BY DENNIS CONNAUGHTON
Managing patients with hepatitis C infection is a tedious business, no doubt about it. Pinning the infection down in the first place is perhaps even more difficult. But hepatitis C may be more common among patients in your practice than you think.
In his Oct. 1 seminar, "Hepatitis C in Primary Care," William Cassidy, M.D., associate professor of medicine at Louisiana State University Health Science Center in Baton Rouge, gave Assembly attendees insights into how to diagnose, treat and counsel patients infected with hepatitis C virus, or HCV.
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The leading cause of cirrhosis in the United States -- responsible for 10,000 to 20,000 deaths per year -- HCV infection represents the most common reason for liver transplantation. About 4 percent of Americans have chronic hepatitis, and, among 20- to 45-year-olds, its incidence is as high as 15 percent. But only about 20 percent of those infected with the virus develop symptoms, said Cassidy. All of which makes this infection extremely challenging for family physicians to diagnose and manage.
Mercurial virus
HCV is an RNA flavivirus that mutates every time the immune system attacks it and, as a result, tends to cause chronic, resistant infection. "Because of its hypervariability, vaccines so far have been impossible to develop, and immunoglobulin is ineffective," Cassidy said.
Transmission is bloodborne, and fully 60 percent of individuals who contract hepatitis C infection in the United States are injection drug users. It is rarely transmitted sexually, Cassidy said, but having a large number of sexual partners is associated with a higher risk of infection.
HCV infection causes a fibrotic liver disease that progresses linearly at a slow, intermediate or rapid pace, Cassidy said. Alcohol use and certain comorbidities, such as hepatitis B virus or HIV infection, increase the rate of progression, as do continued intravenous drug use and hepatic steatosis.
Clinical presentation
Patients typically present with subclinical disease. "Symptoms develop in only 20 percent of patients, and 10 to 20 percent of those have nonspecific symptoms," Cassidy noted.
Certain lab results give clues to a diagnosis of HCV infection. HCV RNA can be detected in blood within one to three weeks after exposure to the virus, and alanine transaminase becomes elevated within four to 12 weeks. The average time from exposure to seroconversion is eight to nine weeks; the average time from exposure to the development of symptoms is six to seven weeks, he said.
The infection is most prevalent among 30- to 39-year-olds, Cassidy said, so be vigilant for it in these patients. Prevalence is higher among men than women, especially among African-American men. An astounding 95 percent of HCV-infected African-American men become carriers of the virus, he said.
Treatment options
Current treatment options are either twice-weekly interferon with ribavirin or pegylated alpha interferon given once weekly with ribavirin. Patients should begin to respond to drug therapy within 12 weeks. If there is no response within that time, stop giving the drugs, Cassidy said. The goal of treatment is to prevent the infected patient from progressing to cirrhosis.
In addition to interferon and ribavirin therapy, all patients should be vaccinated against hepatitis A, and those who are not in monogamous relationships should be vaccinated against hepatitis B, Cassidy said. Patients should also be counseled to avoid alcohol, maintain a healthy weight, and avoid using nonsteroidal anti-inflammatory drugs and aspirin. People with cirrhosis should also receive annual flu shots and they should be appropriately immunized against pneumococcal infection. They should also avoid areas with poor sanitation, which can expose them to hepatitis A.
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