Tuesday, May 17, 2022

Antiviral Medications For Hepatitis C

What Causes Hepatitis C

Repurposed Hepatitis C drugs could boost antiviral treatment for COVID-19, UT research shows

The hepatitis C virus causes hepatitis C. The hepatitis C virus spreads through contact with an infected persons blood. Contact can occur by

  • sharing drug needles or other drug materials with an infected person
  • getting an accidental stick with a needle that was used on an infected person
  • being tattooed or pierced with tools or inks that were not kept sterilefree from all viruses and other microorganismsand were used on an infected person before they were used on you
  • having contact with the blood or open sores of an infected person
  • using an infected persons razor, toothbrush, or nail clippers
  • being born to a mother with hepatitis C
  • having unprotected sex with an infected person

You cant get hepatitis C from

  • being coughed or sneezed on by an infected person
  • drinking water or eating food
  • hugging an infected person
  • shaking hands or holding hands with an infected person
  • sharing spoons, forks, and other eating utensils
  • sitting next to an infected person

A baby cant get hepatitis C from breast milk.18

What Is Viral Hepatitis

Hepatitis means inflammation of the liver. The liver is a vital organ that processes nutrients, filters the blood, and fights infections. When the liver is inflamed or damaged, its function can be affected. Heavy alcohol use, toxins, some medications, and certain medical conditions can cause hepatitis. However, hepatitis is often caused by a virus. In the United States, the most common types of viral hepatitis are hepatitis A, hepatitis B, and hepatitis C.

How Is Viral Hepatitis Prevented

Prevention of hepatitis involves measures to avoid exposure to the viruses, using immunoglobulin in the event of exposure, and vaccines. Administration of immunoglobulin is called passive protection because antibodies from patients who have had viral hepatitis are given to the patient. Vaccination is called active protection because killed viruses or non-infectious components of viruses are given to stimulate the body to produce its own antibodies.

Avoidance of exposure to viruses

Prevention of viral hepatitis, like any other illness, is preferable to reliance upon treatment. Taking precautions to prevent exposure to another individual’s blood , semen , and other bodily secretions and waste will help prevent the spread of all of these viruses.

Use of immunoglobulins

Immune serum globulin is human serum that contains antibodies to hepatitis A. ISG can be administered to prevent infection in individuals who have been exposed to hepatitis A. ISG works immediately upon administration, and the duration of protection is several months. ISG usually is given to travelers to regions of the world where there are high rates of hepatitis A infection and to close or household contacts of patients with hepatitis A infection. ISG is safe with few side effects.

    Hepatitis A

    Individuals at increased risk of acquiring hepatitis A are:

    Some local health authorities or private companies may require hepatitis A vaccination for food handlers.

    Hepatitis B

    Hepatitis B vaccine is recommended for:

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    Who Is More Likely To Get Hepatitis C

    People more likely to get hepatitis C are those who

    • have injected drugs
    • had a blood transfusion or organ transplant before July 1992
    • have hemophilia and received clotting factor before 1987
    • have been on kidney dialysis
    • have been in contact with blood or infected needles at work
    • have had tattoos or body piercings
    • have worked or lived in a prison
    • were born to a mother with hepatitis C
    • are infected with HIV
    • have had more than one sex partner in the last 6 months or have a history of sexually transmitted disease
    • are men who have or had sex with men

    In the United States, injecting drugs is the most common way that people get hepatitis C.13

    Cost Of Hepatitis C Medicines


    The newer direct-acting antiviral medicines for hepatitis C can be costly. Most government and private health insurance prescription drug plans provide some coverage for these medicines. Talk with your doctor about your health insurance coverage for hepatitis C medicines.

    Drug companies, nonprofit organizations, and some states offer programs that can help pay for hepatitis C medicines. If you need help paying for medicines, talk with your doctor. Learn more about financial help for hepatitis C medicines.

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    Infection With Hdv After Hbv:

    The patient with previous chronic HBV infection provides a potential environment for superinfection with HDV after exposure to someone infected with both HBV and HDV. This may be observed as an acute flare of hepatitis and sometimes leads to initial discovery of the underlying HBV infection,with misidentification of the illness as acute HBV infection. Measurement of the IgM anti-HBc titer can assist in differentiating chronic from acute HBV disease circulating titers are typically low in chronic HBV carriers but high in patients with acute HBV infection. Testing for HDV should be considered in any patient with HBV who has an acute flare of hepatitis and risk factors for HDV infection.

    Most patients with superinfection develop a progressive form of chronic hepatitis. Superinfection is often seen as a worsening clinical illness in a previously stable chronic carrier of HBV. Clinical illness with superinfection can be rapidly progressive, leading to cirrhosis within 2 years in 10%-15% of patients. The genotype of HBV may also play a role in the rapidity and severity of progressive disease. HDV will suppress HBV replication in simultaneously infected patients. Even HBV/HDV infected patients with coexisting hepatitis C virus infection will have reduced HCV replication.

    How Can I Prevent Spreading Hepatitis C To Others

    If you have hepatitis C, follow the steps above to avoid spreading the infection. Tell your sex partner you have hepatitis C, and talk with your doctor about safe sex practices. In addition, you can protect others from infection by telling your doctor, dentist, and other health care providers that you have hepatitis C. Dont donate blood or blood products, semen, organs, or tissue.

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    What About Patients With Hepatitis C Who Also Have Hepatitis B

    Hepatitis B virus can flare in patients who are co-infected with hepatitis B and hepatitis C and are taking medication for hepatitis C. This has been reported as a potential risk for patients who are taking hepatitis C treatment and have underlying hepatitis B as well. The flare usually occurs within a few weeks after the patient starts taking medication for hepatitis C. Therefore, patients who have both hepatitis B and hepatitis C should be seen by a hepatitis expertbeforestarting treatment of the hepatitis C they may need to start taking hepatitis B treatment to avoid a hepatitis B flare.

    Sofosbuvir Velpatasvir And Voxilapresvir

    New Directly Acting Antivirals for Hep C

    This drug combination is similar to Epclusa but also includes a drug called voxilapresvir.

    Facts about Vosevi include:

    • Treatment time is 12 weeks for people without cirrhosis or compensated cirrhosis .
    • Dosage is fixed at 400 mg of sofosbuvir, 100 mg of velpatasvir, and 100 mg of voxilapresvir once per day with food.
    • Common side effects include tiredness, a headache, diarrhea, and nausea.

    Doctors often recommend Vosevi for people who have had previous treatment for hepatitis C that did not work.

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    Do You Need Vaccinations Before Traveling Abroad

    The CDC divides travel vaccinations into three categories: 1) routine, 2) recommended, and 3) required. The only vaccine classified as “required” by International Health Regulations is the yellow fever vaccination for travel to certain countries in sub-Saharan Africa and tropical South America.

    “Routine” vaccinations are those that are normally administered, usually during childhood, in the United States. These include immunizations against:

    • tetanus

    Current Antiviral Treatment Strategies

    The introduction of DAA revolutionized the field of antiviral therapy for patients chronically infected with HCV. Antiviral therapy usually consists of at least two antiviral substances from different drug classes with different modes of action . Treatment decisions are based on genotype , presence of cirrhosis and response to prior treatments . Typical treatment regimens for patients with and without compensated cirrhosis are depicted in Tables 1 and 2. All different recommended regimens achieve SVR rates of more than 95% if administered correctly .

    Table 1.

    Treatment of patients with chronic hepatitis C without cirrhosis

    Table 2.

    Treatment of patients with chronic hepatitis C with compensated cirrhosis

    Fig. 1.

    The replication cycle of the hepatitis C virus and modes of action of direct-acting antivirals are displayed .

    The pangenotypic drug combinations sofosbuvir/velpatasvir and glecaprevir/pibrentasvir show high antiviral efficacy against all HCV genotypes. Treatment duration differs from 8 weeks for glecaprevir/pibrentasvir in noncirrhotic treatment-naive patients to 12 weeks for patients with liver cirrhosis or 16 weeks for GT 3 patients with liver cirrhosis and/or prior treatment failure. Sofosbuvir/velpatasvir has to be administered for 12 weeks independently of fibrosis level . Treatment with grazoprevir/elbasvir is possible in patients with GT 1 or 4 infection and has to be administered for 1216 weeks depending on GT, fibrosis stage and viral load .

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    Treatment Of Patients With Prior Daa Treatment Failure

    After failure of DAA treatment, the development of RAS is very likely. RAS linked to the NS5A gene are more likely to persist for a longer time at a significant level than those connected to the NS3/4 gene. RAS relevant for the NS5B inhibitor sofosbuvir are usually rapidly suppressed after treatment cessation due to a significantly impaired viral fitness. Resistance testing and the adaptation of antiviral regimes according to RAS is one possible option for retreatment . Currently, the only approved drug combination for the retreatment of patients with prior DAA failure is the combination of sofosbuvir, velpatasvir and voxilaprevir . This combination is not only well tolerated, but also highly effective, and SVR rates > 95% can be achieved in pretreated patients independently from the initial treatment regimen . The recommended treatment duration for DAA-experienced patients is 12 weeks . Preliminary real-world data confirmed the high efficacy of the SOF/VEL/VOX in previous DAA failures. All of the first 110 patients who had completed SOF/VEL/VOX in the German Hepatitis C Registry achieved SVR . Excellent results have also been reported from French and US cohorts . Due to its effectiveness this combination should be reserved for the retreatment of patients with prior DAA failure and is usually not recommended for the initial treatment of therapy-naive patients .

    How Is Viral Hepatitis Diagnosed

    Management of Hepatitis B in Pregnancy

    Diagnosis of viral hepatitis is based on symptoms and physical findings as well as blood tests for liver enzymes, viral antibodies, and viral genetic materials.

    Symptoms and physical findings

    Diagnosis of acute viral hepatitis often is easy, but the diagnosis of chronic hepatitis can be difficult. When a patient reports symptoms of fatigue, nausea, abdominal pain, darkening of urine, and then develops jaundice, the diagnosis of acute viral hepatitis is likely and can be confirmed by blood tests. On the other hand, patients with chronic hepatitis due to HBV and HCV often have no symptoms or only mild nonspecific symptoms such as chronic fatigue. Typically, these patients do not have jaundice until the liver damage is far advanced. Therefore, these patients can remain undiagnosed for years to decades.

    Blood tests

    There are three types of blood tests for evaluating patients with hepatitis: liver enzymes, antibodies to the hepatitis viruses, and viral proteins or genetic material .

    Liver enzymes: Among the most sensitive and widely used blood tests for evaluating patients with hepatitis are liver enzymes, called aminotransferases. They include aspartate aminotransferase and alanine aminotransferase . These enzymes normally are contained within liver cells. If the liver is injured , the liver cells spill the enzymes into the blood, raising the enzyme levels in the blood and signaling that the liver is damaged.

    Examples of tests for viral antibodies are:

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    What Does Treatment With The New Drugs Involve

    The drugs are easy to take and are taken orally.

    Treatment time is usually 12 weeks. However this may range between 8 and 24 weeks for a complete course of treatment, depending on the patients genotype, whether the patient has cirrhosis, treatment history and which of the drug combinations the prescriber chooses to use.

    Approved Drugs For Adults

    There are currently 7 approved drugs in the United States for adults living with chronic hepatitis B infection. These include 5 types of antiviral drugs that are taken as a pill once a day for 1 year or longer. And there are 2 types of immune modulator drugs called interferon that are given as an injection for 6 months to 1 year.

    It is important to know that not everyone needs to be treated. A liver specialist should evaluate your health through a physical exam, blood tests, and an imaging study of your liver . Then you can discuss together whether you are a good candidate for treatment since the approved drugs are most effective when there are signs of active liver disease. In addition, talk to your provider about HBV Clinical Trials since there are several new drugs being tested that are available for infected adults.

    All adults, however, should be seen regularly by a liver specialist whether they are on treatment or not.

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    Treatment Of Patients With Decompensated Cirrhosis

    Treatment of patients with decompensated cirrhosis ) is limited to regimens containing sofosbuvir and NS5A inhibitors. Protease inhibitors are not recommended due to the hepatic metabolization and subsequently significantly higher drug exposure in this group of patients. Thus, grazoprevir/elbasvir, glecaprevir/pibrentasvir or SOF/VEL/VOX should not be administered. To improve efficacy the remaining combination of sofosbuvir and NS5A inhibitor should be combined with RBV . Many studies and real-world data have shown that IFN-free antiviral therapy is safe in patients with advanced liver disease. However, patients are still at risk of hospitalization during therapy, mainly because of complications from liver disease . The efficacy of sofosbuvir/ledipasvir plus RBV was studied in the SOLAR-1 and -2 study. In GT 1 patients, SVR rates ranged between 87 and 96% and between 72 and 85% in CPS B and CPS C patients, respectively . The ASTRAL-4 study evaluated the use of sofosbuvir/velpatasvir in patients with CPS B, but not CPS C. Treatment duration of 12 weeks showed high rates of SVR for patients with GT 1, 2, 4 and 6 infection. SVR rates of GT 3 were low at 50% but could be increased to 85% by the addition of RBV . Even though the rate of treatment discontinuations is higher in patients treated with RBV, the additional antiviral substance significantly increases SVR rates .

    What To Expect From Your Doctor

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    Your doctor is likely to ask you some of the following questions. If you’ve thought about your answers beforehand, this part of the visit may go more quickly than usual, leaving you more time to address your concerns.

    • Have you ever had a blood transfusion or an organ transplant? If so, when?
    • Have you ever used self-injected drugs not prescribed by your doctor?
    • Have you ever been diagnosed with hepatitis or jaundice?
    • Does anyone in your family have hepatitis C?
    • Is there a history of liver disease in your family?

    © 1998-2019 Mayo Foundation for Medical Education and Research . All rights reserved.Terms of use.

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    Antiviral Drugs In The Immunocompetent Host: Part I Treatment Of Hepatitis Cytomegalovirus And Herpes Infections

    RICHARD COLGAN, M.D., University of Maryland School of Medicine, Baltimore, Maryland

    ROBERT MICHOCKI, PHARM.D., B.C.P.S., University of Maryland School of Pharmacy, Baltimore, Maryland

    LISA GREISMAN, M.D., University of Maryland Medical Center, Baltimore, Maryland

    TRACY A. WOLFF MOORE, M.D., University of Maryland School of Medicine, Baltimore, Maryland

    Am Fam Physician. 2003 Feb 15 67:757-762.

    Since the release of amantadine in 1966, other agents designed to fight a diverse range of viral infections have been released. Part I of this two-part article focuses on agents used to manage hepatitis, cytomegalovirus, and herpes infections. In patients with chronic hepatitis B, interferon alfa-2b or lamivudine is the treatment of choice. Pegylated interferon alfa-2a or -2b, along with ribavirin, is standard treatment for patients with chronic hepatitis C. Although treatment of cytomegalovirus infections generally is supportive, there have been reports of severely ill patients who improved after receiving ganciclovir or foscarnet. Oral antiviral agents for initial and recurrent herpes simplex virus infections have been shown to shorten the duration of lesions. Treatment of herpes zoster infections with antiviral drugs shortens the course of infection and decreases symptoms. Studies have shown that antiviral treatment can prevent prolonged post-herpetic neuralgia, although this use remains controversial.

    Pregnancy And Hepatitis C

    The new hepatitis C medicines have not been tested in pregnancy.

    You should not become pregnant while taking treatment as it could be harmful to unborn babies.

    If you’re pregnant, you must delay treatment until after your baby is born.

    Speak to your doctor before starting hepatitis C treatment if you’re planning to become pregnant in the near future.

    You’ll need to wait several weeks after treatment has ended before trying to get pregnant.

    Women taking ribavirin should use contraception during treatment and for another 4 months after the end of treatment.

    Men taking ribavirin should use a condom during treatment and for another 7 months after the end of treatment. This is because semen can contain ribavirin.

    If you become pregnant during treatment, speak to your doctor as soon as possible to discuss your treatment options.

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    How Hepatitis C Used To Be Treated

    Along with abstinence from alcohol , the standard treatment for chronic hepatitis C used to be a combination antiviral therapy consisting of a pegylated interferon and ribavirin, sometimes called PEG/riba therapy.

    A pegylated interferon is a long-acting form of an interferon, a synthetic copy of an infection-fighting protein secreted by immune system cells in response to pathogens. Ribavirin is a drug that interferes with HCV’s ability to replicate. In some cases, pegylated interferon was used without ribavirin, but ribavirin alone isn’t effective against hepatitis C.

    To treat hepatitis C, doctors prescribed weekly injections of the pegylated interferons along with twice-daily oral doses of ribavirin. PEG/riba therapy was not a cure-all.

    Interferon is not an option for people with liver failure, autoimmune diseases, and psychiatric illness. It can also cause a range of life-threatening complications that prevent many people from completing their therapy.

    Newer drug regimens that can cure hepatitis C have forced a change in the standard treatment for the disease, and in the United States, these medications have largely replaced interferon. But pegylated interferon and ribavirin together or separately may still be used in combination with newer antiviral drugs.

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