I wrote this recently for a friend...
Okay, so your results definatively came in today, you have a 188,000 i/u viral load and a log of 5.6.
From CDC (US based disease government organisation). Expressed as International Units (IU/mL):
• Low grade HCV infection is classed as less than 800,000 IU/mL
• High grade HCV infection is classed more than 800,000 IU/mL
With a 188,000 i/u viral load, you are considered low grade. That means, any statistics quoted after this statement, which are based on generalised populations, you have a higher rate of success.
From CDC:
"Some studies have suggested that the cut-off between low and high viral load may be set too high. These studies have shown that people with a viral load under 400,000 IU/mL respond better to current medications compared to those who have a viral load above 400,000 IU/mL. Larger prospective studies are needed to confirm these observations."
The 5.6 log, is a bit of an anomaly to me, as changes in viral load are sometimes expressed in terms of logs. A log change is a 10-fold increase or decrease. Therefore, does not having a log mean that you have had two tests which indicate some sort of change in viral load? This needs clarification.
Note: A log drop in viral load is measured by decreasing the number by one zero. For instance, a one log drop in a viral load of 1,000,000 International Units is 100,000 International Units; a two log drop in a viral load of 1,000,000 International Units is 10,000 International Units.
Treatment
Because the damage caused by hepatitis C is very gradual in most people, even when treatment is needed there is often some choice of when to start it. "Traditional" treatment for chronic hepatitis C usually involves using a combination of two medicines:
- Pegylated interferon (given as an intradermal injection - less painful) – a synthetic version of a naturally occurring protein in the body that stimulates the immune system to attack virus cells, given once weekly.
- Ribavirin (given as a capsule or tablet) – an antiviral drug that stops hepatitis C from spreading inside the body.
These are traditionally given together, this is known as combination therapy (or BItherapy).
Before treatment — A viral load test will be performed to establish a baseline measurement.
During treatment — Viral load measurements are taken at certain time points during treatment to make sure that the medications are working. Generally, you will have a blood test at 4 weeks to confirm it is working and then another at 12 weeks to see if it cleared.
After treatment — Viral load measurements can be used after cessation of therapy to monitor for relapse — that is, to see if the virus becomes detectable again after being undetectable when treatment was completed. If the viral load is undetectable 12 or 24 weeks post treatment is it considered a sustained virological response (SVR) or commonly referred to as a viral cure.
Course and dosage
The length of your recommended course will depend on which genotype of the hepatitis C virus you have. If you have genotype 1, a 48-week course is recommended (worst case). For all other genotypes, a course of 24 weeks will be recommended (best case).
If the test shows that the medications are having little effect in removing the virus, it may be recommended that treatment is stopped as further treatment may be of little use. You are normally given weekly injections of pegylated interferon. Ribavirin is normally taken twice a day with food.
How effective is treatment?
The effectiveness of combination therapy depends on the genotype of the hepatitis C virus.
Genotype 1 is more challenging to treat. Only half of people treated with combination therapy will be cured. Other genotypes respond better to treatment, with a cure rate of around 75–80%.
Additional, “traditional” treatments - boceprevir and telaprevir.
In April 2012, the National Institute for Health and Care Excellent (NICE) released guidance for two newer medications, boceprevir and telaprevir. Both medications are known as protease inhibitors. Protease inhibitors block the effects of enzymes that viral cells need to reproduce.
The NICE guidance recommends that boceprevir or telaprevir should be made available free of charge on the NHS for people who:
- have genotype 1 hepatitis C that has not previously been treated (a genotype is a particular viral strain)
- have been treated for genotype 1 hepatitis C but treatment was unsuccessful. The medications are designed to be used in combination with pegylated interferon and ribavirin and not as a sole treatment. The tablet is taken three times a day for 48 weeks.
Even newer treatments for hepatitis C...
Many people in the HCV industry are referring to this, best link I found was this…
http://www.england.nhs.uk/2014/04/16/hepatitis-c/
The drug is called Sofosbuvir. Its currently, living in limbo land in the UK/NHS. 16th April NHSEngland said that the will fund it, but only for those who are super ill (i.e. people with a 800k+ viral load - not you), it says that they are looking to extend to all Hep C carriers by the end of the year (in NHS terms, this could be forever).
What is the difference between "Traditional" and "Newer" treatments?
Both have to be used in combination with the interferon injection (this is where the majority of side effects lie). Traditional treatments (already sanctioned by NHS), have 60 to 70 per cent cure rate, the new drug has up to 90 per cent of patients in just 12 weeks, and is tolerated by almost everyone*. Also price, where the traditional treatment for 12 weeks costs around about £1,200, the new drugs cost £35,000.
*Daily, fucking Mail. http://www.dailymail.co.uk/health/article-2550029/Miracle-three-month-course-drug-heralds-end-hepatitis-C-Britain.html. Blah.
Action Plan
- Find out which genotype.
- Find out what the "Log" has to do with the results? Have they taken multiple samples? Does this show a recent increase in viral load?
If genotype 2/3:
If you opt for standard treatment make sure they put you BItherapy of PEGylated interferon (not the standard interferon alfa) and ribavirin.
If genotype 1:
Boceprevir or telaprevir (newer protease inhibitors) with PEGylated interferon AND ribavirin (this is called TRItherapy).
In both cases, you will need the PEGylated interferon which is injected weekly, I haven't seen this in community pharmacy, so it must be performed in hospital.
Duration of treatment (again depends on genotype)
Best case scenario 24 weeks leading to undetectable serotype, discontinuation of therapy.
Worst case scenario is extremely improbable, unresponsive to treatment using BItherapy after 9 months (48 weeks).
Side effects
The most common side effect to treatment, is reduced haemoglobin which means anaemia, which may manifest as tiredness and lethargy, although this will be monitored during treatment and dose adjusted if it becomes severe.
Another side effect is psychiatric, this is not super common, exclusive to interferon, however, if you are in the private sector it would be a good idea to get recommended to have counselling, just so there is a safety net in place.
Should you wait for even newer medicines to come on the market?
This is a weigh it up exercise. If you have very chronic liver problems (such as poor LFT results - which you haven't) get on the “traditional medicines” now. This will ensure there is no further degradation of your liver. If your LFTs are good, there is no huge immediacy, Hepatitis C is a slow progressive disease a 6 month-1 year period will not make much difference to overall prognosis. However, keep in mind the degradation of quality of life over this period, will you be worried about infecting a loved one in this period? Would you not rather rip the plaster off and take the hit in the short term (and suffer potential additional side effects), instead of going for the unknown, unbeaten path?
Secondly, you can always start the traditional treatment, if it doesn't work or the side effects are unbearable you can always postpone and move to the newer treatments at a later date.
Irrespective of this, I believe the answer, can be found in the drug regimen and whether there is any potential damage to yourself LONG TERM of taking the “traditional treatment”. Any long term effects will almost certainly come from the interferon alfa which is common to the BI/TRI therapy of both the “newer treatments” and “traditional ones”, there are very similar side effect profiles of the -vir /-virin drugs as they are molecular analogues of the “traditional treatments”.
In all, personally, if I had a viral load of HCV, currently as of 27th of August 2014, living in England, but with private health insurance I would opt for the “traditional treatment”. Rip the plaster off and improve quality of life in the long term, opposed to short term benefits. I am may be a cynical pharmacist but don’t believe the NHS will “show the money” for the new treatments, for a disease which is primarily inflicted on drug addicts in this country and is relatively prevalent.
PS.
Interesting fact, Pamela Anderson and the founder of the Body Shop (Dame Anita Roddick) both had Hep C and cleared it.
Reference:
http://www.nhs.uk/Conditions/Hepatitis-C/Pages/Treatment.aspx
http://www.bbc.co.uk/news/health-26987653
https://www.medicinescomplete.com/mc/bnf/current/PHP3880-chronic-hepatitis-c.htm (need login)
https://www.medicines.org.uk/emc/medicine/28182
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