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Q: I have just been diagnosed with hepatitis C. What are my options and prognosis?

Dr. Keti:

The Centers for Disease Control and Prevention estimate that 4 million Americans are infected with Hepatitis C.
Already, 10,000 people a year die from the disease and about 2,000 have liver transplants because of it. If you had a blood transfusion before 1992 or if you're "just wondering" about your past, get the Hepatitis C test through your local health department.

If it's positive, see your doctor for therapy:

Interferon alfa-2b, which requires you to inject yourself three times a week for four months to see if it lowers the liver's secretion of enzymes that indicate disease. If it does work, the injections will continue for a total of up to a year at a cost of up to $16,000, and you'll feel like you have flu the whole time.

However, interferon works for only 15 percent of people overall, and the rates vary by race and ethnicity: 5 percent for African Americans, 28 percent for Hispanics, 33 percent for Caucasians and 40 percent for Asians, according to one study.

A combination of interferon with ribavirin pills, a therapy that the Food and Drug Administration approved for people in whom interferon alone doesn't work. Doctors are excited about this therapy, because it shows about 30 percent effectiveness.

Ask your doctor about trying this combination therapy first, rather than waiting to see if interferon works by itself. (This is known as off-label use of a drug, which doctors can do legally.)

You might also want to discuss with your doctor two other emerging issues in drug treatment for Hepatitis C:
how to monitor the drug's effectiveness and whether to start off with a larger dose than is usually recommended for interferon.

In one article published in the Journal Science (October 2, 2000), an international group of researchers showed that interferon attacks the virus more effectively if, in the first two weeks of therapy, it's given much more aggressively than is currently the standard treatment.
Patients who received daily injections for two weeks of 15 million international units of interferon - compared to the standard dose of 3 million IUs three times a week - showed no detectable Hepatitis C in their bodies three months later.

The researchers suggest that this early high-dose therapy, followed by a lower maintenance dose, is a better way to combat the disease long-term.

They also recommend testing viral load - rather than liver enzymes - as a better way of monitoring the treatment progress and ensuring against breeding drug-resistant strains of Hepatitis C within the patient. A blood test for liver enzymes has up till now been the standard method for monitoring hepatitis C.

According John McHutchison, M.D. anyone with hepatitis C who hears about these new findings probably feels at least some measure of relief. But the study conclusions may be overly optimistic.

The unfortunate truth is that we still don't have a clear picture of the long-term outcomes for people with this liver-damaging virus. One reason it's so hard to predict Hepatitis C progression is that many people aren't sure exactly when they contracted the virus because the early phase of infection rarely causes symptoms.

The most common route of infection is through contaminated needles used to inject illegal drugs. The classic Hepatitis C patient is a 45-year-old man who experimented with injectable drugs in the 1970s. But contrary to what you might assume, most of these people today are otherwise productive, healthy people with good jobs and stable families. Another group of Hepatitis C-positive people are those who have received tainted blood transfusions. But since 1990, when blood banks began screening for the virus, the Hepatitis C-transmission risk from transfusions has dropped to practically zero.

We always have questions about what causes a lot of the cases of type C hepatitis and we don't know yet, the virus that is associated with this disease, such as the 55 nanometer RNA Flavivirus. It's in the same family as yellow fever; arthropod-borne disease; but it's interesting to remember this is in the same family as yellow fever virus.

The treatment for Hepatitis C is difficult, debilitating and costly. It involves daily doses of the antiviral pill ribavirin plus thrice-weekly injections of interferon, which can be self-administered.
Nearly everyone experiences at least some side effects -- mainly flu-like symptoms, emotional changes, minor hair loss and rashes. The side effects are usually worst during the first few weeks of treatment and often subside over time. But the therapy lasts between six and 12 months, and only 40 percent of patients achieve a long-lasting remission of their disease.

Given these discouraging odds, some doctors favor watchful waiting, with periodic liver biopsies (a minor surgical procedure) to check for signs of increasing damage. The virus triggers the immune system to kill infected liver cells. Those dead cells are then replaced by scar tissue -- otherwise known as fibrosis. Cirrhosis, nodules of scar tissue, is the end result.

Unfortunately, we have no way of predicting who will develop cirrhosis and how quickly it will occur. We know that men don't fare as well as women, and people who are older when they contract the virus don't do as well as children. Alcohol use also speeds disease progression.

In Hepatitis C-positive people, doctors typically monitor an enzyme produced by the liver, alanine aminotransferase (ALT), and Hepatitis C RNA (a measure of viral particles in the blood). But neither seems to accurately correlate with liver damage. We do know that most people who have persistently normal ALT levels usually have a very benign prognosis, so they are probably good candidates for watchful waiting, as is recommended by the National Institutes of Health.

Still, because the current medical options are far from perfect, a lot of people are interested in alternative therapies, such as milk thistle (purported to help regenerate liver cells) and vitamin E and vitamin A. There's no good evidence that any of these treatments has any effect on the disease, but they do appear to make some people feel better. I suspect this is because they give people a sense that they're taking an active role in their own health care.

Finally, the future isn't all bleak. Studies are under way to better define the course of this disease, and new therapeutic approaches are on the horizon. These may include viral enzyme inhibitors and other substances that disable the virus by preventing it from replicating.

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