Preparing for treatment

Everyone infected with Hep C should be considered for treatment. For those people with active virus, the decision to access treatment is complicated. Many elements affect the success of treatment, from factors related to Hep C to pre-existing medical conditions to personal dynamics. Some of these factors can change over time while others remain constant, but each has a unique impact on treatment.

Adherence

Adherence to the medication schedule is not easy but is crucial to treatment success. It means taking the medications as close to the scheduled time and missing as few doses as possible so that there is enough medicine in the body to fight the virus.

Side effects, like depression or body aches, can make a person feel ill and not want to take the medicine and other side effects, such as nausea or diarrhea, can make it hard to keep the medicine in the body. People who have completed treatment made a decision every day to stick with it. Preparing people to make this commitment requires a clear assessment of their situation. They need to know what treatment means, what their chances of success are, and what they can do to make those chances better.

Disease Factors

These factors are characteristics that relate directly to HCV and affect treatment success:

• HCV Genotype – Genotypes 2 and 3 have treatment success rates as high as 80%, while treatment success is about 50% for genotype 1. The genotype of the virus does not change over time and people can be infected with more than one genotype if they are repeatedly exposed to HCV. The duration of treatment for genotypes 2 and 3 is shorter than for genotype 1.
• HCV Viral Load – The lower the viral load at the start of treatment, the better the chances of success. New treatments are being researched and developed to reduce viral load faster and more effectively.
• Cirrhosis – The longer a person has Hep C, the more likely it is they will develop inflammation, scarring, fibrosis and eventually cirrhosis of the liver. Treatment success is higher for people who have not progressed to cirrhosis.

The following conditions are often aggravated by treatment, can reduce treatment effectiveness and may cause some people to discontinue treatment:

• Heart Disease –Ribavirin often causes anemia (low red blood cell counts) which can make existing heart conditions worse. In rare cases, peg-interferon can cause heart problems.
• Kidney Disease – Because ribavirin is cleared from the body by the kidneys, renal dysfunction can result in a build-up of toxic levels of ribavirin. In these situations, the dose of ribavirin would be adjusted. Monitoring kidney function during treatment is important.
• Depression – A serious potential side effect of Hep C treatment is depression. People who suffer depression while taking treatment, people who have thoughts of suicide or self-harm or people with a family history of depression should be encouraged to access support and counselling. Antidepressant medications can also be prescribed before and during treatment.
• Glucose Abnormalities – Recent research has shown that glucose abnormalities can reduce the effectiveness of Hep C treatment. These abnormalities take the form of higher-than-normal glucose levels in the blood, insulin resistance or diabetes and can be related to other factors like obesity, age and triglyceride levels. Where possible, interventions that can stabilize glucose abnormalities will increase treatment success.

Personal Factors

Personal factors can affect both adherence and treatment effectiveness, and attention should be given to those that can change over time:

• Patient Goal – Some people want treatment no matter what. Others would avoid it at all costs. Others may still be very healthy and have a slow disease progression and want to wait to see if there will be better treatments in the future. The first steps in a pre-treatment evaluation will be connecting with a patient and understanding his or her wishes, as these are key factors in determining adherence to treatment.
• Alcohol Use – Drinking alcohol has serious impacts on treatment, so cutting back or stopping alcohol use is the best decision a person can make to contribute to treatment success. First, alcohol use, especially dependence, may interfere with a person’s ability to stick to his or her meds—he or she may forget to take them, take the wrong dose or miss appointments. Second, alcohol damages the liver and this makes recovery harder.
• Drug Use – Drug use does not necessarily rule out treatment success. People who are using and want to try treatment require the support of a prescribing doctor and a healthcare team. People with an unstable or chaotic lifestyle risk neglecting their treatment schedule. This can be due to the pressures they may be facing around housing, finances or relationships. Providing stability in these areas can improve people’s chances with treatment.
• Finances – Finances relate not only to covering the costs of treatment but also to living costs, such as food, housing and the costs of managing side effects. Some people may not be able to work while taking treatment, and others may not have had employment in the first place. Accessing what financial supports are available before starting treatment may help stabilize a person’s situation and prepare him or her for successful treatment.
• Support Systems – People taking Hep C treatment must manage side effects and maintain adherence to their medications on a daily basis. Having the support of family, friends and a healthcare team that provides holistic care can help people achieve their goal of completing treatment. Support can be accessed through support groups and counselling. Some pharmaceutical companies also provide supplies (such as hot water bottles, treatment diaries and information on managing side effects) and phone support to help people complete treatment. Accessing these is possible through a doctor or nurse or by contacting the pharmaceutical company directly.
• Obesity – Correlation data has shown that people with a high body mass index (BMI) have lower success rates with HCV treatment. BMI can be used to measure obesity based on a ratio of weight to height. In Canada, a high BMI is defined as greater than 25 kg/m2. Steatosis (fat build-up around the liver) is also related to treatment failure.
• Age – Age can affect treatment in several ways. Older age at time of infection and older age at the start of treatment are linked to lower rates of treatment success. Older people with Hep C are also at higher risk of having cirrhosis because they may have been infected for a longer period of time. This means that starting treatment earlier can lead to better treatment outcomes. Often this must be balanced with determining the speed or severity of disease progression, as some people will have a slower, milder form of hepatitis and the side effects of treatment may be harder on them than their disease.
• Ethnicity – Research is ongoing in this area. Some studies of treatment show that Black people have less success at treatment. The exact mechanism of this process is unknown and how this affects people of other ethnic backgrounds is still being researched.
• Sex – It is unclear why this occurs, but females generally have better response rates to treatment than males.

Given the complexity of hepatitis C treatment, patients must be involved in treatment decisions.

Absolute Contraindications

The only hard and fast rules for delaying or avoiding treatment are: 

1) Pregnancy – One of the medications for Hep C, ribavirin, is teratogenic, which means it can cause birth defects in fetuses. Pregnant women cannot start treatment until after childbirth. Both men and women must use effective birth control while on treatment and for at least six months after treatment is finished. 

2) Children are generally not treated until they are older. It is rare that treatment needs to be started earlier and can generally wait until after a child has completed his or her physical and mental development. Current treatment guidelines recommend involving a specialist in caring for HCV-infected children.