More Are Finding Permanent Cures for
Hepatitis C
By JULIE BAIN
New York Times - 5/16/02
Five years ago, R. Scott Bromley, then 57, was returning from a trip to
Sicily with friends when he felt a nagging pain in his right side. He was
scheduled for an annual checkup the next day, and he learned from a blood
test that his liver enzymes were elevated.
Not a big drinker, Mr. Bromley, a New York architect, told the doctor that
while in Italy, "You have a little wine before dinner on the piazza, a
little wine during dinner, a little wine after dinner," and suggested maybe
that was the cause of the unusual numbers.
Two weeks later he was tested again, with the same result. He was referred
to a specialist in liver disease and, after further tests, hepatitis C was
diagnosed. The doctor told him he could have been harboring the virus for 30
years or more with no symptoms. What's more, the disease could be life
threatening. Mr. Bromley was devastated.
More than four million people have hepatitis C in the United States, five
times as many as are infected with H.I.V.
"It's the bulk of my practice," said Dr. Hillel Tobias, the medical
director
of the Liver Transplant Service at New York University Medical Center.
The reason is not that new cases are being contracted. New cases have
declined 80 percent in the last decade, mainly because blood transfusions
have not been risk factors in that period, thanks to testing for the virus.
But because the disease takes so long to progress, more patients are
learning that they have hepatitis C while in their 40's and 50's and that
they contracted the virus many years ago.
The annual death toll, about 10,000 a year in the United States, is expected
to increase for another decade to as many as 30,000 before declining,
according to the American Liver Foundation.
Unlike hepatitis A and B, there is no vaccine for hepatitis C, and the virus
can lead to serious liver disease, like cirrhosis or liver cancer. Hepatitis
C patients make up the largest percentage of people requiring liver
transplants. But with new treatments, more are now finding permanent cures.
Some misconceptions exist about the way the hepatitis C virus is spread,
said Dr. Eugene R. Schiff, a professor of medicine and the director of the
Center for Liver Disease at the University of Miami School of Medicine.
"The
unequivocally major mode of transmission is blood to blood," he said. An
estimated 300,000 Americans now infected got the disease from a transfusion
before 1990.
"Sexual transmission has been way overplayed," he said. "So has
transmission
from mother to baby. It's uncommon, probably less than 3 percent for either
of those, quite the opposite from hepatitis B."
Drugs injected by needle also pose blood-to-blood risks. "The classic
hepatitis C patient today is a very upstanding 50-year-old lawyer who once
tried a needle when he was in college," Dr. Tobias said. "In the 70's,
a lot
of kids in college tried needles once."
Tattoo needles can also spread the disease.
Because of the lack of symptoms, many cases go undetected until the disease
is advanced, although a test can detect antibodies to the virus before it
affects the liver.
Starting in 1992, the treatment of choice was alpha interferon, injected
three times a week for a year. This antiviral protein can kill the virus, as
well as boost the immune system. The rate of permanent viral clearance was 8
to 10 percent, Dr. Tobias said. About five years ago, this treatment was
combined with ribavirin, another antiviral agent. With both drugs taken
together, a permanent cure rate of about 25 percent was achieved. One reason
the rate was not higher was that the interferon was cleared out of the blood
so quickly.
Current treatment is pegylated interferon, a long-acting form of the
treatment that maintains a sustained blood level for a week. Approved by the
Food and Drug Administration in 2001, it brought the cure rate up to about
50 percent. "And if you add ribavirin to it," Dr. Tobias said,
"you get to
over 60 percent."
Five years ago Mr. Bromley began treatment with alpha interferon, and within
two and a half months he was down to a level of zero virus. But the side
effects were devastating. "I didn't sleep well, my sex life was all screwed
up, I lost 40 pounds and the interferon changed my whole personality," he
said.
Then, just a year after he was off the drug, the virus rebounded, even
higher than it was before.
There is no clear correlation between the viral count and what's going on in
the liver, the real danger zone.
"I have patients with advanced liver disease whose viral counts are fairly
low," Dr. Tobias said, "and I have patients with very little liver
disease
whose viral counts are very high. Similarly, there are people who have
normal enzymes and still have significant hepatitis C."
That's why a liver biopsy is usually required to help determine treatment.
For Mr. Bromley, whose tests showed little damage to his liver, it was a
tough decision whether to undergo a second treatment. But a year and a half
later, he began 48 weeks of interferon and ribavirin, and this time the side
effects were even worse. "I couldn't sleep," he said. "I began
forgetting
things. I would fall down in the middle of the street. I became very
depressed."
But the treatment worked, and Mr. Bromley has been free of the virus for
more than three years.
Other patients refuse a second treatment, saying the side effects, including
flulike symptoms and depression, aren't worth it.
"But," said Dr. Tobias, "they should be retreated with the
pegylated
interferon because a significant number of them will respond to it."
Those who previously did not respond with interferon have about a 20 percent
chance of being cured if they are retreated with the pegylated interferon.
Those who have relapsed after successful treatment have a chance of
receiving a permanent cure of greater than 50 percent. Evidence also
suggests that even if a patient doesn't lose the virus, the
anti-inflammatory activity of the pegylated interferon slows the progression
of the disease. Some patients who have advanced liver disease go on lifetime
reduced-dose interferon, which can delay the need for a liver transplant.
New treatments in development may replace interferon and ribavirin, or be
added to them in a drug cocktail, similar to AIDS and H.I.V. treatments.
Vertex and Eli Lilly recently announced that they were developing a protease
inhibitor that could prevent the virus from making infectious copies of
itself. Even more promising, say doctors, is a polymerase inhibitor, which
may also stop the virus from replicating. Another possibility is a ribozyme,
which may cut the hepatitis C virus "like a scissors," said Dr. Schiff.
None of these treatments, however, will be available for several years.
A vaccine remains a challenge because hepatitis C has eight different
molecular configurations that are constantly changing and mutating. A
vaccine would require developing an immune response to a part of the virus
that is relatively stable across all the variations.
Ane Palmo
Director/Founder of Frontline Hepatitis Awareness
http://frontline-hepatitis-awareness.com
206-328-5381
1-866-HEP-GOGO outside WA
