Treatments

Combination therapy

While research is ongoing, Western medicine currently provides a limited choice in terms of pharmaceutical treatment for people with hepatitis C. The standard treatment currently available is usually referred to as combination therapy, as it utilises a combination of two different kinds of drugs.

WHAT IS COMBINATION THERAPY?
In combination therapy, the drugs interferon and ribavirin are used together to help boost the body's own immune response to the hepatitis C infection. Previously, only interferon was used to treat hepatitis C. However, studies have shown that people are more likely to have a sustained positive response in fighting the virus with combination therapy than with interferon alone (monotherapy). Interferon was approved for clinical trials in Australia in 1992 and became available under the Commonwealth subsidised Pharmaceutical Benefits Scheme in 1994. In recent years the combining of interferon with ribavirin has become standard and monotherapy is now usually only considered if there is a known severe reaction to ribavirin.

Treatment will generally take either six or twelve months, depending on which genotype of the virus is being treated. The interferon is given under the skin, usually in the stomach three times a week, and ribavirin tablets are taken orally, usually twice daily. Medical trials are presently assessing the efficacy of pegylated interferon (a slow release interferon), in combination with ribavirin.

HOW DOES IT WORK?
Interferon-alpha is a glycoprotein that is produced naturally in the body as part of the immune system's defence against infection. Synthetically manufactured forms of interferon-alpha are administered in large doses with the aims of boosting the immune response to hepatitis C, reducing the replication of the virus in the body and slowing down or stopping the disease process.

Ribavirin is a drug that alters the body's immune response to viruses. It has been shown to work best on the hepatitis C virus in combination with interferon, rather than as a treatment on its own.

WHAT IS THE RESPONSE RATE?
It is currently believed that a person's response to combination treatment is related to the following factors:

• Genotype (strain): Genotype 2 and 3 have been shown to have a response rate of 50 - 70%, whereas genotypes 1 and 4 have a response rate of between 25 - 40%.
• The level of virus in the blood. The aim of treatment is to achieve a sustained response (no virus detectable in the blood using a PCR test, six months after treatment has ended). The eradication of the virus leads to an improvement in symptoms and a reduction of potential long-term complications such as cirrhosis.
• Current research suggests that if a person has a sustained response for 6 months after the course of treatment, there is a good chance that this response will last indefinitely.

WHY DOES GENOTYPE MATTER?
Research indicates that the response rate to treatment is influenced by genotype. People with genotype 2 and 3 are more likely to have an immediate response to treatment, whereas those with other genotypes are likely to need a longer exposure for treatment to have an effect. This is why combination therapy is given to patients with genotypes 2 or 3 for 6 months, while 12 months treatment is recommended for all other types.

If a person is considering treatment, it is important find out which genotype he or she has, as this influences decisions about length of treatment and expectations of the person’s response to treatment. A person’s viral genotype may also be taken into account when considering the most appropriate time to commence treatment.

Genotypes can be determined using a PCR test (see the section on testing). If a person is about to undergo treatment or take part in a clinical trial, genotype testing is covered under Medicare. Testing requires a blood sample and can be done through a general practitioner or liver clinic. It takes about two weeks to get the results of a genotype test.

At this stage, there is little evidence of any correlation between genotype and severity of disease. Some studies have linked genotype 1b with severe liver disease. It is worth noting, however, that the people in these studies generally had hepatitis C for a long time and acquired the virus through blood transfusion during surgery for another ailment.

WHAT ARE THE SIDE EFFECTS OF TREATMENT?
Combination treatment can cause a range of side effects, which may vary in intensity for each person. The side effects of combination therapy are similar to those experienced with interferon alone, and can include: irritability, mood swings, depression fever, chills, muscle aches and headaches. Some people experience tiredness, loss of appetite, insomnia, nausea, vomiting, skin dryness and itching, dry throat, hair thinning, weight loss and lowering of red blood cell count. Other side effects such as thyroid disorders may occur but are less common.

Ribavirin is tetragenic, which means that it is toxic to a developing foetus. Consequently, combination treatment is not administered to women who are pregnant and/or breastfeeding, to men who may become fathers, or to anyone who does not agree to use adequate contraception during, and for up to six months after treatment.

Ribavirin can also temporarily lower a person's red blood cell count, platelet count and haemoglobin levels. This may cause tiredness, shortness of breath and a decrease in energy levels, and an adjustment of ribavirin doses may be required in some cases. Most of these side effects stop when treatment ceases.

Complementary Medicine

There are many alternative therapies within the field of complementary medicine, and these are becoming an increasingly popular treatment option for people with a wide range of medical conditions. Many people with hepatitis C use herbs from the repertory of both Western herbal medicine and traditional Chinese medicine to improve their general health and manage their symptoms.

Research into the efficacy of herbal medicine in managing the symptoms of hepatitis C is developing and ongoing, with some trials being conducted in Australia and a large number overseas. Many people have reported a significant improvement in their health and quality of life using complementary therapies. On the other hand, people have also reported no observable benefits. Obviously, each individual needs to assess for themselves the appropriateness of complementary therapies in managing their illness.

Those who choose to consult with practitioners of complementary medicine may include:

• People who are philosophically aligned with the principles of complementary medicine.
• People who are not eligible for combination treatment.
• People who wish to modify their experience of pharamaceutical treatment with alternative therapies.
• People who have not found combination therapy to be successful for them.

Different complementary therapies have different impacts on the body and consequently different roles to play in treatment. Some, like aromatherapy and massage, have a particular strength in relaxation, while others such as herbal medicine and homoeopathy, directly impact on the experience of symptoms. As with any powerful medicine, complementary medicines prescribed inappropriately can potentially damage the liver, so it is advisable to seek professional advice before embarking on any course of complementary treatment.

People are encouraged to gather information from both their treating GP and/or specialist along with their practitioner of complementary medicine about any treatment options under consideration. Ideally, to achieve the best possible treatment, both parties should be consulting together, but this can often be difficult to achieve.
There is little data in relation to side effects of combining complementary therapies with drug treatments.

WHAT TO EXPECT FROM COMPLEMENTARY THERAPY
Being listened to
A good practitioner of complementary medicine will be interested in their client. They will take time to listen to their client’s concerns, find out who they are and the problems they are experiencing with their health.

Cost
The Medicare schedule does not provide rebates for consultations with complementary therapists so full fees apply and they vary according to the choice of treatment. Consequently, it is helpful to be informed beforehand of the full cost of an appointment. Some treating practitioners are registered with private health funds. People who are insured with these funds may be entitled to claim a small rebate.

A registered practitioner
Not all practitioners of complementary therapies are registered with a professional regulatory body. To be registered, a practitioner has to have completed a tertiary level course in their field of expertise. Choosing a practitioner who is registered with one of the professional bodies of complementary medicine is recommended. Lists of accredited practitioners can be obtained from these bodies. The yellow pages also list practitioners under their professional membership.

Experience in providing treatment
Questions that would usually be asked of a doctor or specialist about combination therapy are also useful when consulting a new complementary health practitioner. Some questions that are useful to ask include:

• How much experience have you had in the treatment of hepatitis C?
• What benefits can be expected from following this recommended treatment?
• Is there any information about the mental and physical outcomes of this therapy?
• Are there any circumstances in which this treatment could have a harmful or effect on the liver?
• Are there any likely side effects?

The following web sites give more information about complimentary and alternative therapies, but the Hepatitis C Victoria doesn’t necessarily ascribe to all their views or opinions.

National Centre for Complimentary and Alternative Medicine: http://nccam.nih.gov/
Institute for Complementary Medicine: http://www.icmedicine.co.uk/
British Medical Journal: http://bmj.com/cgi/content/full/319/7211/693
Alternative & Complementary Medicine Directory: http://www.worldwidehealthcenter.net/

For more information about this topic go to the Australian Hepatitis Council web site at www.hepatitisaustralia.com or see Frequently Asked Questions on the NSW Hepatitis C Council website at www.hepatitisc.org.au.

Please note: This information DOES NOT aim to replace the advice that would be provided by a doctor or other health care worker. People who have hepatitis C should regularly see their doctor, who can provide monitoring, up-to-date information, advice, and counselling if needed.