Treatments

COMBINATION THERAPY
Research into pharmaceutical treatment of hepatitis C is expanding and developing quickly. Trials of various drug combinations are being examined in search for improved treatment outcomes.

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 pegylated 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.In november 2003 pegylated interferon, a slow release form of interferon, was introduced as the pegylated form gave better results than the standard form of interferon.

Treatment will generally take either 24 or 48 weeks, depending on which genotype of the virus is being treated. The pegylated interferon is given under the skin, usually in the stomach once a week, and ribavirin tablets are taken orally, usually twice daily.

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.

WHY DOES GENOTYPE MATTER?
Researce indicates that the response rate to treatment is influenced by genotype. If a person is considering treatement, it is important to 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.

There is little evidence of any coorelation between genotype and severity of disease.

WHAT IS THE RESPONSE RATE?
The response rate for genotypes 2 and 3 is around 80%, after 24 weeks of treatment, whereas genotypes 1 and 4 have a response rate of around 45% after 48 weeks of treatment. For genotype 5 and 6 research is still being conducted on the most effective treatment regimes. The response rate for 5 and 6 seems to be somewhere between genotypes 2/3 and 1/4.

A person's response to combination treatment is also influenced by the following factors:

• Extent of liver damage. More advanced fibrosis is associated with a lower response rate.
• Body mass index. A condition called 'fatty liver' usually associated with being overweight can decrease the effectiveness of treatment.
• The level of virus in the blood (viral load). People who have low levels of virus in their blood before treatment are more likely to successfully clear the virus from their bodies.
• Alcohol intake. Research has demonstrated that the more alcohol people drink during treatment, the less chance they have of successfully clearing the virus.

Current research suggests that if a person has a sustained response for 6 months after the course of treatment, thare is an excellent chance that this response will last indefinitely.

WHAT ARE THE SIDE EFFECTS OF TREATMENT?
Combination treatment may cause a range of side effects, which may vary in intensity for each person. These may include some or most of the following: irritability, mood swings, depression fever, chills, muscle aches and headaches, 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 will subside within six months of finishing treatment.

COMPLEMENTARY MEDICINE
There are many alternative therapies within the field of complementary medicine, these are becoming an increasingly popular treatment option for people with a wide range of medical conditions to manage/decrease the symptoms of hepatitis C. 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.

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 ongoing research in relation to the issue 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 Herbalist Association of Australia: http://www.nhaa.org.au
Australian Complementary Health Association: http://www.diversity.org.au
The Australian Acupunture and Chinese Medicine Association Ltd (AACMA): http://www.acupuncture.org.au/history_of_aacma.cfm

For more information about this topic go to the Hepatitis Australia website at www.hepatitisaustralia.com or see Frequently Asked Questions on the NSW Hepatitis C Council website at http://www.hepatitisc.org.au/quickref/faq.html.

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.