Do you target hepatitis C? There are 12,000 reasons why you should
Do you target hepatitis C? There are 12,000 reasons why you should
Early screening, treatment prevent major complications
More than 30,000 Americans are walking around with a slow, silent time bomb that may cut them down in their most productive years with little warning.
An estimated 33,200 Americans were infected with the hepatitis C virus (HCV)in 1994 alone. Over the next 10 years, the American Liver Foundation in New York City estimates that roughly 30% of these mostly asymptomatic people will slowly develop cirrhosis, or inflammation of the liver, which will land them on a waiting list for liver transplantation. Today, the Centers for Disease Control and Prevention (CDC) in Atlanta reports that 12,000 Americans die each year of HCV, a rate that’s expected to increase to 38,000 by 2010.
The tragedy of those statistics is twofold, notes John M. Vierling, MD, chairman of the board of directors of the American Liver Foundation and director of hepatology at Cedars-Sinai Medical Center in Los Angeles. "We can’t underestimate the impact of this disease. First, in the next 10 years, we will see adults in their most productive, wage-earning years — their 30s and 40s — affected by hepatitis C to the point that they are debilitated and unable to be productive. Second, if treated in its early stages, roughly 40% of infected individuals respond well to available treatments and slow the progress of disease to the extent that it will not affect them in their lifetime."
HCV is a silent, indolent disease process that takes years to manifest complications such as cirrhosis, notes Vierling. "This is why it’s so important for both American consumers and providers to be aware of the risk factors of HCV. It’s not effective to test all asymptomatic people for HCV, but if patients have a health history that puts them at risk, early testing and treatment may prevent a liver transplant down the road."
"Nearly 40% of all adults undergoing liver transplantation have liver damage related to HCV," adds Vierling. "The waiting list for transplantation was 7,300 three years ago with only 3,900 patients receiving transplants. Last year, that waiting list moved toward 14,000 with only 4,165 transplants done. That’s a nearly 50% increase in the transplant waiting list, and that figure is expected to rise. With a liver transplant costing between $225,000 and $300,000, we simply don’t have the resources to take care of people with chronic HCV that may necessitate a transplant down the road."
Who’s at risk
HCV may be spread by exposure to contaminated blood (fresh or dried) on infected needles, during a blood transfusion, or possibly through sexual intercourse. "The risk of spreading HCV through sexual intercourse is not clear. However, there is an increased risk of becoming infected with HCV in patients with multiple sex partners," notes Vierling.
Vierling urges providers to consider HCV testing for:
• individuals receiving blood transfusions, especially those receiving transfusions prior to 1990 when it became routine to test blood donors for HCV;
• IV drug users;
• health care workers or laboratory technicians exposed to blood and blood products;
• individuals who undergo tattooing or body piercing.
Symptoms of chronic HCV are generally quite mild and vague, and infected individuals are often completely unaware that there is a problem until significant liver damage has occurred, notes Vierling. "The liver is a silent organ. It has no nerve endings to send pain messages to the brain; so patients can have inflammation of the liver for more than a decade and not know it."
Some symptoms of HCV infection may include:
• general discomfort;
• fatigue;
• loss of appetite;
• nausea and vomiting;
• jaundice;
• small, red, spidery veins on the surface of the skin;
• pain or tenderness in the upper right abdomen;
• fever.
In general, providers should consider testing any patient with vague complaints such as fatigue, loss of appetite, and a history of such behaviors as body piercing or tattooing, he notes. Most HCV-infected individuals are identified after routine blood tests indicate elevated liver enzymes. However, Vierling adds that in many cases routine blood panels don’t reveal HCV infection and more specific tests should be performed. (See chart, p. 87 for HCV specific tests and recommended treatments.)
"Once HCV infection is identified, it may be cost-effective to consider a liver biopsy to provide a score, or grade the inflammation and stage of cirrhosis or scaring of the liver," notes Vierling. "We have increasingly effective therapies for HCV, but not to the extent that penicillin cures strep infections in nearly 100% of patients. Interferon therapy does cure HCV in about 40% of patients — not 100%."
For that reason, the first priority for treatment should be given to patients with the greatest likelihood to progress towards cirrhosis, and also those with currently mild cirrhosis, which left alone could progress to a more serious stage, he notes. "Studies indicate that HCV-infected patients without any current signs of cirrhosis may never develop cirrhosis in their lifetime, making interferon therapy a possibly unnecessary expense."
There are three types of interferon approved for treatment of HCV. All three can cause flu-like side effects, including depression, headache, and decreased appetite. These symptoms can be minimized by taking over-the-counter analgesics such as acetaminophen.
However, because patients must remain on interferon therapy for 12 months to 24 months, the cost of treatment can be significant. In addition, interferon may depress bone marrow, leading to reduced levels of white blood cells and platelets. This means that patients must receive frequent blood tests to monitor white blood cells, platelets, and liver enzymes while on interferon therapy, which adds to the total cost of therapy, says Vierling.
In addition to interferon, the U.S. Food and Drug Administration in Rockville, MD, recently approved the drug Rebetron from Scherring-Plough for HCV patients who have relapsed after initially responding to interferon therapy.
"Rebetron is used in combination with one of the three approved interferons and has shown good results. The combination therapy may soon be approved for patients not previously treated with interferon, as well," says Vierling.
Even patients who do not appear to initially benefit from interferon treatment in terms of eliminating the virus often show significant slowing of disease progression, notes Vierling. "Many of these patients experience such a slowed rate of disease progression that they never suffer from cirrhosis and its complications in their normal life span."
Vierling hopes providers hear his message and become more vigilant about testing individuals at risk for HCV. "Only if we test at-risk populations, can we identify the presence of infection and identify the appropriate medical care for HCV-infected individuals," he says. "There is a strong tendency for both patients and providers to deny anything may be going on in relatively healthy, asymptomatic individuals. We have little reference point for discussion of liver disease. It’s an educational issue that delivery systems must address."
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