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

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

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

4. Liver Functions Stores: vitamins, minerals, sugars Stores: vitamins, minerals, sugars Produces: bile, cholesterol and lymph Produces: bile, cholesterol and lymph Regulates: blood clotting, glucose, and hormone levels Regulates: blood clotting, glucose, and hormone levels Cleans: the blood from bacteria and toxins Cleans: the blood from bacteria and toxins

5. Liver Functions - continued Processes: food, alcohol and other drugs Processes: food, alcohol and other drugs Converts: food and drink into forms the body can use Converts: food and drink into forms the body can use Oxidizes: triglycerides to produce energy 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 Acute infection is when the infection is newly acquired Chronic infection lasts 6 months or more and is usually life-long 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 Resolved or cleared infection occurs when the body has gotten rid of the infection

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

9. Hepatitis A Virus found in feces Virus found in feces Transmitted Transmitted –Contaminated food and/or water –Direct contact with infected persons feces Resolves-does not become chronic Resolves-does not become chronic Can lead to fulminant hepatitis with chronic liver disease Can lead to fulminant hepatitis with chronic liver disease

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

11. Hepatitis B Blood, semen, vaginal and other body fluids Blood, semen, vaginal and other body fluids High sexual transmission High sexual transmission –Perinatal –Percutaneous –Noninjection drug use Chronic infection occurs in Chronic infection occurs in –90% of infants infected at birth –30% of children infected at age 1–5 years –30% of children infected at age 1–5 years –6% of persons infected after age 5 years –6% of persons infected after age 5 years Death in 15%–25% of chronically infected Death in 15%–25% of chronically infected

12. What can I do? Avoid contact with body fluid 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 Vaccine available –Three doses within six months –Twinrix

13. Hepatitis C Blood to blood transmission 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 Primarily causes damage to the liver Often no symptoms Often no symptoms No vaccine available No vaccine available

14. Hepatitis C Of 100 persons infected with HCV: 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) HCV Elisa III (EIA) –Detects antibodies Signal to Cut Off Ratio = 95% Signal to Cut Off Ratio = 95% RIBA HCV RIBA HCV –Confirming anti-body test

16. HCV Testing Viral Load Viral Load –Amount of virus in per milliliter of blood Copies or International units Copies or International units –Qualitative – presence of virus Most sensitive Most sensitive –Quantitative – measure amount of virus Some Quantitative are as sensitive as Qualitative Some Quantitative are as sensitive as Qualitative

17. HCV Testing Viral Load 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) 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) AST – (Aspartate Aminotransferase) AP – (Alkaline Phosphatase) AP – (Alkaline Phosphatase) GGT – (Gamma Glutamyl Transferase) GGT – (Gamma Glutamyl Transferase)

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

20. Symptoms** Fatigue Fatigue Brain Fog Brain Fog Flu symptoms Flu symptoms –Muscle, joint, fever Itching Itching Liver pain Liver pain Loss of appetite Loss of appetite Headaches Headaches Nausea/indigestion Nausea/indigestion Depression Depression **Symptoms do not correlate to disease progression

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

22. What can I do? Refrain from shooting drugs Refrain from shooting drugs –If you do, use new or sterile tools Avoid contact with blood 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 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 Alcohol consumption Drug use Drug use Acquired over age 40 Acquired over age 40 Males Males Co-infected with HBV or HIV Co-infected with HBV or HIV Immune system is compromised Immune system is compromised Steatosis Steatosis

27. Liver cells on alcohol

28. Steatosis

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

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

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

32. Goals of Treatment Clear virus Clear virus Improve inflammation Improve inflammation Improve liver health–scarring Improve liver health–scarring Slow disease progression Slow disease progression Improve symptoms and quality of life Improve symptoms and quality of life Put HCV behind them and move on with their life Put HCV behind them and move on with their life

33. Length of Treatment Genotype 1(12 months) Genotype 1(12 months) Genotype 2(6 months) Genotype 2(6 months) Genotype 3(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 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 Overall Health is Stable Active HCV Infection Active HCV Infection Elevated ALTs (exceptions) Elevated ALTs (exceptions) Compensated liver disease Compensated liver disease

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

37. Contraindications to HCV Treatment Pregnancy or patients unwilling or unable to practice two forms of birth control Pregnancy or patients unwilling or unable to practice two forms of birth control Poorly controlled psychiatric disease Poorly controlled psychiatric disease Poorly controlled coronary disease Poorly controlled coronary disease Kidney or heart transplant recipient Kidney or heart transplant recipient Autoimmune Disorders Autoimmune Disorders Cancer Cancer Decompensated liver disease (research only) Decompensated liver disease (research only)

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

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

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

41. Side-effects Interferon Interferon –Headaches –Slight fever –Fatigue –Muscle/joint pain –Nausea/vomiting –Appetite/weight loss –Depression/anxiety –Skin irritation Ribavirin Ribavirin –Increases side effects of interferon, especially fatigue –Anemia –Shortness of breath –Birth defects

42. Managing Side-effects Injections at bedtime Injections at bedtime Vary injection sites Vary injection sites Low doses of pain relievers Low doses of pain relievers Drink lots of water Drink lots of water Small frequent meals Small frequent meals Moderate exercise Moderate exercise Plenty of rest Plenty of rest Support system Support system Anti-depressants Anti-depressants

43. Managing side-effects

44. Depression Psychiatric symptoms require serious attention Psychiatric symptoms require serious attention Depression occurs in 35-57% of HCV patients before treatment Depression occurs in 35-57% of HCV patients before treatment Increases in 20-30% of patients after starting treatment Increases in 20-30% of patients after starting treatment Most common reason for stopping treatment Most common reason for stopping treatment

45. Monitoring Therapy – Potential Problems Neutropenia Neutropenia (low white blood cells) (low white blood cells) –Neupogen Thrombocytopenia (low platelets) Thrombocytopenia (low platelets) Anemia Anemia –Procrit/ EPO Thyroid disease Thyroid disease Depression / anxiety Depression / anxiety –Treat with anti- depressants / anti- anxiety drugs General Health General Health

46. Disease Management Get vaccinated (A & B) Get vaccinated (A & B) Avoid alcohol Avoid alcohol –Lowers immune response –Helps HCV replicate –Lowers treatment response Monitor disease through doctor 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 Be cautious about all drugs, vitamins and herbs –Your liver processes everything –Avoid nicotine, caffeine, drugs, chemicals

48. Lifestyle Management Eat a healthy diet 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 Moderate exercise

49. Lifestyle Management Drink before you become thirsty 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 Limit caffeinated beverages/sugar beverages Keep water around Keep water around Sip throughout day, easier to absorb Sip throughout day, easier to absorb

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

51. Supplements Avoid large doses of vitamins or supplements Avoid large doses of vitamins or supplements General recommendation is multi- vitamin with no iron General recommendation is multi- vitamin with no iron Always discuss supplements and/or herbs with medical provider Always discuss supplements and/or herbs with medical provider

52. Medical Care Prepare for your appointments Prepare for your appointments –Write down questions based on priority –Describe symptoms –Discuss fears and feelings and feelings

53. Medical Care Bring health documents with you Bring health documents with you –Save time and duplication by getting recent records such as labs, special tests, vaccinations Write a brief health history Write a brief health history –Include details that would include previous medical providers, other health conditions, family history of illness

54. Medical Care If you don’t understand, ask again If you don’t understand, ask again If tests are ordered, ask what If tests are ordered, ask what they are for & how they are administered

55. Medical Care Write down what was said Write down what was said Most people won’t remember everything Most people won’t remember everything Take a friend or family member if you need help Take a friend or family member if you need help

56. Hep-Trivia What is the most important thing you can do when in the doctor’s office? A. Follow doctor’s instructions A. Follow doctor’s instructions B. Be your own advocate B. Be your own advocate C. Remember everything said C. Remember everything said

57. What can I do now? Don’t rush into a treatment decision Don’t rush into a treatment decision Do your homework Do your homework Discuss all options with medical provider Discuss all options with medical provider Take care of yourself Take care of yourself  Love your liver and live longer!

58. Resources Arizona Department of Health Arizona Department of Health –http://www.azdhs.gov/phs/oids/hepc/index.htm American Liver Foundation American Liver Foundation –http://www.liverfoundation.org/chapters/arizona /resources/ Hepatitis C Support Project Hepatitis C Support Project –http://www.hcvadvocate.org/