Patient information: Hepatitis C (Beyond the Basics)
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology
- Section Editor — Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
Hepatitis is the medical term for inflammation of the liver. It can be caused by a number of factors, including viruses (like hepatitis B and C), alcohol abuse, large doses of certain medications, and poisons.
Most people infected with the hepatitis C virus have no or only mild symptoms, so they do not always know they are infected.
In some people, over time, chronic infection with the hepatitis C virus can damage the liver and lead to cirrhosis. Drinking alcohol and being overweight add to the risk of developing cirrhosis. (See "Patient information: Cirrhosis (Beyond the Basics)".)
TRANSMISSION OF HEPATITIS C
Many people with hepatitis C infection do now know how they were infected. The hepatitis C virus is spread by contact with blood. The most common ways people have gotten infected are:
●Sharing needles, syringes, or other paraphernalia used for injection drug use
●Receiving a blood transfusion before 1990, when blood was not routinely tested for hepatitis C or other infections
●Having sex with an infected person
It is also possible to get the hepatitis C virus by:
●Getting body piercings or tattoos done with improperly sanitized equipment
●Sharing cocaine straws
●Sharing toothbrushes, razors, or other things that could have blood on them
●Getting stuck with a sharp object that has contaminated blood on it (as might happen in a healthcare setting)
Pregnant women can rarely spread the virus to their fetus.
There is no evidence that any of the following activities lead to transmission of hepatitis C:
●Kissing or hugging
●Sneezing or coughing
●Casual contact or other contact that does not involve blood
●Sharing food, water, eating utensils, or drinking glasses
Acute versus chronic hepatitis c infection — When people are first infected with the hepatitis C virus, they develop what is called an acute infection. Some people are able to fight off the infection at this stage and become cured. But most people – 60 to 80 percent of those infected—go on to develop a chronic infection. That means the virus remains active in their body, even if they do not know they have it.
Prevalence — Hepatitis C is fairly common, affecting almost 3 percent of the population worldwide, and about 1 percent of the population in the United States. In recent decades, the rates of hepatitis C infection have been declining, probably owing to cleaner injection practices among intravenous drug users. Nevertheless, hepatitis C remains a concern, especially among people born between 1945 and 1964, many of whom are unknowingly infected.
SYMPTOMS OF HEPATITIS C
Most people with hepatitis C have no symptoms or only mild nonspecific symptoms that are difficult to attribute to the infection. Among those who do have symptoms, the most frequent complaint is fatigue. Other less common symptoms include nausea, decreased appetite, muscle or joint pain, weakness, and weight loss.
DIAGNOSIS OF HEPATITIS C
Healthcare providers diagnose hepatitis C using two types of test. One type of test checks the blood for antibodies—proteins made by the immune system in response to the virus. The other type of test checks for a substance called RNA made by the virus itself. Most people who have a negative antibody test do not have hepatitis C infection and do not need additional testing. However, healthcare providers may also order an RNA test if they suspect acute infection or if the person being tested has a potentially compromised immune system (such as those with HIV infection). People who have an active chronic infection will have both a positive antibody test and a positive RNA test. People who have a positive antibody test and a negative RNA test either had a false positive antibody test or had the infection at one time but were able to fight it off.
Home testing — The United States Food and Drug Administration has approved a hepatitis C antibody test kit that you can buy without a prescription and use at home. To take the test, you collect your own sample of blood and send it to a lab, which will return the results in 4 to 10 business days. Data presented to the FDA suggest that the at-home test is about as accurate as the test that hospitals use.
Who should be tested? — Healthcare providers generally test for hepatitis C in people with specific risk factors for infection (such as a history of injection drug use) or when a person shows signs of liver disease—usually in the form of abnormal blood tests. Experts also recommend routine testing for people born between 1945 and 1965, because the risk of infection is high in this group.
Determining the virus genotype — Once a diagnosis of hepatitis C is made, it’s important to identify the variant of the virus a person has. There are several forms of the virus—called genotypes—each of which must be treated differently. In the United States, genotype 1 is the most common, but genotypes 2 and 3, and less commonly 4, also occur.
Assessing the degree of liver damage — Another important aspect of hepatitis C diagnosis is to determine the condition of the liver at the time of diagnosis. Healthcare providers can asses the degree of liver damage using a number of blood tests, an imaging test called ultrasound-based transient elastography (which is not available everywhere), or, in some cases, a liver biopsy. (See "Patient information: Liver biopsy (Beyond the Basics)".)
Checking for other infections — People who have hepatitis C are at risk for infection with HIV and hepatitis B, in part because these infections can be transmitted in the same way as hepatitis C. They are also more vulnerable to any infection that targets the liver. As a result, after diagnosing hepatitis C, healthcare providers often do followup tests for HIV, and hepatitis A and B. People whose tests show they are not immune to hepatitis A and B should get vaccinated against these infections.
TREATMENT OF HEPATITIS C
There are a number of medications to treat hepatitis C. In the vast majority of people, these medications have an excellent chance of curing the infection.
Decision to treat — People diagnosed with hepatitis C must decide—in conjunction with their healthcare providers—whether and when to treat their infection. Factors that go into deciding whether treatment is appropriate include the condition of the person’s liver, the person’s overall health, and the genotype the person has. Other factors to consider include whether the person has other illnesses, such as kidney disease and whether the person already had a liver transplant.
Treatment regimens — People who do undergo treatment use one or more medications for several months. The specific combination of agents and the duration of treatment are determined based on the genotype involved and the person’s individual characteristics. The table lists the currently available hepatitis C medications, the genotypes for which they are used, and some of the most common or serious side effects (table 1).
Most hepatitis C medications can interact with other medications. Before you go on any medications for hepatitis C, make sure to tell your healthcare provider about all the medications you take, including herbal and non-prescription medications.
Side effects caused by hepatitis c medications — People being treated for hepatitis C sometimes develop medication side effects, although most are not serious. If you are being treated for hepatitis C, you should call your healthcare provider any time you develop a side effect that bothers you. Some of the medications used to treat hepatitis can make you tired, nauseated, or have headaches; some can cause a problem called anemia, which is when you do not have enough red blood cells to carry oxygen around your body; and some can cause a skin rash.
If you get any side effects that bother you, tell your healthcare provider. If you get a rash, call your healthcare provider right away. He or she will want to see your skin so he or she can decide how bad the rash is. Your healthcare provider will also want to know right away if you start feeling light-headed or extremely weak or breathless, as these can be signs of severe anemia.
In very rare cases, people need to stop taking their medications because of side effects. But DO NOT STOP TAKING YOUR MEDICATIONS because of side effects until you speak with your healthcare provider. Only he or she can tell if you need to stop the medications. Besides, your healthcare provider might have a way to deal with the side effects so that you can keep taking the medications. For example, if you are itchy, your healthcare provider might give you a medication to relieve itch. If you have anemia, your healthcare provider might lower the dose you take of the medication causing the problem. There are often ways to deal with side effects so that you are comfortable enough to keep taking your medications.
Even if your healthcare provider can’t make your side effects go away completely, remember that you only need to take these medications for a while. If you put up with some side effects, there is a good chance you will be cured.
Will I be cured? — If you take your medications exactly as directed, the chances of being cured are excellent. With the newest treatments, people who have not been treated for hepatitis C before are cured over 90 percent of the time. People who have failed treatment before or who have cirrhosis have a slightly lower chance of cure. But cure rates are improved with newer treatments.
Three to six months after discontinuing treatment for hepatitis C, your healthcare provider will give you a blood test to see if you are cured. If there is no trace of the virus in the blood, this is referred to as a Sustained Virological Response and is considered a cure. If you are not cured after your first course of treatment, he or she might suggest trying treatment again or waiting for new medications to come out.
Being cured of hepatitis C means the virus is no longer in the body and can no longer cause damage to the liver. For most people, liver scarring that was caused by hepatitis C can slowly improve over time after a cure. However, for people with cirrhosis, a small risk of worsening liver disease or liver cancer remains even after being cured of hepatitis C.
Being cured of hepatitis C does not make a person immune to the virus. A person who has been treated and cured of hepatitis C can be reinfected after a repeat exposure to the virus.
Importance of taking hepatitis c medications as directed — If you are being treated for hepatitis C and you take the medications the wrong way, they probably will not work as well as they should. You can also end up doing yourself more harm than good. With some of the medications, if people skip doses or do not take all their medications, the hepatitis C virus can quickly become "resistant". That means that the virus learns to outsmart the medications, and so the medications will not work.
To help you remember to take all of your medications at the right time, use special reminders called "memory aids." For instance, use a "talking pill box" or a wrist watch or smart phone app that can be set to tell you whenever it’s time to take your pills.
COMPLICATIONS OF HEPATITIS C
Over time, the liver inflammation caused by hepatitis C can cause serious damage to the liver. In some people, this develops into cirrhosis, which is when the liver becomes severely scarred and cannot function normally. Cirrhosis is discussed in more detail elsewhere. (See "Patient information: Cirrhosis (Beyond the Basics)".)
Successful treatment of hepatitis C prior to the development of cirrhosis prevents this complication. Even people who have already developed cirrhosis from hepatitis C have a reduced risk of liver-related complications and death after being cured of hepatitis C. However, since there is still a small risk of liver cancer in the setting of cirrhosis, patients who have cirrhosis will need continual monitoring by their doctor even if they are cured of hepatitis C.
LONG TERM MANAGEMENT OF HEPATITIS C
There are aspects of treating hepatitis C not directly related to tackling the infection. People with the disease need certain vaccines, and they need to avoid alcohol, recreational drugs, and certain medications.
Vaccines to protect the liver — Vaccines against hepatitis A and B (in those who are not already immune) can help prevent further damage to the liver. It’s also important to get other vaccines, including vaccines to protect against the flu (once a year), pneumonia (at least once), diphtheria and tetanus (once every 10 years) and pertussis (once during adulthood). There is currently no vaccine to prevent hepatitis C.
Avoid alcohol and other drugs that could harm the liver — People with hepatitis C should avoid all substances that are known to damage the liver. This includes:
●Some supplements and herbal remedies, such as kava kava
●Some prescribed medications
People who also have cirrhosis have additional medications they should avoid. (See "Patient information: Cirrhosis (Beyond the Basics)", section on 'Avoid alcohol and other drugs that could harm the liver'.)
To find out if anything you take could harm your liver, put all the bottles of all the medications you take into a bag and take them with you to the doctor who manages your liver disease. Include all over-the-counter medications, supplements, and herbal drugs, as well as any prescriptions you take. Never start any new medications or supplements without first checking with your doctor.
Screening tests — If you have hepatitis C and cirrhosis, you should have an ultrasound done every six months to check for signs of cancer. You might also need a procedure called an upper endoscopy to check for esophageal varices (enlarged veins in the esophagus). (See "Patient information: Esophageal varices (Beyond the Basics)".)
Support — Sharing your concerns with others who have the same diagnosis can help you learn to live with hepatitis C. The American Liver Foundation has helpful advice and a list of support groups (www.liverfoundation.org).
New treatments for hepatitis C are actively being developed and studied in people enrolled in clinical trials. A clinical trial is a carefully controlled way to study how well new treatments or new combinations of known therapies work. If you are not a good candidate for currently available therapies, check with your healthcare provider to see if there is an open clinical trial of a hepatitis C treatment regimen that you would qualify for.
Ask for more information about clinical trials or read about clinical trials at http://clinicaltrials.gov/.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient information: Hepatitis C (The Basics)
Patient information: Vaccines when you have hepatitis C (The Basics)
Patient information: Cirrhosis (The Basics)
Patient information: Blood or body fluid exposure (The Basics)
Patient information: Treatment for hepatitis C (The Basics)
Patient information: Liver transplant (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient information: Hepatitis A (Beyond the Basics)
Patient information: Hepatitis B (Beyond the Basics)
Patient information: Blood donation and transfusion (Beyond the Basics)
Patient information: Liver biopsy (Beyond the Basics)
Patient information: Cirrhosis (Beyond the Basics)
Patient information: Esophageal varices (Beyond the Basics)
Patient information: Pneumonia prevention in adults (Beyond the Basics)
Patient information: Influenza prevention (Beyond the Basics)
Patient information: Adult vaccines (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Characteristics of the hepatitis C virus
Clinical manifestations and natural history of chronic hepatitis C virus infection
Clinical manifestations, diagnosis, and treatment of acute hepatitis C in adults
Diagnosis of hepatitis C virus infection in patients on dialysis
Epidemiology and etiologic associations of hepatocellular carcinoma
Epidemiology and transmission of hepatitis C virus infection
Epidemiology, natural history, and diagnosis of hepatitis C in the HIV-infected patient
Extrahepatic manifestations of hepatitis C virus infection
Hepatitis C and alcohol
Hepatitis C and transfusion: A 'lookback' primer
Hepatitis C virus infection in kidney donors
Hepatitis C virus infection in patients on maintenance dialysis
Investigational therapies for hepatitis C virus infection
Liver transplantation for hepatitis C virus infection
Management of the side effects of peginterferon and ribavirin used for treatment of chronic hepatitis C virus infection
Vertical transmission of hepatitis C virus
Pregnancy in women with pre-existing chronic liver disease
Screening for chronic hepatitis C virus infection
Overview of the management of chronic hepatitis C virus infection
Treatment of hepatitis C virus infection in the HIV-infected patient
Immunizations for patients with chronic liver disease
Treatment regimens for chronic hepatitis C virus genotypes 2 and 3
Predictors of a sustained virologic response following treatment with peginterferon and ribavirin for chronic hepatitis C virus infection
Diagnosis and evaluation of chronic hepatitis C virus infection
The following organizations also provide reliable health information:
●National Library of Medicine
●National Institute of Diabetes and Digestive and Kidney Diseases
- Chou R, Cottrell EB, Wasson N, et al. Screening for hepatitis C virus infection in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2013; 158:101.
- Holmberg SD, Spradling PR, Moorman AC, Denniston MM. Hepatitis C in the United States. N Engl J Med 2013; 368:1859.
- Recommendations for Testing, Managing, and Treating Hepatitis C. Joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America. http://www.hcvguidelines.org/ (Accessed on August 11, 2014).
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.