Hepatitis C-infektion (HCV, Hep C)

Definition og fakta om hepatitis C-infektion (HCV)

Hvad er HCV, hvordan overføres det, er der symptomer, og kan det helbredes?

• Hepatitis C (hep C, HCV) er en af ​​flere vira, der forårsager viral hepatitis (betændelse i leveren).
• Omkring 2,4 millioner mennesker anslås i øjeblikket at leve med hepatitis C i USA.
• Op til 85 % af individer, der oprindeligt er (akut) inficeret med hepatitis C, vil ikke kunne fjerne virussen og vil blive kronisk inficeret.
• Hepatitis C spredes gennem eksponering for inficeret blod. Intravenøst ​​stofmisbrug med brug af kontaminerede, delte nåle er den mest almindelige smittemåde.
• Risikoen for at få hepatitis C gennem seksuel kontakt eller amning er meget lav.
• Generelt har personer med kronisk infektion med hepatitis C ingen symptomer, før de har omfattende ardannelse i leveren (cirrose). Nogle personer kan dog have træthed og andre uspecifikke symptomer, før dette opstår.
• I USA er infektion med hepatitis C den mest almindelige årsag til kronisk hepatitis og den mest almindelige årsag til levertransplantation.
• Der er gjort store fremskridt i behandlingen af ​​hepatitis C. Helbredelseshastigheden er steget (over 90 %-95 %) med udviklingen af ​​direkte virkende, orale antivirale lægemidler.
• Behandling resulterer i reduceret inflammation og ardannelse i leveren hos de fleste patienter, der er helbredt for hepatitis C, og også lejlighedsvis (men i meget mindre grad) hos dem, der får tilbagefald eller ikke bliver helbredt.

Hepatitis C-symptomer

De fleste mennesker, der får hepatitis C (hep C), har ingen symptomer. De, der har symptomer, kan dog opleve:

• træthed,
• tab af appetit,
• muskel- og ledsmerter.
• kvalme,
• mavesmerter,
• opkastning...

Læs mere om hep C symptomer »

Hvad er hepatitis C-infektion? Hvor mange mennesker er smittet?

Hepatitis C-virusinfektion er en infektion i leveren forårsaget af hepatitis C-virus (også kaldet HCV eller hep C). Det er svært for det menneskelige immunsystem at fjerne hepatitis C fra kroppen, og infektion med hepatitis C bliver normalt kronisk. Gennem årtier skader kronisk infektion med hepatitis C leveren og kan forårsage leversvigt. I USA har CDC anslået, at cirka 41.200 nye tilfælde af hepatitis C opstod i 2016. Når virussen først kommer ind i kroppen, er der normalt ingen symptomer, så dette tal er et skøn. Omkring 75%-85% af nysmittede mennesker bliver kronisk inficerede. I USA anslås mere end 2 millioner mennesker at være kronisk inficeret med hepatitis C. Infektion opdages oftest blandt mennesker i alderen 40 til 60 år, hvilket afspejler de høje infektionsrater i 1970'erne og 1980'erne. Der er 8.000 til 10.000 dødsfald hvert år i USA relateret til hepatitis C-infektion. HCV-infektion er den førende årsag til levertransplantation i USA og er en risikofaktor for leverkræft. I 2016 angav 18.153 dødsattester HCV som en medvirkende dødsårsag; dette menes at være en undervurdering.

Omkring 10%-20% af dem, der udvikler kronisk HCV, vil udvikle cirrose inden for 20-30 år. Progression til skrumpelever kan accelereres af alder over 50, mandligt køn, alkoholforbrug, ikke-alkoholisk fedtleversygdom (NASH), samtidig infektion med hepatitis B eller HIV og immunundertrykkende stoffer. HCV-infektion er den førende årsag til levertransplantation på grund af leversvigt i USA.

De, der har cirrhose fra HCV, har også en årlig risiko for leverkræft (hepatom eller hepatocellulært carcinom) på omkring 1%-5%.

Hvad er hepatitis C-virus?

Hepatitis betyder betændelse i leveren. Hepatitis C er en af ​​flere vira, der kan forårsage viral hepatitis. Det er ikke relateret til de andre almindelige hepatitisvirus (for eksempel hepatitis A eller hepatitis B). Hepatitis C er et medlem af Flaviviridae familie af virus. Andre medlemmer af denne familie af vira omfatter dem, der forårsager gul feber og denguefeber.

Der er mindst seks forskellige genotyper (stammer) af virussen, som har forskellige genetiske profiler (genotype 1 til 6). I USA er genotype 1 den mest almindelige stamme af hepatitis C. Selv inden for en enkelt genotype kan der være nogle variationer (f.eks. genotype 1a og 1b). Genotyping bruges til at vejlede behandling, fordi nogle virale genotyper reagerer bedre på nogle terapier end på andre.

Ligesom human immundefektvirus (HIV) formerer hepatitis C sig meget hurtigt og opnår meget høje niveauer i kroppen. De gener, der får virusets overfladeproteiner til at mutere (ændres) også hurtigt, og tusindvis af genetiske variationer af virussen ("kvasi-arter") produceres dagligt. Det er umuligt for kroppen at holde trit med at lave anti-HCV-antistoffer mod alle de kvasi-arter, der cirkulerer på én gang. Det har endnu ikke været muligt at udvikle en effektiv vaccine, fordi vaccinen skal beskytte mod alle genotyper.

Hepatitis C-infektion i leveren udløser immunsystemet, hvilket fører til betændelse. Omkring 20%-30% af de akut inficerede vil opleve typiske hepatitissymptomer såsom mavesmerter, gulsot, mørk urin eller lerfarvet afføring. Men kronisk hepatitis C forårsager normalt ingen symptomer før meget sent i sygdommen, og hepatitis C er blevet omtalt af syge som den "sovende drage". Over flere år eller årtier kan kronisk inflammation forårsage levercellers død og ardannelse ("fibrose"). Omfattende ardannelse i leveren kaldes skrumpelever. Dette forringer gradvist leverens vitale funktioner. Skrumplelever er mere tilbøjelige til at få leverkræft. At drikke alkohol fremskynder leverskader med hepatitis C. Samtidig HIV-infektion såvel som akut hepatitis A- eller B-infektion vil også fremskynde progression til skrumpelever.

Hvad er symptomerne på hepatitis C-infektion?

Omkring 70%-80% af mennesker har ingen symptomer, når de først får HCV-infektion. De resterende 20%-30% kan have

1. træthed,
2. tab af appetit,
3. muskelsmerter, eller
4. feber.

Tidlige symptomer på hepatitis C kan omfatte mørk urin, gule øjne eller lerfarvet afføring, selvom dette er usædvanligt. Over tid kan personer med kronisk HCV-infektion udvikle tegn på leverbetændelse, der tyder på, at infektionen kan være til stede. Inficerede individer kan let blive trætte eller klage over uspecifikke symptomer. De senere symptomer og tegn på skrumpelever er ofte fraværende, indtil betændelsen er ret fremskreden. Efterhånden som skrumpelever skrider frem, øges symptomer og tegn og kan omfatte:

1. Forhøjede leverenzymer i blodet
2. Svaghed
3. Tab af appetit
4. Vægttab
5. Brystforstørrelse hos mænd (gynækomasti)
6. Rødme i håndfladerne
7. Vanskeligheder med at størkne blod
8. Edderkoppelignende blodkar på huden
9. Mavesmerter
10. Lerfarvede afføring
11. Blødning fra spiserøret
12. Væske i maven
13. Gul hud og øjne (gulsot)
14. Forvirring
15. Koma

Hvad er den smitsomme periode for hepatitis C?

Fordi hepatitis C overføres ved eksponering for blod, er der ingen specifik periode med smitsomhed. Mennesker, der udvikler kronisk hepatitis C, bærer virussen i deres blod og smitter derfor af andre hele deres liv, medmindre de er helbredt for deres hepatitis C.

Hvor lang tid tager det, før symptomer vises (inkubationsperiode) efter at have fået hepatitis C?

Det er svært at sige med sikkerhed, hvad inkubationstiden for hepatitis C er, fordi de fleste mennesker, der er smittet med hepatitis C, ikke har symptomer tidligt i infektionsforløbet. De, der udvikler symptomer tidligt efter at være blevet smittet (i gennemsnit 2 til 12 uger, men kan være længere), oplever milde gastrointestinale symptomer, som måske ikke beder om et besøg hos lægen.

Hvordan spredes hepatitis C?

• Ligesom HIV og hepatitis B spredes hepatitis C (hepatitis C-virus eller HCV) ved eksponering for inficeret blod (blodbåret patogen).
• Den mest almindelige måde at få hepatitis C på er fra forurenet blod på nåle, som deles af intravenøse stofbrugere. I en multistatsundersøgelse i 2017 blev omkring 53 % af de mennesker, der injicerer medicin, anslået til at være HCV-inficerede.
• Utilsigtede nålestik hos sundhedspersonale har også overført virussen. Den gennemsnitlige risiko for at få hepatitis C-infektion fra en pind med en forurenet nål er 1,8 %.
• Før 1992 fik de fleste mennesker hepatitis C-virus fra blodtransfusioner eller blodprodukter. Siden 1992 er alle blodprodukter blevet screenet for hepatitis C, og tilfælde af hepatitis C på grund af blodtransfusion er nu yderst sjældne.
• Hepatitis C-infektion kan også overføres fra mor til ufødt barn. Cirka 4%-7% af børn født af mødre inficeret med hepatitis C bliver smittet.
• Hepatitis C overføres ikke med modermælk. Dog kan brystvorterne revne og bløde i løbet af de første par uger, indtil brystvorterne er tilpasset amme, og spædbarnet kan blive udsat for inficeret blod. Hvis dette sker, bør amningen stoppe, og mælkeproduktionen kan opretholdes ved at pumpe mælken og kassere den, indtil den er helet.
• Et meget lille antal hepatitis C-tilfælde overføres gennem samleje. Risikoen for hepatitis C-overførsel fra et inficeret individ til en ikke-inficeret ægtefælle eller seksuel partner uden brug af kondomer i løbet af et helt liv er blevet anslået til at være mellem 1 % og 4 %.
• Hepatitis C overføres ikke ved tilfældig kontakt, kys, hoste, nysen eller deling af spiseredskaber. Der er ingen overførsel ved insektbid. På grund af risikoen for eksponering for blod frarådes medlemmer af husstanden dog at dele barberskraber, negleklippere eller tandbørster.
• Dårlig infektionskontrolspraksis under tatovering og kropspiercing kan potentielt føre til spredning af infektion. Dette kan forekomme i fængsler eller ikke-professionelle situationer, men det er ikke blevet rapporteret i licenserede, kommercielle tatoveringsfaciliteter, hvor det er blevet undersøgt.
• Der har været nogle udbrud af hepatitis C, når instrumenter udsat for blod er blevet genbrugt uden tilstrækkelig rengøring og sterilisering mellem patienterne.
• Hepatitis C kan overføres fra en organdonor til en organmodtager. Donorer af organer testes for hepatitis C.
  • Hvis donoren, der leverer organet, er inficeret med hepatitis C, tilbydes det til en modtager, som også er inficeret med hepatitis C.
  • For nyretransplanterede modtagere ser dette dog ikke ud til at påvirke det langsigtede resultat efter transplantation.
  • For levertransplantationsmodtagere, som har hepatitis C og modtager et organ fra en person, der ikke er inficeret med hepatitis C, forventes det transplanterede organ at blive inficeret inden for et par uger. Heldigvis tillader nyere medicin en vellykket behandling af hepatitis C efter transplantationer, og dette område af medicin fortsætter med at udvikle sig.

Kan hepatitis C-infektion påvirke andre organer end leveren?

De fleste af tegnene og symptomerne på hepatitis C-infektion relaterer sig til leveren. Sjældnere kan hepatitis C-infektion påvirke andre organer end leveren.

Hepatitis C-infektion kan få kroppen til at producere unormale antistoffer kaldet kryoglobuliner. Kryoglobuliner forårsager betændelse i arterierne (vaskulitis). Dette kan beskadige hud, led og nyrer. Patienter med kryoglobulinæmi (kryoglobuliner i blodet) kan have

• ledsmerter,
• gigt,
• et hævet lilla udslæt på benene, og
• generaliseret smerte eller hævelse af deres kroppe.

Derudover kan inficerede individer med kryoglobulinæmi udvikle Raynauds fænomen, hvor fingre og tæer skifter farve (hvide, så lilla, så røde) og bliver smertefulde ved kolde temperaturer.

Hvem er i høj risiko og bør testes for hepatitis C-infektion?

U.S. Preventive Health Services-taskforcen anbefaler, at alle voksne født mellem 1945 og 1965 testes én gang rutinemæssigt for hepatitis C, uanset om risikofaktorer for hepatitis C er til stede. Engangstest anbefales også til:

• Folk, der i øjeblikket injicerer stoffer eller fnyser stoffer, eller nogensinde har gjort det, selv en gang mange år tidligere
• Mennesker med vedvarende forhøjet niveau af alaninaminotransferase (ALT), et leverenzym, der findes i blodet.
• Mennesker, der har HIV-infektion
• Børn født af HCV- eller HIV-inficerede mødre
• Folk, der nogensinde har været i langvarig hæmodialyse
• Folk, der har fået en tatovering i uregulerede omgivelser, såsom fængsel eller af en person uden licens
• Folk, der modtog koagulationsfaktor produceret før 1987
• Personer, der modtog transfusioner eller organtransplantationer før juli 1992, eller som fik besked om, at de modtog blod fra en donor, som senere blev testet positiv for hepatitis C-infektion
• Sundhedspersonale, akutmedicinsk personale og offentlig sikkerhedspersonale efter en nålestik, øjen- eller mundeksponering for hepatitis C-inficeret blod

Personer, der kan have været udsat for hepatitis C i de foregående 6 måneder, bør testes for viral RNA-belastning i stedet for anti-HCV-antistof, fordi antistof muligvis ikke er til stede i op til 12 uger eller længere efter infektion, selvom HCV-RNA kan påvises i blodet så hurtigt som 2-3 uger efter infektion.

Generelt kan årlig screening være passende for personer med vedvarende risikofaktorer såsom gentagne seksuelt overførte sygdomme (STD'er) eller mange sexpartnere, igangværende intravenøs stofbrug eller langvarige sexpartnere for personer med hepatitis C. Hvorvidt der skal testes eller ej. disse personer bestemmes ud fra en sag til sag.

Anbefales screening for hepatitis C under graviditet?

Der er en 4%-7% risiko for at overføre HCV fra mor til spædbarn ved hver graviditet. I øjeblikket er der ingen CDC-anbefaling for rutinemæssig hepatitis C-screening under graviditet, og der er ingen i øjeblikket anbefalet medicin til at forhindre overførsel fra mor til spædbarn (profylakse). CDC overvåger dog forskningsresultater og kan komme med anbefalinger i fremtiden, efterhånden som der opstår beviser.

Mens data stadig er begrænsede, fandt en nylig undersøgelse af over 1.000 tilfælde i Det Forenede Kongerige, at 11 % af spædbørn var blevet smittet ved fødslen, og at disse spædbørn sandsynligvis udviklede skrumpelever i deres tidlige 30'ere. Sagen for screening for HCV under graviditet omfatter potentialet for sikkert at behandle mødre under graviditeten med direkte virkende antivirale midler (DAA'er) til at behandle moderen før skrumpelever udvikler sig, forhindre spædbarnsoverførsel og forhindre overførsel til andre. Børn født af HCV-inficerede mødre kan også tilbydes behandling i en tidlig alder for at forhindre skrumpelever samt overførsel til andre. Koordinering af pleje mellem flere specialister vil være vigtig for at nå disse mål.

Børn af HCV-inficerede mødre kan screenes for hepatitis C så tidligt som i 1-2 måneders alderen ved hjælp af hepatitis C viral load eller PCR-test (se Blodprøver for hepatitis C). Antistoffer mod hepatitis C, som overføres fra mor til barn, vil være til stede i op til 18 måneder, så børn bør tidligst testes for HCV-antistof.

Hvilken type læge behandler hepatitis C?

Hepatitis C behandles af enten en gastroenterolog, en hepatolog (en gastroenterolog med yderligere uddannelse i leversygdom) eller en infektionssygdomsspecialist. Behandlingsteamet kan omfatte mere end én specialist, afhængigt af omfanget af leverskader. Kirurger, der er specialiserede i kirurgi af leveren, herunder levertransplantation, er en del af det medicinske team og bør se patienter med fremskreden sygdom (leversvigt eller skrumpelever) tidligt, før patienten skal have en levertransplantation. De kan muligvis identificere problemer, der skal løses, før operation kan overvejes. Andre personer, der kan være behjælpelige med at håndtere patienter, omfatter diætister til at rådføre sig om ernæringsmæssige spørgsmål og farmaceuter til at hjælpe med behandling af lægemidler.

Hvordan diagnosticeres hepatitis C?

Blodprøver for hepatitis C

Der er flere blodprøver til diagnosticering af hepatitis C-infektion. Blod kan testes for antistof mod hepatitis C (anti-HCV antistof). Det tager omkring 8-12 uger i gennemsnit og op til 6 måneder for antistoffer at udvikle sig efter den første infektion med hepatitis C, så screening for antistoffer kan gå glip af et par nyligt inficerede individer. At have antistoffer er ikke en absolut indikation af aktivt, multiplicerende hepatitis C-virus, men hvis antistoftesten er positiv (antistof er til stede), er den statistiske sandsynlighed for aktiv infektion større end 99 %.

Adskillige tests er tilgængelige for at måle mængden af ​​hepatitis C-virus i en persons blod (virusmængden). Hepatitis C-virusets RNA kan identificeres ved en type test kaldet polymerasekædereaktion (PCR), der detekterer cirkulerende virus i blodet allerede 2-3 uger efter infektion, så det kan bruges til at opdage formodet akut infektion med hepatitis C tidlig infektion. Det bruges også til at bestemme, om aktiv hepatitis er til stede hos en person, der har antistoffer mod hepatitis C, og til at følge virusbelastningen under behandlingen.

Blodprøver udføres også for at identificere genotyperne af HCV. Genotyper reagerer forskelligt på forskellig behandling, så denne information er vigtig ved udvælgelsen af ​​det mest passende behandlingsregime.

Estimering af leverfibrose ved hjælp af blodprøver er også ret pålidelige til diagnosticering af klinisk signifikant ardannelse; disse omfatter FIB-4, FibroSure, Fibrotest og aspartat aminotransferase-til-blodplade-forholdsindeks (APRI).

Leverbiopsi og ikke-invasive tests for hepatitis C

Det næste trin er at bestemme niveauet af leverardannelse, der er opstået. Leverbiopsi tillader undersøgelse af en lille prøve af levervæv under et mikroskop, men leverbiopsi er en invasiv test og har betydelige risikoer for blødning. Det kan også savne unormale områder i tidlig sygdom.

Ikke-invasive tests har stort set erstattet leverbiopsi undtagen i særlige situationer. Leverstivhed indikerer, at fremskreden leverardannelse eller skrumpelever kan være til stede. Transient elastografi kan bruges til at måle denne stivhed ved hjælp af ultralyd eller magnetisk resonansbilleddannelse (MRI).

Evaluering før behandling for hepatitis C bør også omfatte:

• Test for hiv
• Testing for antibodies to hepatitis B and hepatitis A and vaccination if antibodies are not present
• If past or current hepatitis B infection is detected, it may need to be treated at the same time. There are reports of hepatitis B that reactivated or progressed to serious liver failure or death in some patients who were treated only for hepatitis C. This has been reported to occur during or even after HCV treatment.
• Recommending abstinence from alcohol use
• Counseling about measures to prevent the spread of hepatitis C and HIV
• If cirrhosis is present, vaccination against pneumococcal infection, regardless of age

What medications cure hepatitis C infection?

Interferons, for example, Roferon-A and Infergen, and pegylated interferons such as Peg-Intron ^T , Pegasys, were mainstays of treatment for years. Interferons produced sustained viral response (SVR, or cure) of up to 15%. Later, peglatedll forms produced SVR of 50%-80%. These drugs were injected, had many adverse effects, required frequent monitoring, and were often combined with oral ribavirin, which caused anemia. Treatment durations ranged up to 48 weeks.

Direct-acting anti-viral agents (DAAs) are antiviral drugs that act directly on hepatitis C multiplication.

• They are taken by mouth, are well tolerated, and cure over 90% of patients.
• Treatment time is much shorter, often 12 weeks, depending on drug and genotype.
• Similar to treatments for HIV, treatment of HCV is most effective if the drugs are given in combination.
• The earliest options were sofosbuvir (Sovaldi) and simeprevir (Olysio). These were approved by the FDA in 2013.
• Ledipasvir and sofosbuvir (Harvoni) followed as a once-a-day combination pill, in 2014.
• With this combination of DAAs, about 94%-99% of people achieve an SVR (cure) in 12 weeks with few side effects.
• Ombitasvir, paritaprevir and ritonavir co-packaged with dasabuvir tablets (Viekira Pak), is a combination approved in 2014. SVR with this combination is 91%-100%. The combination of elbasvir and grazoprevir (Zepatier) was approved in 2016. SVR with this combination depends on the HCV genotype and whether individual patient factors require the addition of ribavirin. Genotype 1 has a 94%-97% SVR, and SVR is 97%-100% in genotype 4.
• In August 2017, FDA approved an 8-week regimen of glecaprevir and pibrentasvir (Mavryet) for all HCV genotypes. Unlike some of the earlier regimens, this combination is effective whether or not the patient has cirrhosis. It also can be given to people on kidney dialysis, whose kidney function limits treatment options. Moreover, this regimen is effective in people with genotype 1 who have failed treatment with some of the other regimens.

What are the treatment guidelines for hepatitis C?

Hepatitis C treatment is best discussed with a doctor or specialist familiar with current and developing options as this field is changing, and even major guidelines may become outdated quickly.

The latest treatment guidelines by the American Association for the Study of Liver Disease (AASLD) and Infectious Disease Society of America (IDSA) recommends use of DAAs as first-line treatment for hepatitis C infection. The choice of DAA varies by specific virus genotype, and the presence or absence of cirrhosis. In the U.S., specific insurance providers also might influence the choice due to the high cost of DAAs. Although the individual, public health, and cost benefits of treating all patients with hepatitis C is clear, the most difficult barrier to treating all people with HCV is the very high cost of the drug regimens. Patients are encouraged to discuss options with their health care professional.

Treatment is recommended in all patients with chronic hepatitis C unless they have a short life expectancy that is not related to liver disease. Severe life-threatening liver disease may require liver transplantation. Newer therapies with DAAs have allowed more and more patients to be treated.

What are the goals of therapy for hepatitis C infection?

The ultimate goals of antiviral therapy are to

• prevent transmission of hepatitis C,
• normalize liver tests,
• reduce inflammation and scarring,
• prevent progression to cirrhosis and liver cancer, and
• improve survival and quality of life.

A side goal is preventing co-infections with other hepatitis viruses, such as A and B, which can cause more liver disease than HCV alone. These can be prevented by vaccines and treatment.

What is the treatment for people with acute hepatitis C infection?

When people first get hepatitis C, the infection is said to be acute. Most people with acute hepatitis C do not have symptoms so they are not recognized as being infected. However, some have low-grade fever, fatigue or other symptoms that lead to an early diagnosis. Others who become infected and have a known exposure to an infected source, such as a needlestick injury, are monitored closely.

Treatment decisions should be made on a case-by-case basis. Response to treatment is higher in acute hepatitis infection than chronic infection. However, many experts prefer to hold off treatment for 8-12 weeks to see whether the patient naturally eliminates the virus without treatment. Approaches to treatment are evolving. Patients with acute hepatitis C infection should discuss treatment options with a health care professional who is experienced in treating the disease. There is no established treatment regimen at this time.

How effective is hepatitis C treatment? Is hepatitis C curable?

If the hepatitis C RNA remains undetectable at the end of the treatment and follow-up period, this is called a sustained virologic response (SVR) and is considered a cure. Over 90% of people treated with DAAs are cured. These people have significantly reduced liver inflammation, and liver scarring may even be reversed.

About 5% of people who are treated for HCV infection are not cured by some of the older regimens. These people may still have options for cure with the newer regimens.

Who should not receive treatment with antiviral therapy?

Few people with hepatitis C are at risk for problems if they are treated, however there are some factors that affect treatment regimens, such as concurrent HIV medications and kidney dysfunction. Some drugs are not safe for people with cirrhosis. Individuals who are unable to comply with the treatment schedule for psychological reasons or ongoing drug or alcohol abuse may not be good candidates for treatment because the drugs are very costly and require adherence to the pill regimen and regular follow-up visits. There are some important drug interactions with some of the medications that should be considered by the health care professional.

People with past hepatitis B or who have chronic active hepatitis B should not be treated for HCV without treating for HBV as well. As highly effective treatment for HCV has emerged, reports of serious hepatitis B have come to light. Similar to HCV, hepatitis B usually does not clear from the liver after acute infection, even though it is far less likely to cause chronic active hepatitis than hepatitis C infection. It remains dormant in most people, but it can reactivate with changes in the immune system. It is not clear why eliminating the HCV can allow the HBV infection to flare up. Hepatitis B screening is an important part of the hepatitis C evaluation. Those who have laboratory evidence of active or past infection with HBV should be monitored while receiving HCV treatment.

What are the side effects of treatments for hepatitis C infection?

Side effects of interferon or pegylated interferon

• The most common side effects of interferon or pegylated interferon include fever, flu-like symptoms, and depression. Patients must be monitored closely for depression. Risk of suicide is a reason to avoid interferons.
• Interferons also reduce white blood cell and/or red blood cell counts (leucopenia and anemia, respectively). This may cause increased susceptibility to infection. Interferons also increase the risk of certain cancers. Death rarely occurs as a result of therapy, but may occur from progression of liver failure in patients with advanced cirrhosis.

Side effects of ribavirin

• Ribavirin most commonly causes anemia due to destruction of red blood cells (hemolysis). This can be severe enough that people with heart disease may suffer a heart attack from insufficient blood flow, so people with heart disease should not receive this drug. Anemia improves with a reduction in the dose of ribavirin. Injected growth factor (erythropoietin) that stimulates the production of red blood cells often is used to improve the anemia associated with ribavirin. Ribavirin also accumulates in the testicles and ovaries and causes birth defects in animals. Although no birth defects have been reported in humans, both men and women should use contraceptive measures to avoid pregnancy during and for at least six months after ribavirin treatment.

Side effects of DAAs

Compared to interferons and ribavirin drugs, the side effects of DAAs are far fewer and more tolerable. These side effects usually do not require discontinuation of therapy and are self-limiting after completion of therapy.

• The most common and significant side effects of boceprevir (Victrelis), sofosbuvir (Sovaldi), and ledipasvir/sofosbuvir (Harvoni) include
  • fatigue (feeling tired),
  • hovedpine og
  • trouble sleeping (insomnia).
• The most common side effects of simeprevir (Olysio) include
  • kløe,
  • skin rash, and
  • photosensitivity (tendency to get sunburns).
• Simeprevir has significant drug interactions with other medications. Certain medications can affect levels of simeprevir in the body and make simeprevir less effective or more toxic.
• The combination of ombitasvir, paritaprevir, and ritonavir tablets with dasabuvir tablets (Viekira Pak) is very well tolerated, and the most commonly reported side effects are
  • træthed,
  • trouble sleeping, and
  • itching.
• The combination of elbasvir and grazoprevir (Zepatier) is well-tolerated. Most common side effects include
  • træthed,
  • hovedpine og
  • kvalme.
  • It may be used with ribavirin, which adds the side effect of anemia.
  • About 1% of people in studies may develop elevated liver enzyme blood tests last into treatment or afterward, so these tests are closely monitored.
• The combination of glecaprevir and pibrentasvir (Mavryet) is well tolerated. Most common side effects include
  • træthed,
  • hovedpine og
  • kvalme.
• Use of milk thistle should be discussed with the treating doctor, because it interacts with several DAAs.

Patients with hepatitis B co-infection should be monitored for symptoms of reactivation of hepatitis, which are the same as the symptoms of acute hepatitis. The treating doctor may perform blood screening for this as well.

Is liver transplantation an option for a person with hepatitis C?

Hepatitis C is the leading reason for 40% to 45% of liver transplants in the U.S. Hepatitis C usually recurs after transplantation and infects the new liver. Approximately 25% of these patients with recurrent hepatitis will develop cirrhosis within five years of transplantation. Despite this, the five-year survival rate for patients with hepatitis C is similar to that of patients who are transplanted for other types of liver disease.

Most transplant centers delay therapy until recurrent hepatitis C in the transplanted liver is confirmed. Oral, highly effective, direct-acting antivirals have shown encouraging results in patients who have undergone liver transplantation for hepatitis C infection and have recurrent hepatitis C. The choice of therapy needs to be individualized and is rapidly evolving.

How is monitoring done after treatment for hepatitis C?

Once patients successfully complete treatment, the viral load after treatment determines if there is an SVR or cure. If cure is achieved (undetectable viral load after treatment), no further additional testing is recommended unless the patient has cirrhosis. Those who are not cured will need continued monitoring for progression of liver disease and its complications.

While cure eliminates worsening of fibrosis by hepatitis C, complications may still affect those with cirrhosis. These individuals still need regular screening for liver cancer as well as monitoring for esophageal varices that may bleed.

Because hepatitis B co-infection may reactivate or worsen even after treatment for HCV, monitoring for hepatitis symptoms may be needed after the end of therapy.

What home remedies are available for hepatitis C?

At this time there are no effective home or over-the-counter treatments for hepatitis C.

What are the complications of undiagnosed hepatitis C?

• Hepatitis C is known to be associated with two skin conditions, lichen planus and porphyria cutanea tarda.
• Diabetes, heart disease, and arterial blockage are more common among patients with chronic hepatitis C infection than in the general population. It may be that liver damage and chronic inflammation caused by hepatitis C may affect the levels of blood fats (lipids) and blood sugar.
• Low platelet counts may occur as a result of the destruction of platelets by antibodies.
• Hepatitis C also is associated with B-cell lymphoma, a cancer of the blood.

End-stage liver disease

Over several years or decades, chronic inflammation may cause death of liver cells and cirrhosis (scaring, fibrosis). When the liver becomes cirrhotic, it becomes stiff, and it cannot perform its normal functions of clearing waste products from the blood. As fibrosis worsens, symptoms of liver failure begin to appear. This is called "decompensated cirrhosis " or "end-stage liver disease. " Symptoms of end-stage liver disease include:

• Small spider veins begin to appear on the skin as the stiff, scarred liver obstructs the forward flow of blood.
• Body fluids back up and accumulate in the abdomen (ascites).
• The spleen enlarges because of back-pressure.
• Yellowing of eyes and skin (jaundice) occurs because the liver is not clearing bilirubin (a yellow pigment from breakdown of red blood cells) from the blood.
• A serious complication is severe bleeding from varicose veins that develop in the swallowing tube or esophagus (esophageal varices).

Cirrhosis-associated immune dysfunction syndrome

The liver and spleen have an important function of clearing bacteria from the blood stream. Cirrhosis affects many areas of immune function, including attraction of white blood cells to bacteria, reduced killing of bacteria, reduced production of proteins involved in immune defenses, and decreased life span of white blood cells involved in immune defenses. This may be referred to as having cirrhosis-associated immune dysfunction syndrome or CAIDS.

• Fluid in the abdomen often becomes infected (spontaneous bacterial peritonitis), and preventive antibiotics may be given for this type of infection.
• Bacteria also may enter the bloodstream easily (bacterial translocation), referred to as sepsis, especially when esophageal varices bleed.
• Individuals may succumb to many types of bacterial infections more easily than normal, but some are specific to liver disease. People with chronic hepatitis C and fibrosis should avoid being exposed to these bacteria.
  • Vibrio species of bacteria are a serious risk from eating raw oysters or exposure to sea water. Vibrio vulnificus may cause sepsis, cellulitis, and necrotizing fasciitis, a “flesh-eating” infection.
  • Listeria species may cause sepsis and meningitis, and are a risk from unpasteurized dairy products and salty processed meats.
  • Yersinia species may be picked up from raw or undercooked pork, especially intestines (chitterlings).

Can hepatitis C be prevented?

Transmission of hepatitis C can be prevented in several ways.

Prevention programs aim at needle sharing among drug addicts. Needle exchange programs and education have reduced transmission of hepatitis C infection. However, IV drug users are a difficult to reach population, and rates of hepatitis C remain high among them.

Among health care workers, safe needle-usage techniques have been developed to reduce accidental needlesticks. Newer needle systems prevent manual recapping of needles after use of syringes, which is a frequent cause of accidental needlesticks

There is no clear way to prevent hepatitis C transmission from mother to fetus at this time.

People with multiple sexual partners should use barrier precautions such as condoms to limit the risk of hepatitis C and other sexually transmitted diseases, including HIV.

If one partner is infected, monogamous couples may want to consider the low risk of transmission of hepatitis C infection when deciding whether to use condoms during sex. Some couples may decide to use them and some may not.

Screening of the blood supply has almost eliminated the risk of transmission of hepatitis C infection through transfusion.

People with hepatitis C infection should not share razors or toothbrushes with others because of the possibility that these items may be contaminated with blood.

People who want to get a body piercing(s) or tattoo(s) are encouraged to do so only at licensed piercing and tattoo shops (facilities), and verify that the body piercing or tattoo shop uses infection-control practices.

It is critical that physicians and clinics follow manufacturers and regulatory agency directions for sterilizing/cleaning instruments and that disposable instruments be discarded properly. There is no need to use special isolation procedures when dealing with hepatitis C infected patients.

What is the prognosis of hepatitis C?

In general, among patients with untreated hepatitis C:

• 75% to 85% become chronically infected,
• 60% to 70% develop liver disease,
• 5% to 20% develop cirrhosis, and
• 1% to 5% will die from complications of cirrhosis or liver cancer.

Drinking alcohol and acquiring other hepatitis viruses are risk factors for worse liver disease. People with chronic hepatitis C should avoid drinking alcohol and should be screened for antibodies to hepatitis A and B. If they do not have antibodies, they should be vaccinated against these other hepatitis viruses.

People with hepatitis C should be educated about preventing HIV infection. Infection with both HIV and hepatitis C speeds up and worsens liver damage caused by hepatitis C. Hepatitis C also can affect the HIV infection and how it is treated. About 25% of people with HIV infection are co-infected (also infected) with hepatitis C, and up to 90% of IV drug users with HIV are co-infected with hepatitis C. Screening for hepatitis viruses is important in all people infected with HIV, just as screening for HIV is important in people who have hepatitis C.

Liver cancer (hepatocellular carcinoma, or hepatoma) is associated with cirrhosis from chronic hepatitis C. Some experts recommend screening patients with hepatitis C infection and cirrhosis for liver cancer periodically.

What is the current research and what is in the future for hepatitis C?

As our knowledge of hepatitis C increases, more and more patients are being diagnosed with chronic infection. Current research is very active and includes diagnosis, natural history, treatment, and vaccine development. Thus the field is constantly changing, with new guidelines added frequently.

• Hepatitis A (HAV, Hep A)
• Hepatitis C-kur:Symptomer, transmission, behandlinger og omkostninger