Hepatitis C is classically known as a chronic disease though there is a phase of acute HCV that occurs during the first six months of exposure. In the majority of cases, this acute phase will lead to chronic Hepatitis C. The chronicity of this disease is important because until recently Hepatitis C was considered a lifelong illness and one of the leading causes of cirrhosis and liver cancer.
Different patient populations are considered to be at high risk for Hepatitis C - current or former injection drug users, recipients of blood transfusions or solid organ transplants prior to 1992, chronic hemodialysis patients, persons with known exposure to HCV (healthcare workers after needle sticks with HCV-positive blood), persons with HIV, and children born to HCV-positive mothers. Hepatitis C can be transmitted sexually, but the risk is significantly lower compared to those listed above.
Given how common hepatitis C is in our population, the next obvious question is: what symptoms should we be looking for? That is a bit more challenging since approximately 70 to 80 percent of patients with acute Hepatitis C and a large percentage of patients with chronic Hepatitis C do not have any symptoms. For acute Hepatitis C, some patients may have mild to severe symptoms including fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, joint pain, and jaundice. For chronic Hepatitis C, the majority of patients will not have symptoms until they begin to have liver damage, even in the setting of normal liver function tests. Unfortunately, asymptomatic patients can still spread the virus to other individuals.
Chronic Hepatitis C is a serious disease than can lead to long-term health problems. Of every 100 people infected with Hepatitis C, 75 to 85 people will develop chronic Hepatitis C. Of those, 60 to 70 people will go on to develop chronic liver disease, five to 20 will go on to develop cirrhosis over a 25 year period, and one to five people will die from cirrhosis or liver cancer. Approximately 15,000 people die every year from Hepatitis C related liver disease.
Because HCV infection is frequently asymptomatic, screening patients who may have an increased likelihood of being infected with HCV is an important step toward improving the detection and treatment of infected individuals. Screening for HCV generally focuses on testing those who have an individual risk factor for exposure, who have evidence of liver disease, and who belong to certain demographic groups that have a high-prevalence of infection-including individuals born in the United States between 1945 and 1965. Several organizations have provided guidelines for who should be tested/screened for HCV infection.
Screening is performed initially via a Hepatitis C antibody test. A positive antibody test is followed by an RNA test. If positive, it is important to discern the genotype, as treatment regimens are tailored to the genotype the patient has. It is important to avoid alcohol if diagnosed with Hepatitis C as alcohol and Hepatitis C can have a synergistic effect on disease progression. Vaccinations are important as well. Patients should be vaccinated against Hepatitis A and B, as well as against the flu (once a year), pneumonia (at least once), diphtheria and tetanus (once every 10 years) and pertussis (once during adulthood).
Treatment for Hepatitis C has come a long way from where we started. Approximately 20 percent of patients with Hepatitis C will spontaneously clear the virus; however, the remaining 80 percent of patients will be looking for treatment options. In the early days, our options were limited, typically committing patients to 2-drug (and even 3-drug) therapy from anywhere between six and 12 months with the primary medications being interferon and ribavirin. In some cases, we were only able to offer successful treatment less than 50 percent of the time. These medications were noted to have multiple side effects ranging from anemia, to fatigue, to depression, which decreased compliance.
Over the last few years, great strides have been made in the treatment of Hepatitis C to the point that, depending on the genotype, we can potentially offer non-interferon treatment regimens (i.e. an all-oral regimen) and have a near 90 percent chance of clearing the virus – thus providing not only treatment but a cure.
Rishi K. Agarwal, MD practices gastroenterology with Birmingham Gastroenterology Associates.
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