Viral Hepatitis

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Side Effects Guide

for Veterans and the Public

Side Effects Guide: Entire Lesson

Side effects overview

One of the most difficult things for people on hepatitis C therapy to deal with is the side effects caused by the interferon injections and ribavirin pills. For more information on hepatitis C treatment, see Treatment Decisions.

Side effects vary a lot from person to person. Some people will hardly notice that they are taking medications. Others will feel like they have a cold for much of the time on therapy, and sometimes they will feel even worse.

If you are on hepatitis C therapy:

  • You need to be able to recognize and identify the side effects that you are having.
  • You need to learn how to manage the side effects, including knowing when to ask your doctor for help.
  • You need to know which side effects are serious, so that you can report them immediately to your health care provider.

Being educated about your treatment is important so that you can finish with good results and so that you can feel better sooner. To learn more about how to deal with treatment, you can click on each of the side effects on the right.

Mental health

People getting treated for hepatitis C often find it difficult to sleep. The lack of sleep can lead to anxiety, irritability, and depression. What follows are tips for coping with each of these side effects.

Poor sleeping

Many people on interferon therapy have trouble sleeping. This happens because interferon injections stimulate (excite) certain areas of your body. Lack of sleep can make all side effects--including fatigue, short temper, depressed mood, and headaches--a lot worse. So just getting better sleep can improve the other side effects.

Quick Tips: Poor sleeping
  • Develop good sleep habits (don't read or watch TV in bed).
  • Try to go to sleep and wake up at the same time every day.
  • Keep afternoon naps short.
  • Limit fluids at night to avoid having to go to the bathroom in the middle of the night.
  • If ribavirin makes you "jittery," take your pills at 4 PM or 5 PM instead of right before bedtime.
  • Close to bedtime, try to avoid large meals, too much exercise, tobacco, alcohol, and caffeine.

Feeling anxious

Many patients feel a little anxious when they are on interferon therapy. This is a side effect of the medications, especially the interferon. As with many of interferon's side effects, it can be hard to notice--it changes you without your realizing it. You may feel a little "jittery," or feel that your interactions with others are slightly "off."

Quick Tips: Feeling anxious
  • Try relaxation techniques (yoga, meditation, deep breathing).
  • Remind yourself: "The doctor told me that the medications would make me feel anxious, so this is not really me... The medication is making me feel this way."
  • Avoid stimulants such as caffeine in coffee and tea.
  • Tell your provider if your symptoms are getting worse; your doctor may be able to give you medicine for some of your symptoms.

Being short-tempered

Most people taking interferon are more likely to get angry about things than they normally are. This can happen even to people who never seem to get angry about anything. You may find yourself yelling at people in traffic when that never happened to you before.

By being aware of a short temper, you can expect it and control it better. If your family members and close friends know you are on medications that can cause you to be mad about things, they will be more understanding.

Quick Tips: Being short-tempered
  • Try relaxation techniques (yoga, meditation, deep breathing).
  • Take deep breaths and count to 10.
  • Share your feelings with friends and family.
  • Join a support group.
  • If you are tired, depressed, or losing sleep, find ways to deal with those side effects too.
  • Your job may make your temper worse, so try to arrange ways to make your work less stressful. For example, you might want to talk to your boss about flexible hours, if that would help.

Feeling down--depression or sadness

It's not unusual to feel "down" while you are on interferon. This is purely a side effect of the medication. Stopping the interferon will make these feelings go away within 1-2 weeks.

If you find that you're more than a little down--maybe you feel worthless or hopeless or have lost interest in your favorite activities--you could be depressed. Depression is a common side effect of interferon. It can be treated by either by changing how much interferon you take or by taking antidepressant medications. Be sure to always discuss medication changes with your VA health care provider.

Quick Tips: Feeling down
  • Do something you enjoy, such as reading a book, going to your favorite restaurant, or visiting a museum.
  • Get involved with a support group.
  • Spend time with supportive people, such as family members and friends.
  • Talk with your doctor about treatments for depression, such as therapy or medicines.
  • If you ever feel that you may harm yourself or are contemplating suicide, get help immediately- any hospital should be able to help you, or you can dial 911. Interferon causes these symptoms, and nothing is worth putting yourself in danger.

Whole body

Hepatitis C drugs can cause fatigue, headaches, fever, and muscle aches. What follows are tips for dealing with each of these side effects.

Feeling tired

Feeling tired (fatigued) is the number one side effect of interferon and ribavirin. You may feel like you have a cold.

Ribavirin also can make you feel tired, because it is harmful (toxic) to red blood cells. This can lead to low red blood counts, a condition called "anemia."

In rare cases, the thyroid gland (a gland in the neck that is involved in a lot of body functions) can fail to function right, leading to low thyroid levels. This condition is called "hypothyroidism," and it can make you feel tired, too. You can ask your VA health care provider more about this condition.

Quick Tips: Feeling tired
  • Try going to sleep and waking up at the same time every day.
  • Take a short nap after work.
  • Get regular, moderate exercise.
  • Eat healthy meals to maintain your weight.
  • If fatigue is worse 1 to 2 days after injecting interferon, take 325 to 1,000 mg of Tylenol before your shot. (Talk with your doctor about this.)

Headaches

Headaches can be a direct result of the interferon. They can also be due to anemia (low red blood cells) caused by ribavirin.

Quick Tips: Headaches
  • Drink more fluids.
  • Try to get plenty of sleep.
  • Take a hot, relaxing bath.
  • Lie down and rest in a quiet, dark room.
  • Try to reduce your stress level.
  • Check with your VA health care provider about taking Tylenol and/or ibuprofen.
  • If you have a history of migraine headaches (a certain type of headache, which often comes with vision changes), talk to your health care provider about taking medications (such as Imitrex) for them.

Fever

Fever is usually caused by the interferon. The fever tends to be worse with the first few shots, and usually occurs within the first day or two after the shots.

Seek immediate medical attention if:

  • your fever goes above 101ºF (38ºC), particularly for more than a day
  • you also have chills or feel extremely weak

This is because high fever can be associated with infections that may need a specific treatment. Your health care providers will know whether this is the case.

Quick Tips: Fever
  • Check with your VA health care provider about taking Tylenol before your interferon shots. This can lessen the fever that the shots cause. You can also talk with your provider about taking Tylenol after your shots when you have fever.
  • Drink plenty of liquids and try eating well to keep yourself hydrated during fever.
  • Go to a health care provider if your temperature:
    • is above 101ºF, unless it followed an interferon injection
    • is above 101ºF repeatedly or lasts for more than 24-48 hours

Muscle and body aches

Muscle aches can result from inflammation (swelling) of the muscles due to interferon. Ribavirin also can cause muscle inflammation and dehydration and loss of fluid in your blood vessels, and this can lead to muscle aches. (Dehydration is partly what causes your muscles to ache after you exercise for a long time.)

Quick Tips: Muscle and body aches
  • Check with your VA health care provider about taking Tylenol, aspirin, ibuprofen, Advil, Motrin, or Aleve for your body aches.
  • Follow a moderate, low-impact exercise plan.
  • Apply a warm, moist washcloth to areas that hurt.
  • Take a hot bath.
  • Drink a lot of fluids.

Mouth, stomach, and digestion

It's important to eat a good, healthy diet while you are on treatment and afterward, even if you want to lose a few pounds. Your body needs good nutrition and healthy foods to fight the hepatitis C infection and repair damage that it has caused over time. This can be difficult because treatment can cause problems with your mouth and stomach. What follows are tips for coping with these side effects.

Poor appetite

Interferon treatment can cause you to lose your appetite. This can cause poor nutrition (not eating right), which can contribute to weakness and your not feeling well.

Quick Tips: Poor appetite
  • Take a walk or do stretches before a meal. This may increase your appetite.
  • Eat 5 or 6 small meals each day, instead of 3 large meals. For example, eat an 8:30 AM breakfast, 10 AM snack, 12:30 PM lunch, 3 PM snack, 5:30 PM dinner, and a 7:30 PM snack.
  • Eat your favorite food, even if just a little bit.
  • Drink homemade fruit shakes of nutrition supplements (such as Ensure and Carnation Instant Breakfast) instead of skipping a meal. Drink liquid supplements with a straw if you find that their smell makes them less appealing.
  • Keep snacks handy, such as hard-boiled eggs, cheese, and peanut butter. Keep snacks that don't require refrigeration near your bed or by the television.
  • Pack foods that don't need to be refrigerated for snacking when you are away from home.
  • Stock up on frozen meals in single-portion packages. These are quick and easy to prepare.
  • Try different food textures (add chopped nuts, seeds, or water chestnuts to dishes) to make eating more interesting.
  • Watch cooking shows and keep cookbooks around.
  • Make eating enjoyable--eat with others, eat in a pleasant place, light a candle.
  • When possible, do not drink fluids with your meals. They can make you feel full sooner.

Bad taste in mouth

Interferon can cause a bitter or metallic taste in your mouth. Ribavirin can cause mouth sores and dehydration, which can make your mouth feel dry and have a bad taste.

Quick Tips: Bad taste in mouth
  • Tart food can "mask" a metallic taste. Drink orange, cranberry, and pineapple juice, and lemonade. Add vinegar, lemon juice, pickles, or relish to your food.
  • Marinate meat, chicken, turkey, fish, or tofu in vinegar, wine, salad dressing, or soy sauce. Add fresh herbs, dried herbs, or condiments to your food (such as onion, garlic, chili powder, rosemary, thyme, basil, oregano, cumin, mustard, catsup, and mint). For example, try sweet and sour pork with pineapple.
  • Eat cold food, such as sorbet, sherbet, fruit slushes, ice chips, or frozen yogurt to numb your taste buds. Eat frozen grapes, orange slices, or pieces of cantaloupe and watermelon. Or create frozen popsicles out of sports drinks.
  • Chew lemon drops, zinc lozenges, mints, or gum, which can help get rid of bad or "off" tastes that linger after eating. (If you have diarrhea, go easy on your use of sugar-free candies and gum.)
  • Eat dark chocolate.
  • Rinse your mouth with tea, ginger ale, salted water, or water with baking soda before eating. This will help clear your taste buds.
  • Use plastic utensils instead of metal utensils.
  • Eat fresh or frozen foods instead of canned foods.

Dry mouth and thick saliva

Ribavirin kills red blood cells. As a result, you don't have as much blood in your blood vessels, and you get dehydrated. This can cause dry mouth or thick saliva.

Quick Tips: Dry mouth and thick saliva
  • Use sugar-free candy or sourballs, popsicles, ice cubes, or sugarless chewing gum to moisten your mouth.
  • Start and end each day with a glass of water.
  • Moisten food with sauce, gravy, yogurt, or salad dressing.
  • Dunk bread, crackers, and cookies in soup, milk, juice, or hot chocolate.
  • Drink plenty of beverages, such as lemonade or tea with lemon.
  • Rinse your mouth with club soda or warm, salted water.
  • Keep fluids by your bed so you can drink during the night if you are thirsty.
  • Ask your VA doctor about mouth rinses and other products to treat your dry mouth.

Sore mouth and sore throat

Ribavirin can cause you to have an allergic reaction that might show up as a rash on your skin. It can also show up as an irritation in your mouth and throat. If you normally get mouth ulcers, they may get worse while you are on treatment.

Quick Tips: Sore mouth and sore throat
  • Eat soft or pureed foods. Baby foods or toddler foods may be good substitutes.
  • Drink nectars instead of juices.
  • Drink instant breakfast formulas or milkshakes instead of eating solid food.
  • Use a straw.
  • Eat lukewarm or cool foods, not foods at hot temperatures.
  • Gargle or rinse your mouth out often with warm, salted water.
  • Talk to your doctor about a prescription for lidocaine mouthwash. It can ease discomfort from mouth sores.
  • Try to stay away from:
    • foods that are spicy, salty, acidic, or high in citrus content (such as oranges and grapefruits)
    • rough food like dry toast, granola, and pretzels
    • chili powder, cloves, curry, hot sauces, nutmeg, and pepper
    • carbonated beverages (such as colas)

Nausea and vomiting

Nausea is a common side effect of hepatitis C therapy. It can be caused by both interferon and ribavirin. Vomiting repeatedly can lead to dehydration and chemical imbalances in your body. Tell your doctor if you vomit frequently, or if nausea and vomiting stop you from taking your ribavirin.

Quick Tips: Nausea and vomiting

What to try:

  • Try the BRATT diet (bananas, rice, applesauce, tea, and toast).
  • Eat small, snack-sized meals every 2 to 4 hours, instead of 2 to 3 big meals during the day.
  • Take your ribavirin with food.
  • Eat foods cold or at room temperature. Fruit or a sandwich with cold cuts or cheese is fine. Hot food can contribute to nausea and vomiting.
  • If you've vomited, be sure to "refuel" your body with broth, carbonated drinks, juice, Jell-O, or popsicles.
  • Leave dry crackers by your bed, and eat a few before getting up in the morning.
  • Foods that may help your nausea and vomiting:
    • Salty foods, such as crackers, pretzels, and unbuttered popcorn
    • Dry foods, such as dry ready-to-eat cereal, crackers, melba toast, and cookies; keep these foods close to your bed or favorite chair so they are within easy reach
    • Peppermint, chamomile, and ginger tea; they can calm the stomach
    • Cold carbonated drinks such as ginger ale, 7-Up, and Sprite
  • Talk to your VA health care provider about whether you should take medicine for your nausea.

What to avoid:

  • Don't lie flat for at least 1 hour after you eat.
  • Avoid smells and foods that trigger nausea (use boiling bags, microwave ovens, or covers for pots). Open the windows to decrease food odors when you are cooking.
  • Avoid eating if nausea is extreme.
  • Avoid very sweet foods and foods that are hot, spicy, strong-smelling, or greasy.

Diarrhea

While you are on therapy, you may experience diarrhea at times. For some people, diarrhea can be the main side effect of treatment. It's important to replace lost fluids, which can lead to dehydration and weakness.

Quick Tips: Diarrhea

What to try:

  • Try the BRATT diet (bananas, rice, applesauce, tea, and toast).
  • To replace lost fluids, drink plenty of mild, clear liquids throughout the day. These include sports drinks (Gatorade, Powerade, All Sport), chicken or beef broth, herbal tea, or water. Drink liquids at room temperature.
  • Eat foods high in soluble fiber. This kind of fiber can slow diarrhea by soaking up liquid. Foods high in soluble fiber include oatmeal, cream of wheat, grits, toast (not whole grain), bananas, rice, and applesauce. A tablespoon of Metamucil mixed with juice may also help.
  • Try psyllium husk fiber bars, available in health food stores. Two bars eaten 1 hour before bedtime with a large glass of water can help.
  • Eat small, frequent meals and snacks throughout the day.
  • Drink and eat high-sodium foods, such as broth, soups, sports drinks, crackers, and pretzels.
  • Choose foods and drinks high in potassium, a mineral that you lose with diarrhea. These include bananas, potatoes (without the skin), fish, chicken, and meat, and juices such as orange, apricot, mango and peach, V-8, and Gatorade.
  • Drink at least 1 cup of liquid after each loose bowel movement.
  • Ask your doctor about antidiarrheal medications such as Lomotil, Kaopectate, Imodium, and Pepto-Bismol.

What to avoid:

  • Avoid greasy, fried, spicy, or very sweet foods.
  • Limit drinks with caffeine, such as coffee and cola.
  • Avoid dairy products (avoid for at least 3 days after symptoms resolve).
  • Avoid food and drinks that may cause cramps or bloating, such as beans, cabbage, broccoli, brussels sprouts, onions, green peppers, and carbonated drinks.
  • Limit use of sugar-free gums and candies made with sorbitol.

Skin and hair

Hepatitis C treatment can cause temporary hair loss, skin rashes, and injection site reactions. Here are ways to deal with these side effects.

Hair loss

About 1 of 3 patients on interferon loses hair while they are on therapy. The hair loss usually happens little by little, not in big patches (like it does during cancer chemotherapy). After you stop interferon, your hair will grow back slowly to its normal thickness.

Quick Tips: Hair loss
  • Wear caps or scarves.
  • Use a wide-toothed comb.
  • Don't pull on your hair or comb it a lot.
  • Don't blow-dry, dye, perm, braid, or cornrow your hair.

Skin rash

Skin rashes, particularly on the arms and trunk (torso), often result from the ribavirin. These rashes tend to come and go during the course of the treatment.

Quick Tips: Skin rash
  • Take cool baths and use moisturizing soaps (such as Dove, Oil of Olay, and Cetaphil).
  • Apply skin lotions (such as Aquaphor, Curel, Aveeno, and Absorbase).
  • Use hydrocortisone cream as prescribed by your provider.
  • If your scalp is dry, use shampoos with selenium.
  • Protect your rash from sun exposure, which can make the rash worse.
  • Avoid hot showers and baths. They can irritate the skin.
  • If these lotions and creams don't work, talk to your doctor about oral medications.

Injection site reactions

Red, "blotchy" areas can appear around the site of your injection. Sometimes they will itch. They tend to get better over the course of several days.

Quick Tips: Injection site reactions
  • Apply a cold pack to the area.
  • Use hydrocortisone cream for itching (ask your health care provider about this).
  • Change the site of injection--from abdomen to thighs, or switch to the other side of the body.

Other side effects

Hepatitis C therapy sometimes can result in chest pain, shortness of breath, vision changes, and thyroid problems. Some of these side effects need to be promptly reported to your doctor. What follows are tips on dealing with each.

Chest pain

Chest pain is a fairly common side effect of therapy. Hepatitis C therapy affects your whole body--from muscles to joints, lung airways, and digestive system.

Your esophagus (food-swallowing tube), lung airways, chest muscles, ribs, and heart can produce different symptoms in the chest area. These can feel like chest pain.

But if you develop chest pain while on therapy, particularly if it is very noticeable, different from one you have had before, or mostly occurs when you are exerting yourself (eg, climbing a flight of stairs), you should seek medical attention. This is because chest pain can come from the heart, which can require specific treatment.

Quick Tips: Chest pain
  • Go to the emergency room so a doctor can make sure the pain isn't from a heart attack or serious lung problem.

Shortness of breath

When taking interferon and ribavirin, many patients will feel a little more short of breath than they usually do. This is a common side effect of therapy. It usually happens because of the low red blood cell counts (anemia) caused by ribavirin.

Shortness of breath can be scary, so if there are times when you find it difficult to catch your breath, you should seek prompt medical attention. Your doctor will want to be sure you don't have asthma, a lung infection, or other problems that require specific medical treatment.

Quick Tips: Shortness of breath
  • Take note of when and what activities you are doing when you become short of breath, so you can tell your provider.
  • Check with your health care provider to make sure your shortness of breath isn't caused by a heart or lung problem.

Vision changes

Changes in your vision that cause you to not be able to see clearly are uncommon. If they do occur, however, they should be promptly reported to your doctor. Eye specialists will be able to look into your eyes and see if there are any problems.

Quick Tips: Vision changes
  • To help describe any vision changes to your doctor, try to remember when the symptoms occur (at night? in bright light? at certain times of the day?) and what they involve (blurry vision? inability to see in a part of one or both eyes? eye pain?).
  • For dramatic visual changes (such as sudden poor vision or sudden change in vision in one eye), seek medical care within 24 hours.

Thyroid problems

Your thyroid is a gland in the front of your neck that is about the size of an apricot. It helps control many of the functions of your body. It affects your appetite, weight, energy level, digestion, and concentration, among other important functions.

Interferon can lead the thyroid gland to be overactive or underactive. This can have a big effect on how you feel. Most people do not have any problems with their thyroid from interferon, but you should tell your VA provider if you notice any big changes in how you feel. Rarely, changes in thyroid function can appear even after interferon and ribavirin treatment has been completed.

Quick Tips: Thyroid problems
  • Tell your provider about the side effects that you are noticing from interferon. Discuss whether any of these could be related to changes in how your thyroid gland is functioning. Your provider can then order blood tests, if necessary.

Blood tests

Your VA health care providers will look at your blood test results every 1-2 months while you are on treatment with interferon and ribavirin. They want to be sure that the medicines are not lowering your blood counts to unsafe levels. Blood tests also give your providers an idea of how well your treatments are working.

Following are some things that can be found by blood tests.

Low red blood cells

Ribavirin is harmful (toxic) to red blood cells and can damage them. Interferon leads to fewer red blood cells being produced. This results in low red blood cells, or "anemia." Anemia can make you feel tired.

Quick Tips: Low red blood cells
  • Your provider will tell you whether your red blood cell count is low and what can be done about this.
  • Decreasing the ribavirin dose will help to improve anemia (your provider will advise you about this).
  • Sometimes another injectable medication, Epogen (or Procrit), may be used to increase the number of red blood cells and bring them up to more normal levels.

Low white blood cells

Interferon slows your body's production of white blood cells. This leads to lower amounts of an important group of white blood cells called "neutrophils" (pronounced "noo-troh-fills"), which fight many different infections. Patients with low neutrophil counts are at risk for infections, such as pneumonia or skin infections.

Quick Tips: Low white blood cells
  • Your provider will tell you whether your white blood cell count is low and what can be done about this.
  • Decreasing the interferon dose can help to improve the white blood cell count (your provider can advise you about this).
  • Sometimes another injectable medication, Neupogen (or G-CSF), may be used to increase the number of white blood cells and bring them up to more normal levels.

Low platelets

Platelets (pronounced "playt-letts") are clusters of proteins that act like bricks to form blood clots. They are produced by cells in the bone marrow. Platelet counts often drop if you are on interferon and ribavirin therapy. This can put you at a higher risk for bleeding.

Quick Tips: Low platelets
  • Your provider will tell you whether your platelet count is low and what can be done about this.
  • If you have a low platelet count, you should pay particular attention to bleeding. Nosebleeds and bruises are more common. If you are concerned that you are bleeding or can't stop bleeding from a cut, seek medical attention.
  • Decreasing the interferon dose can help to improve the platelet count (your provider will advise you about this).

Resources

Treatment Decisions

Treatment Guides

  • Triple Therapy Workbooks
    Detailed workbooks to guide patients through their treatment course with triple therapy--pegylated interferon, ribavirin and either boceprevir or telaprevir.
  • Taking Your Hepatitis C Triple Therapy
    One-page printable handouts for patients who are taking boceprevir or telaprevir--with tips on how and when to take the medications, and what to do if you miss a dose.

Clinical Trials

  • ClinicalTrials.govLink will take you outside the VA website. VA is not responsible for the content of the linked site.
    ClinicalTrials.gov provides regularly updated information about federally and privately supported clinical research in human volunteers. Site gives information about a trial's purpose, who may participate, locations, and phone numbers for more details.

Treatment Side Effects

Challenges When in Drug/Alcohol Recovery

  • Alcoholics AnonymousLink will take you outside the VA website. VA is not responsible for the content of the linked site.
    A.A. World Services, Inc.
    P.O. Box 459
    New York, NY 10163
    (212) 870-3400
  • Narcotics AnonymousLink will take you outside the VA website. VA is not responsible for the content of the linked site.
    World Service Office in Los Angeles
    P.O. Box 9999
    Van Nuys, CA 91409
    (818) 773-9999