Alcohol abstinence does not offset the strong negative effect of lifetime alcohol consumption on the outcome of interferon therapy

Impact of alcohol consumption among patients in hepatitis C virus treatment

ABSTRACT BACKGROUND: Recent studies have questioned the recommendation of abstinence from alcohol for at least 6 months for alcoholic patients to be treated for hepatitis C. OBJECTIVE: The present study aimed to assess the impact of alcohol consumption among patients undergoing hepatitis C treatment. METHODS: In this cross-sectional study, 121 patients [78 (64.5%) men; 28-70 years] were evaluated. They were divided as follows: patients who consumed <12 g of ethanol/day throughout life (Group 1), 12-59 g/day (Group 2) and ≥60 g/day (Group 3). Patients were treated with pegylated-interferon plus ribavirin. RESULTS: These three groups could not be distinguished in terms of the severity of liver fibrosis and frequency of HCV genotype-1 infection. In Group 3, treatment discontinuation (32.4%) was higher than in the Group 1 (9.4%) or Group 2 (0%), it was higher among patients who drank during treatment (66.7% vs 21.4%) and among those who had not been abstinent for at least 6 months (72.7% vs 15.4%). Moderate alcohol drinkers showed good adherence and did not discontinue the treatment. The frequencies of sustained viral response among patients in Group 3 (44.4%) were similar to those in Group 1 (61%) and Group 2 (68.4%). CONCLUSION: Heavy drinkers more often discontinued treatment for hepatitis C, but those that received this treatment had acceptable sustained viral response rates. These results suggest that heavy drinkers should not be systematically excluded from the treatment, but they should be monitored to avoid drinking and abandoning treatment, mainly those who have not been abstinent for at least 6 months.

Psychological, lifestyle and social predictors of hepatitis C treatment response: a systematic review

BACKGROUND

To increase cure rates for Hepatitis C, barriers to treatment adherence and completion must be identified and overcome.

AIMS

This study systematically reviewed evidence on the psychological, lifestyle and social determinants of achieving viral eradication with antiviral therapy.

METHODS

An electronic search strategy was used to identify relevant studies that examined psychological, lifestyle and social factors related to achieving a sustained virological response (SVR).

RESULTS

Thirty-four studies that matched our criteria were identified. Of the factors that predict response to treatment, Asian ethnicity was an independent predictor of SVR. We found an indirect relationship between diet and SVR, with non-responders to treatment consuming more polyunsaturated fatty acids, fats and carbohydrates than those who attained SVR. The effect of alcohol consumption relied on the amount consumed; fewer than 30 grams daily had no effect on SVR, whereas >70 grams daily had an adverse impact on a patient's ability to achieve SVR, with termination rates up to 44% in those who drank >2 drinks a day. Patients with psychiatric illnesses had comparable SVR rates to controls if they continued psychological therapy (average 42%), although discontinuation rates were high with 11 studies reporting rates from 14 to 48%.

CONCLUSIONS

There are major gaps in current knowledge of the impact of variables such as diet, exercise, attitudes and coping skills on cure rates in chronic Hepatitis C. Those who drink limited amounts of alcohol or have psychiatric disorders should be offered treatment for their disease, with adjunctive education and support to improve treatment completion.

Management of hepatitis C virus infection in heavy drinkers

AIM

Optimal management of hepatitis C virus (HCV) infection is controversial in heavy drinkers. We compared the management of HCV infection of heavy drinkers with that of patients without a history of alcohol abuse.

METHODS

In a retrospective case-control study, 69 HCV-infected heavy drinkers [daily alcohol consumption at referral above 60 g/day, hereafter 'alcohol group'] were compared with matched HCV-infected patients with low alcohol consumption (<40 g/day, 'control group').

RESULTS

Patients of the 'alcohol group' were younger (42 vs. 45 years, P = 0.05), more often male (69.6 vs. 56.5%, P = 0.11) and had been infected by intravenous drug use (85.5 vs. 45.0%, P < 0.0001). The percentage of patients with a recommendation for treatment according to the French 2002 consensus (bridging fibrosis or genotype 2 or 3) was 52 of 69 (75.4%) in both groups, while the proportion of patients treated was higher in the control group (71.0 vs. 44.9%, P = 0.002). In the 'alcohol group', patients had better access to treatment if they were employed or consumed 170 g/day or less at first referral. Sustained virological response (SVR) was obtained in 10 of 31 patients (32.3%) of the 'alcohol group' vs. 8 of 31 patients (25.8%) of the control group matched for genotype and type of treatment (P = 0.58).

CONCLUSION

Heavy drinkers are less often considered for antiviral therapy compared with patients without a history of alcohol abuse. However, once treatment is actually initiated, SVR rates are comparable with those achieved in non-drinkers despite the continuation of alcohol consumption during therapy in some patients.

The impact of lifetime alcohol use on hepatitis C treatment outcomes in privately insured members of an integrated health care plan

Treatment of chronic hepatitis C infection (HCV(+) ) has historically been shown to be less effective in patients with a heavy drinking history. The effect of moderate and heavy alcohol use on treatment with pegylated interferon-alpha and ribavirin (P/R) in an insured household population has not been previously reported. We investigated the effect of alcohol on treatment outcome in a cohort of 421 treatment-naïve HCV(+) patients, members of an integrated health care plan treated with P/R between January 2002 and June 2008. A detailed drinking history was obtained for 259 (61.5%) eligible patients. Regular drinking was reported by 93.1% of patients before HCV diagnosis, by 30.9% between HCV diagnosis and treatment, by 1.9% during treatment, and 11.6% after the end of treatment. Heavy drinking patterns were reported by 67.9%, 63.5% of patients drank more than 100 kg of ethanol before initiating HCV treatment, and 29.3% reported abstaining less than the required 6 months before treatment. Despite these reports of heavy drinking, sustained virological responses (SVRs) were obtained in 80.2% of patients with HCV genotypes 2 or 3 and 45.1% of patients with genotypes 1, 4, or 6. Pretreatment drinking patterns and total alcohol intake were both unrelated to SVR rates. Abstaining less than 6 months before treatment was related to lower SVR rates in moderate, but not heavy, drinkers. HCV treatment relapse was unrelated to drinking after treatment ended.

CONCLUSION

The amount of alcohol consumed before HCV treatment did not have a negative effect on treatment outcomes in our population. A history of heavy drinking should not be considered a deterrent to HCV treatment in members of an integrated health care plan who are closely monitored.

Evolution of interferon-based therapy for chronic hepatitis C

Since 1986, interferon-alfa (IFN-α) monotherapy has been administered for patients with chronic hepatitis C (CHC). However, sustained response rate is only about 8% to 9%. Subsequent introduction of ribavirin in combination with IFN-α was a major breakthrough in the treatment of CHC. Sustained virological responses (SVRs) rate is about 30% in hepatitis C virus genotype 1 (HCV-1) patients, and is about 65% in HCV-2 or -3 patients. After 2000, pegylated interferon (PegIFN) much improved the rates of SVR. Presently, PegIFN-α-ribavirin combination therapy has been current standard of care for patients infected with HCV. In patients with HCV-1, treatment for 48 weeks is optimal, but 24 weeks of treatment is sufficient in HCV-2 or -3 infected patients. Clinical factors have been identified as predictors for the efficacy of the IFN-based therapy. The baseline factor most strongly predictive of an SVR is the presence of HCV-2 or -3 infections. Rapid virological response (RVR) is the single best predictor of an SVR to PegIFN-ribavirin therapy. If patients can't achieve a RVR but achieve a complete early virological response (cEVR), treatment with current standard of care can provide more than 90% SVR rate. HCV-1 patients who do not achieve an EVR should discontinue the therapy. Recent advances of protease inhibitor may contribute the development of a novel triple combination therapy.

Hepatitis C comorbidities affecting the course and response to therapy

Several studies have demonstrated that the outcome of chronic hepatitis C (CHC) infection is profoundly influenced by a variety of comorbidities. Many of these comorbidities have a significant influence on the response to antiviral therapy. These comorbidities negatively affect the course and outcome of liver disease, often reducing the chance of achieving a sustained virological response with PEGylated interferon and ribavirin treatments. Comorbidities affecting response to antiviral therapy reduce compliance and adherence to inadequate doses of therapy. The most important comorbidities affecting the course of CHC include hepatitis B virus coinfection, metabolic syndrome, and intestinal bacterial overgrowth. Comorbidities affecting the course and response to therapy include schistosomiasis, iron overload, alcohol abuse, and excessive smoking. Comorbidities affecting response to antiviral therapy include depression, anemia, cardiovascular disease, and renal failure.

Treatment of hepatitis C infection for current or former substance abusers in a community setting

Substance abusers account for the largest number of hepatitis C infected cases in developed countries. We describe a care model for treating current or former substance abusers with antiviral therapy for hepatitis C virus (HCV) infection. The care model involved hepatitis nurses, a psychologist, infectious disease specialist and primary care physicians. Clients met selection criteria including regular attendance at clinic appointments and social stability. Use of alcohol and illicit substances was monitored with urine toxicology screens. The association between substance use, rates of completion of therapy and rates of response were assessed using multivariable regression analyses. A total of 109 clients (75 with genotype 1/4 and 34 with genotype 2/3) received at least one injection with pegylated interferon between November 2002 and January 2006. Treatment completion rates of 61 and 74% were achieved for genotypes 1/4 and 2/3, respectively. Treatment response rates in an intention to treat analysis were 51% for genotypes 1/4 and 68% for genotypes 2/3. A positive urine toxicology screen indicating use of illicit substances 6 months prior to initiating therapy was significantly associated with lower rates of treatment completion but not lower rates of sustained virological response. A positive urine screen indicating use of alcohol prior to therapy was significantly associated with lower rates of completion and lower rates of response. Rates of completion and response are comparable to non-substance abusing populations. Antiviral therapy for HCV infection can be successful within the context of ongoing care for substance abuse for carefully selected patients.

Alcoholic liver disease and hepatitis C: A frequently underestimated combination

Alcoholic liver disease (ALD) and hepatitis C virus (HCV) infection represent, either alone or in combination, more than two thirds of all patients with liver disease in the Western world. This review discusses the epidemiology and combined impact of ALD and HCV on the progression of liver disease. ALD and HCV affect the progression of liver disease to liver cirrhosis and hepatocellular carcinoma (HCC) in a synergistic manner. Thus, the risk for HCC increases five times with a daily alcohol consumption of 80 g; in the presence of HCV it is increased 20-fold, and a combination of both risk factors leads to a more than 100-fold risk for HCC development. Alcohol consumption also decreases the response to interferon treatment which is probably due to a lack of compliance than a direct effect on HCV replication. Several molecular mechanisms are discussed that could explain the synergistic interaction of alcohol and HCV on disease progression. They include modulation of the immune response and apoptosis, increased oxidative stress via induction of CYP2E1 and the hepatic accumulation of iron. Thus, both HCV and alcohol independently cause hepatic iron accumulation in > 50% of patients probably due to suppression of the liver-secreted systemic iron hormone hepcidin. A better understanding of hepcidin regulation could help in developing novel therapeutic approaches to treat the chronic disease in the future. For now, it can be generally concluded that HCV-infected patients should abstain from alcohol and alcoholics should be encouraged to participate in detoxification programs.

Psychiatric problems in patients infected with hepatitis C before and during antiviral treatment with interferon-alpha: a review

OBJECTIVE

Neuropsychiatric symptoms are common in patients with chronic hepatitis C (CHC) and can potentially be exacerbated by interferon-alpha treatment. Such symptoms can contribute to problems with treatment adherence, which can significantly compromise epidemiological virus control. This review summarizes current knowledge about the etiology, course, and management of neuropsychiatric symptoms in patients with CHC.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULTS

Psychopathological syndromes that occur during interferon-alpha treatment frequently have atypical features that may complicate their recognition using standard diagnostic criteria. In addition, prospective studies in this area often exclude patients with psychiatric disorders and have methodological disparities that make it difficult to develop guidelines for management of psychiatric side effects induced by interferon-alpha. Despite the high prevalence of chronic hepatitis C virus (HCV) infection in patients with psychiatric and substance use disorders, neuropsychiatric concerns often lead to the exclusion of such patients from interferon-alpha treatment, inappropriately depriving them of the potential benefits of this therapy.

CONCLUSION

Consultation-liaison psychiatrists should become familiar with the clinical spectrum of presentations associated with HCV infection as well as with related neuropsychiatric symptoms in order to promote the creation of multidisciplinary teams who specialize in the care of patients with HCV infections. More studies are needed to define neuropsychiatric syndromes that can be induced by interferon-alpha and to clarify best assessment and treatment procedures for these syndromes. It is also important to create and evaluate psychoeducational programs for all patients with chronic HCV infections, even those with low risk of complications, in order to promote adherence to therapy and optimize patients' quality of life.

Hepatitis C virus and alcohol

This review will focus on the prevalence of hepatitis c virus (HCV) infection in alcoholics with and without liver disease. Evidence will be presented to demonstrate that ethanol and chronic HCV infection synergistically accelerate liver injury. Some of the major postulated mechanisms responsible for disease progression include high rates of apoptosis, lipid peroxidation, and generation of free radicals and reactive oxygen species with reduced antioxidant capacity of the liver. Acquisition and persistence of HCV infection may be due to the adverse effects of ethanol on humoral and cellular immune responses to HCV. Dendritic cells (DC) appear to be one of the major targets for ethanol's action and DC dysfunction impairs the ability of the host to generate viral specific cluster of differentiation 4 (CD4+) and cluster of differentiation 8 (CD8+) immune responses. There is a relationship between increased alcohol intake and decreased response to interferon (IFN) therapy, which may be reversed by abstinence. Clinical studies are needed to optimize treatment responses in alcoholic patients with chronic HCV infection.

[Alcohol, steatohepatitis, insulin resistance and hepatitis C]

Patients with chronic hepatitis C have frequently other morbidities, either because they are frequent in the general population (metabolic syndrome) and/or because the route of contamination (chronic alcohol consumption succeeding to drug abuse). These co-morbidities have a harmfull impact on fibrosis progression during the natural history of HCV infection and reduce the efficacy of antiviral treatments. Thus, it is crucial to diagnose early and treat these different diseases which may be combined. They are the metabolic syndrome and/or chronic alcohol consumption resulting in insuline resistance, infection by the human immune deficiency virus or by the hepatitis B virus as well as chronic tobacco use or excessive consumption of cannabis. An optimal is based on a multidisciplinary approach to reduce fibrosis progression and improve the efficiency of antiviral therapies. However, the hepatologist has to come back to a global care, which is mandatory at the individual level as well as for the public health.

Communicating about alcohol consumption to nonharmful drinkers with Hepatitis C: patient and provider perspectives

BACKGROUND

Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C(HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not bea problem in the absence of their HCV diagnosis.

OBJECTIVE

This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.

DESIGN

We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N=50) and healthcare providers (N=14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.

RESULTS

We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients.Patient respondents who reported hearing “stop completely”were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in“medical language” than were GI providers.

CONCLUSIONS

To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.

An overview of HIV and chronic viral hepatitis co-infection

Combination antiretroviral therapy often controls HIV disease, may indirectly slow HCV progression, and creates an immune environment which may optimize HCV drug therapy response. Monitoring for antiretroviral-related liver adverse events is vital. However, this complication infrequently causes clinically significant liver toxicity. HCV antiviral therapy should, in most cases, be reserved for those abstaining from alcohol and achieving HIV RNA suppression and immune restoration on combination antiretroviral therapy or for those with nadir CD4 counts above 350 cells/mul. Given the high prevalence of HBV and HCV co-infection, chronic viral hepatitis will influence the health and treatment of HIV-infected individuals for the foreseeable future.

Communicating about alcohol consumption to nonharmful drinkers with hepatitis C: patient and provider perspectives

BACKGROUND

Abstaining from alcohol consumption is generally recommended for patients with Hepatitis C (HCV). However, mixed research findings coupled with a lack of consistent guidelines on alcohol consumption and HCV may influence what healthcare providers tell their HCV patients about drinking. This may be more problematic when advising nonharmful drinkers with HCV, a population for whom consumption would not be a problem in the absence of their HCV diagnosis.

OBJECTIVE

This study explores what healthcare providers advise their HCV patients who are drinking alcohol at nonharmful levels about alcohol use and what these patients actually hear.

DESIGN

We conducted separate focus groups and interviews about alcohol use and HCV with nonharmful drinkers with HCV (N = 50) and healthcare providers (N = 14) at a metropolitan teaching hospital. All focus groups and interviews were audio-taped, transcribed, and analyzed using NVivo, a qualitative data management and analysis program.

RESULTS

We found similar themes about HCV and alcohol consumption (stop completely, occasional drink is ok, cut down, and provision of mixed/ambiguous messages), reported by both providers and patients. Patient respondents who reported hearing "stop completely" were more likely to have had their last medical visit at the gastroenterology (GI) clinic as opposed to the internal medicine (IM) clinic. Furthermore, IM providers were more likely to give their recommendations in "medical language" than were GI providers.

CONCLUSIONS

To make the best health-related decisions about their disease, HCV patients need consistent information about alcohol consumption. Departments of Internal Medicine can increase provider knowledge about HCV and alcohol use by providing more education and training on HCV.

Mechanisms of synergy between alcohol and hepatitis C virus

BACKGROUND

Since the discovery of the hepatitis C virus (HCV), extensive literature has emerged on alcohol and HCV interaction.

GOAL

To understand the impact of alcohol and HCV infection on the severity of liver disease and the mechanisms of interaction between the two.

STUDY

Of 1269 articles (1991 to 2006) searched through MEDLINE and cited cross references, 133 were thoroughly reviewed to assess: (a) prevalence of combined alcohol use and HCV, (b) severity of liver disease (c) treatment response, and (d) mechanisms of interaction between HCV and alcohol. Data on study design, patient demographics, diagnostic tests used, and study outcomes were extracted for critical analysis.

RESULTS

Prevalence of HCV is 3-fold to 30-fold higher in alcoholics compared with the general population. Patients with HCV infection and alcohol abuse develop more severe fibrosis with higher rate of cirrhosis and hepatocellular cancer compared with nondrinkers. Increased oxidative stress seems to be the dominant mechanism for this synergism between alcohol and the HCV. Abstinence is the key to the management of liver disease due to HCV and alcohol. Data have shown that lower response rates to interferon in alcoholics with HCV infection are likely due to noncompliance.

CONCLUSIONS

Alcoholics with HCV infection have more severe liver disease compared with nondrinkers. Patients should be encouraged to enroll in rehabilitation programs so as to improve treatment adherence and response.

Alcohol and hepatitis C mortality among males and females in the United States: a life table analysis

OBJECTIVE

Evidence from previous studies suggests that heavy alcohol use (HAU) exacerbates the rate of fibrosis progression in the liver and results in increased probability for premature death among patients with hepatitis C virus (HCV) infection. The current study uses population-based mortality data to investigate whether heavy drinking affects the age of death among individuals with HCV and, if so, whether this effect differs between men and women.

METHODS

A total of 7,263,163 death records in the United States between 2000 and 2002 were drawn from the Multiple Cause of Death (MCD) public-use data files compiled by the National Center for Health Statistics (NCHS). International Classification of Diseases, Tenth Revision (ICD-10) codes were used to identify the presence of HCV (B17.1 and B18.2) and HAU (as indicated by alcohol-induced medical conditions, F10 and K70) either as the underlying cause or as one of the contributing causes of death. The deaths were divided into 4 distinctive cause-of-death categories: HCV without HAU, HAU without HCV, HCV plus HAU, and all others. The mean ages of death and the cumulative probabilities of death derived from multiple-cause life table were compared across these categories.

RESULTS

Hepatitis C virus deaths showed an excessive prevalence of HAU when compared with non-HCV deaths. Compared with deaths of HCV without HAU, the mean age of death was shortened for deaths of HCV plus HAU (from 55.1 to 50.0 years among males, and from 61.0 to 49.1 years among females). The cumulative probability of death before age 65 was much higher for the latter than the former group (0.91 vs 0.68 among males, and 0.88 vs 0.47 among females). While HCV alone showed a disproportionate effect on premature death in males, HAU presented a stronger effect in females, resulting in a "catching-up" effect that diminished the gender difference in age of HCV death.

CONCLUSIONS

This study provides mortality-based evidence to further establish heavy alcohol consumption as one of the key risk factors contributing to premature deaths from HCV in the United States. More importantly, this study, for the first time, presents empirical evidence that alcohol consumption affects men and women differently in HCV mortality.

Interferon alpha therapy for hepatitis C: treatment completion and response rates among patients with substance use disorders

Background

Individuals with substance use disorders (SUDs) are at increased risk for hepatitis C viral infection (HCV), and few studies have explored their treatment responses empirically. The objective of this study was to assess interferon alpha therapy (IFN) completion and response rates among patients with HCV who had a history of comorbid SUDs. More data is needed to inform treatment strategies and guidelines for these patients. Using a medical record database, information was retrospectively collected on 307,437 veterans seen in the Veterans Integrated Service Network 20 (VISN 20) of the Veterans Healthcare Administration (VHA) between 1998 and 2003. For patients treated with any type of IFN (including regular or pegylated IFN) or combination therapy (IFN and ribavirin) who had a known HCV genotype, IFN completion and response rates were compared among patients with a history of SUD (SUD+ Group) and patients without a history of SUD (SUD- Group).

Results

Odds ratio analyses revealed that compared with the SUD- Group, the SUD+ Group was equally likely to complete IFN therapy if they had genotypes 2 and 3 (73.1% vs. 68.0%), and if they had genotypes 1 and 4 (39.5% vs. 39.9%). Within the sample of all patients who began IFN therapy, the SUD- and SUD+ groups were similarly likely to achieve an end of treatment response (genotypes 2 and 3, 52.8% vs. 54.3%; genotypes 1 and 4, 24.5% vs. 24.8%) and a sustained viral response (genotypes 2 and 3, 42.6% vs. 41.1%; genotypes 1 and 4: 16.0% vs. 22.3%).

Conclusion

Individuals with and without a history of SUD responded to antiviral therapy for HCV at similar rates. Collectively, these findings suggest that patients who have co-morbid SUD and HCV diagnoses can successfully complete a course of antiviral therapy.

Hepatitis C virus eradication in intravenous drug users maintained with subcutaneous naltrexone implants

The effectiveness of HCV antiviral therapy in patients who have undergone recent drug dependency treatment and continue to inject drugs sporadically is presently not clear. Patients attending a community-based drug rehabilitation and naltrexone implant clinic from October 2002 until March 2005 were screened for HCV infection and if positive offered further assessment and treatment with interferon and ribavirin therapy. The first 50 patients to commence HCV therapy and complete at least 6 months follow-up were prospectively studied. ETR response (HCV PCR negative) was 34/50 (68%) and SVR 6 months post-treatment was 31/50 (62%). Viral eradication was maintained in those 22 patients that have had 12 months or more post-treatment follow-up. Eleven (22%) patients stopped therapy early due to side effects or poor compliance. Only two patients with an ETR likely reinfected due to unsafe injection practices. One was re-treated and achieved an SVR. Of the patients achieving a 6-month SVR, 17 of 31 patients reported no further IDU and 13 of 31 patients occasional IDU during treatment and this was maintained after HCV treatment cessation. 46% of patients received antidepressant and/or antipsychotic medication during treatment.

CONCLUSION

This study of HCV treatment in a community-based subcutaneous naltrexone implant clinic found antiviral therapy resulted in a 62% SVR. This result is comparable to that reported in hospital-based clinics in non-IDU patients. The side effect profile and compliance was also similar. HCV antiviral therapy should be offered to this large and currently under treated group.

Therapeutic challenges in hepatitis C-infected injection drug using patients

Hepatitis C Viral (HCV) infection in the injection drug user (IDU) population is a major medical concern. Concurrent substance abuse, co-morbid mental health conditions, poor socioeconomic status and a complex treatment protocol that is often incompatible with the life styles of IDUs combine to account for poor uptake and completion of HCV treatment. This article discusses HCV antiviral treatment issues relevant to IDUs chronically infected with this virus. The effect of non-injected substances of abuse on treatment outcome is considered. Priority issues requiring research are discussed.

Optimizing Treatment Outcomes in Chronic Hepatitis C: Management of Non-Response

The overarching goal in treating chronic hepatitis C (CHC) is the prevention of serious hepatic complications such as cirrhosis, end-stage liver disease and hepatocellular carcinoma. Successful eradication of the hepatitis C virus has been shown to prevent liver disease progression and even promote regression of fibrosis. The treatment of CHC has improved significantly over the past decade with the introduction of interferons (IFNs), and more recently, pegylated IFNs. Up to two-thirds of all patients treated with a pegylated IFN combined with ribavirin can now achieve viral eradication if treated according to current guidelines. Despite this success rate, limited treatment options currently exist for the growing number of patients who do not respond to this combination, and those who have previously failed treatment with conventional IFN-based regimens. There are numerous host-and viral-related factors that can contribute to these outcomes. In addition, treatment insufficiency, whether due to treatment type, side effects or non-compliance, can result in inadequate antiviral pressure and a reduced likelihood of response. This review explores putative management strategies for patients who have previously failed to achieve a response to IFN-based therapy, and summarises retreatment options that have been, and are currently being evaluated.

Barriers to treatment of hepatitis C in HIV/HCV-coinfected adults with alcohol problems

BACKGROUND

Alcohol use and human immune deficiency virus (HIV) infection are both associated with accelerated progression of hepatitis C virus (HCV) disease and reduced response rates to interferon therapy. In this study, we assessed the prevalence of barriers to interferon treatment in a population of HIV/HCV-coinfected patients with current or past alcohol problems and the extent to which they received treatment to address the barriers.

METHODS

This is a cross-sectional, descriptive analysis of baseline data from a prospective study assessing the impact of HCV and alcohol use on HIV disease progression. Using consensus guidelines, subjects were categorized as having absolute, relative, or no contraindications to interferon therapy for HCV. Absolute contraindications to treatment included heavy alcohol use, decompensated liver disease, CD4 cell count <100 cells/microL, recent needle sharing, and suicidal ideation. Relative contraindications included moderate alcohol use, recent injection drug use, depressive symptoms, and CD4 cell count from 100 to 199 cells/microL.

RESULTS

Of 401 HIV-infected subjects, 200 were HCV RNA-positive. Fifty-three percent had an absolute contraindication to interferon therapy, 35% a relative but no absolute contraindication, and only 12% had no contraindication. Of those with an absolute contraindication, 61% reported heavy drinking and the majority (88%) had multiple contraindications. These contraindications were present despite the fact that over 50% were in receipt of substance abuse and mental health treatment.

CONCLUSIONS

Continued alcohol and drug use as well as depressive symptoms are the major barriers to interferon therapy in HCV/HIV-coinfected subjects and these barriers persist despite high treatment rates for these problems. Therefore, more intensive treatments of alcohol, drug, and mental health issues are needed to improve HCV treatment eligibility in HCV/HIV-coinfected persons.

Psychiatric and substance use disorders in individuals with hepatitis C: epidemiology and management

Hepatitis C virus (HCV) infection is a major health concern in the US as well as in other countries worldwide. Treatment issues and disease management strategies are complicated by the extremely high rate of psychiatric and substance use disorders in those who have HCV. The majority of new and existing cases of HCV are related to injection drug use and, in this population, the prevalence of psychiatric comorbidity is high. Optimally, all patients with HCV should be screened for psychiatric and substance use disorders before initiation of antiviral therapy. If a patient screens positive, he or she should be referred to a mental healthcare provider or addiction specialist, assessed for the presence of a psychiatric or substance use disorder, and appropriately treated prior to initiation of antiviral (i.e. interferon) therapy. Although interferon-based therapies can lead to severe neuropsychiatric adverse effects, including in rare instances suicide, evidence suggests that many patients with comorbid psychiatric and substance use diagnoses can be treated safely and effectively using comanagement strategies. However, most patients with HCV are not treated with antiviral therapy. Therefore, we must expand our definition of HCV 'treatment' to include treatment of the comorbid psychiatric and substance use disorders that accompany HCV infection and precede antiviral therapy. This paper reviews the epidemiology and management of psychiatric and substance use disorders in patients with HCV, the issue of psychiatric and substance use disorders as contraindications for antiviral therapy, and current treatment strategies for HCV patients with these comorbid conditions.

Xerophthalmia secondary to alcohol-induced malnutrition

BACKGROUND

Xerophthalmia refers to the ocular manifestations associated with vitamin A deficiency. Vitamin A deficiency can be caused by numerous disorders, including alcohol-induced malnutrition. The ocular manifestations of xerophthalmia include conjunctival and corneal xerosis (drying), keratomalacia (corneal necrosis/ulceration), nyctalopia (night blindness), and Bitot's spots (conjunctival lesions).

CASE REPORT

A 47-year-old white male with complaints of dryness and difficulty seeing at night presented to our clinic for consultation from general medicine to rule out xerophthalmia. Laboratory testing and general medicine, psychiatry, and nutrition evaluations confirmed the systemic diagnosis of alcohol-induced malnutrition. He admits that his alcoholism was induced by depression. Confirmed associated disorders compounding the malnutrition include alcoholic cirrhosis, protein deficiency, and megaloblastic anemia. The patient had xerophthalmia diagnosed in the optometry clinic as a result of symptoms, slit lamp examination signs, and the associated disorders. The associated disorders were treated with systemic medications and vitamins. Ophthalmic treatment consisted of carboxymethylcellulose-based artificial tears.

CONCLUSIONS

Although xerophthalmia and vitamin A deficiency are more common in underdeveloped countries, their presentation in the United States may be induced by conditions such as liver cirrhosis, malnutrition, and alcoholism. This report summarizes ocular manifestations of alcoholism and presents a case of xerophthalmia secondary to alcohol-induced malnutrition and the role of optometry in its treatment and management.

The impact of past alcohol use on treatment response rates in patients with chronic hepatitis C

BACKGROUND

Studies have shown that past alcohol consumption reduces response rates in patients with chronic hepatitis C treated with interferon monotherapy.

AIM

To clarify the importance of alcohol consumption on response rates in patients undergoing treatment with pegylated interferon and ribavirin.

METHODS

In a single centre, prospective study, median daily alcohol consumption (determined by previously validated method) and quartiles of alcohol consumption were calculated. Univariate and binary logistic regression analyses were performed using treatment response status as the dependent variable.

RESULTS

Overall, in an intention-to-treat analysis, 34 of 115 patients (30%) responded to treatment. In univariate analysis, black patients, especially those with hepatitis C virus genotype 1, high viral load and low alanine aminotransferase were significantly less likely to respond. Predictors of response by regression analysis included alcohol <30 g/day (OR=3.02, 95% CI: 1.02-8.93; P=0.04), non-genotype 1 status (OR=1.98, 95% CI: 1.03-3.80; P=0.04) and non-black race (OR=2.79, 95% CI: 1.33-5.85; P=0.006).

CONCLUSIONS

Median daily alcohol use >30 g/day is associated with failure to respond to pegylated interferon and ribavirin for treatment of hepatitis C. Past alcohol use should be evaluated when considering treatment for hepatitis C.

Therapeutic Interventions for HIV Infection and Chronic Viral Hepatitis

Combination antiretroviral therapy reduces overall and liver-specific morbidity and mortality in coinfection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) and represents the most beneficial pharmaceutical treatment intervention for most coinfected patients. Antiviral therapy for HCV infection is potentially organ- and life-saving but, in general, should be reserved for patients who achieve suppression of HIV RNA and immune restoration from combination antiretroviral therapy or for patients with nadir CD4+ T lymphocyte levels of >350 cells/microL. Safe and virologically active treatment of coinfection with HIV and hepatitis B virus can be concurrently achieved by the use of combination antiretroviral therapy regimens containing lamivudine and/or tenofovir.

Therapies for HIV and viral hepatitis coinfection

The natural history of chronic viral hepatitis is altered by HIV coinfection. Liver fibrosis rates and clinical features of liver disease develop more rapidly. Although HIV-hepatitis C virus coinfected subjects may progress more rapidly to AIDS, this is probably explained by comorbid illness, substance abuse and socioeconomic circumstances. Safe and virologically active treatment of HIV-hepatitis B virus coinfection can be concurrently achieved by the use of highly active antiretroviral therapy regimens containing lamivudine and/or tenofovir. In most cases, highly active antiretroviral therapy represents the most beneficial initial pharmaceutical intervention for HIV-hepatitisC virus coinfection. HepatitisC virus antiviral therapy should, in most cases, be reserved for those achieving HIV RNA suppression and immune restoration from highly active antiretroviral therapy or with nadir CD4 T-lymphocytes above 350 cells/microl.

Effect of alcohol on viral hepatitis and other forms of liver dysfunction

Alcohol is a known hepatotoxic agent, which may exacerbate liver injury caused by other agents. The wide prevalence of alcohol use and abuse in society makes it an important cofactor in many other liver diseases. Examples of liver diseases that are significantly influenced by ingestion of alcohol include chronic viral hepatitis, disorders of iron overload, and obesity-related liver disease.

Alcohol and hepatitis C

BACKGROUND/AIMS

Alcohol use and hepatitis C are prominent risk factors for liver injury and this review offers the current understanding of each factor's effects on liver disease.

METHODS

A Medline database search was preformed for English articles with a focus on alcohol, hepatitis C and liver disease. Article citations were also considered for further applicable articles, and the strongest studies were included in our review.

RESULTS

Up to 60% of patients with hepatitis C have a past history of alcohol use. In patients with hepatitis C, chronic alcohol consumption of more than 5 drinks/day increases the rate of liver fibrosis, risk for cirrhosis, hepatocellular carcinoma, and, possibly, death from liver disease. Numerous studies have further found that even moderate amounts of alcohol can be detrimental to hepatitis C patients. The prevalence of hepatitis C is higher in alcoholics with advanced liver disease than in alcoholics without liver disease. Also, recent alcohol use decreases the response rate to interferon treatment.

CONCLUSIONS

Hepatitis C and alcohol use are often co-occurring risk factors for liver disease, and though their interaction is not clear, it is known that heavy drinking significantly promotes liver disease progression.

Liver disease in alcohol and hepatitis C

The prevalence of hepatitis C is 7-10-fold higher in alcoholics than it is in the general population. Among alcoholics, the prevalence of hepatitis C is higher in alcoholics with advanced liver disease. Serum ALT and hepatitis C viral load may improve if alcoholic patients with hepatitis C stop drinking for more than 4 months.Up to 60% of patients with hepatitis C have a past history of alcohol use. In patients with hepatitis C, chronic alcohol consumption of more than 5 drinks per day increases the rate of liver fibrosis. Hepatitis C patients who ingest more than 5 alcoholic drinks per day are at increased risk for cirrhosis, hepatocellular carcinoma and, possibly, death from liver disease. Recent alcohol use decreases the response rate to interferon treatment. The detrimental effects of small amounts (3 or fewer drinks per day) of alcohol consumption in patients with hepatitis C are not known.

Comprehensive review of hepatitis C for psychiatrists: risks, screening, diagnosis, treatment, and interferon-based therapy complications

Hepatitis C is an RNA virus responsible for chronic infection in at least 4 million Americans. Patients are often unaware that they have contracted the virus until the appearance of long-term consequences of the infection, primarily cirrhosis and hepatocellular carcinoma. Many patients with hepatitis C have comorbid psychiatric and/or substance abuse disorders. Treatments for hepatitis C infection are based on interferon-alfa therapy and have shown increasing effectiveness in recent years; however, interferon-alfa therapy also poses significant risks for physical and neuropsychiatric side effects. Since psychiatrists often serve as primary caregivers for patients who are at higher risk for hepatitis C infection, knowledge about the diagnosis, prognosis, and treatment of this disease is needed. In the first half of this article, the authors review the epidemiology, transmission, pathophysiology and disease course of hepatitis C, as well as the neuropsychiatric complications of hepatitis C infection. They also discuss the incidence of comorbid psychiatric disorders in patients with hepatitis C infection and consider the impact of the infection on patients' quality of life. The authors then provide an overview of the clinical management of HCV infection, including screening procedures, decision-making about treatment, available treatments (interferon-alfa, pegylated interferon-alpha, combination therapy with interferon and ribavirin) and their side effects and potential drug-drug interactions, and prediction of treatment response. The authors then discuss management of the neuropsychiatric complications of treatment with interferon-alpha and ribavirin, including depression, mania and psychosis, and cognitive and neurological complications. The final section of the article focuses on special issues related to the treatment of hepatitis C infection in patients with substance abuse or dependence and/or other comorbid psychiatric illness.

Alcohol use and hepatitis C

Excess alcohol consumption can worsen the course and outcome of chronic hepatitis C. It is important to distinguish between alcohol abuse, which must be treated on its own merits, and the effect of alcohol use on progression, severity, and treatment of hepatitis C. Most studies on the effects of alcohol on hepatitis C have focused on patients with high levels of daily alcohol intake. Indeed, the adverse effects of light and moderate amounts of alcohol intake on hepatitis C virus (HCV) infection have not been clearly shown, and only limited studies have been performed. Sex differences exist in the effect of alcohol on fibrosis as well as on the severity of hepatitis C. Alcohol use has been reported to be associated with lower responses to therapy and, in some studies, higher HCV RNA levels and increased HCV quasi-species. Few studies address the treatment of hepatitis C in the alcoholic individual or determine the effect of continued light or moderate alcohol use on the outcome of treatment response. In summary, many critical questions remain regarding the interactions between alcohol and hepatitis C. Currently, the evidence from the literature shows that heavy alcohol intake worsens the outcome of HCV infection. The literature is inadequate to provide definitive recommendations regarding the effect of light to moderate alcohol use in patients with hepatitis C.

Alcohol use and hepatitis C

Excess alcohol consumption can worsen the course and outcome of chronic hepatitis C. It is important to distinguish between alcohol abuse, which must be treated on its own merits, and the effect of alcohol use on progression, severity, and treatment of hepatitis C. Most studies on the effects of alcohol on hepatitis C have focused on patients with high levels of daily alcohol intake. Indeed, the adverse effects of light and moderate amounts of alcohol intake on hepatitis C virus (HCV) infection have not been clearly shown, and only limited studies have been performed. Sex differences exist in the effect of alcohol on fibrosis as well as on the severity of hepatitis C. Alcohol use has been reported to be associated with lower responses to therapy and, in some studies, higher HCV RNA levels and increased HCV quasi-species. Few studies address the treatment of hepatitis C in the alcoholic individual or determine the effect of continued light or moderate alcohol use on the outcome of treatment response. In summary, many critical questions remain regarding the interactions between alcohol and hepatitis C. Currently, the evidence from the literature shows that heavy alcohol intake worsens the outcome of HCV infection. The literature is inadequate to provide definitive recommendations regarding the effect of light to moderate alcohol use in patients with hepatitis C.