OUR TREATMENTS
Hepatitis C Virus (HCV)
It is estimated that around 170 million people worldwide have chronic Hepatitis C infection. Some areas of the world have significantly higher rates of infection, in South East Asia there are prevalence rates of 3.9%, the Eastern Mediterranean 4.6%, Africa 5.3% and Pakistan and Egypt up to 10%. In the UK it is estimated that there are between 250,000 and 600,000 with chronic infection (0.4 to 1% of the population.)
Under diagnosis of Hepatitis C is a major problem within the UK and in other countries, with as many as five out of every six people infected not diagnosed. Although HCV is a potentially curable disease, the under diagnosis of those infected means that only one to two percent of sufferers are receiving the treatment recommended in the UK by the National Institute of Clinical Excellence (NICE.)
Risk Factors
As a blood borne virus there are a number of ways that the virus may be spread, the most common routes of infection are:
- Receiving blood transfusions prior to 1991 or blood products prior to 1987 (e.g. clotting factors given to haemophiliacs).
- Being born or having spent a significant amount of time in a high risk country.
- Having medical or dental treatment in a developing country where there is inadequate infection control.
- Tattoos or piercing where unsterile equipment is used.
- Sharing straws etc while snorting drugs.
- Sharing of toothbrushes/razors etc, where there is a risk that they may have had contact with contaminated blood.
- Sexual transmission (low risk, but estimated at up to 3 %.)
- History of intravenous drug use.
- Healthcare workers who have received needlestick injuries.
Testing/Diagnosis
It is important that prior to testing for HCV patients have a good understanding of the condition and are given the opportunity to discuss their fears and anxieties. The implications of positive and negative results need to be discussed so that each patient is able to make an informed decision regarding their future care. At the Wellington Hospital patients are encouraged to contact the Clinical Nurse Specialist who will happily discuss any issues or answer any questions patients may have and support them throughout the phase of diagnosis, treatment and follow up.
The testing process will normally begin with a blood test that looks for the antibody to the Hepatitis C virus (AntiHCV). Everybody exposed to the virus will develop these antibodies (normally within 3 months.) Some people however (about 20 – 25%) will clear the virus naturally. It is important to be able to tell if someone who tests positive for AntiHCV has cleared the virus or has developed chronic infection (if the immune system has not cleared the virus within 6 months.) To check if the virus is still present in the body a blood sample will be sent to test for HCV RNA. This checks if there is circulating virus in the blood and how much virus is present (viral load.)
If there is circulating virus present in the blood it is important to know what genotype (or strain) of the virus it is.
There are 6 different genotypes of HCV. The most common in the UK is Genotype 1, with genotypes 2 and 3 becoming more prevalent. Genotype 4 is common in Egypt and the Middle East, genotypes5 and 6 are less common.
It is important to know the genotype as this plays a major part in how successful treatment is likely to be, and for how long the treatment needs to be given.
Ultrasound
If diagnosed as Hepatitis C RNA positive, patients will go on to have an ultrasound scan of their liver. This quick and painless scan can give a good indication of the appearance and size of the liver and can be used as a screening tool to look for advanced liver disease.
Liver Biopsy
Liver biopsy involves taking a very small portion of the liver tissue which is then examined in a laboratory. The function of liver biopsy is to determine the degree of damage present in the liver. With HCV this may range from mild to severe and the results and implications would be discussed by the patient’s
doctor. At the Wellington Liver Unit we use a transjuglar liver biopsy. Compared to the standard biopsy when the small needle is inserted between 2 ribs, this is less painful, enables better samples to be taken and is more convenient for patients. Hospital stay is 6 hours or less.
Fibroscan
This test is an indirect way of evaluating scarring of the liver. In some patients in whom a liver biopsy is not indicated or cannot be done, this can be a useful test. It can be repeated without harm and is useful for follow up in some patients.
Treatment
The aim of treating patients with HCV is to clear the virus from the body thereby eliminating the risk of developing or of worsening liver damage.
Success rates and duration of treatment vary according to the genotype of the virus.
Genotypes 2 and 3 have a success rate of up to 80%, and treatment lasts for 24 weeks.
Genotypes 1, 4, 5 and 6 have a success rate of aprox 50% or less, and treatment lasts for 48 weeks.
In some cases the length of treatment may be reduced depending on how the patients respond to treatment within the first month. If the patient has an early virological response (EVR), meaning the virus has become undetectable at treatment week 4, then for genotype 2&3 patients treatment may be reduced to 12 – 16 weeks, for genotype 1 treatment may also be significantly reduced. However other factors, such as body mass, diabetes and tolerance to full doses of therapy may come into play, such that full length treatment may be needed.
Successful response to treatment is when a patient achieves sustained virological response (SVR); this means that the virus is still undetectable 6 months after completing treatment.
The current NICE guidelines advocate that for patients who have not responded to treatment by week 12 treatment is stopped. However there are some patients who have a delayed or slow response to treatment (meaning that there is not a significant drop in the amount of virus by treatment week 12), who benefit from an extended course of treatment (in excess of the standard 24 or 48 weeks). Most NHS centres are obliged to follow the NICE guidelines. However at the Wellington a longer course of treatment may be a viable option and will be discussed with the patient should the need arise.
For those patients who do not manage to achieve a SVR after treatment because they have not cleared the virus during treatment (non responder) or because the virus has come back after stopping therapy (relapser) NICE guidance does not currently advocate a second course of treatment within the NHS. However this is a treatment option that will be considered at the Wellington, as it is in other European countries, as a certain proportion of patients do respond to further courses of antiviral therapy.
Treatment involves a combination of drugs. Pegylated Interferon is a subcutaneous injection once a week (into the tissues under the skin – like insulin), and Ribavirin are tablets taken twice a day (morning and evening.) There are some side effects from both drugs, most settle after the first few weeks, and these will be gone through in depth prior to starting treatment.
Some of the more common side effects are:
- Flu symptoms following the injection (these tend to lessen after the first few injections)
- Fatigue (many people with HCV complain of fatigue even before treatment)
- Anaemia (often mild, can be helped with drugs if more severe)
- Loss of appetite
- Mood disturbance (irritability, depression – seldom serious)
- Sleep problems
- Rash/itching (normally mild)
- It is important that women do not become pregnant, and men use measures to prevent pregnancy whilst on treatment and for 6 months after the end of treatment.
Diagnosis and treatment of Hepatitis C is effective in many patients but is a prolonged treatment so it can be difficult for patients and their families. The Clinical Nurse Specialist together with liver disease specialists is essential for support and advice from initial enquiries and throughout the treatment process.
Contacts
If you have any questions regarding any aspect of viral hepatitis treatment at the Liver Unit at the Wellington Hospital, Please contact:
The Clinical Nurse Specialist on 0207 586 7156 or via e-mail on liverunit.wellington@hcahealthcare.co.uk