HEPATITIS C TREATMENT ALONE AND WITH HEPATITIS B OR WITH HIV INFECTION;

DR.D.R.NAKIPURIA ,SENIOR GASTRO INTEST SPECIALIST & HIV/AIDS CONSULTANT
drnakipuria@gmail.com, 09434143550,09832025033
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Treatment for hepatitis C virus (HCV) infection is indicated even in acute stage as result is ver good and resonse comes early and SVR IS ACHIEVED,ALTHOUGH 15-20 % of ACUTE HCV themselves clear witout treatment but 80% become chronic mostly spead by blood contamination or needle stick injury (1-10%) very less by sexual exposure,mother to child only 4%,huggung kissing ,eating together almost never transmit it,direct with blood in veins,or breached skin or even contact mith mucosa spreads it but chance by sweat,saliva,tear is less but blood,peritoeneal, ascitic,csf, vaginal,semen,urine,stool is infective.treatment for HCV has advanced dramatically in the past few years as direct-acting antiviral agents, or DAAs or drugs kike SOBOSFUVIR,SIMEPREVIR,SOVAPREVIR,DAROPREVIR,GS5885,DACLATASVIR, have improved cure rates and shortened treatment duration WITH ADDED TELAPREVIR AND BOCEPREVIR with standarad Peglyated Interferon and Ribavarin.

Mostly patient know about infection in late stage or chrnic stage when patient notice fatigue,weakness,malaise,nausea,vomiting,fever,or jaundice where we get either by ELSA ENNZYME BASED ANTIBODIES AAGINST HCV IS FOUND which is 95% correct but comes after 6 months some time so acute case is diagnosed late and reconfirmed by Blot Testing of HCV ANTIBODIES ALSO CALLED RIBA,once HCV RNA BY PCR IS DETECTED THEN CONFIRM DIAGNOSIS MADE .The main measure of hepatitis C treatment success is virologic response, or reduction of HCV RNA. Viral load is typically measured after four weeks on treatment (rapid virologic response, or RVR), after 12 weeks (early virologic response, or EVR), at the end of treatment, and after finishing treatment.Beside raised Liver enzymes,altered level of Blodd clottings due to liver disease or features of cirrhosis and ascites with oesophageal varices usually comes late and even jaundice some times comes very late till then cirrhotic changes in LIVER confirmed by Biopsy or mostly by FIBOSCAN or ELSATOGRAPHY is done now a days,biopsy also excludes malignancy and associted advancing inflammation as seen diminished after good therapy responding to treatment .

Sustained virologic response (SVR), or continued undetectable HCV viral load 24 weeks after completing treatment, is traditionally considered a cure. The FDA recently said SVR at 12 weeks post-treatment can also be considered a cure. Sustained response can halt liver disease progression and lowers the risk of developing cirrhosis and liver cancer.Usually 6 genotypes of HCV is known where no 1 is further divided in a,b,c,etc,Type 1 and 4 are late responder and 2,3 good responder,again genetic analysis of "cc is better responding than""tt" or "ct" type.

Not everyone with hepatitis C needs treatment, but it is recommended for people with at least moderate liver damage, usually determined by a liver biopsy. Treatment during acute infection (the first six months after infection) has a very high success rate, but most people do not realize they are infected this soon. Overall, about 25% of people clear HCV spontaneously without treatment, but the proportion is lower among people with HIV.

The previous standard of care for chronic hepatitis C was pegylated interferon alfa-2a (Pegasys) or alfa-2B (PegIntron) injected once weekly plus a weight-adjusted oral dose of ribavirin. Treatment duration is 48 weeks for people with difficult-to-treat HCV genotypes 1 or 4 and 24 weeks for those with genotypes 2 or 3. The overall SVR rate for HCV mono-infected people is about 75% for genotypes 2 or 3, but less than 50% for genotype 1. For the most difficult-to-treat groups of patients, response rates can be as low as 5%.

Several factors influence how well interferon-based therapy works. In addition to HCV genotype, high pre-treatment HCV viral load, advanced liver fibrosis or cirrhosis, insulin resistance, and HIV co-infection are associated with poorer response. People trying treatment again after previous non-response do not do as well as those being treated for the first time. People of African descent generally do not respond as well as white patients.

In 2009, researchers discovered that the latter two factors are largely attributable to variations in the IL28B gene. People with the favorable "CC" gene pattern respond best to interferon, people with the "TT" pattern have the lowest response rates, and people with the "CT" pattern are in between.

Pegylated interferon causes notorious side effects, including flu-like symptoms (fever, chills, fatigue, muscle aches), depression, and low white blood cell count. Ribavirin can cause anemia due to red blood cell destruction. These side effects may be severe enough that people avoid going on treatment, stop treatment prematurely, or lower their drug doses.

"Overall, about 25% of people clear HCV spontaneously without treatment, but the proportion is lower among people with HIV."
In 2011, the FDA approved the first two DAAs for genotype 1 chronic hepatitis C, the protease inhibitors Incivek (telaprevir, developed by Vertex) and Victrelis (boceprevir, developed by Merck). In pivotal clinical trials, adding one of these drugs to pegylated interferon/ribavirin raised overall treatment response rates significantly, both for HIV-negative and HIV-positive patients.

Both drugs are taken three times daily with pegylated interferon/ribavirin (Incivek for 12 weeks, Victrelis for 28 or 36 weeks), followed by continued treatment with pegylated interferon/ribavirin alone. Treatment-naïve people with good early viral suppression can stop treatment sooner (at 24 or 28 weeks), while others continue treatment through week 48.

In Phase 3 clinical trials of HIV-negative people, Incivek SVR rates were 79% for previously untreated people, 86% for prior relapsers, and 32% for prior null responders (those who previously had little or no decrease in HCV viral load). Victrelis SVR rates were 90% for previously untreated people and 66% for prior relapsers and partial non-responders (null responders were excluded).

So-called difficult-to-treat patient groups do not respond as well to hepatitis C therapy but may have a more urgent need for treatment. People with liver cirrhosis can be successfully treated with triple therapy including Incivek or Victrelis, but they have a higher frequency of side effects; studies of liver transplant recipients are underway. HIV/HCV co-infected people using Incivek or Victrelis can achieve response rates close to those of HCV mono-infected people with similar side effects. However, due to drug-drug interactions, these DAAs should not be combined with certain antiretrovirals.

Not surprisingly, adding another drug to the mix can increase adverse events. The most notable side effect of Incivek is skin rash, while Victrelis can cause anemia.
Most cirrhotic liver goes for LIVER TRANSPLANT but usually relapse of HCV occurs after 03-05 yrs but chances of tumor is less so it is practised very much.
Ptient with HBV ARE TREATED WITH HEPATITIS B DRUGS USUSALLY RIBAVARIN IS ADDED AS IT HELPS BOTH OR TENOFOVIR ,EMTRICITABINE AND LAMUVIDINE IS ALSO TRIED,PEGLYATED INTERFERON 21 OR 2B IS ALSO USEFUL,both are treated at a time.
With HIV if cd4 count less than 200 then first HIV is treated and after improvemnet treatment for HCV taken but in presence of HBV or HCV HIV TREATMENT is started soon irrespective of CD4 count ,same way along with HIV,HCV TREATMENT STARTED DASS DRUGS ARE ADDED WITH INTERFERON AND RIBAVARIN WITH HIV MEDICINES SOME DRUGS LIKE PROTESE INHIBITORS AND NUCLOSIDE OR NUCLEOTIDE ANALOGUE INTERACT WE AVOID IT,NEVIRAPINE,DDS IS AVOIDED .