hepatitis c treatment side effects management...

Hepatitis C treatment side effects management guide

hepatitis info line1800 703 003

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About this guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Maintaining a positive attitude . . . . . . . . 5Attitude........................................................................... 5

Support............................................................................ 6

Personal appearance.......................................................6

Exercise........................................................................... 6

Relaxation........................................................................ 7

Social events................................................................... 7

Other daily strategies..................................................... 7

Side effects that need urgent attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Side effects to watch for................................................ 8

Aches and pains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Flu-like symptoms......................................................... 9

Body aches...................................................................... 9

Headaches.................................................................... 10

Fatigue and sleep . . . . . . . . . . . . . . . . . . . . . . . . . . 11Fatigue.......................................................................... 11

Insomnia........................................................................ 12

Mental and psychiatric symptoms . . . 14Cognitive changes and difficulty concentrating....... 14

Depression, anxiety and other mood changes............. 15

Anxiety and depression............................................... 15

Symptoms of depression.............................................. 15

Help for anxiety and depression.................................. 16

Self help for mood changes.......................................... 17

Contents

Symptoms related to eating and nutrition . . . . . . . . . . . . . . . . . . . . . . . 18Nausea........................................................................... 18

Diarrhoea....................................................................... 19

Weight loss.................................................................... 19

Staying well hydrated................................................... 20

Changes in taste............................................................ 21

Mouth sores and ulcers................................................ 22

Dental hygiene.............................................................. 23

Skin, hair, nails and eyes . . . . . . . . . . . . . . . . 24Skin rashes and itching............................................... 24

Injection site reaction.................................................. 25

Nail changes................................................................. 25

Hair loss........................................................................ 26

Eye problems................................................................ 27

Blood deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . 27Haemolytic Anaemia.................................................... 27

Neutropenia................................................................... 28

Thyroid disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Hypo- and hyperthyroidism................................... 30

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Libido changes........................................................ 30Sex............................................................................ 30Mentrual and menpausal irregularities................. 31Words for family and friends................................... 31Depression, anxiety and irritability........................ 31

Resources and support . . . . . . . . . . . . . . . . . . . 32

hepatitis info line 1800 703 003

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Concerned about side effects? call...

Information in this guide is designed to help youunderstand and manage hepatitis C treatment sideeffects and is not intended as medical advice. We recommend that you use this resource as areference guide to look up your hepatitis Ctreatment side effects as they occur and to learnwhat you can do to effectively manage them. Alsoremember not everyone on treatment has all theseside effects.

If you are at any time concerned about your sideeffects while you are on hepatitis C treatment werecommend that you contact your treatmentspecialist or hepatitis C nurse as soon as possible.

People with hepatitis C should consult their doctor or liver specialist for diagnosis, ongoing medicalmanagement of their condition and treatment ofhepatitis C.

Some sections in this guide are excerpts fromCoping with Depression and Hepatitis C, which waswritten by Lucinda Porter, RN and Eric Dieperink,MD and published by the Hepatitis C SupportProject, San Francisco. All excerpts have beenadapted in line with Australian health promotionguidelines and terminology.

Hepatitis Victoria gratefully acknowledges theHepatitis C Support Project, San Francisco, for kindly allowing us to use their resource.www.hcvadvocate.com

Revised and distributed by Hepatitis Victoria – June 2010

Address:

Suite 5, 200 Sydney Road, Brunswick 3056Telephone: (03) 9380 4644Email: [email protected]: www.hepvic.org.auHepatitis Infoline: 1800 703 003

About this guide

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Treatment for hepatitis C has dramatically improvedin the past few years with the introduction ofpegylated interferon plus ribavirin combinationtherapy and with the development of ‘responseguided therapy’. It is now possible to eradicate thevirus in between 50% to 80% of people who receivehepatitis C treatment. However, treatment can havemany side effects which can lead to dose reductionor discontinuation of treatment for some people.

Successful hepatitis C treatment requires staying on the prescribed dose of medications for theprescribed period of time. Side effects that interferewith quality of life can hamper this goal, so it is important to manage side effects early, assertivelyand appropriately.

The good news is that the management oftreatment-related side effects has also dramaticallyimproved, which makes treatment easier to tolerate.Fortunately, there are many simple and practicalsteps you can take to avoid or reduce side effects.

This Hepatitis C treatment side effect managementguide provides useful tips to help handle the sideeffects of hepatitis C treatment. One of the mostimportant things you can do is to try to manage anyside effects before they become serious.

Remember that not everyone experiences the sameside effects, nor are all side effects necessarilysevere. In fact, some people may experience few or no side effects. However, it is important to beprepared for the worst, and hopefully yoursymptoms will be less severe and easier to manage.

Another important component of successful sideeffect management is to establish a good supportsystem prior to starting hepatitis C treatment. Peer support groups, family and friends can help peopleget through the most difficult times during hepatitisC treatment.

This information is designed to help you understandand manage your hepatitis C treatment side effectsand is not intended as medical advice. If you areconcerned about how you are feeling on treatmentor your treatment side effects you should contactyour treatment specialist and/or hepatitis C nurse.

Important NoteReport all side effects of treatment andsymptoms of illness to your hepatitis C nurse and/or treatment specialist as soon as possible. Treatment side effects should always be evaluated and managed by your healthcare professionals.

Foreword

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Maintaining a positive attitude while undergoinghepatitis C treatment may be difficult at times, butit is essential and should be at the top of your listfor side effect management.

There is no scientific data at this time to supportthe notion that a positive attitude will have animpact on hepatitis C or treatment outcomes.However, many people report that attitude was animportant part of staying on treatment.

Strive to maintain a positive attitude, but berealistic. No one can achieve perfection 100% ofthe time. A positive attitude is a process and not afinal goal. Do not set yourself up for failure. This isa time when you need to be gentle with yourself.

AttitudeHow do you maintain a positive attitude? There are many steps you can take. For example,before beginning therapy, make a list of thereasons why you are receiving treatment and read the list often.

Reasons to undergo treatment

• To improve your health.

• To live longer.

• To feel that you have done all that you can do.

• To be alive and well for your children, grandchildren, and loved ones.

• To experience life and all it has to offer.

• To simply get rid of the virus.

• To put hepatitis C and its treatment behind you.

• To reduce symptoms and increase your quality of life.

• To prevent liver cirrhosis and liver cancer.

• To help you reach personal and professional goals.

• To avoid being a burden to others.

Starting the day off with a positive attitude is oftenhalf the battle. When you wake up in the morning,try to think of something you are grateful for in your life. For example:

• I am grateful that I have the opportunity to take this treatment.

• I am grateful for the people in my life.

• I am grateful that I have a roof over my head and a bed to sleep in at night.

Try restructuring your thought processes. Substitutepositive thoughts for negative ones. Repeat them toyourself even if you do not believe them at first.

• Instead of thinking, I’m overwhelmed, say, I am doing the best I can.

• Instead of thinking, I’m tired, substitute, This will eventually pass.

• Instead of saying, I can’t do this,try saying, I can do this because it is only temporary.

In the evening, before you go to sleep, look back onyour day and define what made you feel better andwhat made you feel worse. Congratulate yourself forgetting through the day. Remind yourself that youare one more day closer to your goal of completingtreatment.

Maintaining a positive attitude


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SupportStaying positive while on treatment can be difficult if you do not have an established support system in place well before starting on treatment. Supportcan come from many sources, including family,friends, co-workers, healthcare providers andsupport groups.

If you do not already attend a hepatitis C supportgroup, consider joining one before startingtreatment. Talking to other people who are either on treatment or have completed it can be a greatsupport, and it will give you the best insight possibleinto what to expect on treatment. Call the HepatitisInfoline on 1800 703 003 to find out more about support groups.

Personal appearanceKeeping a positive attitude is easier when you takegood care of your body and appearance. When youlook good you generally feel better. If you wake upin the morning feeling achy and out of sorts you may feel better if you take some steps to stay wellgroomed. Starting your day feeling fresh can have a positive influence on your emotions for the entire day.

Try these strategies

• Shower or bathe daily. Spoil yourself with bathproducts that smell and feel good.

• Take care of your hands and nails.

• Moisturise, moisturise, moisturise.

If you experience hair thinning consider getting a different hairstyle that is attractive, easy tomanage and flattering. Not everyone experienceshair loss, but hair thinning is quite common.

• Brush and floss your teeth regularly.

• Men: shave or trim facial hair.

• Women: if you regularly use make-up, continue while on treatment.

• Get dressed even if you will be lying on thecouch. Choose comfortable clothing.

• Wear colours that make you feel good.

ExerciseExercise is one of the most important components of health maintenance, and this remains true duringhepatitis C treatment. Physical activity helps youstay positive and focused and improves yourgeneral well-being. Moderation is the key tophysical activity. Exercise comes in many forms.You do not have to spend an enormous amount ofmoney or run a marathon to stay fit.

Try low-impact activities such as:

• stretching

• walking

• hula-hooping

• swimming

• dancing

• gardening

• Yoga

• Pilates

• T’ai chi .

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RelaxationBeing on hepatitis C treatment can be stressful.Some people can become overwhelmed when theyneed to remember to take medications, deal withside effects, continue to work at a job and handlefamily responsibilities. It is important to build in timefor relaxation.

Try some of these strategies to help you relax

• Meditation: There are many types of meditation.Find one that suits you and practice it daily.

• Light a candle and listen to soothing music.

• Instead of holding your breath when you feelstressed out, try breathing in and out gently and slowly.

• Sit or walk in a place of natural beauty, such as a beach, forest, garden or park.

• Talk to a counsellor about learning a relaxationtechnique; try several different techniques untilyou find one that works for you.

• If you have a religious or spiritual belief, practiceyour preferred observances at least once a day.

Social eventsHepatitis C treatment-related side effects and the everyday demands of life can create someuncertainty about maintaining a social life. Berealistic when scheduling dates or appointments.The surest way to become depressed is to isolateyourself from family and friends. However, it isimportant to talk with family and friends beforestarting treatment so that they can understand andbe supportive if you need to cancel or adjust yourplans. Sometimes just the knowledge that you cancancel or leave a social activity early may helpreduce stress.

Try to relax and enjoy the time spent with friendsand loved ones.

Other daily strategiesEngage in activities that make you laugh. Choosecomedies rather than movies with painful orupsetting themes. Read the comics, watch sitcomsor do something else you enjoy. Use humour during difficult moments to get a better senseof perspective. Laughter may not be ‘the bestmedicine,’ but it sure helps. Indulge in a favouritehobby. Most of all – learn to pamper yourself, andlet other people pamper you too.


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Side effects to watch forIt is important to know the symptoms of the mostserious side effects. Call your treatment specialist or hepatitis C nurse immediately if you experience:

• severe depression

• thoughts of harming yourself or others

• chest pain

• persistent fever or fever that continues to increase

• loss of vision or blurry vision

• difficulty breathing (some shortness of breathwith exertion is common with hepatitis Ctreatment but you should report any seriousdifficulty breathing)

• worsening psoriasis

• bloody diarrhoea

• unusual bleeding or bruising

• severe abdominal or lower back pain

• any symptom that might be potentially life-threatening or causes excessive anxiety.

Side effects that need urgent attention

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Flu-like symptomsInterferon is a natural chemical produced by ourimmune system. When we fight a cold or flu, we feel the effects of our own internal interferon: fever,chills, malaise, body aches, and headaches.Synthetic interferon (as used in hepatitis Ctreatment) causes the same effects. These flu-likesymptoms generally last for a few hours afterinjecting, but they may continue into the next day.Some people have flu-like symptoms after everyinjection, some will never have flu-like symptoms,others might have them only after their first injectionand some may have random symptoms.

Tips for managing flu-like symptoms

• Schedule interferon injections for just before bedtime.

• Do not schedule the first injection the night before a major event.

• Ask your treatment specialist or hepatitis C nurse if it is alright for you to take cold and flumedication. This may help alleviate some of theflu like symptoms.

• Drink sufficient water throughout the day beforeyour injection and throughout treatment.

• Put layers of blankets and clothes at yourbedside to manage chills.

• If your teeth chatter, remove dentures or otherbreakable dental appliances.

• Stay cool to reduce fever, but do not get chilled.Remove blankets or clothing, and use alukewarm sponge bath to provide relief.

• Get plenty of rest.

Remember that these initial reactions to themedication are usually only temporary (typicallylasting four to eight hours). Losing a good night’ssleep is not the end of the world. Don’t forget: youare investing in your future!

Body achesMuscle, joint and body aches are common sideeffects of interferon treatment. Some peopleexperience body aches throughout treatment, either intermittently or continuously.

There are several self-help measures you can try.Start by getting a proper diagnosis for the cause ofyour body aches or pain before beginning a self-help regimen. Many conditions can cause bodyaches, and a proper diagnosis is the first and mostimportant step in good medical care.

Some dietary supplements are purported to relieveinflammation and arthritis. Discuss this with aqualified naturopath and then advise your treatmentspecialist or hepatitis C nurse of all over-the-counteror complementary medicines you are taking.

Tips for managing body aches

• Ask your treatment specialist or hepatitis C nurse about the use of prescription and non-prescription medications to help with pain.

• Try gentle stretching exercises.

• Avoid prolonged periods of inactivity.

• Apply heat or ice packs.

• Try a warm bath. Spoil yourself with a bubblebath (Beware: hot baths can dry the skin).

• Massage may be helpful.

Aches and pains


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HeadachesAbout 60% of people experience headaches whileon treatment. Although in some cases the head -aches associated with treatment can be debilitating,most people find that they have mild headaches that come and go. If you experience a persistent or ongoing headache for more than 24 hours, contact your hepatitis C nurse or treatment specialistimmediately. There are many strategies to helprelieve headache pain. First, it is important to ruleout any causes other than treatment side effects that may be causing or contributing to a headache.Stress, insomnia, and diet can all induceheadaches. After ruling out other possible causes,there are some simple steps that may help preventthe occurrence or reduce the severity of a headache.

Tips for preventing headaches

• Limit caffeine intake by avoiding caffeinatedcoffee, teas and soft drinks, especially in the late afternoon or evening.

• Drink lots of water or other clear fluids.

• Avoid loud noises, bright lights and strongodours.

• Try to go to sleep and wake up at the same time each day.

• Eat all meals, especially breakfast, at roughly the same time each day.

• Pamper yourself during stressful times.

• Get moderate exercise regularly, at least three times per week.

• Don’t forget to play, relax and enjoy life.

• Try to find a pattern or the reason for theheadache, such as food, stress, or other trigger factors.

Talk to your treatment specialist or hepatitis C nurseabout over-the-counter or prescription medications.Never self-medicate as this can be a recipe fordisaster. Certain types of pain medication maycause ‘rebound’ headaches, which can be as badas, or worse than the original headache. If aheadache is already underway then try using one of the strategies that prevent headaches. It may stillhelp to alleviate the pain.

Tips for relieving headaches

• Depending on the type of headache, a cool dampcloth (or frozen peas) applied to the back of theneck or forehead may provide some relief. Someheadaches respond to warm compresses.

• Place a lavender-scented aromatherapy pillow on your eyes while you rest.

• Learn acupressure points for headache relief or see an acupuncturist.

• Try relaxation techniques; meditation, prayer or other religious/spiritual observances may help with the pain and stress that come with a headache.

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FatigueFatigue is a common side effect of treatment and a symptom of hepatitis C itself. Approximately 65%of people on treatment report fatigue side effects.Talk to your hepatitis C nurse or treatment specialistif this is a concern. Other medical conditions thatlead to fatigue may occur during treatment.Anaemia, depression, insomnia and hypothyroidismare side effects of treatment associated with feelings of exhaustion. These can all be treated.

Assuming you have already consulted your doctor,examine three important factors that influenceenergy levels: sleep, nutrition and exercise.

Sleep

Inadequate or poor quality sleep can lead to feelingsof daytime tiredness. Make sure you are gettingsufficient sleep. The average adult needs seven to nine hours of sleep per night.

Nutrition

Be sure to eat foods with high nutritional value.Fruits and nuts are good choices. Eat small,frequent meals. Make sure you are getting sufficientquantities of vitamins and minerals. Stay wellhydrated by drinking plenty of water. For theaverage adult, this means drinking up to 2 litres of water daily. If you have more advanced liverdisease, discuss your daily water intake with yourtreatment specialist or hepatitis C nurse.

Exercise

Light exercise is probably the single most effectiveantidote for fatigue. This can be hard to believe,especially if just getting out of bed is an ordeal.When you do not feel like moving, move anyway! As a popular advertisement says, ‘Just do it.’

Try exercising for 10 to 15 minute intervals, two to three times daily. If you are not accustomed tophysical activity, start slowly and for shorter, less frequent periods.

For exercise activities refer to ‘Exercise’ on page 6.

Tips for managing fatigue

• Stress can be draining – learn relaxationtechniques.

• Unmanageable pain can be exhausting – seekhelp to manage pain.

• Vary your activities e.g. do not sit too long orstand too long.

• Balance rest with activity – try to rest before youget too fatigued.

• Rest even if you are not tired. This may help youavoid future fatigue.

• Take short naps – no more than 20 minutes andnot close to bedtime.

• Take a shower – alternate water temperaturesfrom warm to cold.

• Practice good posture.

• Stretch.

• Avoid alcohol, tobacco and other drugs.

• Make sure your indoor space is sunny or well lit.

• Ask for help with chores and other activities.

• Create short cuts.

• Organise your work areas so you can work more efficiently.

• Schedule your most demanding tasks for the times of the day when you are usually at your best.

Fatigue and sleep


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• Take ‘mini vacations.’ Spend an afternoon doingsomething you really enjoy.

• Rub your earlobes for at least seven seconds.

• Find ways to laugh.

• Practice deep breathing for a minute wheneveryou feel tired.

Attitude cannot cure fatigue, but it can be a powerfulally. Watch the negative ‘self-talk’. When all elsefails, laugh! There is no doubt about it: fatigue puts a damper on life. However, fatigue accompanied byhumour is more tolerable than fatigue accompaniedby misery. The choice is yours.

There are also herbs, supplements and vitamins thatmay help relieve fatigue. However, opinion abouttheir use during hepatitis C treatment is divided asthere has been little research into this. Always see a qualified naturopath/complementary therapistbefore taking complementary/alternative therapiesand advise your treatment specialist or hepatitis Cnurse of all over-the-counter and complementary/alternative medicines you are taking.

InsomniaInsomnia, or having trouble getting to sleep andstaying asleep, is one of the most common sideeffects of treatment. Anyone who has ever sufferedfrom insomnia can attest to the fact that it can makeyou miserable. It may even make the other sideeffects of treatment worse. Start by talking to yourdoctor or treatment specialist. A variety of medicalissues can cause sleep problems. One example is sleep apnoea. Sleep apnoea interferes withbreathing during sleep and can cause serious healthproblems. People with sleep apnoea often do notknow they have it. Fortunately, sleep apnoea can be treated. Tell your doctor about any dietary

supplements and drugs you are taking (over-the-counter, prescription, or recreational). Some of thesemay be contributing to your sleep problems. Forinstance, ginseng and certain cold medicines cankeep people awake.

Getting too agitated before bedtime can also make ithard to fall asleep. Worrying can cause us to tossand turn. Watching the news or exercising beforebedtime can be overly stimulating. Sleep expertsrecommend leaving the TV out of the bedroom. Turn off the TV and your computer an hour or twobefore bedtime.

Things that can disrupt a good night’s sleep are:

• caffeine in coffee, soft drinks, tea and chocolate

• tobacco

• a room that is too hot or too cold

• light

• noise

• an uncomfortable bed

• using alcohol before bedtime

• being hungry

• eating a large meal close to bedtime

• drinking too many liquids before sleep

• a snoring bed partner

• a pet in the bedroom.

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Tips that can promote sleep

• Make eight hours of sleep a regular habit.

• Go to bed at the same time every night.

• If you have a clock that is always lit, turn it so you can’t see the time.

• Exercise every day.

• Keep daytime naps short and early in the day.

• Try reading before bedtime, but use a low-watt bulb.

• Do not eat during the few hours before bedtime,but don’t go to bed hungry. If you eat something,choose food that is light and nutritious. Avoidspicy or greasy foods.

• Have a warm bath before retiring.

• If you feel you need to worry, tell yourself that you will only worry in the daytime. Make yourbedroom a fret-free zone. Learn relaxationtechniques to reduce stress and worrying.

• Listen to relaxation tapes or relaxing music before retiring.

• Do not lay awake in bed for more than 20 or 30 minutes. Get up, do something boring for a little while, and then go back to bed.

• Your bed is for sleep and sex. If you are not doing either of these, stay out of bed.

Some herbal teas can be used to aid relaxation.Chamomile tea is one of the more widely used herbsfor sleep promotion. The downside of herbal teas isthat some people are awakened during the night bythe need to urinate. The scent of lavender on bedlinen or near the bed is thought to promoterelaxation.

If you use herbs to aid sleep, be very cautious.People with hepatitis C should avoid some herbs,especially while undergoing treatment. Alwaysconsult a qualified naturopath with experience ofhepatitis before taking complementary therapies.

If sleep problems persist, your treatment specialistor hepatitis C nurse may be able to prescribemedication to help you sleep. Both prescription andover-the-counter drugs can be very effective, but donot self-medicate. Some medications can be habit-forming. Always advise your treatment specialist orhepatitis C nurse about all medication taken duringtreatment. With sufficient and accurate informationyour treatment specialist is more likely to find amedication that is suited to your needs. If themedication you try does not work well for you, report this to your treatment specialist.


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Cognitive changes anddifficulty concentratingLoss of concentration, forgetfulness, and theinability to think clearly are frequently mentionedside effects of treatment.

Not everyone will have these symptoms, but if youdo talk to your treatment specialist or hepatitis Cnurse. Many factors can cause cognitive changes.Medication may help to alleviate some of theproblems.

Tips for managing concentration and cognition problems

• Be physically active on a daily basis. A combination of stretching, strength training,and aerobic activity is an ideal approach.

• Eat a nutritional diet. Fruits and vegetables,along with other high-value foods, can providenourishment for your brain. Do not skip meals.

• Drink sufficient water.

• Manage stress - meditation and relaxationtechniques can help you think more clearly.

• Avoid alcohol.

• Avoid or minimise illicit drug use.

• Get sufficient sleep. The average adult needsseven to nine hours of sleep each night.

• Breathe deeply to get oxygen into the bloodstream and into the brain.

• Stay mentally active.

• There are techniques you can use to improveyour memory. Libraries usually have books onmemory improvement.

Tips for remembering important things

• Use daily or weekly pill containers.

• Use a calendar or journal to record when you arescheduled to take medications as well as whenyou have taken them. You can also use this tokeep track of your medical appointments.

• Use a diary to record side effects and symptoms.Take the diary with you to medical appointmentsto refer to when you see your doctors.

• Use post-it notes to remind yourself of medicalappointments and medication schedules. Alwayskeep your lists in the same place.

• Set the alarms on your wristwatch, mobile phone, alarm clock, electronic organiser, orcomputer to remind you about medication and appointment times.

• Get yourself organised.

• Create habits and daily routines.

• Do one task at a time. Don’t multi-task.

• Pay attention to what you want to remember.

• Visualise what you wish to recall.

• Use repetition to fix a task in your memory.

Mental and psychiatric symptoms

Important Note: The diagnosis and treatment of psychiatricand other medical disorders requires a trainedmedical professional. Information contained in this guide is intended for educationalpurposes only. It should not be used as asubstitute for professional diagnosis andtreatment of any mental or psychiatricdisorder. Please consult a medical profess -ional if the information here leads you tobelieve you or someone you know may have a psychiatric or other medical illness.

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Depression, anxietyand mood changesThe prescribing information that accompaniespegylated interferon and ribavirin lists depression,psychosis, and suicidal thoughts among thepotential side effects. Agitation, mood alteration,aggressive behaviour, difficulty concentrating,mania, and bipolar disorder have also beenreported. In clinical trials, irritability, anxiety, andnervousness were reported by a third of people.

A person with bipolar disorder may have symptomsof depression, but no obvious symptoms of mania.However, the symptoms of mania may becomeapparent after starting medication for the treatmentof depression. Any symptoms of mania after startingantidepressants should be reported immediately.

Research suggests that insomnia occurs in 30% ofpeople while 65% experienced fatigue. Insomniaand fatigue are both symptoms of depression, andcan also cause or worsen depression and anxiety.Nervousness, insomnia, and fatigue may also besymptoms of other underlying disorders, such asthyroid abnormalities, substance abuse, or medication problems.

This section will describe some of theneuropsychiatric side effects of hepatitis C treatmentmedications so you can discuss them with yourtreatment specialist or hepatitis C nurse.

Important Note: Interferon may cause or aggravate life-threatening neuropsychiatric disorders. If youhave thoughts of suicide or hurting yourself or others, seek immediate professional help!

Anxiety and depressionDepression is one of the most common side effectsof treatment, reported by 20% – 30% of people inclinical trials. Some healthcare professionalsbelieve this percentage may be significantly higher.Depression may range from mild to severe. In trials,1% – 2% of people reported suicidal thoughts orattempts, and 2% stopped treatment prematurelydue to depression.

Most people think that anxiety and depression areopposite sides of the coin, but in fact, they oftenoccur together. Anxiety accompanies depression inclose to half of all depressed people. Sometimesreferred to as agitated depression, such people may have feelings of irritability, anger, restlessness,or of being “on edge.” Some people may report anincrease in worrying or have obsessive thoughts.

Symptoms of depressionThe symptoms of hepatitis C treatment-induceddepression are often similar to those seen in regular depression, and may include:

• feeling sad, ‘down,’ or ‘blue’

• fatigue or feeling apathetic or ‘empty’

• irritability or anger

• agitation, restlessness or feeling ‘on edge’

• mood swings

For people with a history of depression, interferoninduced depression may be experienced differentlyfrom a typical episode. For example, a person whopreviously felt withdrawn when depressed mightexperience feelings of anger and irritability duringhepatitis C treatment. It is important to recognisethese differences and report them to your treatment specialist.


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Help for anxiety and depressionIf you are considering hepatitis C treatment and have a current or past history of depression orpsychiatric illness you should tell your treatmentspecialist or hepatitis C nurse. You may be asked tosee a psychiatrist prior to starting treatment. It isespecially important to report severe depression,hospitalisation for any psychiatric illness or anysuicide attempts. Antidepressant medications canbe prescribed in conjunction with hepatitis Ctreatment. Many people say that antidepressantsmade a huge difference in their quality of life whileundergoing treatment.

Depression does not always start immediately afterbeginning treatment. Sometimes, people do notnotice depression until four to twelve weeks or evenlonger into treatment. If you notice any fatigue ormood changes such as irritability, lack of pleasure,or signs of depression after starting interferon, talkto your hepatitis C treatment specialist or hepatitis Cnurse as soon as possible.

It takes time for antidepressant medications to takeeffect, so do not expect immediate results. Whilesome people may notice improvement after a weekor two, antidepressants typically must be takenregularly for six to eight weeks before their full effectis felt. Starting antidepressants before beginninginterferon can help prevent depression or lessen itsseverity. Since antidepressants can help with othermedical complaints, such as fatigue and insomnia,some doctors routinely start people on thesemedications prior to initiating hepatitis C treatment.

Either talk with your hepatitis C treatment specialistabout whether you should start antidepressantsprior to treatment beginning, or start interferon firstand then talk with your doctor about whether youneed treatment for depression.

There are many different types of antidepressantmedication. Antidepressants themselves can causeside effects, but they are usually mild. However,some side effects can be serious; tell your doctorabout any side effects that are unusual, annoying or affect your activities or quality of life. Commonantidepressant side effects include drowsiness,headaches, nausea, feelings of agitation, feelingjittery and sexual problems. Sometimes a drug’sside effects can actually work in a positive way.Insomnia, for example, may be alleviated by anantidepressant that is slightly sedating.

Antidepressants can interact with certain drugs.Inform your treatment specialist or hepatitis C nurse about any over-the-counter or prescriptionmedications, recreational drugs, herbs, orsupplements you are using, since these may affect how your antidepressant works.

Important Note: Avoid or minimise alcohol, since it can worsen depression and may interact with antidepressants and reduce theireffectiveness.

The symptoms of interferon-induced depression andanxiety will usually fade away gradually after yourhepatitis C treatment has ended. People often waitfor a while after completing treatment before theyfeel ready to stop taking antidepressants.

When it is time to stop taking antidepressantmedications, people need to taper off slowly. Never stop a medication without first talking withyour doctor.You may notice increased anxiety anddepression after discontinuing antidepressants. Itmay take time before you feel life has ‘returned tonormal.’ Patience and support will serve you well.

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Self-help for mood changesFeeling unwell can lead to increased fatigue andmore depression. Breaking the cycle of depressionmay require a mind-body approach. There are anumber of ways you can help yourself. Thefollowing suggestions are not intended to replacemedical care or advice, but may enhance yourquality of life.

Tips for managing mood changes

• Get support. Look for a support group, either forhepatitis C or for depression or both. Ask yourfamily and friends for support; avoid isolation.

• Avoid or reduce stress. Try stress managementtechniques such as yoga and meditation, or takea stress management class.

• Try to be physically active every day. Even if you do not like to exercise, find a way to move your body.

• Get at least 7 to 9 hours of sleep each night.

• Avoid or minimise alcohol, tobacco, excesscaffeine, and other drug use as these can cause or worsen depression and anxiety.

• Eat a healthy low-fat, high-fibre diet that includesfruits, vegetables and whole grains.

• Balance rest and activity; pace yourself, takebreaks, plan ahead and delegate.

• Practice positive thinking. Try to replace negativethoughts with messages of hope and affirmation.

• Find ways to laugh and amuse yourself. Try topick at least one pleasurable activity and find thetime to do it often.


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NauseaNausea is a common side effect of treatment and ofhepatitis C itself. It may also be caused by stress,headaches, other viruses or bacteria, alcohol, lackof food and drink, or overindulgence in food anddrink. Regardless of the cause, nausea can have a serious impact on a person’s well-being andquality of life. It can also affect how you take your medications and even your willingness tocontinue treatment.

Nausea is typically described as feeling sick to thestomach, and the sensation can range from generalqueasiness to a strong urge to vomit. Vomiting is nota common treatment side effect so ‘bloody’ orpersistent vomiting requires urgent medicalattention. Try to figure out what triggers yournausea. The solution may be as simple as alteringyour eating and drinking habits.

Tips for controlling nausea

• If morning nausea is a problem, eat some drycrackers when you first wake up, and get out ofbed slowly.

• Avoid foods and odours that trigger nausea.

• Avoid spicy, deep-fried and greasy foods.

• Eat small amounts of food regularly rather thantwo or three large meals per day.

• Avoid acidic juices during periods of nausea (E.g. orange, grapefruit and pineapple). Instead,try clear juices, ginger ale, chicken broth, herbal tea or sports drinks.

• Drink and eat slowly.

• Consume foods that are at room temperature(neither very hot nor very cold).

• Use peppermint, chamomile, or ginger tea to help calm your stomach.

• Try raw or cooked ginger.

• Suck on ginger candy or lollipops.

• Try relaxation techniques.

• Exercise lightly (walking or yoga).

• Try acupuncture or acupressure.

If nausea improves to the point where you feel ableto eat, choose bland, easily digestible foods, suchas bananas, rice, apple sauce, toast, and tea.

If nausea is continuous, worsens or interferes withtaking your medications then contact your hepatitisC treatment specialist. There are many prescriptionmedicines to help treat nausea. It is important to beas proactive as possible so that you can focus onmaintaining your hepatitis C treatment.

DiarrhoeaDiarrhoea is defined as loose or watery stools thatoccur three or more times per day. It can lead todehydration, reduced quality of life and contribute tonutrient deficiencies. In addition to being a potentialside effect of interferon and ribavirin treatment, otherfactors can cause diarrhoea including bacterial andviral infections, drugs, certain foods or beverages,and anxiety.

Report severe diarrhoea to your hepatitis Ctreatment specialist immediately. Your doctor may recommend over-the-counter medication orprescribe a drug to treat diarrhoea. Do not self-medicate. Controlling diarrhoea is an important partof taking care of yourself. It will ensure that you stayhealthy and feel better, and will help optimise yourhepatitis C treatment outcome.

Notify your treatment specialist if you haveany of the following symptoms

• Severe diarrhoea that lasts longer than two days.

• Blood in the stool or around the anal area.

• Uncontrolled fever (fever higher than 38°C, or fever that lasts more than 24 hours).

• Severe stomach or intestinal cramping.

Symptoms related to eating and nutrition

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Tips for controlling diarrhoea

• Drink plenty of clear fluids to stay hydrated;water, weak tea or broth (vegetable, chicken or beef).

• Eat icy poles.

• Eat small frequent meals.

• Keep track of bowel movements.

• Consume foods that are high in potassium, such as bananas and potatoes.

• Stay away from high-fibre foods, such aswholegrain breads and cereals (while you have diarrhoea).

• Avoid spicy, deep-fried and greasy foods.

• Stay away from very hot or very cold foods.

• Abstain from alcohol, caffeine drinks and tobacco products.

• Choose bland and easily digestible foods:bananas, rice, apple sauce, toast and tea.

Diarrhoea can dry, chafe, and irritate the anal area.After a bowel movement, wash and rinse the areawith warm mildly soapy water or baby wipes and pat dry with a soft tissue or cloth. Apply a water-repellent cream around the anal area to help relievepain and irritation. A warm bath may relieve painand discomfort, as well as help you to relax.

Weight lossSevere weight loss can be a serious problem duringhepatitis C treatment. Many factors can contribute to weight loss. These include taste changes, nausea, vomiting, diarrhoea, depression and thyroid dysfunction.

Getting proper nutrition from a healthy diet is animportant part of maintaining your overall healthduring this time. A majority of people undergoingtreatment report mild to moderate weight loss.Unfortunately, the weight loss associated withhepatitis C treatment may be a combination ofregular weight loss and a reduction in body muscle mass. Getting some exercise is important as it increases muscle mass and stimulates the appetite.

The underlying causes of weight loss should beevaluated by your hepatitis C treatment specialist.

Tips for preventing weight loss

• Consult with a dietician or nutritionist forinformation on healthy food choices.

• Choose foods that are high in calories andprotein.

• Drink clear juices in addition to water for extracalories.

• Add powdered milk to regular milk, milkshakes,casseroles, soups, eggs, mashed potatoes, hotcereal and puddings.

• Spread peanut butter on bread, tortillas, waffles,pancakes, fruit and celery.

• Add cooked beans or hard-boiled eggs to soups,casseroles and pasta dishes that already containcheese or meat.

• Try products designed to promote weight gainsuch as nutritional supplements, cannedformulas, protein powders, instant breakfastdrinks, power bars, and high-calorie puddings.

If you have severe weight loss (more than 2 kilo’sper week), shortness of breath, or dizziness, consultwith your treatment specialist immediately.


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Staying well hydratedThe importance of drinking an adequate amount of water during hepatitis C treatment cannot beoverstated. Many of the side effects associated withinterferon-based medication can be greatly reducedsimply by drinking water.

Can you drink too much water? Yes. Drinking excessive amounts of water can affect thebody’s electrolyte balance, which could lead toserious health problems. Therefore, it is important tocheck with your doctor before dramaticallyincreasing the amount you drink every day.

The positive effect of drinking water on side effectmanagement is quite substantial. Many peopletaking hepatitis C treatment report that theyexperience a marked decrease in side effects ondays when they drink plenty of water, compared todays when they drink little or no water.

It is recommended that you drink water right beforeand after self-injection and stay well hydratedthroughout the week.

Drinking water benefits the body by:

• flushing out wastes and transporting nutrients

• regulating body temperature

• hydrating the skin and helping to reduce dry skinirritation caused by treatment medications

• lubricating the respiratory tract and helping torelieve coughing sometimes caused by ribavirin

• aiding the digestive system and preventingconstipation and other problems

• replacing fluids lost from vomiting or diarrhoea

• counters the reduction of natural salivaproduction (caused by hepatitis C treatmentmedication) which may lead to increased risk ofdental cavities and disease

• keeping your gums hydrated and rinseing awayharmful bacteria in the mouth.

Tips for drinking enough water

• Drink water before you feel thirsty. This will helpyou to stay well hydrated, since thirst is a sign ofdehydration.

• Drink water instead of caffeinated beveragessuch as soft drinks, tea, and coffee. Caffeinatedbeverages deplete the body of fluids, whichnecessitates drinking even more water.

• Keep water in places you frequent at home, in the office and in the car.

• Add a slice of lemon, lime, mint, ginger, orcucumber to add flavour to the water.

• Sip water throughout the day instead of gulping it,to give your body more time to absorb it.

Recommended daily fluids

Approximately six to eight glasses (at least 150mleach) of a variety of fluids can be consumed eachday. More than eight glasses may be needed forphysically active people, children and for people in hot or humid environments. Less water may beneeded for sedentary people, older people, peoplein a cold environment or people who eat a lot of high water content foods.

Sources of fluid

Fluids include fresh water and all other liquids likejuice, soft drinks, coffee, tea, milk and soup. Freshwater is the best drink because it does not containkilojoules. Milk is important (especially for children)and tea can be a source of antioxidants, whichappear to protect against heart disease and cancer.Fresh fruit is preferable to fruit juice because it hasmore fibre and nutrients and less sugar. Sweetdrinks should be limited because they add calories without nutrient value.

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Keeping track of your fluid intake

Numerous studies have measured the amount ofwater people drink daily. It has been shown that theamount of water most people drink each day ismuch less than they need to stay healthy and wellhydrated. Also, people usually drink less water thanthey think they do, because most people do notkeep track of their daily consumption. For thisreason, it is important to keep a record of how much you drink while you’re on hepatitis C treatment.

Tips for keeping track of water intake

• Fill a bottle with fresh water. Write down thevolume of water the bottle holds and how many times you refill it throughout the day.

• Buy commercial water bottles that list the fluidcontent. Fill up or buy enough bottles to meetyour daily requirement. Set the bottles in plainview to help you remember to drink all the bottles.

Changes in tasteChanges in the way foods and beverages taste is a real problem for many people on hepatitis Ctreatment. Some may describe this as having a metallic taste in the mouth. Other medicalconditions, such as a zinc or vitamin B12 deficiency,can also cause taste changes.

Taste changes can affect our social lives and over all health. To sustain wellness, it is important to maintain a healthy diet throughout hepatitis Ctreatment. Treat food as part of your medical regimen.

Report taste changes to your hepatitis C treatmentspecialist so they can rule out other causes.

Tips for managing taste changes

• Drink plenty of water.

• Eat with plastic, wooden, or porcelain utensilsinstead of metal ones.

• Use non-metallic cookware, such as glass.

• Add tart flavourings such as vinegar, lemon, lime or orange juice to your food.

• Eat cold foods rather than hot ones.

• Marinate meats to enhance or disguise flavours.

• Avoid strong foods and odours.

• Try foods that are high in protein, such as eggs,tofu, chicken, fish or nuts.

• Sample various dairy products, such as cheese,yogurt, cottage cheese or ice cream.

• Sorbet, sherbets, frozen fruit bars and smoothiesmay taste better to you.

• Flavour your food with horseradish or mustard.

• If a food does not taste good to you then take a break from it for a while.

• Try a new food or one that you did not like in thepast. You might find that you enjoy it while youare going through hepatitis C treatment.

• Eat crisp, cold foods, such as apples.

• Before eating, rinse your mouth with club soda,warm salt water, or a mouthwash made of ateaspoon of salt and a teaspoon of baking sodain 1 cup of warm water.

• Do not eat or drink flavoured foods, especiallycitrus, immediately before or after brushing your teeth.

• Take good care of your teeth: brush, floss andreceive regular dental check-ups.

• Some people report that eating just a small pieceof chocolate helps to eliminate the metallic taste.

Remember, your sense of taste will return after youhave completed hepatitis C treatment.


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Mouth sores and ulcersSome people complain of mouth soreness duringhepatitis C treatment. This may include sores orulcers on the gums, cheeks and tongue, possiblyaccompanied by redness. The medical term isAphthous Ulcers. Before treating mouth soreness,consult your doctor to obtain a proper diagnosis.Many factors can cause mouth sores, and it isimportant to understand what is causing the problembefore it can be treated.

There are remedies that can make mouth sores lesspainful or hasten their healing, but as with thecommon cold there is no reliable cure for AphthousUlcers. The exception is if your particular variety ofmouth sores is a symptom of an underlyingcondition, which can be remedied. Mouth sores that are associated with foodsensitivities, medications or nutritional deficiencies,can be treated if these conditions are resolved.

There are several home remedies you can try. Talkto your doctor about these suggestions.

Tips for preventing and relieving mouth sores

• Maintain oral hygiene. Be gentle when brushingyour teeth, but don’t avoid brushing.

• Avoid dental products that contain sodium lauryl sulfate.

• Use a soft bristle toothbrush.

• Drink lots of water. Adequate hydration isimportant for health maintenance, particularlyduring hepatitis C treatment.

• Do not drink excessively hot liquids. Ice or frozenjuice bars may soothe mouth sores.

• Try over-the-counter products which may providetemporary pain relief. Some products form a filmto cover mouth lesions, making them lessvulnerable to irritation.

• Maintain good nutrition by eating well. Discusswith your doctor whether you should take amultivitamin or other dietary supplement. (Somepeople suck on zinc lozenges, but there is nodata to support the effectiveness of this remedy).

• Avoid foods that are hard, crunchy, spicy, salty or acidic.

• Reduce stress.

• Keep a food diary to see if a particular food iscausing mouth sores. Try eliminating suspectedfoods.

• Swish, then spit or swallow a teaspoonful of anantacid such as milk of magnesia or Mylanta with a teaspoonful of liquid Benadryl four to sixtimes daily.

• Try tea. Black and some herbal teas are high intannin. A used tea bag placed on a mouth soremay provide relief.

• Consider taking an anti-inflammatory medicationsuch as Ibuprofen.

Important Note:

Always consult your hepatitis C treatmentspecialist before taking any pain medication.

• Infuse sage and chamomile in water and use as a mouthwash four to six times daily.

• Try raspberry, peppermint and liquorice.

• Try taking lactobacillus. These harmlessbacteria, sometimes called probiotics, are part of the natural intestinal flora. (Discuss this with your treatment specialist as it may not berecommended if you have a prosthetic heartvalve or valvular heart disease, asthma or anallergy to dairy products.

• Lysine may be beneficial for herpes-relatedmouth sores.

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Medication for mouth soresTalk to your doctor about prescription drugs if non-prescription remedies do not provide sufficient relieffrom mouth soreness. Depending on your particularcondition, there are a number of different choicesranging from oral medication to lotions used tolessen the discomfort of mouth sores.

Talk to your doctor if a herpes virus causes yourmouth sores. They may prescribe medication toprevent or lessen the duration and severity ofoutbreaks. Your doctor may also prescribe oralsolutions to be swished and either swallowed orspat out, depending on your particular condition.Pain killing solutions may also be applied to mouthsores for temporary relief.

If your doctor prescribes a medication that must beapplied directly to the mouth sore, do the following:dry the sore by gently dabbing it with a tissue, putthe medicine on a clean cotton swab and dab thesore with the swab. Do not eat or drink until themedication has had a chance to dry and form abarrier. Use all medications for the length of timeyour doctor advises.

Do not ignore mouth ulcers/sores that are verypainful or large, or those that recur, do not heal, orappear in clusters. Mouth sores may not seem to bea big deal, but those who have suffered throughthem know just how painful they can be. Reducingpain and controlling recurrences can helpimmensely and improve your quality of life.

Dental HygieneNot paying attention to your dental hygiene can lead to tooth decay, gum disease, mouth blisters,and other problems. People are encouraged to haveany necessary dental fillings, gum surgery and rootcanal surgery well before starting hepatitis Ctreatment. Natural saliva production decreasesduring treatment, which can lead to increased riskfor dental problems such as tooth decay andinfection.

Tips for maintaining good dental health

• Brush teeth regularly (before and after meals)with a soft bristle toothbrush.

• Floss on a regular basis, but be gentle so thatyour gums are not injured.

• Use saliva substitute products if necessary.

• Self-examine your teeth, gums, and all areas of the mouth frequently.

• Rinse out your mouth often, especially after meals.

• Suck on sugar free lollies, such as peppermint, to produce more saliva.

• If you can afford it, schedule an additional teethcleaning during hepatitis C therapy. If youregularly see your dentist twice a year, considergoing three times.


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Skin rashes and itchingIt seems like almost every person undergoinghepatitis C treatment develops some type of skinproblem. The most common is caused by ribavirin,sometimes called a ‘ribavirin rash.’ Skin problemsare usually not serious, but can be very annoying.Interferon can induce underlying autoimmune skindiseases such as psoriasis.

Consult with your hepatitis C treatment specialist ora dermatologist (skin specialist) if you develop skinproblems during treatment. It is even more importantto see a specialist if there is any redness, swellingor accumulation of fluid or pus, which could indicatean infection.

Interferon and ribavirin can cause dry skin so it is notsurprising that most people suffer from this sideeffect during hepatitis C treatment. Symptoms mayrange from mild dry flaky skin to severe skin irritationincluding bumps and blisters. The itching associatedwith rashes is usually mildly annoying. At itsextreme, itching can be so irritating that it interfereswith quality of life. Itching often tends to be worse inthe evening and may interfere with sleep.

Generally, skin rashes are not particularlydangerous, except in cases where infectionsdevelop from scratching. Avoid scratching; if youmust scratch, never use your fingernails or sharpobjects, since this can lead to infection. This isespecially important for people on treatment, sinceinterferon can lower the white blood cell count,which, in theory, can lead to a greater chance ofinfection.

Tips for combating dry skin and itching

• Avoid soap. Use non-soap cleansers instead.

• Try rubbing, vibration, or applying pressureinstead of scratching. A good thing to ‘scratch’with is an ice cube.

• Drink plenty of water or other clear fluids to keepyour entire body hydrated.

• Apply moisturiser immediately after a shower orbath before drying off with a towel. Creams aremore effective moisturisers than lotions.

• Apply moisturiser at least twice a day. Effectivemoisturisers include Vaseline Intensive Care,vitamin E cream, etc.

• Use only non-perfumed, mild bath and personalcare products.

• Avoid extremely hot showers and baths. Take an oatmeal bath to relieve itching and help with relaxation.

• Try baking soda or unscented bath oils for bathing.

• Apply cold packs (wrapped in a towel) to the skin.

• Whenever possible, wear loose fitting clothesmade from natural fabrics that breathe.

• Wear sunscreen to protect your skin from thesun. Look after your lips by using a lip balm thatcontains sunscreen.

• Get plenty of rest.

• Keep rooms ventilated and at a temperature between 16 and 21 degrees celsius.

• For mild itching or rashes, ask your doctor if youcan use topical hydrocortisone cream. Do not use hydrocortisone on your face or for prolongedperiods unless directed to do so by your doctor.

• Talk to your doctor about oral antihistamineswhich can relieve itching and also help with sleep problems.

Skin, hair, nails and eyes

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Injection site reactionsSome people experience a generalised skin reactionin the area where they inject interferon. If youexperience continued pain, swelling, irritation, orinfection at the injection site, consult your hepatitis Ctreatment specialist immediately. Fortunately, themost common injection site reactions are mild andmore of a nuisance than a serious problem.However, it is important to follow the necessarysteps to ensure that you are using the correctinjection technique.

Tips for safe injection

• Carefuly read the injection technique instructionsfound in the medication package insert.

• Wash your hands with soap and water before injecting to prevent infection.

• Make sure the medication is at room temperature.

• Wipe the injection area with an alcohol swab and let it dry for 10 to 20 seconds before injecting.

• The easiest and least painful areas to injectinclude the abdomen and thighs. Avoid injectinginto the waistline or too close to the navel.

• Rotate injection sites; use a different place eachtime you inject. Some people alternate betweenthe abdomen and the thigh to ensure they do notaccidentally inject in the same spot twice in a row

• Inject at a 45 – 90º angle.

• Do not massage the injection site.

• After injecting, cover the site with a sticking plaster.

• Clothing can irritate the injection site, so wear loose natural fabrics.

• Topical creams can help with minor irritations.

Nail changesHepatitis C treatment can affect your fingernailsand, to a lesser extent, toenails. Nails may becomedry and brittle. They may also develop ridges andmay break easily.

Tips for taking care of your nails

• Keep nails short.

• Use hand lotions and creams as often aspossible, especially after your hands have been in water.

• Wear gloves to protect your hands when doing chores such as dishwashing, cleaning,gardening or using chemicals.

• At bedtime, apply oils or thick creams (such asAveeno or Eucerin) to your hands. Smear extraon your nails. Wear cotton gloves while you sleep to protect your sheets and clothing.

• If you polish your nails, use gentle polishremovers. Better yet, avoid nail polish and other harsh nail products altogether.

• Use nail strengtheners and try buffing to bring out a shine.


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Hair lossSome hair loss is common for healthy people. Infact, the average person looses between 50 and 150 hairs each day. Hair loss can be caused bymany different factors, including heredity, harsh hair treatments, and various medical conditions.Interferon therapy can cause excessive hair loss(alopecia) and changes in hair texture. Suchchanges may occur all over the body, not just on the head. It is rare for a person on interferon to lose all of his or her hair or go bald, but manypeople notice that their hair is thinning, or that it isbecoming brittle and breaking off. Hair color maybecome dull and hair texture may change duringtreatment. Curly hair may even become straight or vice versa.

Treatment-related hair loss and changes in texturemay affect body image and mood, so it is highlyrecommended that people seek professionalpsychological support from a counsellor or from ahepatitis C support group. Talking with others whohave had a similar experience can be very helpful.

The good news is that hair loss and changes in hairtexture are only temporary. The hair will usuallygrow back after treatment is completed. Somepeople even report that their hair grows back fullerand thicker than before. It is important to know thatMinoxidil (Rogaine) will not work to counteractinterferon-induced hair loss. In fact, Minoxidil shouldbe avoided because it can irritate and dry out thescalp. Finasteride (Propecia) is also unlikely toprovide any benefit. Most people will havecompleted hepatitis C treatment by the time it takesFinasteride to start working.

Tips to reduce hair loss and related problems

• Do not wash your hair too frequently.

• Avoid the chemicals found in hair dyes and usenatural products. If you do use chemicals on your hair, choose the mildest products available.

• A short, layered haircut will make hair lookthicker and fuller.

• Keep your hair conditioned. Use moisturisers and detangling products.

• Use hair products that add body and texture.

• Avoid hair dryers, rollers, and curling irons.

• Comb and brush your hair less; choose a softbrush or wide-tooth comb.

• Do not ‘tease’ or ‘back-comb’ your hair.

• Use a sunscreen, hat, or scarf to protect yourscalp and hair from sun damage.

• Avoid hairstyles that could strain your hair, such as hair weaves or braiding.

• Sleep on a satin pillow.

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Eye problemsSome rare but serious eye problems can occurduring hepatitis C treatment, so early diagnosis andintervention is essential. Your treatment specialistshould evaluate any vision or eye problems.

Important Note:

A loss or decrease of vision requires immediate medical attention.

Some common eye problems caused by treatmentare not immediately serious. Dryness is one ofthese. Talk to your doctor about the use ofpreservative-free non-prescription artificial tears.Some people report that the quality of their eyesightdiminishes during treatment. This may be due to dryeyes, fatigue, normal ageing or medication. Again,talk to your doctor if this is a concern.

A baseline eye exam before you start treatment maysometimes be recommended. Your eyes shouldreturn to normal in the weeks and months followingthe end of treatment. Exceptions to this are changesdue to normal ageing and possibly some rare oruntreated medical problems.


Haemolytic AnaemiaRed blood cells carry oxygen to body tissues,providing fuel the body needs to stay alive andhealthy. The normal average life span of a red bloodcell is about 120 days; after red blood cells haveworn out, the spleen removes them from circulation.Haemolytic anaemia is a condition in which redblood cells are destroyed faster than the body canmake enough new ones to replace them. Ribavirincan cause haemolytic anaemia. It is estimated thatup to 22% of people taking pegylated interferon plusribavirin experience haemolytic anaemia. The likelihood of anaemia increases with higherdoses of ribavirin.

Symptoms

The most common symptoms of anaemia includeshortness of breath, fatigue, pale skin, chills, rapidheart rate, depression and reduced quality of life. If left unchecked haemolytic anaemia can lead tojaundice, dark urine and an enlarged spleen. Insevere cases it can lead to heart attacks. It isrecommended that you have a physical exam to rule out any potential heart problems before starting treatment.

Diagnosis

A simple blood test called a ‘complete blood count’measures various components of the bloodincluding red cells, white cells and platelets.Anaemia is diagnosed using two tests that measurered blood cells and their oxygen-carrying capacity:haemoglobin and hematocrit. A low haemoglobin or hematocrit indicates anaemia.

Treatment

There are two approaches to treating haemolyticanaemia: ribavirin dose reduction and use of agrowth factor hormone (erythropoietin) to promotered blood cell production.

Blood deficiencies

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Ribavirin-induced haemolytic anaemia cannot betreated by eating iron rich foods or taking iron orvitamin B12 supplements. Generally, ribavirin dosereduction or the use of red blood cell growth factorsare recommended when the haemoglobin level goesbelow normal ranges or if there is a significant dropin haemoglobin level over a short period of time.People with heart disease should be monitored very carefully when their haemoglobin level starts to drop.

Ribavirin may have to be discontinued if the drop in haemoglobin level is substantial. The generalrecommendation is to stop taking ribavirin orhepatitis C treatment altogether if the haemoglobinlevel drops below safe ranges. Some medicalexperts believe that ribavirin dose reductions shouldbe avoided, especially during the first 12 weeks oftherapy, since an adequate ribavirin dose helpsprevent relapse and improves the chances ofachieving sustained virological response (SVR).

NeutropeniaThe primary function of white blood cells is to fightinfection. There are many different types of whiteblood cells, such as neutrophils, lymphocytes,monocytes, eosinophils and basophils. Neutropeniais a condition characterised by an abnormally lownumber of neutrophils.

Decreased production or destruction of white bloodcells can also cause neutropenia. Some diseasescan cause neutropenia, including viral infections,tuberculosis, typhoid fever, and some bone marrowdisorders. Interferon and other medications can alsocause neutropenia. Neutropenia is a common sideeffect of conventional and pegylated interferon withor without ribavirin. Clinical studies have shown thatas many as 95% of people on treatment experience

some reduction in neutrophil count below the normal range. People taking pegylated interferonare especially at risk, with about 20% of peopledeveloping significant neutropenia.

Technically speaking, interferon boosts the immunesystem. The vast majority of people who developinterferon-induced neutropenia do not seem todevelop any serious infections. However, eventhough the risk of a serious infection is low, it is stillvery important that people be closely monitored toprevent severe neutropenia. Neutropenia is usuallymanaged by interferon dose reduction.

About one-fifth of people treated with pegylatedinterferon plus ribavirin require dose reduction dueto neutropenia. Since dose reduction is usuallyeffective, complete treatment discontinuation israrely necessary. The decision about how tomanage neutropenia is a complicated process thatrequires expert guidance from your treatmentspecialist.

Tips for avoiding infection

• Avoid crowds and sick people.

• Get a flu shot and other vaccines to protectagainst infections.

• Practise good hygiene and wash your handsfrequently.

• Use your elbows, shoulders or hips whentouching common public objects such as doorsand elevator buttons.

• Stay away from raw or undercooked eggs, poultryand shellfish.

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Hypo- and hyperthyroidism

Interferon may induce thyroid dysfunction (bothhypo and/or hyperthyroidism) and is seen in a smallproportion of people during therapy. Onset of thyroiddisorders may not always justify stopping treatment,but careful monitoring is recommended.

The antiviral effects of interferon depend ongeneralised activation of the immune system, but a genetic predisposition to thyroid auto-immunedisease is probably necessary for the developmentof thyroid disease during treatment.

Estimates of the prevalence of thyroid side effectsvary widely, from 1% – 35% of people receivinginterferon. The low end of the range is likely to be a substantial underestimate. Women are betweenthree and seven times as susceptible as men. Some researchers have suggested that hepatitis Cinfection may itself predispose a person to thyroiddisease, but population-based studies have notsupported this hypothesis.

Thyroid dysfunction during treatment is variable and may range from a few weeks to a few months.Treatment with beta-blockers is useful to controlsymptoms and corticosteroids can be helpful.Graves' Hyperthyroidism is relatively uncommon,and low doses of anti-thyroid drugs usually controlthis condition.

Except in the case of severe hyperthyroidism, it is usually possible to continue cautiously withinterferon treatment.

Consult your treatment specialist if you think youmay have thyroid dysfunction side effects.

Thyroid disorders


Libido changesPeople commonly report decreased sexual interestduring hepatitis C treatment. Additionally, certainantidepressant medications may decrease libido(sexual drive) and sexual performance. Interest willusually return to normal after treatment is completedand antidepressant medications are stopped.

Depression and fatigue may also dampen interest in sex. Men may have difficulty achieving ormaintaining an erection. Women may find thatintercourse is uncomfortable due to vaginal drynesscaused by interferon. Both men and women reportfeeling less attractive during treatment. Start bytalking with your doctor.

Many factors can contribute to sexual problemssuch as low thyroid hormone levels, other hormonalimbalances or the side effects from other medicationsso it is important to start with an accurate diagnosis.Medications are available to treat erection problems.If you are taking an antidepressant your doctormight switch you to a different medication that isless likely to affect your libido. Ask for a referral to a gynecologist, urologist or sex specialist if sexualproblems do not improve.

Important Note: People should never stop taking medicationswithout speaking to their prescribing doctor.

Tips for maintaining libido

• Use a water-soluble vaginal lubricant. Do not usepetroleum-based products for vaginal dryness.

• Talk to your partner about the changes you areexperiencing. Your partner may be relieved toknow that your current condition is a medicalrather than an interpersonal problem.

• Find ways other than sex to give and receivephysical and emotional pleasure.

Miscellaneous

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• Get adequate rest throughout the day.

• Find ways to pamper yourself and feel good about yourself.

• Check out books and videos that address sexual issues.

• Remember that this is a temporary condition.

Your body will usually return to normal afterstopping hepatitis C treatment and antidepressantmedications

Important Note: Ribavirin is associated with birth defects. It is essential that females, as well as female partners of males, receivingribavirin avoid pregnancy during treatmentand for six months after ribavirin is discontinued.

SexMaintain as much sexual, physical, and emotionalintimacy as possible. Be open-minded and creativewhile finding ways to obtain pleasure and fulfilment.Do not take it personally if your partner turns downinvitations for sexual or emotional intimacy. Whileyour loved one is undergoing treatment, make sureyou take care of yourself. It is not necessary for youto ignore your own needs during this time. If youneed to, find someone you can talk with, and whowill support you.

Engage in activities that give you pleasure. If yoursex life is impacted, try to find other ways to giveand receive physical affection with your loved one.Remember that treatment does not last forever. It will end, and so will the side effects.

Partners, family and friends of people living withhepatitis C are also welcome to call the HepatitisInfoline 1800 703 003 for information and support.

Menstrual and menopausal irregularitiesThe effect of hepatitis C treatment on the menstrualcycle and menopause is an area that has not beenwell studied. Some women report menstrualirregularities during treatment. These may includeheavier or lighter periods, fewer or more frequentperiods, more or less premenstrual syndrome(PMS), and so forth. There is no one singlepredictable course of menstrual irregularities whileon treatment.

Women who are approaching menopause alsoreport changes. Some have more hot flushes, while others have fewer. Some women report more bleeding; others say their periods are shorter,fewer or lighter.

After menopause, women are at higher risk for boneloss. Abnormal bone loss is called osteopenia.Osteoporosis means the bone loss is significantenough to create a risk of fracture. A number offactors increase this risk, including smoking andfamily history. Small studies have linked ribavirin to bone loss, but not enough is known to draw firmconclusions. It is known that inactivity can alsoincrease bone loss.

While undergoing hepatitis C treatment, people whoare normally physically active may find themselvescutting back on the intensity, frequency or durationof their normal fitness routines. This may leave them with one less tool for bone loss prevention.Calcium, magnesium, vitamin D, and other nutrientsare necessary for good bone health. Talk to yourdoctor or a dietician about which dosages aresuitable for you.

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Words for family and friendsHepatitis C treatment affects many people besidesthe person who is on treatment. This may be astressful and challenging time for you if you areclose to, or supporting someone on treatment.Educating yourself about the side effects oftreatment may help you understand some of the issues your loved one is confronting while on treatment.

People often ‘look well’ during treatment. This cancreate problems, especially if the person feels awfuland assumes everyone around him/her can see this.Open communication is the best way to find out howyour loved one feels. But don’t expect too muchfrom the person undergoing treatment, especially if he or she was not a good communicator beforetreatment. Some people do not want to talk abouttheir experiences. Others want to talk about them a great deal.

The two best things you can do for your loved one is to encourage him or her to join a hepatitis Csupport group, or seek other forms of support suchas counselling and for you to take care of your ownhealth and wellbeing.

The experience of undergoing treatment issomewhat unique, and people frequently state thatthe only ones who understand them are otherpeople with hepatitis C who have treatmentexperience. Although you may not be able toempathise completely, you can still be supportiveby showing compassion and patience. It may behelpful to find support if your loved one isdepressed. Encourage him or her to speak to adoctor or their treatment specialist. Appropriatediagnosis and treatment are essential.


Depression, anxiety and irritabilityDepression is a common side effect of hepatitis Ctreatment. Watching a loved one experiencedepression can be frightening. Feeling helpless is acommon reaction to someone else’s depression. Ifyou are a friend or family member, you are alreadyhelping by reading this. By gaining information andtools you can be a great source of power and support.

Treatment for depression may take anywhere fromtwo to eight weeks to become fully effective. Youcan encourage your friend or family member to stickwith it until the medications start to work, or to talk tohis/her doctor about alternatives if there seems tobe no improvement.

Important Note: Do not ignore remarks about suicide orhurting others. Report these immediately tothe person’s doctor or other professional. Ifyou are concerned that a suicide attempt maybe imminent - call 000. If you feel the personcould physically harm you, get immediatehelp. Do not put yourself in harm’s way.

If there are any hepatitis C support groups availablein your area, encourage your loved one to attend.You may offer to drive him or her to the group. If thegroup is open to everyone, perhaps volunteer toattend together. Call the Hepatitis Infoline 1800 703003 for information about support groups.

You may want to encourage the depressed personto go for a walk, go to the movies, or engage in other activities that previously gave pleasure.However, if the offer is refused, do not push it. It may be enough to just sit and listen to the radio or watch TV together. Some people have difficultyreading during treatment, so perhaps listening to an audio book might interest you both.

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People with hepatitis C are sometimes irritableduring treatment. Try not to take this personally.Keep your expectations to a minimum. Do notexpect a depressed hepatitis C treatment person to“snap out of it” or to be able to turn his or her moodaround through positive thinking.

hepatitis C treatment medication-induceddepression is influenced by physical factors, and allthe willpower in the world won’t make it go away.Act sooner rather than later. Partners, family andfriends of people with hepatitis C undergoingtreatment are also very welcome to call the Hep CInfoline for support and information.

BookletsHepatitis C Treat it - Beat itA booklet by Hepatitis Australia

ImpactAn information booklet by Hepatitis C Victoria

Taking Care of Yourself and Your FamilyA resource book for good mental health produced by Beyond Blue. Contact Beyond Blue on 1300 224 636

All the above booklets can be ordered by contacting the Hepatitis Infoline: 1800 703 003

Hepatitis C treatment supportHepatitis Infoline 1800 703 003Opening Hours: 9.30am – 6.00pm Monday to Friday.Hepatitis Information, Support and ReferralTelephone Service

Hepatitis Victoria Support Group2nd Sunday of each month 2.00pm – 4.00pmNo appointment necessary Call Hepatitis Infoline 1800 703 003 for more details

Hepatitis Victoria Suite 5, 200 Sydney Road, Brunswick 3056Telephone: (03) 9380 4644Email: [email protected]: www.hepvic.org.auHepatitis Infoline: 1800 703 003

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