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Home | Articles | Liver Disease | Hepatitis C

Hepatitis C

Last updated 10th October 2022

Last updated on 4th December 2013 by Calum Murray

What is Hepatitis C?

  1. Bloodborne virus discovered in 1989. UK prevalence 0.5-1%; Over 700 identified cases D&G. Six genotypes: types 1 & 3 common locally.
  2. Scotland has a national programme to identify and treat people with HCV to reduce the future burden of patients with chronic liver disease/failure

Who Should Be Screened?

  1. Patients with persistently elevated ALT
  2. Any patient with jaundice or liver failure
  3. Past or present injecting drug users
  4. Recipients of blood products pre-screening in 1991
  5. Children of mothers known to be infected with HCV – risk <5%
  6. Healthcare professionals following needlestick injury in patient known or suspected to be infected with HCV – risk 3%
  7. People who received medical or dental treatment in countries where HCV is common
  8. People who have had tattoos or body piercing in circumstances where infection control is thought to be suboptimal
  9. Sexual partners of patients with HCV. Risk of sexual transmission ~ 3% in 10 year relationship. Be aware of recent outbreaks of HCV infection in men who have sex with men
  10. Blood/tissue donors
  11. Haemodialysis patients
  12. Healthcare professionals pursuing careers in specialties requiring them
  13. Consider testing patients with chronic fatigue

Principles of Testing

  1. HCV-RNA indicates current infection – can be detected from as early as one or two weeks post infection
  2. HCV antibody indicates past or current infection – can be detected at seven to eight weeks post infection, persists even after spontaneous viral clearance or successful trweatment.
  3. Healthcare professionals with needlestick injuries should have HCV-RNA at 6, 12 and 24 weeks, and HCV antibody at 12 and 24 weeks 
  4. Individuals with positive antibody and repeatedly negative HCV-RNA do not require further active management of their infection, but do need to be advised about lifestyle risks as presence of antibody doesnt protect against reinfection
  5. Specialist clinic only – should have HCV genotyping if considering antiviral therapy.

Clinical Presentation

  1. Acute infection usually asymptomatic but if associated with jaundice the likelihood of spontaneous viral clearance is higher (ie good prognosis).
  2. Early chronic disease; fatigue, myalgia and arthralgia, depression, memory impairment, reduced alcohol tolerance.
  3. Late disease; features of cirrhosis.
  4. Extra-hepatic features often mediated through cryoglobulins include rashes, renal impairment.

Investigations

  1. Jaundice is rare and usually only appears in decompensated cirrhosis
  2. Transaminases usually raised in range 50-200u/l with ALT>AST
  3. Around 25% patients with chronic hepatitis C have persistently normal serum ALT – such patients more likely to be women and to have mild disease.
  4. Liver biopsy is not an essential test prior to antiviral therapy – now only considered after treatment failure or high likelihood of other liver disease

Progression of Untreated Disease

  1. Around 20% patients will clear the virus spontaneously
  2. The rest have significant risk of progression to cirrhosis and HCC
  3. Progression to cirrhosis is around 20% after 20 years for patients attending liver clinic with around 20% cirrhotics developing HCC
  4. Male sex, older age, smoking, alcohol and coinfection with HAV, HBV or HIV can all accelerate progression of liver disease
  5. No association between HCV genotype and disease progression

Management

  1. Always offer to screen for HBV & HIV
  2. Always offer Hepatitis A and B immunisation.
  3. Offer to test sexual partners, children and injecting contacts

Antiviral Therapy

  1. All patients with CHC should be considered for antiviral therapy.
  2. Benefits have been shown right across the spectrum of HCV infection from mild disease including patients with persistently normal ALT up to those with compensated cirrhosis
  3. Treatment naive patients with HCV genotype 1 should be considered for Pegylated Interferon SC with Ribavirin orally plus a Protease Inhibitor as triple therapy. Optimal treatment duration is 48 weeks
  4. For patients with HCV genotypes 2 or 3 standard treatment should be Pegylated Interferon and Ribavirin for 24 weeks
  5. Treatment regimens, which are complex, are changing rapidly as new oral medications become available. Current recommendations given in more detail in the SIGN guideline – click on link below
  6. Drug users may require support to remember to attend clinic – contact Claire Starr (Dr Jones’ Secretary for Tuesday pm clinic 33787)

Management of Adverse Effects

  1. These are common and usually managed by Clinical Nurse Specialists Marie Murray and Liz Scotney
  2. Flu-like symptoms – minimise by paracetamol and increased fluids
  3. Anaemia and neutropenia – consider dose reduction Ribavirin, EPO, G-CSF on a case by case basis
  4. Depression – consider treatment with antidepressant
  5. The new protease inhibitors can cause life threatening rash but if treatment is stopped then it cannot be restarted. Must discuss with specialist.
  6. Other side effects include skin reactions, thyroid dysfunction, weight loss, dyspnoea, retinopathy, alopecia – click on link below

Response Rates

  1. Sustained viral response (SVR), defined as HCV-RNA negative 6 months after end of therapy, should be used as marker of viral clearance – relapse thereafter is very uncommon
  2. SVR is currently 70% for genotype 1 (triple therapy) and 70-80% for genotype 2 or 3 (dual therapy)

Screening for Hepatocellular Carcinoma

  1. The rate of development of HCC in patients with HCV who are not cirrhotic is extremely low so screening should be limited to those with cirrhosis
  2. Serum AFP and liver ultrasound every 6 months is recommended

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