1. Presented by NIAZY B HUSSAM PhD. Cinical Pharacy
علاجيات / خامس صيدلة
2016/12/5
Hepatitis- C- Viruses
Presented by
NIAZY B HUSSAM
PhD. Cinical Pharacy

2. Hepatitis- C- Viruses Definition of Hepatitis:
Hepatitis is swelling and inflammation of the liver. It is not a condition, but is often used to refer to a viral infection of the liver.

3. Type of Hepatitis A B C D E Source of feces blood/ blood/ blood/ feces
virus
blood-derived
blood-derived
blood-derived
body fluids
body fluids
body fluids
Route of
fecal-oral
percutaneous
percutaneous
percutaneous
fecal-oral
transmission
per mucosal
permucosal
permucosal
Chronic no
yes
yes
yes no
infection
Prevention
pre/post-
pre/post-
blood donor
pre/post-
ensure safe
exposure
exposure
screening;
exposure
drinking
immunization
immunization
risk behavior
immunization;
water
modification
risk behavior

4. HCV Group Education Slide Set
2/7/2018
HCV Group Education Slide Set
Hepatitis C
Identified in 1989
Blood test became available in 1992
Used to be known as “non-A, non-B” hepatitis
Spread through blood-to- blood contact
No vaccine available to prevent hepatitis C C
Important to stress the fact that HCV does not always have symptoms. Can feel healthy for or more years before developing symptoms. Patient can be asymptomatic but have hepatitis C.
Symptoms are often very mild, but liver damage can occur without symptoms
No vaccine is available for hepatitis C, but researchers are working hard. The virus mutates quickly making it difficult to make a vaccine.

5. Hepatitis C - Clinical Features
Incubation period: Average 6-7 wks Range wks
Clinical illness (jaundice): % (20-30%)
Chronic hepatitis: %
Persistent infection: %
Immunity: No protective
antibody response identified 8 8 8

6. Acute infection Hepatitis C infection causes acute symptoms in 15%
Symptoms are generally mild including a decreased appetite, fatigue, nausea, muscle or joint pains, and weight loss
Most cases of acute infection are not associated with jaundice
The infection resolves spontaneously in 10-50% of cases
 which occurs more frequently in individuals who are young and female

7. Chronic Hepatitis C Infection
About 80% of those exposed to the virus develop a chronic infection
Most experience minimal or no symptoms during the initial few decades of the infection
Chronic hepatitis C can be associated with fatigue
Hepatitis C after many years becomes the primary cause of cirrhosis and liver cancer

8. Hepatitis C is the cause of 27% of cirrhosis cases and 25% of hepatocellular carcinoma worldwide

9. Risk Factors Associated with Transmission of HCV
Transfusion or transplant from infected donor
Injecting drug use
Hemodialysis (yrs on treatment)
Accidental injuries with needles/sharps
Sexual/household exposure to anti-HCV-positive contact
Multiple sex partners
Birth to HCV-infected mother 11 11 11

10. •Received a tattoo or acupuncture with contaminated instruments (the risk is very low with licensed, commercial tattoo facilities)
•Share personal items such as toothbrushes and razors with someone who has hepatitis C (less common)

13. HCV Group Education Slide Set
2/7/2018
HCV Group Education Slide Set
Hepatitis C
About 3 million Americans infected
About 170 million infected worldwide
Many do not experience symptoms
4 times more common than HIV
Fewer people are transmitting HCV now compared to years ago.
About 30,000 more become infected each year

15. Hepatitis C Progression
Mechanisms associated with progression of fibrosis are poorly understood
Rate of progression variable but slow in general
Older age, male gender, excessive alcohol consumption, overweight, and immune deficiency associated with more rapid progression
Alcohol consumption controlled in correctional environment
Treatment of overweight & HIV is critical

16. Laboratory Diagnosis
HCV antibody - generally used to diagnose hepatitis C infection. Not useful in the acute phase as it takes at least 4 weeks after infection before antibody appears.

17. HCV-RNA - various techniques are available e. g. PCR and branched DNA
HCV-RNA - various techniques are available e.g. PCR and branched DNA. May be used to diagnose HCV infection in the acute phase. However, its main use is in monitoring the response to antiviral therapy.
HCV-antigen - an EIA for HCV antigen is available. It is used in the same capacity as HCV-RNA tests but is much easier to carry out.

18. Prevention of Hepatitis C
Screening of blood, organ, tissue donors
High-risk behavior modification
Blood and body fluid precautions 15 15 15

19. Treatment of Chronic Hepatitis C
2/7/2018
HCV Group Education Slide Set
Treatment of Chronic Hepatitis C

20. HCV Group Education Slide Set
2/7/2018
HCV Group Education Slide Set
Goals of Treatment
Clear all the hepatitis C virus from the body (“sustained response”)
Slow or stop damage to the liver
Help decrease symptoms
Primary goal is to clear the virus. You will still need to be followed your M.D.
You can relapse, or be a non-responder to treatment.
Throughout your treatment you will be monitored by labs that will screen your blood for hepatitis C viral load and serologies.

21. What Treatment is Available?
2/7/2018
HCV Group Education Slide Set
What Treatment is Available?
Interferon
Given by short iv, usually 3 times a week
Pegylated interferon
Long-acting, taken once a week
Combination therapy
Interferon (standard or pegylated) taken with ribavirin
Ribavirin is a pill taken twice daily
Some patients may undergo mono-therapy or combination therapy with either standard or pegylated interferon.
How do you determine which treatment a patient should go on?
Knowing the genotype or serotype (genotype-specific antibodies) of HCV is helpful in making recommendations and counseling regarding therapy. Patients with genotypes 2 and 3 are almost three times more likely than patients with genotype 1 to respond to therapy with alpha interferon or the combination of alpha interferon and ribavirin.
Furthermore, when using combination therapy, the recommended duration of treatment depends on the genotype. For patients with genotypes 2 and 3, a 24-week course of combination treatment is adequate, whereas for patients with genotype 1, a 48-week course is recommended.
1. CDC, Viral Hepatitis C, Frequently Asked Questions,
What is Ribavirin?
Ribavirin is an antiviral pill. By itself, Ribavirin does not treat HCV, but in combination with interferon it is highly effective in treating HCV.

22. HCV Group Education Slide Set
2/7/2018
HCV Group Education Slide Set
Does Treatment Work?
Interferon alone:
10 – 15% chance of clearing the virus from the blood
Interferon & ribavirin:
Up to 40% chance of clearing the virus
Pegylated interferon alone:
About the same as interferon & ribavirin 40%
Pegylated interferon & ribavirin:
Up to 50% chance of clearing the virus
Response rates vary depending on other things, such as how much damage has been done to your liver and the strain of virus, or genotype, that you have. Your provider will discuss this with you at your clinic visit.
Can I get HCV again?
Yes, it’s possible to be re-infected with either the same genotype or with another genotype.
1. CDC, Viral Hepatitis C, Frequently Asked Questions,
If a patient has failed all the available treatments, what does he/she do next?
Alternative treatments are available, however, no complementary medicine or alternative medical therapies have been scientifically proven to cure or ease symptoms of hepatitis C. The most common alternative is the use of herbs. Herbs have been used to help treat the HCV itself or to help manage side effects of interferon. The most common herbal medication used is milk thistle, however, there is no scientific evidence that shows milk thistle directly affects HCV. If you want to try alternative medicines to help you cope with your infection, please follow these guidelines:
Always check with your doctor
See an expert
Beware of false promises
For more information on refer to reference 20

23. HCV Group Education Slide Set
2/7/2018
HCV Group Education Slide Set
During Treatment
Medications taken for either 6 or 12 months
Blood testing required 2 to 3 times the first month, then every 4 weeks
Clinic visits every 1 month
Length of treatment depends on genotype and response to medications during treatment.

24. Side Effects of Interferon & Ribavirin
2/7/2018
HCV Group Education Slide Set
Side Effects of Interferon & Ribavirin
Common Side Effects:
Flu-like symptoms
Headache
Fatigue
Muscle & joint aches
Fever, chills
Psychiatric symptoms
Depression
Difficulty sleeping
Difficulty concentrating
Irritability
Side effects are how most people with hepatitis C feel everyday but worse. You may have several side effects from the medications used to treat HCV, but side effects can be dealt with effectively in many ways .
IFN and ribavirin each have their own set of side effects. We don’t know whose going to get which side effects. It’s completely variable, on average you get 2-3 side effects
These are the common side effects seen, but these can vary between individuals.
Flu-like symptoms - These tend to occur in the first few weeks of therapy and many are manageable.
Mood changes can sometimes occur late in therapy and should be constantly monitored.
Depression and mood disorders must be under control before treatment. Your physician & health care provider will refer you to a professional if needed, and work closely with that person during your course of treatment. On treatment, depression and other mood disorders can occur because of a direct response to the medication on your levels of serotonin in your brain.
To treat the side effects:
Fatigue - regular light exercise, get a good night sleep, manage stress
Mood changes/sleeplessness - relaxation exercises, support systems, discuss meditations with physician.

25. Side Effects of Interferon & Ribavirin
2/7/2018
HCV Group Education Slide Set
Side Effects of Interferon & Ribavirin
Less Common Side Effects:
May occur from the beginning:
Upset stomach, diarrhea
Decreased blood counts
Skin irritation from shots
May occur later in treatment:
Hair loss
Weight loss
Thyroid problems
Nausea, vomiting, diarrhea, poor appetite
Try to eat small meals, choose nutritious foods, and drink plenty of fluids to help these symptoms.
Weight loss
Most patients are happy about this.
Hair loss
Is reversible
Wear hats/scarves
Use mild hair products

26. New Hepatitis C Treatment
FDA recently approved two new protease inhibitors for treatment of Hep C
Boceprevir and Telaprevir
Are added to, do not replace, original therapy because resistance will develop
previously untreated or who have failed previous interferon and ribavirin therapy.
Same side effects plus additional side effects (anemia, Neutropenia, Thrombocytopenia, Severe Rash