Jonathan Fenkel, MD
Jonathan Fenkel, MD, an assistant professor of medicine at Thomas Jefferson University in Philadelphia, where he directs the Jefferson Hepatitis C Center and is the associate medical director of liver transplantation.
As more and more people are getting tested for hepatitis C, new advances are making it easier than ever to eliminate the virus and its potential to cause deadly diseases such as cirrhosis and liver cancer. In case you missed it, in 2012, the CDC advised that everyone born between 1945 and 1965 get tested for hepatitis C—along with people of any age who have risk factors.
Why the CDC took action: Even though hepatitis C can strike at any age, more than two million US baby boomers are infected with the virus—and most don’t realize it or even think they’re at risk.
But the fact remains that anyone can be infected with hepatitis C. People at greatest risk include those who received blood transfusions before 1992 (when screening became more advanced) or anyone who used self-injected drugs with possibly contaminated needles. In some cases, people are believed to have become infected with the virus while getting tattoos or piercings done with contaminated ink or equipment or when being stuck with an infected needle in a health-care setting.
You can be vaccinated for hepatitis A and B, but there is no vaccine for hepatitis C.
Antiviral medication and immune therapy that requires self-injections have long been the main treatments for chronic hepatitis C. However, these drugs often cause grueling side effects, such as debilitating fatigue, headaches, depression, muscle aches and anemia. Also, the drugs need to be taken for at least 24 weeks or up to 48 weeks.
What’s new: The FDA has recently approved two new medications that block enzymes that the hepatitis C virus needs to survive. Now patients are given a two- or three-drug cocktail that includes a new drug—sofosbuvir (Sovaldi) or simeprevir (Olysio)—combined with the antiviral ribavirin and sometimes interferon, which tends to have the most side effects. For the first time, some patients may be eligible for interferon-free therapies if they have a favorable hepatitis C genotype.
With the new regimen, 80% to 90% of patients will be completely cleared of the virus and often in as little as 12 weeks. Previous combination therapies had cure rates of 40% to 80%. Plus, even with interferon, the side effects of the new drug cocktail, such as stomach upset, fatigue and headache, last about half as long as they do with older regimens.
Some experts argue that the high cost of the new medication—a full course of treatment can cost roughly $100,000—means that it should be given only to those who have already developed liver disease.
My advice: Everyone with chronic hepatitis C should consult a doctor who is familiar with the risks and benefits of treatment, because even if your liver is healthy, you may still benefit from treatment, especially if the virus is causing joint pain, rashes, kidney disease or certain types of cancer such as lymphoma. Check with your insurance company to see if treatment is fully covered.
Because chronic hepatitis C progresses slowly, you could potentially wait months or even years before starting treatment. Interferon-free treatments are expected to be available within the next year or two, so some doctors advise patients to delay getting treatment—both to avoid the side effects of interferon and to take advantage of an all-oral treatment plan (interferon is given by injection once a week). To determine the treatment schedule that’s best for you, discuss all the options with your doctor.
Even when hepatitis C is cured, many patients still have liver damage—and a higher-than-average risk of developing liver cancer.
How I advise my patients: Get screened (with ultrasound) for liver cancer one year after treatment and every few years after that. Those who have cirrhosis will need an ultrasound every six months and an upper endoscopy every two to three years. A low-sodium (less than 2,000 mg a day) diet is also recommended, and raw shellfish, which can cause sepsis, should be avoided.
If you have liver damage: Don’t drink alcohol. If you take acetaminophen (Tylenol) for pain, don’t use more than 2,000 mg daily.
Also, make sure your vitamin-D levels are checked at your annual physical—liver damage can cause vitamin-D deficiency.
A simple blood test reveals if you ever have been exposed to the hepatitis C virus, but a second test is needed to determine if you’re still infected.
Shocking: About half of individuals who test positive on the first test do not follow up with the second test, meaning that they probably won’t get the treatments that can save their livers—and their lives.
TEST #1: An initial antibody test will reveal if you’ve been exposed to the virus at any time in your life. If the test is positive, you’ll need a second test (see below). If test #1 is negative, you can relax and will not need testing again unless you’re possibly exposed to the virus in the future (for example, you find out that you have shared a razor or toothbrush with someone who has hepatitis C). Even if results were negative to test #1, test again in six months if you have hepatitis risk factors.
TEST #2: A viral load assay, also a blood test, will reveal if the infection is chronic (still active in the body). If it is, discuss treatment options with your doctor and be tested for the strain—or genotype—of the virus, which will help determine the most effective medication.