Hepatitis C (and Aging)

Martine Stomp RNHepatitis C Treatment Nurse

Sanguen Health Centre

Hepatitis C: History

• 1940’s –Occurrence of hepatitis after transfusion of prison-sourced blood.

• 1950’s –Named “non-A non-B”hepatitis.• 1989 –Hep C virus identified. Specific antibody

tests for Hep C developed.• 1990 –Screening of blood supply in Canada

introduced.• 1995 –Hep C virus is first seen using electron

microscope.

U.S.A. 4 M

SOUTHAMERICA10 M

AFRICA 32 M

EAST MEDITERRANEAN20M

SOUTH EAST ASIA30 M

AUSTRALIA0.2 M

SOURCE, WHO 1999

WEST EUROPE 9 M

FAR EAST ASIA60 M

170 Million Carriers Worldwide, 3 - 4 MM new cases/year

3% of World Population

HCV: A Global Health Problem

CANADA 300,000

Hepatitis C in Canada

• Estimated 300,000 HCV infections in Canada

• 110,000 in Ontario (1 in 170 people)

• 5,000 in Waterloo/Wellington

Risk Factors for HCV

• IDU• Travel to/residence in endemic countries• Sharing equipment for inhalation drug use• Tattooing/ body piercing• Sharing personal hygiene items• Street involvement• Incarceration• Sexual/perinatal transmission• Occupational blood exposure• Contaminated blood products

Distribution of mutually exclusive risk factors for newly-acquired HCV infection among cases with known risk factor information in EHSSS,

2004-2008

PHAC. Epidemiology of Hepatitis C Infection in Canada. Results from the EHSSS. 2008

Natural History of Hep C

Adapted from Lauer and Walker, NEJM 2001

Healthy Liver

Acute Infection

Chronic Infection

20% Clear the

Virus

80% Virus Continues to Damage

Liver

Only 20% willshow symptomsInitially !

Natural History Con’t

ChronicHepatitis

Cirrhosis20-30%

LiverCancer

1-4%/year

Most symptoms begin to show only when liver is more severely damaged

Signs and Symptoms• Individuals may have one or more of the

following symptoms, while others experience no symptoms:

–Tiredness–Nausea–Muscle or joint pain–Trouble sleeping–Loss of appetite

–Weight loss–Abdominal pain–Itchiness–Depression–Dark urine

Hep C Treatment

Goals of Therapy

Primary objective =

cure

• No virus1

• Stop progression

(necrosis/fibrosis)

• No symptoms

Secondary objective =

delay/prevent

• Reduce progression of fibrosis1

• Reduce progression to cirrhosis2

• Prevent decompensation

• Prevent HCC2

1. Worman. Hepatitis C: Sourcebook 2002. 2. Peters et al. Medscape HIV/AIDS eJournal. 2002;8(1).

Therapy for Chronic Hepatitis C before November 2011

• Best results with combination Pegylated IFN plus Ribavirin

• Two pegylated IFN products available: Peginterferon alfa-2a (Pegasys©) Peginterferon alfa-2b (Pegetron©)

• Hep C treatment can be problematic for former users because of the possibly triggering effect of the injections.

Treatment duration varied according to genotype and mono- or co-infection

24 weeksHCV mono-infected, genotype 2 or 3

48 weeksHCV mono-infected, genotype 1 or 4

48 weeksHIV/HCV co-infected (regardless of genotype)

Cure Rates before November 2011

HCV Genotype 1: 40-50%HCV Genotype 2: 80-90%HCV Genotype 3: 70-80%HCV Genotype 4: 60-70%

Since November 2011

Triple therapy for genotype 1:Pegylated Interferon, Ribavirin and a protease inhibitor (Boceprevir/Telaprevir)

Treatment length depends on the following factors:• Previously treated or never treated before• Previous response to treatment ( if previously treated)• Response to current treatment• Amount of liver damage

Protease Inhibitors

Boceprevir Telaprevir

Treatment with PI’s

Pros

• More effective• Shorter treatment

duration possible

Cons

• High pill burden• Additional side-

effects

Additional Issues

• Limited coverage• Not straight forward

(Regimen differences/Algorithms)

• Drug/Drug Interactions• Timing of medications• Adherence/Resistance

Side-effects

• Fever/Chills• Muscle & Body Aches• Headaches• Fatigue• Depression• Anxiety• Irritability• Insomnia• Dry Mouth/Ulcers

• Bad Taste in Mouth• Poor appetite• Nausea/Vomiting• Diarrhea• Cough• Dry Skin/Rashes• Injection Site Reactions• Ano-rectal discomfort• Anaemia

Factors Affecting Treatment Response

• HCV genotype 1• High viral load • Increasing fibrosis • Being male • Black race

• Age > 40 years • Insulin resistance• Steatosis• Renal failure• High BMI

The Aging HCV Patient

• Most of the older adults with chronic hepatitis C virus infection acquired the disease earlier in life

• They often present with complications of liver disease like cirrhosis and HCC

• Chronic infection is prevalent and may be more severe in the elderly population

• Persons <20 years old at time of infection progress very slowly during the subsequent 10 years, whereas for those aged >50 years, fibrosis progression is rapid.

The Aging HCV Patient Cont’d

• The burden of chronic hepatitis C virus infection in elderly persons is expected to increase significantly during the next 2 decades

• The management of chronic HCV infection in older adults is complex in terms of comorbidities and quality of life.

• Hepatitis C is the leading cause of both liver transplantation and hepatocellular carcinoma (HCC, liver cancer)

Cognitive Impairment

• Chronic HCV infection is associated with cognitive impairment, which is reported in patients aged 28–69 years with mild liver disease.

• The prevalence of cognitive impairment among older patients may be higher as they might have a higher susceptibility to this complication.

• Because depression, fatigue, and cognitive impairment are common among the general elderly population, they may be overlooked in those with HCV infection or may not attributed to the disease.

Healthy Aging with HCV

• Cultivate a positive attitude• See your doctor for regular check-ups• Get protection from the flu, pneumonia and hepatitis A

and B. Talk to your doctor or nurse about immunization for these conditions

• Be careful about mixing any drugs especially with alcohol

• Eat a healthy and well-balanced diet• Talk to your doctor or nurse about whether you need

to be treated for hepatitis C

Healthy Aging with HCV Cont’d

• Keep physically fit. Ask your doctor about an exercise program that is right for you.

• Maintain a healthy diet. Eat a low fat, low cholesterol, low sodium high-fiber diet with lots of fruits and vegetables. Try to lose weight sensibly if it’s advised

• Aim for 7 to 9 hours of sleep every night• Learn to manage stress• Drink generous amounts of water – 6 to 8 glasses a day• Seek support. Join a support group. Maintain friendships and

social contacts• Engage in activities that actively stimulate your brain• Maintain a sense of humor

Questions?

Thank You!

Martine Stomp RNSanguen Health Centremstomp@sanguen.com

www.sanguen.com