Liver Disease

Living with Liver Disease

Hepatitis A

A suddenly or recently contracted hepatitis A infection can be diagnosed by a blood test. The problem is that some people are asymptomatic when infected and so may not know to go for the blood test.

There is no specific treatment for people with hepatitis A. The only thing that can be done is to treat the symptoms. In mild to moderate cases of infection the infected patient usually takes 4-6 weeks to recover. However, in severe cases the recovery time could last up to several months. Only under very rare and severe circumstance will hepatitis infection result in liver failure and death.

Hepatitis B

Hepatitis B is a very common worldwide problem with over 350 million affected people around the world.  The disease is most common in Asia and about a third of the cases worldwide are in China.  Many people who carry this infection feel well and do not know they have the disease.  It is estimated that in British Columbia there are 30,000 to 60,000 people who live with the infection. Having a blood test is the only way to determine whether you have Hep B or not.

Hepatitis B is caused by a virus.  This virus infects all cells of the liver by becoming a part of the liver cell’s genetic material.  When our immune system recognizes the virus, it tries to destroy the virus in the liver cell.  It is this immune response to the virus within the liver cell that causes progressive damage to the liver.  Since most cases of chronic hepatitis B start as an infection early in life, our immune system at that time is immature and has difficulty recognizing this infection.  If the infection is not recognized by the immune system, these patients have a relatively inactive form of the disease called hepatitis B carrier.  These patients still have the virus and are infectious but do not have significant active liver damage.

Some people with hepatitis B have more severe liver damage. Over a long period of time, these people with chronic active hepatitis B can develop liver cirrhosis (a condition in which the liver does not function properly) and decompensated liver disease.  The virus can also cause liver cancer over time. Most people will feel completely well until they develop decompensated liver disease or liver cancer.

Some of the initial symptoms include:

  • Fatigue
  • Jaundice
  • Weight loss
  • Abdominal distension
  • Gastrointestinal bleeding

It is therefore critical that if you have this infection you see your family doctor regularly to determine if you need treatment.  The aim of treatment is to avoid complications from this disease.

For a long time in British Columbia there was very little provincial funding for the treatment of hepatitis B.  These medications work well but are expensive and until recently there was no political will to fund effective treatment for those who need it.  However, on March 25 2008 the government announced that it will start funding effective drug treatment through the Pharmacare program.  This is due in part to pressure from the Asian community and recommendations by physicians who treat hepatitis B.

There are two types of treatment medication:

  • Interferon – administered by injection:
    • Increases the strength of the immune system
    • Provides a boost to the immune system so that your own body can get rid of the infection
    • Interferon treatment is successful in about 30% of people to inactivate the virus
    • Patients prescribed this medication are often treated with injections one to three times per week for about 12 months. 
    • Patients taking this medication often feel like they have the flu (fatigue, muscle aches, headaches) for the duration of the treatment.
  • Nucleoside analogues – administered orally:
    • Interferes with the production of more of the virus
    • Suppresses the replication of viruses but does not eliminate the virus
    • Needs to be taken every day and often the duration of treatment is indefinite
    • Since viruses are living organisms, resistance to this antiviral medication can develop.  It often takes years to develop resistance to medication but once it occurs a change in medication is necessary otherwise the amount of virus will increase again and more liver damage can occur.

Medications are a temporary measure to decrease liver damage.  Therefore patients with severe active liver disease benefit the most from treatment.  Some patients have severe liver damage but feel completely well and have no symptoms related to hepatitis B.  Only your family doctor and liver specialist can determine if your liver disease is serious and requires treatment.  Some patients need to undergo tests to determine this including regular blood testing or taking a tissue sample from the liver (a liver biopsy).

If you are prescribed medication for hepatitis B it is important that the medications are taken as instructed.  If treatment is interrupted or incomplete there is a higher chance for developing drug resistant forms of hepatitis B.  This would make it more difficult to treat in the future.  If the side effects are intolerable your family doctor and liver specialist can provide support to carry on with treatment.  Only your family doctor and liver specialist can determine whether you need treatment as many patients do not need treatment.

Hepatitis B is very difficult to cure completely.  We have new medications to control the disease but there are side effects.  The best form of treatment for hepatitis B is prevention.  Prevention involves identifying your own risk for the disease, getting tested and immunization.  Immunization does not benefit those patients who already have the infection. 

Hepatitis B is spread by bodily fluid or blood contact.  The following people are at high risk of contracting Hepatitis B virus and hence should be tested:

  • People born in Southeast Asia are at highest risk as approximately 8% of the population has hepatitis B 
  • If you had childhood immunizations in Southeast Asia with shared needles 
  • Sexual transmission can occur with an infected partner without protection 
  • Many infections are caused by transmission of the virus from mother to child at the time of childbirth
  • If you have had a family member develop liver cancer or have a household contact with hepatitis B
  • Children and infants are at highest risk for developing chronic hepatitis B 

These groups should be immunized as the best protection against acquiring the infection.  The only effective prevention is to have all household contacts immunized for the virus.  The immunization is a series of three injections separated by at least 4 weeks between injections.  Patients receiving hemodialysis where there is a greater risk of infection by needles are routinely immunized. 

Hepatitis C

Hepatitis C is a complex of viruses (many different types) that can be subdivide into six groups of distinct genotypes (G1-6) – in other words the classification is genetic. The most commonly seen genotypes in North America and BC are 1-3. Whether these genotypes are relevant to the development of late stage liver disease is still controversial. However, it is clear that Hep C genotyping is relevant to the response to the different Hep C treatments.

Genotype 1 is the most resistant to treatment and unfortunately also the most commonly seen in North America (close to 70% of Hep C infection is genotype 1). Genotype 2 and 3 are relatively easier to treat. In North America the least commonly seen genotypes (4-6) behave similarly to genotype 1.
 
Up until the beginning of this century the treatment for Hep C developed very rapidly. However, from 2001-2003 there has not been any new drug treatment products appearing on the market. Right now is a period of transition with some exciting drugs (including a group called protease inhibitor, e.g. Telepravir and Beceptovir) already completed their preliminary study which is required by government regulation. The study is now recruiting patients for clinical trials. These tests are completed under more precise and stringent regulations implemented by the government. The expectation is that these drugs will acquire their commercial license and appear in the market in 2010.  However with the policy for funding support from the respective government agencies, such as the BC Pharmacare, it may take a lot longer. The second stage testing results of polymerase inhibitor has already been submitted to America and Europe conferences for discussion. According to the report it is more effective in comparison to all the medical drug treatments that are currently available in market.
 
Throughout the 1990s, the standard interferon (which acts as both an antiviral and to strengthen the immune system) alone is the only medication available. This treatment is also frustrating – less than 20% of patient had virus clearance. In 1998 standard interferon and ribavirin combination treatment appeared. It is a 48 weeks treatment and the results are: 30% of genotype 1 patients became clear of the Hep C virus; and 65-69% of the genetic 2 or 3 patients became clear of the Hep C virus. Additionally, reducing the treatment from 48 weeks to 24 weeks does not appear to be affect the results for genotype 1 or 2 patients.

PEGylated interferon (PEG IFN) & Ribavirin
Pegylated interferon is a long-acting interferon taken once a week. A clear antiviral effect is observed when taken in combination with Ribavirin. PEG-IFN and Ribavirin combination drug is the current go to treatment for Hep C. Genotype 1 patients are expected to be completely clear of Hep C upon taking this medication for 48 weeks. 42-50% of the genotype 2 or 3 patients can clear of 76-80% of the virus after on the medication for 24 weeks.

Side effects: In comparison to the conventional interferon combination therapy, PEG-IFN and Ribavirin is accepted more easily by the body. However, it is still common to see side effects. Generally the patient will have:

  • fatigue
  • joint and muscle pain
  • stomach upset
  • loss of appetite
  • irritability
  • some degree of depression

These symptoms can be controlled by simple medications, such as acetaminophen, Tylenol and aspirin. Since the patients will generally get better most people are able to cope with these symptoms.

Depression can sometimes become very serious and some patients may require antidepressants. If patients have had a history of severe depression then the doctor should not provide this type of treatment. The less common side effects include thyroid disease and skin rash. However, PEG IFN will likely stimulate or worsen any disease the patient has. During the time of treatment your doctor or nurse will monitor your blood condition because the cases where blood is affected is very common. Despite the side effects it is important to keep taking the drug as prescribed so it is very important that you do not lower the drug dose unless the side effect are extremely serious.

In summary, Hepatitis C is a serious disease that can lead to cirrhosis, liver failure and liver cancer. The organ supply for liver transplant is insufficient and therefore only a few lucky people will receive a liver transplant. A better practice is to treat the Hep C prior to developing cirrhosis. In comparison to the previous method of treatment PEG IFN and ribavirin combination greatly increased the effectiveness of Hep C treatment. However better drugs should appear in the near future.

Fatty Liver

There is no drug treatment for fatty liver. Patients must abstain from drinking any alcoholic beverages. A healthy diet  with plenty of vegetable and fruit is beneficial. Regular exercise helps as well.

Fatty liver and hepatitis both may result in cirrhosis. Once a person has cirrhosis all their liver function will be affected. Cirrhosis has very similar signs and symptoms as hepatitis. Also, approximately 25% of cirrhosis cases become liver cancer. Therefore please take diligent care of your “precious liver”.