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Viral Hepatitis

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Hepatitis C Medications: A Review and Update for Patients

Hepatitis C medications: A review and update for patients

How is hepatitis C treated?

Patients sometimes ask whether there are ways to treat hepatitis C other than taking medicines. There are no vaccines to prevent hepatitis C, and once a person is infected, the only way to treat it is with drugs. Some patients worry that having hepatitis C means they will need a liver transplant. Although a fraction of people with hepatitis C do require a liver transplant, most people with hepatitis C do not. A transplant is performed only when damage to the liver is extremely advanced and the liver is unable to perform its basic functions. A transplant provides a new liver, but a transplant does not actually cure hepatitis C. It does not get rid of the virus.

Until recently, there were only two drugs approved for the treatment of hepatitis C (pegylated interferon and ribavirin). These medications are taken for a limited period of time, not lifelong. In May 2011, the U.S. Food and Drug Administration (FDA) approved two new drugs: boceprevir (Victrelis) and telaprevir (Incivek). In 2013, they approved sofosbuvir (Sovaldi) and simeprevir (Olysio).

You will be given a treatment regimen based in large part on your genotype, your subtype (for example, 1a or 1b), your treatment history (whether you were ever treated before), your stage of liver disease (if you have cirrhosis or do not have cirrhosis) and any other medical issues which may be related to the choice of drug.

What is the reason to use medications for hepatitis C?

The purpose of using medications for hepatitis C is to:

  • remove (or clear) all the hepatitis C virus from your body permanently
  • stop or slow down the damage to your liver
  • reduce the risk of developing cirrhosis
  • reduce the risk of developing hepatocellular carcinoma (HCC)
  • reduce the risk of decompensating if you already have cirrhosis

Most patients with hepatitis C usually do not have any symptoms, and the drugs for hepatitis C virus are not intended to manage any symptoms (such as fatigue or abdominal pain) that they do have.

What medications are available for hepatitis C?

Interferon

Interferon is a medicine that helps your body's immune system to attack infected liver cells and to protect healthy liver cells from new infection. Pegylated interferon is taken by injection once a week.

Ribavirin

Ribavirin is a medicine that can fight certain viruses, though, by itself, it does not work against hepatitis C. It is taken in pill form and in combination with pegylated interferon.

Sofosbuvir

Sofosbuvir is an antiviral drug. It works directly on the hepatitis C virus itself to stop it from replicating. It can be taken with any genotype of hepatitis C. It can be taken for HIV-HCV coinfection. This drug can be taken either with or without interferon--and can be combined with simeprevir, another antiviral. In clinical trials, sofobovur is also being studied in combination with other antivirals. Sofosbuvir can never be taken alone.

Simeprevir

Simeprevir is an antiviral drug. It works directly on the hepatitis C virus itself to stop it from replicating. It can only be taken for genotype 1 infection. It can be taken with pegylated interferon and ribavirin. It can also be taken with sofosbuvir--though this combination is not FDA approved currently. When taken with sofosbuvir, there is no interferon used.

Boceprevir and telaprevir

Telaprevir and boceprevir are anti-viral drugs. They can only be taken for Genotype 1 infection. They work directly on the hepatitis C virus itself to stop it from replicating. These drugs cannot be used together, and they each must be taken in combination with pegylated interferon and ribavirin.

How long is the treatment?

Treatment duration is changing. Most of the regimens with sofosbuvir are for 12 weeks, though there are exceptions. Treatment duration with simeprevir, interferon and ribavirin is for 24-48 weeks. Future regimens may potentially be shorter than 12 weeks.

How likely is it that the treatment will work?

Patients who have never taken medications to treat their hepatitis C are called "treatment naïve."

For patients who have taken medications, there are 2 main types of response to treatment:

Sustained virological response

This means that the treatment worked while you were taking the medicine and continued to work even after you stopped taking it. Sustained virological response (SVR) means no virus is present in the blood 3 months after the medications have been stopped. Studies have shown that patients who achieve an SVR almost always have the virus undetectable (absent) for years, for as long as the studies have followed them.

  • Rapid Virological Response

    At 4 weeks into treatment if the virus is undetectable or has dropped 2 logs then this is a Rapid Virological Response. It is very likely that if a patient has an RVR that they will also have an SVR.

  • Early Virological Response

    At 12 weeks into treatment if the virus is undetectable or has dropped 2 logs then this is an Early Virological Response. It is very likely that if a patient has an RVR that they will also have an SVR

  • End of Treatment Response

    At the end of treatment (usually 24 or 48 weeks depending on planned course) if the virus is undetectable then this is an End of Treatment Virological Response. After the End of Treatment response, treatment is stopped and virus is measured for the next 6 months for any evidence of relapse.

Relapse

The treatment worked to achieve no detectable virus while the medications were present, but after the drugs were stopped, the virus was found again in the bloodstream.. The medicine and your immune system were able to clear the virus for a time, but could not do so completely. When you stopped taking the medicine, the hepatitis C virus came back.

Nonresponse

The treatment did not remove (or clear) the virus from your blood by 24 weeks and if it was continued did not clear the virus by 48 weeks.

Factors that affect treatment results

Not everyone will have the same results from hepatitis C treatment. The following are some things that can affect how the treatment works:

FactorEffects
Viral loadThis is the amount of virus in your blood. If you have lower levels of virus in your blood when you start treatment, you may have a better chance of getting rid of the virus. Having a high viral load does not mean you have worse liver damage but it is harder to get rid of the virus with treatment.
Ongoing use of alcoholStudies have found that patients who continue to drink alcohol regularly during treatment have lower rates of clearing the virus.
EthnicityStudies in the United States have shown that African American patients have lower rates of clearing the virus than do Caucasian patients, though the Newer regimens are showing fewer differences between ethnic and racial groups.
Length of infection You may have a better chance of clearing the virus from your body if you haven't been infected with the hepatitis C virus for very long.
Adherence (taking medications as prescribed)Adherence to prescribed medications can be challenging but is a very important part of making sure the treatment works. Studies have shown that patients who receive adequate doses of interferon and ribavirin have much higher rates of clearing the virus.
ObesityA number of studies have shown that patients who are overweight have lower rates of clearing the virus. If you are overweight, losing some weight prior to treatment may make the medications more effective.
HIV coinfectionIn the past, before direct-acting antivirals (DAAs), studies of patients with HIV-HCV coinfection showed that treatments have a much lower success rate in coinfected patients compared to HCV patients without HIV. With studies of sofosbuvir in HIV-HCV infected patients, success rates were much higher and comparable to the success rates for patients without HIV infection.

Expected treatment results

Your response to treatment depends on several factors, such as what genotype you have, age, race, weight, extent of liver damage, amount of virus in the blood (viral load), whether you have HIV infection, and whether you were treated in the past and did not have a successful response. In general, all patients treated for the first time have around a 60-80% chance of being "cured."

How will your doctor monitor you during the treatment?

Laboratory tests help keep tabs on your health during treatment. You will have frequent lab tests while you are being treated.

Here are 2 lab tests that can be done to give some information about whether the treatment is working:

ALT level (alanine aminotransferase)

This test measures the amount (or level) of an enzyme called ALT that is made in liver cells. If liver cells are damaged or die, ALT leaks into the bloodstream. One goal of treatment is to bring high levels of ALT back to normal.

If the treatment is working, ALT levels often come down to normal. If the ALT level decreases quickly in the treatment process, this is a positive factor in the response to treatment.

Viral load (hepatitis C virus ribonucleic acid level or hepatitis C RNA level)

This test measures the amount of hepatitis C virus in your blood. Treatment for hepatitis C is aimed at reducing the viral load, and specifically at making it negative (undetectable). "Undetectable" means that no virus is currently present in your blood. Your doctor will check your viral load approximately every 4 weeks while you are on treatment, but possibly more often than this.

For more information, see Understanding Lab Tests.

Coping with side effects

Side effects are a major issue with hepatitis C medications. It is very hard to predict which patients will experience which types of side effects. Almost all patients have a few side effects. Some are mild and don't last long. Some are more significant, require attention, and persist through the course of treatment. Side effects go away after treatment is stopped. Pegylated interferon has many potential side effects. The side effects are similar to the potential side effects of standard interferon.

Possible side effects of various hepatitis C drugs

Pegylated or standard interferon

  • Fatigue
  • Flu-like symptoms
  • Mood changes
  • Drop in platelet count (thrombocytopenia)
  • Drop in white blood cell count (leukopenia)
  • Drop in neutrophil count (neutropenia)
  • Loss of appetite
  • Nausea or change in bowel habits
  • Weight gain or weight loss
  • Hair loss
  • Changes in thyroid function
  • Increase in blood sugar level
  • Disturbed sleep (insomnia)

Ribavirin

  • Drop in red blood cell count (anemia)
  • Sore throat
  • Cough
  • Shortness of breath
  • Rash
  • Birth defects (harm to embryo or fetus of pregnant patients)

Sofosbuvir

  • Fatigue
  • Headache
  • Nausea
  • Insomnia

Simeprevir

  • Sun sensitivity
  • Dry skin/rash

Boceprevir

  • Impaired sense of taste
  • Anemia

Telaprevir

  • Rash
  • Anemia
  • Itching
  • Nausea

General recommendations on side effects during treatment

Here are some things you can do to make sure that your hepatitis C treatment works best:

  • Always follow your health care providers' advice, particularly the instructions on taking your medicine.
  • Take good care of yourself. Eat well, drink 8 to 10 glasses of water each day, and try to get a full night's sleep.
  • Learn about the hepatitis C medications you are taking. This includes special risks and warnings.
  • Practice 2 forms of birth control while on ribavirin, and continue to use birth control for 6 months after the last dose of ribavirin before trying to conceive a child.
  • Practice 2 forms of "non-hormonal" birth control while on treatment that includes ribavirin.
  • Keep all your appointments with your doctor. If you have to cancel an appointment, call your doctor and schedule a new one as soon as possible.
  • Write down your doctor's name and phone number. Carry this information with you at all times.
  • Write the names and amounts of the medicines you are taking. Carry this information with you at all times.
  • Check with your doctor before starting new medicines. This includes vitamins, supplements, herbal remedies, prescription drugs, or other over-the-counter drugs.

Why would my doctor recommend that I wait and be treated in the future, but not now?

There are several reasons that your doctor may recommend treatment be in the future but not right now. One reason is that the new drugs for hepatitis C are newly being used--and although they have been used in clinical trials and scientific studies, in the real world and in real patients, these drugs can sometimes have slightly different outcomes. So, in patients who are not urgently needing treatment, it may be wise to wait and see how well these drugs are working in the real world before starting the treatment yourself. Another reason that your doctor may recommend waiting is that not all types of patients are getting the same results in clinical trials--and if your type of hepatitis C did not have the strongest results in the studies, then it may be wise to wait until one of the new regimens demonstrates the strongest possible outcomes in your type of hepatitis C.

What should I be doing now if I am waiting to be treated in the future?

  • having liver enzyme blood tests once or twice a year
  • going to regular doctor appointments
  • following your doctor's lifestyle recommendations such as avoidance of alcohol or tobacco, because reducing further damage to your liver is crucial
  • attaining or maintaining a healthy BMI
  • minimizing risk of steatosis with good control of diabetes and lipids

More information

For more information about hepatitis C treatment, see our patient tutorial, contact the Centers for Disease Control and Prevention (CDC) Hepatitis Toll-Free Information Line at 1-888-4 HEPCDC (1-888-443-7232), or visit the CDC website at http://www.cdc.gov/hepatitis/index.htmLink will take you outside the VA website..