Hepatitis B and C Treatment

Hepatitis B

Over 400 million people globally have chronic hepatitis B virus (HBV) infection. HBV which is the globally the major cause of hepatocellular carcinoma (liver cancer), which is also Australia's most quickly increasing cause of cancer mortality. HBV infection is also an important cause of liver cirrhosis, which is preventable and possibly even reversible with appropriate treatment.

Hepatitis B is an infection, but has an important relationship with your body's immune system. Most people are infected when they are babies or young children and their immune system is unable to respond to clear it- often at birth from an infected mother. Others attain infection horizontally later in life through injection drug use or sexually. Most people who are infected as adults go on to clear the infection, as their immune systems are more mature.

In chronic infection, irrespective of when or how the infection was attained, there are four phases. Early infection is characterized by the immune tolerant phase, when the levels of HBV ("viral load") can be quite high but no injury is clearly evident in liver tests. Over time the immune system recognizes and tries to clear the virus ("immune clearance phase") which may result in higher liver tests and lower viral loads. If successful, the immune system can control the virus, keeping the level of the virus low and without liver injury ("immune control phase").

People can be in the immune control phase for many decades, which typically is safe and does not result in liver scarring. Previously this phase was called the "healthy carrier state". This term is misleading, as the viral-immune system interaction is a dynamic one that needs regular surveillance. Eventually in some people, viral mutations can develop a key to unlock this immune control, when the viral load increases and liver enzymes increase- with result liver injury. Thus it is always important to keep an regular check on the liver tests and at least an annual check on the hepatitis level.

In addition, all patients with chronic hepatitis should consider liver cancer surveillance, which is individualized to gender and race. Early detection of liver cancer has been shown to improve treatment options and survival.

Treatments such as entecavir and tenofovir can effectively suppress the virus. Typically however, treatment is lifelong, as with cessation the virus returns. Given treatment is lifelong and expensive to the community, the pros and cons ,and options for HBV treatment is an important discussion. Treatment is based on the immune-phase of infection, the viral load and liver tests, as well as the presence or absence of cirrhosis. All patients require a thorough liver fibrosis assessment. These treatments can only be initiated by a specialist.

Hepatitis C

Chronic hepatitis C is the most common notifiable disease in Australia. Approximately 1% of the population are infected with the hepatitis C virus (HCV), but it impacts the livers of many more loved ones and family members.

HCV progresses to cause liver injury or fibrosis in many people, with the most severe scarring called cirrhosis of the liver. Cirrhosis has important secondary effects including increasing the circulation pressure in the gut and liver (portal hypertension) causing bleeding (from varicose veins in the upper gut), fluid in the abdomen (ascites) and effecting the kidneys (hepato-renal syndrome) and brain (hepatic encephalopathy). Additionally, patients with cirrhosis are at increased risk of liver cancer.

New oral hepatitis C medications are now available that offer safe and effective treatment for all infected patients. Treatments include sofosbuvir, dalcaltasvir, ledipasvir and Veikera Pak, with other newer treatments likely to be available soon. Treatment is determined by the type ("genotype") of hepatitis C, whether you've had previous treatment, and in some genotypes, whether you have cirrhosis or not.

Treatment is highly effective, resulting in cure for the vast majority of patients, without the side-effects and safety concerns of previous hepatitis C regimens based on interferon and ribavirin.

Before treatment all patients need to be assessed for liver fibrosis and cirrhosis. We use a number of available technologies to do this non-invasively, to ensure that a possible diagnosis of cirrhosis is not missed. It is important to clarify all medications prescribed by your doctor as well as over the counter and herbal medications you may take, as drug-drug interactions can impact both the effectiveness of HCV medications or vice versa.

Typically, patients need one or two visits prior to treatment to clarify genotypes and liver fibrosis, and one or two visits while on treatment to review progress, with follow up three months after treatment is finished, to determine whether the HCV has been eradicated ("sustained viral response"). Patients who have cirrhosis require long term follow up for liver cancer surveillance as early detection improves survival.



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