Louis Roller takes a look at hepatitis in Australia

Hepatitis is an inflammatory condition of the liver, often characterised by jaundice, hepatomegaly, anorexia, abdominal and gastric discomfort, abnormal liver function, light-coloured stools, and dark urine.

The condition may be caused by bacterial or viral infection, parasitic infestation, alcohol, drugs, toxins or transfusion of incompatible blood. It may be mild or brief, or severe, fulminant and life-threatening. The liver is usually able to regenerate its tissue , but severe hepatitis  may lead to cirrhosis, chronic liver dysfunction and death.

There are five commonly recognised hepatitis viruses: A, B, C, D and E. Additionally, there are the lesser known hepatitis F and hepatitis G.

Hepatitis C (HCV) is an infectious disease caused by the hepatitis C virus (HCV) that primarily affects the liver. It is transmitted most commonly by blood transfusion or percutaneous inoculation, such as when IV drug users share needles.

At the end of 2014, there were an estimated 230,000 people in Australia living with chronic hepatitis C (hep C).

As recently as 2014, an estimated 5,400 new hepatitis C infections occurred annually.

  • around 89% of these new infections occur through blood-to-blood contact between people sharing equipment used for injecting illicit drugs;
  • around 7% occur among immigrants to Australia (through medical procedures and other transmission routes in their countries of origin); and
  • around 4% involve other blood-to-blood contact such as unsterile tattooing and body piercing.

In Australia, only a relatively small proportion of people remain undiagnosed and unaware of their condition.

An estimated 22% of liver transplants are due to hepatitis C in Australia.

The disease progresses to chronic hepatitis in up to 80% of acutely infected patients. Severe infection may cause prolonged illness, destruction of liver cells, cirrhosis, increased risk of liver cancer, or death. Diagnosis is made through identification of antibodies of HCV or by detection of viral RNA.

Needle and syringe programs are very effective in helping to stop the spread of hepatitis C. Education about blood awareness and transmission risks is also critical. 

Unlike Hepatitis A and Hepatitis B, there is no vaccine to protect against hepatitis C, but the infection can be prevented, and in many cases, cured. 

There has been advances from injectable interferon-based treatments for chronic hepatitis C to several new oral treatments registered in Australia for treatment of hepatitis C genotype 1 and 3 infections. These new generation direct-acting antiviral (DAA) regimens are oral regimes and do not usually require interferon.

Treatment duration for most patients on these new oral hepatitis C treatments is 12 weeks, and virological cure rates of >90% have been seen in clinical trials for these treatments.

Pharmacists can advise patients who are concerned about their risk of hepatitis C or who wish to discuss their treatment options should be advised to contact their doctor or a liver specialist or call the Hepatitis Australia Helpline 1800 803 990.

The rationale for drug use is

  • clearance of hepatitis C virus and improvement in quality of life; and
  • to prevent or delay progression to cirrhosis and hepatocellular carcinoma with possibility of recovery and/or improvement in liver function.

Before starting treatment, the following must be determined:

  • the virus genotype as it influences likelihood of response and length of treatment; an individual will usually have one genotype;
  • hepatitis C virus (HCV RNA) viral load;
  • baseline complete blood count and liver function tests;
  • alcohol intake and mental health, particularly depression and suicide risk (psychological symptoms, especially depression, often occur with peginterferon alfa, and are common in chronic hepatitis C); and
  • consideration of concomitant medications for risk of drug–drug interactions.

HCV infection is curable, and all Australians living with HCV should be considered for antiviral therapy.

Interferon-free regimens involving combinations of the direct acting antivirals HCVNS5A inhibitors (daclatasvir, ledipasvir,ombitasvir), HCVNS5B nucleptide inhibitors (sofosbuvir), HCVNS5B non-nucleotide inhibitors (dasabuvir), HCV-PIs (asunaprevir, boseprevir, simeprevir, paritaprevir, and Rivacirin with peginterferon alfa and/or ribavirin for 8, 12 or 24 weeks are now listed on the Pharmaceutical Benefits Scheme (PBS) for treating people with genotypes 1–3 HCV and can be dispensed by community pharmacists.

Practice points

Treatment response is impaired by alcohol intake (contributes to development of cirrhosis, especially if >50 g daily), insulin resistance, and obesity (may contribute to development of fibrosis).

Some suggestions for coping with treatment including:

  • maintaining adequate hydration;
  • dosing to coincide with lighter work days or weekends;
  • using analgesia and antipyretics, eg paracetamol; and
  • using moisturisers to help with rash.

When a patient has been correctly diagnosed and treatment initiated pharmacists can provide appropriate advice about their new medicine.s Patients should be encouraged to maintain a positive, but realistic attitude while undertaking treatment and ensure that they complete the course  Studies show a positive attitude is beneficial in a number of illnesses and treatment situations.  

Support: An effective support system in place prior to going on treatment can be helpful. 

Exercise: One of the most important factors in maintaining good health, exercise is beneficial in reducing treatment-related fatigue and is important in helping the individual feel better physically and mentally. 

Relaxation: Undertaking treatment can be stressful.  Some people will be overwhelmed by the experience of treatment, managing side effects and maintaining their normal life

Nutrition: A nutritious balanced diet is vital to maintain energy levels, general good health and feelings of well-being. 

http://www.hepatitisaustralia.com/

Associate Professor Louis Roller, from the Faculty of Pharmacy and Pharmaceutical Sciences Monash University, was the 2014 recipient of the PSA Lifetime Achievement Award.