Download Guidelines for ongoing patient management

Guidelines for ongoing patient management
As part of an ongoing management and support plan for patients with hepatitis C, there are a
number of ways in which referring practitioners can manage their patients irrespective of
whether they chose to undertake treatment or not. These strategies have been divided into
the following sections:
Symptom management
alcohol usage
complementary therapies
psycho-social considerations
diet
other potential hepatotoxins
vaccinations
referral.
Symptom management
Patients with hepatitis C who have never had hepatitis C treatment can experience a broad
range of non-specific symptoms that are not dissimilar from many other illnesses. Symptoms
attributed to hepatitis C include:
Fatigue– both physical & mental
nausea
irritability
myalgia
depression
fever
headache
sleep disorder
abdominal Pain
forgetfulness
Complementary therapies & herbal preparations
St Mary’s Thistle is the most popular alternative therapy used by patients with hepatitis C. It
has some anti-oxidant properties with studies showing its use leading to a reduction in liver
enzymes, although it shows no reduction in the hepatitis C virus. CH100 is another
alternative therapy consisting of extracts of 16 herbs. Controlled studies show that its use
improves liver enzymes, however no patients have been cleared of the hepatitis C virus.
Liver biopsies were not repeated in either of these studies to assess effect on the liver tissue.
Currently there is little evidence to show that herbal preparations cause harm over short
periods of time, although rarely there can be severe hepatotoxicity associated with herbal
therapies.
Diet
Patients should be encouraged to eat a standard healthy diet. Nutritional supplements are
not necessary if diet is balanced, with a good intake of protein and fresh fruits and
vegetables. Studies have shown that obesity increases liver damage. This occurs because
there is an association between obesity and fat accumulation in liver cells (steatosis).
Steatosis appears to cause more scar tissue and is more common with genotype 3 infection.
Weight reduction (diet and exercise) in overweight or obese people with hepatitis C virus will:
Hepatitis Primary Care Resource Package
www.som.uq.edu.au/hivandhcvprojects
Last updated in March 2007
Last updated 2011
Guidelines for ongoing patient management
1) reduce hepatic steatosis 2) arrest or reverse liver fibrosis (Hickman et al, GUT (2002)
51(1): 89-94
Vaccinations
There is no vaccine for hepatitis C. All patients with the hepatitis C virus should be offered
hepatitis A (HAV) and hepatitis B (HBV) vaccination if they are not immune, to prevent further
liver damage from these infections.
Alcohol usage
Alcohol consumption increases hepatitis C virus replication. It also appears to accelerate the
progression of liver disease to cirrhosis (Corrao G & Arico S, Hepatology Vol 27 No.4 pages
914-919 1998). Reducing alcohol consumption can improve liver enzymes levels and reduce
hepatitis C viral load. Recommendations should be consistent with NHRMC guidelines; that
people with hepatitis C should consider drinking alcohol infrequently. If a patient has
concerns about alcohol dependency their referring practitioner can consider referring them to
an alcohol & drug treatment service.
Psycho-social considerations
A hepatitis C virus infection may occur in the setting of a lifestyle that involves a number of
potentially harmful behaviours including significant alcohol or drug use. Hepatitis C is more
prevalent in a number of marginalised communities: including people suffering from mental
illness; people who were born in areas of high endemicity; and people who have been
incarcerated in prisons. Patients with the hepatitis C virus may therefore have a range of
psychosocial issues and may benefit from having these explored and addressed.
Other Potential Hepatotoxins
Iron accumulation is common in hepatitis C patients usually at the upper end of normal
range. Some studies suggest that increased iron accumulation causes more scar tissue in
hepatitis C infected patients, although the benefits of reducing mild overload are not clearly
established. Venesection is not recommended in the absence of haemochromatosis.
Cigarette smoking may increase fibrosis in people with hepatitis C. Preliminary data suggests
marijuana may also increase hepatic fibrosis and scarring. There is very little data available
regarding the effects from amphetamine, opiate, and ecstasy usage, on hepatitis C. Although
it is rare, amphetamines and ecstasy can cause severe liver disease.
Hepatitis Primary Care Resource Package
www.som.uq.edu.au/hivandhcvprojects
Last updated in March 2007
Last updated 2011
Guidelines for ongoing patient management
Referral
Referral options can be discussed with hepatitis C patients including:
Trained hepatitis C counsellor
queensland Injectors Health Network (QuIHN)
hepatitis Queensland
psychiatrist or Psychologist
dietician
alcohol and drug treatment service
specialist in hepatitis C
oral Health specialist
complementary or alternative therapist experienced in hepatitis C management.
Hepatitis Primary Care Resource Package
www.som.uq.edu.au/hivandhcvprojects
Last updated in March 2007
Last updated 2011