Hepatitis C Management
Ask The Experts
Archived Questions and Responses
Management
of Side Effects
In an HCV-infected patient with neutropenia who is receiving pegylated interferon and ribavirin, what is the recommended absolute neutrophil count (ANC) target range when treating with filgrastim (Neupogen)? At what ANC value should filgrastim therapy be initiated, and what is the suggested dosage?
Laboratory Assessment
Treatment of HCV
Which patients should be treated for their chronic hepatitis C?
A 49-year-old man with HCV, genotype 1, and a high viral load has cryoglobulinemia and a history of vasculitic rash. He had received a 9-month course of peginterferon with ribavirin in 2001, discontinued because of complications related to drug abuse. A second course of treatment this year was stopped when he did not achieve an early viral response (EVR). He did not have the rash while on treatment, but he did have a recurrence while off treatment. Is there any role for maintenance therapy with peginterferon in this setting?
What is the expected rate of recurrence for a 40-year-old female patient whose viral load has dropped from 457,000 IU/mL to less than detectable during the first 3 months of interferon/ribavirin therapy? She cannot tolerate side effects.
What is your recommendation for hepatitis B vaccination in chronic HCV-infected patients who are hepatitis B core-antibody positive but hepatitis B surface-antigen/antibody negative?
How should a dentist approach treatment of a patient with hepatitis C who needs a complete denture?
Is a viral load of 3,500,000 IU/mL considered high in a patient with genotype 1a hepatitis C? If so, what are the implications for treatment or development of complications? The patient has recently contracted the virus and does not know whether to attempt treatment.
A 32-year-old woman was diagnosed 2 years earlier with idiopathic thrombocytopenic purpura (ITP) and hepatitis C infection. Her ITP is in remission, and she continues to take Prezolon, 10 mg/day. Her liver chemistry is normal and HCV PCR is positive (viral load 100,000 IU/mL). Does this indicate that the hepatitis C infection played a role in the ITP?
A female patient who has had hepatitis C for 3½ years was sent to a GI specialist, who started interferon therapy. The patient had a very bad adverse reaction to it, and in less than a year, her PCR had substantially increased to nearly twice the level. Her liver enzymes are slightly elevated. Is the doubling of the PCR a concern?
A male patient develops anemia after 4 weeks of treatment with ribavirin and pegylated interferon (PEG-IFN). Currently, his hemoglobin has dropped from 14.3 to 10.3, with significant fatigue. At what point should you treat the anemia? Are other laboratory studies needed? Do you give epoetin alfa?
A 36-year-old woman with HCV genotype 3 was treated with the standard dosage of PEG-IFN and ribavirin for 24 weeks. Her biopsy showed some fibrosis and much fat. Her body mass index is 25. She had an excellent response, with normalization of liver tests and hepatitis RNA negativity at 3 and 6 months. However, she relapsed at 3 months post-treatment and her HCV RNA turned positive. What treatment should be recommended — retreatment with the same dosage and duration, or retreatment with same dosage but for a longer duration?
What are the guidelines for treating a pregnant patient with hepatitis C who has a moderate viral load, including the best drug combination, the risk of transmission during delivery, and recommendations about breastfeeding?
The patient is a 47-year-old male who has been a hepatitis C carrier for 20 years. Post-transfusion, he is asymptomatic and has normal liver function tests. His physical examination is normal. Is he a candidate for interferon therapy?
Does interferon cure hepatitis C or does it just help to induce remission?
Should a healthy patient with hepatitis C infection and normal liver tests be treated?
I have a patient with a positive antibody for hepatitis C. Should I refer him for treatment?
I know that pegylated interferon and ribavirin are the standard treatment for chronic hepatitis C, but what else is available?
I have heard a lot about polymerase and protease inhibitors for treating hepatitis C. Can you tell me how to use them?
Can you please explain the difference in stopping rules for genotypes 2 and 3? Why aren’t they the same as genotype 1? Aren’t we wasting money and resources this way?
Retreatment
Screening for Liver Cancer
Transmission of HCV
Two questions: What procedure should be followed after a needlestick while treating an patient infected with HCV? Also, can HCV be transmitted to a doctor who has naked eye contact with blood droplets from an HCV-positive patient during surgery?
I am a dentist who works out (sports jujitsu and grappling similar to wrestling) with a man recently diagnosed with hepatitis C infection. Is sweat transmission a concern? Should I be tested?
Liver Biopsy
What is the standard of care when determining duration of time between liver biopsies in patients with chronic active hepatitis C, genotype 1a, in the evaluation of cellular degradation for purposes of staging and grading?
I have a 44-year-old female patient recently diagnosed with HCV, genotype 1a. Her viral load is 176,000 copies per mL but she has no symptoms. She has a history of sickle cell-thalassemia and has received many blood transfusions. Currently, she is being treated with hydroxyurea and is maintaining a hemoglobin of 8.5 to 9.9 g/dL. Considering that interferon and ribavirin will lower hemoglobin, is treatment with those drugs advisable? Is viramidine a treatment option?
Should a liver biopsy be obtained for all newly diagnosed patients with hepatitis C?
Special Groups
What are the criteria for treating HCV-related decompensated cirrhosis?
Our patient is a 40-year-old Hispanic male co-infected HIV/HCV. His HIV is well-suppressed (<50 copies/mL for over 6 years) and he has a CD4 >800 on combination lamivudine/zidovudine (Combivir) and efavirenz. We treated his HCV 1a (stage 2 grade 2) infection with 48 weeks of peginterferon alfa-2a/ribavirin, which decreased his HCV viral load to <50 copies/mm3 since week 12 of treatment and sustained the level throughout his therapy. Six months after completion of therapy, his HCV viral load is positive at 1 million copies/mm3. What can we offer him next?
The patient is a 39-year-old, 222 lb male coinfected with HIV who started peginterferon alfa-2a with ribavirin last week. He experienced bloody diarrhea twice. His last platelet count before therapy was 166. Could this be related to therapy?
How do you manage a patient with HCV who is on hemodialysis?
What are the management strategies for HCV in a 7-year-old child?
I use nitazoxanide (Alinia) for multiple gastrointestinal infections in my pediatric patients. I am hearing that it may also treat hepatitis C. Is this true? How is it used?
A biopsy diagnosed a patient’s liver to be in stage 4 from hepatitis C and alcohol consumption. What is the prognosis for this patient?
Management of Psychiatric Disorders in HCV
Miscellaneous
What is the prognosis for a 45-year-old woman with hepatitis C, recently diagnosed gestational diabetes, and stage 1 liver cancer who is 7 months into her second pregnancy?
What effect will a vitamin B12 injection have on a patient in her 14th week of therapy? The patient achieved undetectable viral load in her 8th week and has viral genotype 1a. She is currently on pegfilgrastim (Neulasta) and epoetin alfa for hematological side effects.
This patient has persistent right upper-quadrant pain. She had her gallbladder removed 18 months ago and still has the pain. Her liver enzymes are elevated. She has had CT scans and a magnetic resonance cholangiopancreatography (MRCP), which were normal. What would be a suggested course of action?
Once hepatitis C is diagnosed, is it necessary to order more tests to rule out other hepatic diseases before beginning treatment?
A male with a history of head and neck cancer (in remission) was diagnosed with idiopathic thrombocytopenic purpura (platelets 70,000) and then contracted hepatitis C after surgery. Can this patient be treated with interferon?
I have had good experience with the use of DDB (biphenyl dimethyl bicarboxylate) 15 mg tds plus amantadine 100 mg bid in treating Egyptian patients with HCV (mostly type 4). They have had SVR of about 30% and stabilization of the condition chemically and pathologically in 90% of patients. What is your comment?
This patient is a 54-year-old female health care worker in a wound/ostomy clinic with genotype 1 HCV, mild fibrosis, and an HCV viral load of 13,000,860. She had two treatments with mild silver protein IV 400 ppm. The last treatment was 5 months ago. The side effects were so bad that she had to stop treatment. She does not know how she contracted HCV; she did not use drugs or have blood transfusions. She has had breast biopsy, neuroma surgery, and arthroplasty. She was lethargic and had laboratory tests that showed an HCV RNA of 12 million IU/mL. After reading about peginterferon/ribavirin treatment, the side effects sound the same as those she had: projectile vomiting, headaches, a feeling of broken bones for days to weeks, nausea, and rigors. Are there any treatments with fewer side effects? Another important question is: Is there a way to accurately pinpoint when one contracted the virus?
My mother contracted acute hepatitis C following a surgery, but has recovered fully. Twice, her hepatitis C titers were negative. Now, she again shows 6,000, but has a normal AST and ALT and is totally asymptomatic. She is not willing to have a biopsy. Should aggressive treatment be initiated or can we wait considering the very low titers, normal liver function, and absence of any symptoms?
After being diagnosed with hepatitis C (2b), I was placed on pegylated interferon and ribavirin therapy. Unfortunately, I had to discontinue treatment after 11 weeks because of side effects. My doctor tested my level 6 months later, and there was no virus detected. For more than 2 years, my liver enzymes have been normal. I also have rheumatoid arthritis (RA). Since treatment for hepatitis C, my RA has been out of control. I am currently taking indomethacin and increasing doses of prednisone. My rheumatologist does not want to try anything else because of my past liver problems. Would medications that suppress the immune system cause the hepatitis C to surface again? Do you know if this situation has come up before and how it was managed?
The Team Approach to Hepatitis C Management
