Liver Specialists of Texas

Neutropenia (low white blood cells)

Tue, 18 Dec 2007 23:11:52 GMT

Similar to a drop in hemoglobin related to ribavirin, interferon caused a drop in white blood cells (WBC), manufactured in the bone marrow. Hite blood cells are used to fight infections in the body. If the WBC drops below an acceptable value, G-CSF (filgrastin) may be used. This stimulated the bone marrow to produce WBC, raising their value above acceptable limits. Similar to ribavirin, it seems beneficial to maintain the appropriate dose of interferon rather than dose reduce. If the WBC is below a critical level, therapy may be reduced or discontinued. G-CSF is associated with certain adverse reactions including skin rash, bone pain, muscle aches, and an exacerbation of psoriasis.

Anemia

Tue, 18 Dec 2007 23:11:34 GMT

Anemia is a very predictable complication of therapy, usually due to ribavirin. Ribavirin causes a hemolytic anemia, damaging red blood cells, which are later removed from the body resulting in the anemia. Symptoms of anemia include increasing fatigue, shortness of breath, lightheadedness, and dizziness. A significant complication of anemia is myocardial ischemia, which can lead to heart failure or a heart attack. For this reason, anemia is treated aggressively.

Reducing the dose of ribavirin usually results in a rise in hemoglobin and improvement in the anemia. This dose reduction in ribavirin may jeopardize the final result of therapy and a lack of viral clearance. It has been generally accepted to treat the anemia without reducing the dose of ribavirin. This is accomplished by making use of erythropoietin.

Erythropoietin is a protein naturally made in the body, which regulates red blood cell production in the bone marrow. It has been successfully manufactured nearly identical to the form in the human body and used in an assortment of conditions for the past 10 years. It is safe and well tolerated. It is very effective in treating the anemia seen with ribavirin use.

The use of erythropoietin not only increases hemoglobin, but also improves upon the fatigue reported in these patients. In most situations, the dose of ribavirin can be maintained, increasing the likelihood of clearing the virus. Blood transfusion is rarely required, but may be an option. Monitoring the effects of erythropoietin requires more frequent blood tests, usually on a weekly basis. Once erythropoietin is used, it is generally used the entire duration of therapy. It is given by weekly injection similar to the interferon.

Headaches

Tue, 18 Dec 2007 23:10:23 GMT

Minor headache complaints generally respond to remaining well hydrated and over the counter preparations such as acetaminophen and non-steroidal anti-inflammatory agents, such as ibuprofen. Patients that have a history of migraine headaches may find that there will be an exacerbation of these headaches once therapy with interferon and ribavirin begin. If they have been on prior therapy for these migraines it may be ineffective.

It will be recommended that in such situations, consultation from a neurologist or headache specialist will be required to continue on with anti-viral therapy. If such a specialist has already evaluated you, we will need to work closely with them to organize a specific plan of care for you.

Nasal Congestion

Tue, 18 Dec 2007 23:10:02 GMT

Nasal congestion is an uncommon complaint, but if present, can be annoying. Symptomatic relief can be obtained with over the counter medications, such as Claritin-D. Remain well hydrated, and avoid cigarette smoke and other nasal and sinus irritatants.

Nausea

Tue, 18 Dec 2007 23:09:45 GMT

Nausea on its own is difficult to treat. There are so many other causes for nausea that this complaint on its own may require a visit to the office. Results vary, but over the counter medications such as Zantac or Pepcid-AC may help. If not, we may recommend other prescription strength medications to reduce stomach acid. There are other classes of drugs that specifically address nausea, but as stated above, this may require a visit to the office for evaluation.

Mouth Ulcers

Tue, 18 Dec 2007 23:09:31 GMT

Some patients are prone to mouth ulcers, which can be rather painful. This may contribute to reduced calories and weight loss (see anorexia). My personal recommendation is to use Kenalog Orabase Dental Paste, which requires a prescription. There are other lesions that affect the mouth so it may require a quick visit to the office before we fill the prescription for you.

Heart Burn/Indigestion

Tue, 18 Dec 2007 23:09:14 GMT

Many patients develop an upset stomach during therapy. If they gave symptoms of gastroesophageal reflux (GERD), symptoms may get worse. Typically, over the counter agents work, such as Zantac or Pepcid-AC. Maalox or Mylanta may also alleviate symptoms. Prescription strength medications such as Nexium, Protonix, or Acifex may be needed. Avoid going to bed with a full stomach, and I recommend at least 4 hours after your last meal before going to bed.

Eye Complications

Tue, 18 Dec 2007 23:08:57 GMT

A baseline examination of your eyes is usually ordered prior to starting therapy with interferon, especially in patients with diabetes or hypertension. Be alert for changes in your vision and report them to the office. Changes may occur in the form of red eyes, blurred vision, eye fatigue, or the need for new prescriptions. It may be necessary to discontinue therapy.

Hair Loss

Tue, 18 Dec 2007 23:08:28 GMT

This is probably the most asked about side effect.

Hair loss is usually diffuse, but can be patchy. Thinning will resolve after therapy is completed.

Avoid excessive treatments to your hair, such as coloring, permanents, braiding, and ponytails. Reduce shampoo frequency where possible. Selsun Blue shampoo may reduce hair loss.

Shorter hairstyles may allow for more manageable hair. Satin pillowcases results in less pulling on the hair when you sleep and can contribute to less hair loss.

Diarrhea

Tue, 18 Dec 2007 23:08:10 GMT

Few patients complain of diarrhea. If present, it tends to be seen early in therapy.

Initial recommendations include increasing dietary fiber, with over the counter fiber supplements such as Metamucil or Citrucel twice daily. You can also try Kayopectate as directed. If diarrhea persists, or is associated with blood, fever, or abdominal pain, call the office immediately.

Loss of Appetite

Tue, 18 Dec 2007 23:07:52 GMT

This is another common problem patients encounter. Anorexia is a loss of appetite. This occurs due to multiple problems including a bad taste patients develop from the medication, resulting in a loss of appetite and desire to eat. Also, patients report bloating, and filling up quickly with meals. The total amount of food consumed is reduced, leading to fewer calories.

Consume smaller meals throughout the day. The era of "three square meals" should be put on hold during therapy. Plan your day to have 6 smaller meals/day. Don't skimp on breakfast. This should be your largest meal of the day.

Record you weight several times per week. If you are experience excessive weight loss, contact the office. We may need to adjust the dose of medication you are on, and see that there is no other reason for the weight loss. An evaluation by a dietitian may be needed.

Management of Dehydration

Tue, 18 Dec 2007 23:07:34 GMT

Patients on combination therapy frequently complain of dehydration. It cannot be stressed enough how important drinking enough fluids is. I prefer water flavored with fresh lemon or lime, rather than drinking excessive amounts of sport drinks such as Gatorade or PowerAde (both contain a lot of sugar). I recommend a minimum of 3 liters/day with a goal of four liters/day. Avoid drinking too close to bedtime, and reduce caffeine intake due to its diuretic effect.

How is skin itching (pruritis) managed?

Tue, 18 Dec 2007 23:03:22 GMT

Itching of the skin is also a common complaint reported with hepatitis C therapy. It may be localized or diffuse.
Try and change injection sites if itching develops.

Improvements with cool/wet packs to the area reduce the intensity of the itching.

Topical agents such as antihistamine creams, steroid creams, cool baths, skin lotions, medicated moisturizers, or calamine lotion should be tried.

How are flu-like symptoms managed?

Tue, 18 Dec 2007 23:03:05 GMT

Flu-like symptoms includes fever, chills, body aches, headache, fatigue, and possible nausea. These are EXPECTED complaints. The first few injections are usually the worst, and subside with time.
It is usually recommended that the interferon injection be taken close to bedtime.

Premedication with acetaminophen (not to exceed 3 grams/day) or ibuprofen 400 mg 1 hour before injection reduces symptoms.

Remain well hydrated, drinking 3-4 liters of water per day.

If a fever persists > 101 degrees, call the office.

How are the side effects of hepatitis C therapy managed?

Tue, 18 Dec 2007 23:00:13 GMT

Over the years, we have become much more aggressive in managing the side effects of interferon and ribavirin therapy. For the discussion of the web site, I will not be making a distinction between the commercially available products (Peg-Intron versus Pegasys) because their side-effect profiles are very similar.

The recommendations below are general guidelines that have been pooled from numerous sources and shown to work in most situations. The goal has been to reduce the side effects and make them more manageable, rather that expecting that they will be fully alleviated. Management of the side effects to treatment includes medical and psychiatric intervention, comfort measures, and possibly dose reduction.

Does everyone need a liver biopsy?

Tue, 18 Dec 2007 22:59:31 GMT

Because no two individuals have the same natural history, it is difficult to determine the extent of damage the liver has experienced. In many cases, the laboratory values and ultrasound images do not accurately determine the degree of fibrosis or scarring that is present. Additionally, the presence of symptoms (fatigue) does not correlate with liver damage. Because of these factors, I believe a liver biopsy yields the greatest amount of information to make subsequent decisions regarding treatment.

What is the natural history of hepatitis C?

Tue, 18 Dec 2007 22:59:08 GMT

The natural history is the expected course in a particular disease. In the majority of diseases, it is well known what will occur when someone has a disease and receives no treatment. Hepatitis C does not always follow a particular set of rules. It is estimated that if left untreated, hepatitis C has the potential to progress to cirrhosis in 15% of the cases over a 20-25 year span. Individuals who consume alcohol or have other diseases of the liver may develop cirrhosis in a shorter period of time. There are many factors that affect the natural history of hepatitis C, all of which need to be discussed with the patient.