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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


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    1. First Steps:Understanding Hepatitis C and What You Can Do About It August 19, 2008

    2. What is Hepatitis? • Inflammation of the liver • Causes • Viruses • Toxins • Genetic Disorders • Bacteria • Parasites • Unknown causes

    3. Liver • Largest internal organ • Located on right side under rib cage • 3 lbs • Size of a football • Has over 500 vital functions

    4. 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

    5. 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!

    6. Hep-Trivia How many quarts of blood does the liver filter every minute? A. .5 quart B. 1 quart C.1.5 quarts

    7. 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

    8. Viral Hepatitis • Hepatitis A (HAV) • Hepatitis B (HBV) • Hepatitis C (HCV)

    9. 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

    10. What can I do? • Prevent by hand washing • Vaccine available • Two doses over a six month period • Life-long

    11. 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

    12. 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

    13. 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

    14. 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

    15. HCV Testing • HCV Elisa III (EIA) • Detects antibodies • Signal to Cut Off Ratio = 95% • RIBA HCV • Confirming anti-body test

    16. 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

    17. 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

    18. 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)

    19. Liver Biopsy • Measures liver health • Measures scarring • Treatment decisions • Benchmark • Predictor of progression?

    20. 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

    21. Hep-Trivia Which of these can be avoided by getting a vaccine? A. Hepatitis A B. Hepatitis B C. Hepatitis C

    22. 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

    23. Healthy Liver

    24. Fibrosis: Light Scarring of the liver

    25. Cirrhosis: Extensive scarring

    26. Factors That Cause Progression • Alcohol consumption • Drug use • Acquired over age 40 • Males • Co-infected with HBV or HIV • Immune system is compromised • Steatosis

    27. Liver cells on alcohol

    28. Steatosis

    29. No Association with Progression • Genotype • ALT • Viral load • Mode of transmission

    30. What can I do? • Enroll in treatment • Talk to your doctor about your options • Disease Management • Keeping your liver healthy

    31. Treatment • Only effective ~50% of time • Dependent upon individual • Genotype • Duration 6 – 12 months

    32. 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

    33. Length of Treatment • Genotype 1 (12 months) • Genotype 2 (6 months) • Genotype 3 (6 months)

    34. 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

    35. General Treatment Guidelines • Overall Health is Stable • Active HCV Infection • Elevated ALTs (exceptions) • Compensated liver disease

    36. HCV Treatment & Substance Use History • General Guideline 6 months clean/sober? • No alcohol on treatment • Requires counseling on medication adherence • Key component – SUPPORT!

    37. 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)

    38. Optimal Response to Treatment • Younger • Female • Low Viral load • Minimal Liver Damage • Genotype 2 or 3 • Lower Weight / BMI • Little or No Steatosis

    39. Preparing for Treatment • Psychiatric Evaluation • Drug and/or Alcohol Evaluation • Ophthalmology Evaluation • Adherence Consultation • Side-Effect Consultation

    40. Pegylated IFN and Ribavirin • Interferon plus ribavirin • Genotype 1: 42 to 46% • Genotype 2&3: 28 to 82%

    41. 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

    42. 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

    43. Managing side-effects

    44. 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

    45. 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

    46. 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

    47. Disease Management • Be cautious about all drugs, vitamins and herbs • Your liver processes everything • Avoid nicotine, caffeine, drugs, chemicals

    48. 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

    49. 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

    50. Support Groups • Informational • Speakers • Emotional • People with HCV • 12 step programs • Focus on different aspects of recovery