How Hepatitis C Is Treated

Doctor with Patient
Doctor with Patient. Adam Berry / Stringer / Getty Images

Hepatitis C (HCV) treatments are highly effective in curing the infection, and newer generation drugs can improve the condition of people with cirrhosis caused by HCV, even if previous therapies have failed.

Typically, between 20% and 30% of HCV infections are spontaneously cleared with no medical intervention. Of the remaining 70% to 80%, the infection can progress over the course of decades and gradually damage the liver.

  About 30% of  people who become infected with HCV develop serious consequences such as cirrhosisliver cancer, or end stage liver failure, and may eventually need to have a liver transplant.

Prescriptions

The goal of hepatitis C treatment is to suppress the virus to the point where it becomes undetectable in the blood. When the virus remains undetectable with blood tests for the long term, this is defined as a sustained virologic response (SVR).

Research has shown that people who are chronically infected with HCV who have an SVR for 24 weeks following HCV therapy have only a 1% to 2% chance of experiencing a return of the virus. An SVR-24 is classified as a cure. Even people who have HCV who do not have an SVR-24 experience slower disease progression and reversal some of the liver scarring associated with infection.

Direct Acting Antivirals (DAAs)

Direct acting antivirals (DAAs), are a new class of medications that achieve cure rates of up to 99%, with treatment duration of approximately 12 weeks, and with minimal and mostly transient side effects.

These medications can be used for acute and chronic HCV infection, as well as for advanced liver disease.

DAAs can treat an increasing number of HCV genetic strains, and each DAA is recommended only for certain strains. 

The following DAAs have been approved by the FDA for the treatment of chronic hepatitis C:

A number of older medications, such as Incivek and Victrelis, were voluntarily retired by the manufacturers, because they were no longer in demand when new DAAs were approved.

Peginterferon and Ribavirin

Peginterferon, and ribavirin, have long been considered the standard treatment for chronic HCV infection prior to the emergence of DAAs.

They are not the standard treatment anymore, but they are still considered important for people who have with advanced disease, including cirrhosis, or as alternatives if DAAs are not effective. In general, the efficacy of peginterferon, and ribavirin is about 90%, which is not as high as that of the newer DAAs, Some DAAs are recommended to be taken with concurrent ribavirin or peginterferon treatment.

Among the disadvantages of peginterferon and ribavirin are the side effects of the medications. Side effects include:

  • Anemia
  • Headache
  • Irritability, anxiety, depression and suicidal ideation
  • Hair loss 
  • Itchiness and skin rash
  • Insomnia and fatigue
  • Joint and muscle pain
  • Nausea and vomiting
  • Fever, chills

The response to DAA or other antiviral therapy is defined by the following criteria:

  • Rapid viral response (RVR)- An undetectable viral load after four weeks of treatment
  • Extended rapid viral response (eRVR)- An undetectable viral load at 12 weeks. following the initial RVR
  • Early viral response (EVR)- An undetectable viral load or a 99 percent reduction in viral load by 12 weeks
  • End of treatment response (ETR)- An undetectable viral load achieved at 12 weeks
  • Partial responder- Achieves EVR, but unable to sustain an undetectable viral load 24 weeks after therapy completion
  • Null responder- Unable to achieve EVR by 12 weeks
  • Sustained viral response (SVR)- Able to sustain undetectable viral load for 12 weeks (SVR-12) and 24 weeks (SVR-24) following completion of therapy

Surgery

HCV can cause severe liver disease, and may advance to end stage liver disease. This is a life threatening condition that results when the liver is so damaged that it cannot function as it should. Surgical treatments for end stage liver disease include symptomatic management and possibly a liver transplant. 

  • Liver Transplant: A liver transplant is considered the curative treatment for end stage liver disease. However, HCV may recur even after a transplant because the virus can still survive in the blood. In general, a liver transplant is performed using a liver from a deceased donor. A liver transplant can be performed with the use of a partial liver from a living donor. If you receive a liver from a living donor, your new partial liver is expected to regenerate fairly quickly. The partial liver that remains in the body of the living donor is also expected to regenerate quickly. While the surgery is a major procedure for both the donor and recipient, each individual is expected to survive and to have fully functional liver. 
  • Esophageal Banding: Development of esophageal varices, a complication of end stage liver disease, is the swelling of blood vessels of the esophagus caused by problems with blood flow in the diseased liver. The varices may eventually bleed. A procedure called banding can stop the bleeding of esophageal varices by placing rubber bands on the vessels. 

Personal Care/Lifestyle

If you have HCV, there are some important considerations that you need to keep in mind as you recover. Making sure that you avoid anything that can harm your liver is a priority. 

  • Avoid Alcohol: Heavy alcohol use can cause liver failure. In moderation, alcohol should not cause liver failure for a person with a healthy liver. But, if you already have a condition that affects your liver function, you cannot metabolize alcohol normally, so even a small amount can be dangerous. 
  • Do Not Use Acetaminophen: Several medications are processed in the liver, and you cannot take them if you have liver damage from HCV. Most of these medications require a prescription, so it is unlikely that your doctor or pharmacist would allow you to take them if you have known HCV. However,  acetaminophen (Tylenol) is an over the counter, commonly used medicine that you might already have at home. You cannot take it if you have liver disease of any cause, including HCV. If you have symptoms of pain or fever, ask your doctor to suggest an alternative medication for you that does not interfere with other medications you are taking or require good liver function. 
  • Managing Blood Pressure: Liver failure may cause a condition called portal hypertension, which is an increase in pressure in the blood vessels of the liver. While this is not directly related to your overall blood pressure, maintaining a normal blood pressure is an important way to avoid adding to the complications of portal hypertension. 

Complementary and Alternative Medicine

Some vitamin deficiencies have been noted among people with HCV. Vitamin deficiencies cannot cause HCV, because it is caused by an infection. The liver failure itself causes a deficiency of certain vitamins. 

  • Vitamin D: Vitamin D, in particular, has been considered a risk factor for worse HCV infections, and the cause of this association is unclear. Vitamin D is a fat soluble vitamin, meaning that it requires fats to be properly absorbed. If you have liver failure due to HCV, this may make it difficult for you to absorb vitamin D. It is only recommended to take supplements if your vitamin D level is low. 
  • Vitamin A, Vitamin E: Both are fat soluble vitamins that cannot be properly absorbed if you have liver failure. Supplementation may be necessary, but only if your levels are low. 

A number of alternative therapies have been suggested in various communities for treatment and management of HCV, but there are no studies that demonstrate safety of effectiveness. Because many herbs and vitamins are processed in the liver, some alternative treatments that could be beneficial if you have a healthy liver may cause harm if your liver is unhealthy. It is important for you to take extra caution if you already use vitamin or herb supplements, as you might not be able to process them any more if you have HCV.

Some common supplements that are dangerous if you have liver failure from HCV:

  • Vitamin K: A powerful vitamin that helps your blood to clot, it can cause excessive blood clotting due to the imbalance of blood clotting function caused by liver failure. 
  • Ginkgo Biloba: An herb that causes blood thinning, this can cause dangerous bleeding if you have liver failure, because liver failure already causes blood clotting abnormalities. 
  • Mixed Herbs: Recent studies suggest that herbal remedies can cause liver injury. This means that you must be extra cautious if you have HCV. It is best to check with your doctor or pharmacist before taking an herbal supplement, even if you have already been taking it for a while. 

Sources:

Beig J, Orr D, Harrison B, Gane E. HCV Eradication with New IFN Free Treatment Improves Metabolic Profile In HCV-related Liver Transplant Recipients. Liver Transpl. 2018 Mar 25. doi: 10.1002/lt.25060. [Epub ahead of print]

Buonomo AR, Zappulo E, Scotto R, et al. Vitamin D deficiency is a risk factor for infections in patients affected by HCV-related liver cirrhosis. Int J Infect Dis. 2017 Oct;63:23-29. doi: 10.1016/j.ijid.2017.07.026. Epub 2017 Aug 10.

Caicedo LA, Delgado A, Garcia VH, et al. Liver Transplantation in Hepatitis C-Infected Patients: Experience From a South American Transplant Center. Transplant Proc. 2018 Mar;50(2):493-498. doi: 10.1016/j.transproceed.2017.11.046.

Jing J, Teschke R. Traditional Chinese Medicine and Herb-induced Liver Injury: Comparison with Drug-induced LiverInjury. J Clin Transl Hepatol. 2018 Mar 28;6(1):57-68. doi: 10.14218/JCTH.2017.00033. Epub 2017 Oct 27.

Nookala AU, Crismale J, Schiano T, et al. Direct-acting antiviral regimens are safe and effective in the treatment of hepatitis C in simultaneous liver-kidney transplant recipients. Clin Transplant. 2018 Mar;32(3):e13198. doi: 10.1111/ctr.13198. Epub 2018 Feb 1.