry cough Headache Fatigue Diarrhea Irritability Nasal stuffiness, sinusitis Shortness of breath Neutropenia (low white blood cell count, affects immune system)

9. Managing Side Effects • Take a week or two off of work or other strenuous activities when beginning treatment • Time interferon injection before bedtime • Ask your support systems (family, friends, peers) for help in coping with side effects • Join the Centeforce Hep C Education Group (Living Well with Hep C)

10. Managing Side Effects (cont’d) • For Flu-like symptoms • Use pain relievers as recommended by Dr. (check with your Doctor BEFORE taking any medications) • Drink plenty of clear fluids every day, avoid caffeine • Inject interferon at bedtime • Sponging with lukewarm (not hot or cold) water to reduce fever • For Fatigue • Rest as much as possible • Drink plenty of water and clear fluids • Get regular moderate exercise

11. Managing Side Effects (cont’d) • For having trouble sleeping • Use relaxation techniques • Develop consistent routines before going to bed • Try over-the-counter medications (medications you can buy without a prescription from a doctor) such as Benadryl, as recommended by a physician • Avoid exercise, vigorous activity, caffeinated drinks or medications that include stimulants before bedtime • Problems with sleeping can be treated with medications - ask your doctor

12. Managing Side Effects (cont’d) • For Headaches • Massage • Apply heat to back of the neck • Resting • A small amount of acetaminophen or ibuprofen (***always check with you Dr.)

13. Managing Side Effects (cont’d) • For Loss of appetite • Eat regularly even if no appetite • Think of food as medicine-good for your health • Drink clear juices in addition to water • Brush teeth often to get rid of metallic taste in mouth

14. Managing Side Effects (cont’d) • For Irritability, depression, mania, anxiety • Attend support groups • Get support from family, loved ones, friends • Try relaxation techniques • Depression may be treated with antidepressants (see your Dr) • Anxiety can be treated with medications (see your Dr)

15. Managing Side Effects (cont’d) • For Weight Loss • Eat foods high in calories and protein • Add powdered milk to milk, milkshakes, casseroles, soups, eggs, mashed potatoes, hot cereal, puddings • Spread peanut butter on bread, tortillas waffles, pancakes, and fruit • Add cooked beans or hard boiled eggs to soups, casseroles, and pasta that already has cheese or meat • Melt cheese on sandwiches, vegetables, rice, or noodles • Try products designed to promote weight gain, such as nutritional supplements, canned formulas, etc

16. Managing Side Effects (cont’d) • For Nausea and Vomiting • Take over the counter meds for nausea (ask your Dr) • Avoid foods that trigger your nausea (incl odors) • Avoid spicy, greasy, and deep-fried foods • Eat small amounts of food every few hrs • When nauseated, avoid acidic juices (orange, pineapple, and grapefruit) • When nauseated, drink clear juices, ginger ale, chicken broth, herbal teas, or sports drinks • Eat slowly and sip drinks slowly • Eat foods at room temperature (neither very hot nor very cold) • If nauseated in the morning, eat some dry crackers when first waking up and get out of bed slowly

17. Managing Side Effects (cont’d) • For Diarrhea • Ask Dr if you need to reduce your dose of interferon • Try medications such as diphenoxylate/atropine (Lomotil) and psyllium bulking agents such as Metamucil (ask your Dr) • For Mild Hair Loss • Try a different hairstyle that makes hair look fuller (women);Short hair (men) • Try hair extensions • Wear hats or scarves • Remember: Hair loss is only temporary

18. Module 8: HCV Disease Progression By the end of this module, participants will have: • Learned what happens, on average, to every 100 people infected with Hepatitis C • Learned the average timeline of progression of the disease • Learned the stages of Hepatitis C disease progression • Identified the symptoms of Hepatitis C associated with each stage of the disease 18

19. Chronic Hepatitis C infection • Lasting longer than 6 months • Does not mean severe disease progression • 75 to 85 of every 100 adults infected with Hep C become chronically infected • 5 to 20 of these people have serious disease progression over a 10 to 40 year period • Fibrosis • Compensated Cirrhosis • Decompensated Cirrhosis • Primary hepatocellular carcinoma (HCC) 19

20. HCV disease progression is not a linear process Progression of the disease can be slow for many many years and then…the process can suddenly speed up For some people, progression is fast For others, progression is slow For some, progression is unpredictable: slow at times, fast at others 20

21. 100 people infected with Hepatitis C 100 people with Hep C 75 to 85 will be chronically infected 15-25 will clear the virus within 6 mo.s 60 to 70 will develop chronic liver disease If no treatment 5 to 20 will develop cirrhosis If no treatment 1 to 5 will die of cirrhosis or liver cancer 21

22. 100 people with Chronic Hepatitis C 100 people with chronic Hep C 71 to 93 will develop chronic liver disease 7 to 29 will not develop chronic liver disease If no treatment 9 to 27 will develop cirrhosis If no treatment 1 to 7 will die of cirrhosis or liver cancer 22

23. Chronic Liver Disease Progression This happens over a 10 to 40 year period Decompensated Cirrhosis Liver Cancer Chronic HCV Infection Compensated Cirrhosis Fibrosis How long each of these steps take is different for every person

24. Chronic Liver Disease Progression This happens over a 10 to 40 year period Steatosis Having Steatosis can increase the speed at which HCV disease progresses Decompensated Cirrhosis Compensated Cirrhosis Chronic HCV Infection Liver Cancer Fibrosis How long each of these steps take is different for every person

25. Fibrosis • The accumulation of tough, fibrous scar tissue in the liver. • The build-up of nonfunctional connective tissue • Means that the liver is not able to function as well and, therefore, perform all of its 500 important functions well. • Does not occur at the same rate in all people with Hepatitis C. • Can remain stable or may even regress (get better) over time. 25

27. Factors that increase progression of Fibrosis • Men • Age (over 50) • As more damage occurs, the process accelerates • Compromised immune systems • Heavy alcohol consumption • Steatosis (will talk about this in a minute) • Insulin resistance • NOT viral load 27

28. Effects of Fibrosis • In early stages • Liver functions relatively well • Few people experience symptoms • As inflammation and liver injury continue • Scar tissue builds up • Eventual disruption of the metabolic functions of the liver • Can lead to cirrhosis or severe scarring of the liver. • At the advanced stage of fibrosis, liver cancer can develop. 28

29. Treatment of Fibrosis • Treatment for HCV can slow or halt fibrosis • May potentially even reverse existing liver damage • Slowing, halting, and reversing damage is most likely when patients achieve a SVR • Improvement has been seen in some partial responders and non-responders 29

30. Cirrhosis • When fibrosis becomes so extensive that severe scarring has occurred • The liver is not able to perform its many functions as well 30

31. Cirrhosis • 10-25% of people with chronic Hepatitis C will develop cirrhosis • Takes many years or decades to develop • Cannot predict who will and who will not develop cirrhosis so it is important to be monitored by a medical provider 31

32. Compensated Cirrhosis • Means that the liver is heavily scarred but is still able to perform most of its vital functions • Many people experience few or no symptoms • It is important to be monitored by your Dr. on a regular basis. 32

33. Compensated Cirrhosis • Remember that HCV disease progression is not a linear process • It is important to be monitored by your Dr. on a regular basis • People with compensated cirrhosis can live for a long time • Ideal time to make healthy lifestyle changes • Ideal time to seek out HCV treatment that will hopefully stop, slow down or even reverse some of the damage 33

34. Decompensated Cirrhosis • The liver is so extensively scarred that it is not able to function properly • People with decompensated cirrhosis eventually develop many symptoms and complications that can be life threatening • When the liver completely breaks down and is unable to perform its job, it is called end-stage liver disease 34

35. Symptoms of Decompensated Cirrhosis • Fatigue • Exhaustion • Loss of appetite • Nausea • Jaundice • Weight Loss • Stomach pain • Impotence • Bruising and bleeding 35

36. Complications of Decompensated Cirrhosis • A person can get really sick and may eventually die from complications caused by decompensated cirrhosis • This is end stage liver disease 36

37. Liver Cancer • 3-5 of every 100 people with chronic HCV develop liver cancer • About 1-2 of every 100 patients with HCV cirrhosis develop liver cancer each year. • Steatosis, cirrhosis, and increasing age are reported as independent and significant risk factors for liver cancer. 37

38. Steatosis • “Fatty Liver”: • A condition characterized by the accumulation of fat in the liver • About 55% of HCV positive individuals have steatosis • The combination of HCV and Steatosis increases the risk of HCV disease progression • The combination of HCV and Steatosis may contribute to the development of liver cancer 38

39. Steatosis • Factors that increase incidence of Steatosis: • Type II diabetes • Hyperlipidemia • Elevation of lipids (fats) in the bloodstream, including cholesterol, cholesterol esters (compounds), phospholipids, and triglycerides • Heavy alcohol consumption • High body mass index (BMI) • Assesses one’s body weight relative to their height • Genotype 3 Hep C infection • 74% of people with genotype 3 Hepatitis C have some degree of steatosis compared with 47.9% of those with non-genotype 3 Hepatitis C 39

40. Steatosis • Treating Steatosis: • There are no medications at this time to treat Steatosis • 3 strategies to help reduce and possibly eliminate Steatosis: • Diet • Exercise • Maintaining a Health Weight 40

41. Diet Recommendations for reducing likelihood of Steatosis • Do not take in more calories than you burn • Low fat diet • No more than 20 -30% of your total daily calories from fat • Less than 7% of your daily calories from saturated fat • Less than 1% of your daily calories from trans fats • Total cholesterol intake should be less than 300 mg/day • Carbohydrates • Carbs should account for 50 to 60% of your daily calories • Eat at least 5 to 7 servings of fruits and vegetables • Eat as much fiber as possible • Approximately 15% of daily calories should be protein • Avoid high-fat protein sources such as red meat & whole milk • Eat fish, beans, soy, egg whites or egg substitutes 41

42. Ways to slow down HCV Disease Progression • HCV medical treatment • Regular Exercise and Rest • Stress Reduction • Eating a healthy, well-balanced diet that follows the new Food Guide Pyramid • Low in fat and salt • High in whole-wheat products • Has enough protein • Don’t use recreational drugs 42

43. Slowing HCV Disease Progression (cont’d) • Don’t drink alcohol • At the very least, limit how much you drink • Take prescription drugs ONLY as instructed by your Dr. • Be careful when mixing over-the-counter drugs, prescription drugs, herbal supplements, street drugs, and/or alcohol-check with your Dr. 43

44. Slowing HCV Disease Progression (cont’d) • Stay away from poisonous liquids and fumes • Including solvents, paint thinners, and bug killers • If you have to use these chemicals, cover your skin, wear gloves and a mask and keep windows open and allow air to flow in. • Do not eat raw or undercooked shellfish • Get vaccinated against Hep A and Hep B • Learn as much as you can about Hepatitis C 44

45. Module 9: Hep C Tests to Monitor Disease Progression By the end of this module, participants will have: • Learned the purpose and types of common tests to monitor Hep C disease progression 45

46. Liver Biopsies A liver biopsy is the ONLY way to determine how much scarring and inflammation is happening in your liver. Lab tests help give an idea, but a biopsy is the only way to really tell. 46

47. Liver Biopsies • It involves taking a very small specimen of liver tissue for evaluation by a specialist • Done to • Measure the degree of liver inflammation (grade) • Measure the amount scarring (stage) • Assess the general health of the liver • Provide a starting point to compare against future biopsies • Help make decisions about the best treatment • Determine if treatment is working 47

48. Liver Biopsies • Metavir Score • Grade • An indication of the activity or amount of inflammation • Scored from 0-4 • 0 is no activity • 2 is moderate activity • 3 or 4 is severe activity • Amount of inflammation is considered a precursor to fibrosis 48

49. Liver Biopsies • Metavir Score (cont’d) • Fibrosis (or stage) • 0 = no scarring • 1 = minimal scarring • 2 = scarring has occurred and extends outside the areas of the liver that contains blood vessels • 3 = bridging fibrosis is spreading and connecting to other areas that contain fibrosis • 4 = cirrhosis or advanced scarring of the liver 49

50. Purpose of Liver Biopsies • Information about the grade and stage of liver disease is helpful in guiding the healthcare provider and patient in the medical management of the patient’s HCV infection. 50