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Hepatitis C:
Occult Infection
Liz Highleyman
There remains much we don't know about
chronic hepatitis C. One such mystery is occult HCV. Usually
the virus betrays itself by the presence of antibodies or
viral genetic material (RNA) in the blood serum or plasma
(the clear, fluid portion of whole blood). But some people
who have no detectable HCV antibodies and no evidence of HCV
in their serum nevertheless harbor hidden virus elsewhere
in their bodies.
A Brief History of Hepatitis C
Alan Franciscus, Editor-in-Chief
The management and care of hepatitis
C has come a long way in the last decade. While there are
still many unanswered questions, we have a much better understanding
of hepatitis C transmission, prevention, disease progression
and treatment. This article will focus on a brief review of
the history of hepatitis C and the major strides made in treating
HCV since the identification of the virus.
HealthWise: Making Fitness Fun
Lucinda K. Porter, RN, CCRC
The holidays have passed and the
next event that involves chocolate is not until Valentine’s
Day. Food is an essential part of life. Unfortunately, too
much food or an excess of “empty calories” may
have a negative impact on life expectancy and quality of life.
The Importance of Water
Kara Wright, PA-C
Water is especially important for people who have liver
disease—whether on or off interferon treatment. It provides
many important functions, which we will discuss here.
News Briefs
Alan Franciscus, Editor-in-Chief
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Hepatitis
C: Occult Infection
Liz Highleyman
There remains much we don't know about chronic hepatitis C.
One such mystery is occult HCV. Usually the virus betrays
itself by the presence of antibodies or viral genetic material
(RNA) in the blood serum or plasma (the clear, fluid portion
of whole blood). But some people who have no detectable HCV
antibodies and no evidence of HCV in their serum nevertheless
harbor hidden virus elsewhere in their bodies. (HCV is not
the only virus that can take an occult form; HIV, for example,
can hide in "reservoir" sites such as the brain
and lymph nodes even if blood viral load is undetectable.)
Occult HCV may be suspected if a person has persistently elevated
liver enzyme levels or extrahepatic (outside the liver) conditions
commonly associated with hepatitis C. About one-third of people
with chronic HCV have persistently normal levels of one such
enzyme, alanine aminotransferase (ALT). Although many people
with normal ALT do not progress to serious liver disease,
some do develop fibrosis. A recent large study showed that
patients with normal ALT can benefit from therapy with pegylated
interferon plus ribavirin, suggesting that HCV-infected people
with normal ALT should be treated based on the same guidelines
as those with elevated ALT.
Unfortunately, an estimated 10% of people with persistently
abnormal liver enzymes have no readily identifiable cause
of liver damage using standard tests. There is concern that
such patients may be missed and therefore not offered therapy
due to false negative antibody or serum viral load tests.
While occult HCV appears to be relatively mild in comparison
with its more obvious counterpart, some patients with hidden
virus may still progress to serious liver injury. Another
concern is that HCV in donated blood and tissue may elude
current screening tests.
At the annual meeting of the American Association for the
Study of Liver Diseases this past October, and again in the
January 1, 2004 issue of the Journal of Infectious Diseases,
researchers reported that patients with persistently elevated
liver enzymes may harbor HCV even if they have no serological
evidence of the virus. Immaculado Castillo and colleagues
from Madrid studied 100 patients who had abnormally high ALT,
aspartate aminotransferase (AST), or gamma glutamyl transpeptidase
(GGT) levels for at least 12 months. All readily apparent
causes of liver disease were ruled out. The group had no evidence
of HCV antibodies or serum HCV RNA (using a viral load test
with a limit of detection of 10 IU/mL). Thirty patients with
liver damage due to non-viral causes were studied as controls.
The researchers used two different types of test to detect
occult HCV. First, they analyzed the presence of HCV RNA in
liver biopsy samples using the reverse transcription-polymerase
chain reaction (PCR) assay, the most commonly used viral load
test. Using a PCR test that identifies the 5' NC region of
the HCV genome, they found evidence of HCV genetic material
in the liver samples of more than half (57%) of the 100 patients
with unexplained elevated liver enzymes, but in none of the
samples from the controls. Using a PCR test that detects the
core region of the HCV genome, they detected RNA in 70% of
the samples from the 57 patients previously found to have
occult virus.
Second, using a test called in situ hybridization, the researchers
found positive-strand HCV RNA in the liver biopsy samples
from all of the 57 patients with occult HCV and none of the
controls. Negative-strand RNA was detected in 84% of these
57 subjects. (Positive-strand RNA can be used to directly
manufacture viral proteins within an infected cell. Negative-strand
RNA, in contrast, is used as a "template" to produce
a complementary positive strand. Thus, the presence of negative-strand
RNA indicates that the virus is actively replicating.)
In addition to the liver biopsy samples, the researchers also
detected HCV RNA in the peripheral blood mononuclear cells
(PBMC, a type of immune system white blood cell) in 70% of
the 57 patients with occult HCV in their livers.
Patients harboring HCV genetic material in their livers were
more likely to have liver inflammation and fibrosis than those
with no evidence of hidden HCV. About one-third (35%) of patients
with occult HCV had METAVIR inflammation scores of A1 or higher,
versus 14% of those without evidence of HCV. Likewise, just
over 17% of patients with occult HCV had stage F1 or higher
fibrosis, versus about 2% of those with no detectable HCV
in their livers.
In an editorial in the same issue of the Journal of Infectious
Diseases, Hervé Lerat, MD, and F. Blaine Hollinger,
MD, of Baylor College of Medicine suggested that doctors should
measure both ALT and GGT to identify patients with suspected
occult HCV. The study results suggest that testing of peripheral
blood cells may be as informative as invasive liver biopsies.
The authors noted that several mysteries remain, including
whether hidden HCV genetic material is infectious that is,
whether people with occult hepatitis C can spread the disease.
Along with persistently elevated liver enzymes, extrahepatic
conditions often associated with HCV infection may also suggest
that occult virus is present. These include thyroid dysfunction,
low platelet levels (which can lead to impaired blood clotting),
lichen planus (an inflammatory condition of the skin and mucous
membranes), vasculitis (blood vessel inflammation), and cryoglobulinemia
(a condition in which abnormal proteins form in the blood
and clump together, thus restricting blood flow). In the November
2003 edition of the Journal of Viral Hepatitis, for
example, Milvia Casato, MD, and colleagues from Rome reported
results from a study of three cryoglobulinemia patients with
no evidence of HCV antibodies or serum HCV RNA. Two of them
were nevertheless treated with interferon and demonstrated
good clinical response, but their cryoglobulinemia relapsed
after interferon was stopped, suggesting that HCV was indeed
the likely culprit. At the time of relapse, HCV genetic material
was detected in blood protein clusters (cryoprecipitates)
of both patients for the first time. In the third patient,
HCV RNA was detected for the first time during a cryoglobulinemia
"flare" associated with a herpes virus infection.
The authors concluded that some cases of so-called "essential"
(that is, unknown cause) cryoglobulinemia are in fact due
to occult HCV infection.
People with immune dysfunction may be especially likely to
harbor hidden HCV, since their immune systems are less able
to produce antibodies against the virus. Studies have shown
that people with HIV (especially those with CD4 cell counts
below 200) and transplant recipients taking immune-suppressing
drugs often have HCV infection but no HCV antibodies. Marcel
Beld and colleagues of the University of Amsterdam reported
in the August 15, 1999 issue of Blood that injection
drug users (IDUs) sometimes had a prolonged period of being
HCV antibody negative after infection (as long as eight years),
and that some also had intermittently undetectable serum HCV
RNA. The authors suggested that IDUs may have impaired immune
function independent of their HIV status. Research to date
suggests that IDUs, people with HIV, and others whose immune
function may be compromised should be tested carefully for
HCV (possibly using PBMC or liver biopsy tests) if they have
elevated liver enzymes or other signs that may indicate hidden
HCV infection.
With more sensitive testing, occult HCV may prove to be the
culprit behind many previously mysterious cases of liver disease.
Like all people with hepatitis C, these patients should be
considered for treatment since hidden HCV, like its more apparent
counterpart, can lead to severe, long-term liver damage.
Back to top
A
Brief History of Hepatitis C
Alan Franciscus, Editor-in-Chief
The management and care of hepatitis C has come a long
way in the last decade. While there are still many unanswered
questions, we have a much better understanding of hepatitis
C transmission, prevention, disease progression and treatment.
This article will focus on a brief review of the history of
hepatitis C and the major strides made in treating HCV since
the identification of the virus.
Prior to 1990
It is impossible to really know the origins of hepatitis C
since there are no stored blood samples to test for the virus
that are older than 50 years. However, given the nature of
the evolution of all viruses, hepatitis C has probably been
around for hundreds of thousands of years or more before evolving
into the current strains.
Some experts speculate that since HGV/GBV-C, a close relative
of HCV, originated in Old and New World primates, the beginnings
of HCV might be traced back to 35 million years ago. However,
this is just speculation and it is impossible to corroborate
these theories at the present time. On firmer ground is the
prediction that the different subtypes of HCV originated approximately
200 years ago and that the six main genotypes of HCV most
likely had a common ancestor approximately 400 years ago.
However, it has also been pointed out that it is difficult
to limit the origin of HCV to such a short period of human
history because the virus is found in remote areas all over
the world. As well, the virus is mainly spread by direct blood
to blood contact, making it difficult to spread and evolve
rapidly—especially considering that the main transmission
routes (blood product use and needle use) have only been in
existence for a short period of time.
1957
Scientists discovered the antiviral properties of interferon,
a naturally occurring substance in 1957. It was named interferon
since it has the ability to 'interfere' with viral replication.
Three different types of interferon were identified—alfa,
beta and gamma. While it was found that there is only one
form of beta and gamma interferon, it was discovered that
there were many forms of alfa interferon. Interferon was approved
to treat a variety of disorders including hairy cell leukemia,
and Kaposi's sarcoma.
1960-1970's
Scientists developed blood tests to identify hepatitis B (1963)
and hepatitis A (1973), but many of the blood samples taken
for post-transfusion illness tested negative for hepatitis
A and hepatitis B.
Given that the mode of transmission (blood transfusion) was
the same, scientists classified the unidentified cases as
non-A, non-B hepatitis. It is now believed that approximately
90-95% of cases previously classified as non-A, non-B were
actually hepatitis C.
In the 1980's, investigators from the Centers for Disease
Control (headed up by Daniel W. Bradley) and Chiron (Michael
Houghton) identified the virus. In 1990, blood banks began
screening blood donors for hepatitis C, but it wasn't until
1992 that a blood test was perfected that effectively eliminated
blood transfusion supply. Now the risk of contracting hepatitis
C through a blood transfusion is approximately .001%. Prior
to the screening of the blood supply for hepatitis C, approximately
300,000 Americans contracted hepatitis C through blood transfusions
or blood products.
Treatment Timelines
1991 - FDA approves first alfa interferon
(Schering's Intron A) to treat hepatitis C.
1992 - FDA approves first interferon (Schering-
Intron A) to treat hepatitis B.
1996 - FDA approves alfa interferon (Roche-
Roferon A ) to treat hepatitis C.
1997 - FDA approves consensus interferon
(Amgen- now InterMune-Infergen) to treat hepatitis C.
The general treatment protocol was to inject 3 million units
of interferon, three times a week for 48 weeks. Sustained
virological response rates (negative viral load 6 months post-treatment)
were approximately 9% for genotype 1 and 30% for genotypes
2 and 3.
Treatment Breakthrough
1998 - FDA approves Rebetron (Schering's
Intron A plus ribavirin) for the treatment of hepatitis C.
Ribavirin is a synthetic nucleoside analogue with a broad
spectrum of antiviral activity that was initially developed
as a possible treatment of HIV. As it turned out, ribavirin
was not effective against HIV, but it was found that it did
have antiviral activity against several flaviviruses (a family
of viruses that includes hepatitis C), and it was studied
as a single agent for the treatment of hepatitis C. In some
small studies, ribavirin was found to reduce serum ALT levels,
but that it had no effect on the hepatitis C virus. The clinical
findings that ribavirin reduced ALT levels led to the studies
of combination ribavirin and interferon therapy. It was found
that ribavirin when combined with interferon produced a snygery
that proved to be a major breakthrough for treating hepatitis
C. Ribavirin (in a mist form) is also approved for the treatment
of respiratory syncytial virus (RSV) infection in children.
The treatment with combination therapy consists of interferon
(Intron A - 3 million units thrice weekly) plus ribavirin
(800-1200mg/day). The clinical trials conducted on combination
therapy also determined the duration of treatment for genotype
1 as 48 weeks and 24 weeks for genotypes 2 and 3. Overall
sustained virological response rates are genotype 1 - 29%
(high viral load - 27%); genotypes 2 and 3 - 62% (high viral
load - 60%).
A New Era in the Treatment of Hepatitis
C
Synthetic interferon is a protein that is broken down rapidly
by the body within 12 to 24 hours after injection. The standard
protocol for interferon was to inject 3 times a week. The
synthetic interferon was eliminated by the body, and, without
further interferon available, the body could not suppress
or kill the virus.
Pegylation is a process that attaches polyethylene glycol
(a biologically inert compound) strands to the interferon
molecule making it less likely to be cleared from the bloodstream.
The benefit of increased concentrations of interferon levels
is that these help to constantly suppress the virus and increase
the likelihood of a sustained virological response.
2001
Peg-Intron (Schering’s pegylated interferon alpha-2b)
was the first pegylated interferon FDA approved to treat hepatitis
C. Peg-Intron is a powder that needs to be reconstituted (with
a sterilized solution) before it can be injected. Peg-Intron
also needs to be dosed by a person's body weight.
The sustained virological response rates for Peg-Intron monotherapy
are 14% for genotype 1, and 47% for genotypes 2 and 3.
PEG-Intron plus Rebetol (ribavirin) was also approved in 2001
to treat hepatitis C. Sustained virological response rates
are 42% for genotype 1 (high viral load - 30%) and 82% for
genotypes 2 and 3.
2002
Pegasys (Roche's pegylated interferon alpha-2a) was approved
to treat hepatitis C in 2002. Pegasys comes in a ready made
solution (does not need to be reconstituted) and in a dose
fixed at 180 micrograms regardless of a person's weight.
The sustained virological response (SVR) rate for Pegasys
is 28% for genotype 1, and 56% for genotypes 2 and 3. People
with advanced fibrosis or compensated cirrhosis (a group that
is more difficult to treat) achieved a SVR of 20%. This clinical
trials on cirrhotic patients also showed that Pegasys reduced
liver inflammation and scarring in treatment responders and,
to a lesser degree, in non-responders. Data from this trial
and other conventional interferon clinical trials led to the
NIH HALT C trial that is studying the role of interferon in
reducing liver inflammation and slowing or 'stopping/halting'
liver disease progression.
In 2002 Pegasys plus Copegus (Roche's brand of ribavirin)
was also approved for treatment of hepatitis C. Sustained
virological response rates for genotype 1 are 46-51% (high
viral load 41-45%) and 76-78% for genotypes 2 and 3.
It is clear that we have come a long way in a relatively short
period of time in the understanding of HCV disease and the
therapies used to treat it. We are by no means close to completely
understanding and treating hepatitis C, but with increased
research it is clear that we will have many more answers within
the next 5-10 years and perhaps discover a medication that
will be effective for treating everyone with hepatitis C.
Back to top
HealthWise:
Food for Thought
Lucinda K. Porter, RN, CCRC
Exercise! The very thought of it can induce tears in those
who do not enjoy physical activity. For those who have medical
issues, exercise is an even more complicated venture. People
living with hepatitis C report fatigue, muscle and joint aches.
Depression, weight gain, and mental "fogginess"
can also create obstacles. We know that physical fitness is
"good for us." Healthcare professionals recommend
exercise. Insurance companies and employers promote physical
fitness because ultimately it is good for business. Just pick
up a newspaper or turn on the TV and it’s clear that
athletes and sports are a popular part of our culture. Even
the office of the President encourages exercise and has done
so since 1956 with the creation of what is now known as the
President's Council on Physical Fitness and Sports. Regular
exercise is known to have a positive influence on a number
of medical problems including arthritis, osteoporosis, back
pain, diabetes, depression and cardiovascular disease. Certain
fitness programs can improve flexibility, balance, tone, strength
and stamina. Being physically active may improve sleep, reduce
food cravings, and help us feel more energetic.
If this is true, then how do we get moving? The key may be
the way we perceive exercise. If we view exercise as a chore
or something that creates pain, then physical activity may
feel like an obstacle. Perhaps the first step is as simple
as replacing the words "exercise" and "fitness"
with "play" and "fun." If exercise is
seen as an act of recreation or play, it might help us to
move in the right direction.
Being willing to move is important but not enough to propel
us off the couch. How do we get started? First and foremost,
consult your health care practitioner. There may be medical
reasons to limit or modify a fitness program. After medical
advice is given then develop an action plan.
Start by setting short- and long-term goals. Goals should
be reasonable, specific, measurable, and time-limited. Start
small and gradually work up to a goal. If the long-term goal
is to walk 30 minutes four days a week by the end of the year,
then 5 minute walks 3 days a week for the next month is an
example of a short-term goal. Attaching a reward to accomplishing
the goal can be motivating. The reward can be something small,
but still desirable. Choose a healthy reward. A hot bath may
be a better choice than a piece of chocolate cake. Other examples
are new exercise clothes, like socks or a warm-up jacket;
exercise gadgets, such as a pedometer or a heart rate monitor;
and additional time for relaxation or engaging in a favorite
activity.
Evaluate the goal. If the goal is reached, collect the reward
as well as congratulations. What made the goal attainable?
If the goal is not met, evaluate the reasons. Was the goal
realistic? Is it a goal worthy of commitment? What interfered
with reaching the goal? Can something be done differently
that will make the goal more achievable? Perhaps the goal
was too big and needed to be broken down into smaller parts.
Whether the goal is met or not, praise is important. The effort
alone has merit. After goal assessment, set another or commit
to the same goal. Continue to celebrate every victory.
Here are some other suggestions, especially when it is hard
to maintain a fitness program:
• Show up and suit up. Some people find the act
of putting on sneakers and starting the activity helps overcome
mental resistance.
• Find a fitness buddy. We are less likely to
cancel out on a friend than we are on ourselves.
• Join a group or class.
Common types of exercise focus on strength, flexibility, balance
and aerobic endurance. Some activities combine all of these
elements, while others concentrate on one aspect. It is advisable
to begin exercise by warming up and to practice the habit
of stretching and cooling down. For those new to exercise,
a reasonable beginning regimen might be to walk a few minutes,
stretch, and call it a day. Always allow a day of rest between
weight training workouts. Some fitness trainers recommend
a day of active rest every week. Active rest means taking
a break from a regular fitness regimen but does not mean spending
it all on the couch.
Walking, hiking, swimming, dancing, bicycling and weightlifting
are some common recreational activities. Physical fitness
is more likely to be successful if it is portable, not dependent
on the weather, and fits any budget. Staying fit does not
have to be an all or nothing proposition and can fit into
the busiest schedules. Some ways to do this include gardening,
using the stairs, choosing a parking spot on the outskirts
of the lot, getting off the bus before the scheduled stop
and walking the rest of the way, window shopping, sweeping
the floor, and mowing the lawn. Replace power tools with manual
tools. Mowing the lawn with a push mower is an excellent way
to be active. Walk instead of driving. Don't use the remote
control when watching T.V. Talking on the phone or watching
television are excellent opportunities to stretch, do leg
exercises or lift light weights. Any opportunity to be active
helps us to stay in shape.
Just as in life, variety is an important aspect of exercise.
If you walk, add activities at various intervals that increase
your heart rate and use other muscles. Examples of this: Every
5 minutes of walking, try skipping for a min-ute, or do 4
lunges, or 2 minutes of speed walking. If you use weights
for toning, try a session using light weights with 20 to 30
repetitions, and another session using heavy weights and perhaps
only 5 or 6 repetitions. You can also vary the speed of your
workout. Lifting weights at a very slow rate can be incredibly
challenging. Some local parks and trails have workout stations
call "par courses." These are free and a simple
way to add variety to your walk or run.
Be sensible about exercise. Remember to drink water, apply
sunscreen and avoid injuries.
Pain is NOT gain. However, sore muscles may occur. Heat, cold
packs, and stretching may be beneficial. Remember to consult
a doctor for injuries and discuss a back-up fitness plan for
common injuries. Avoid exercise when ill.
Videos, magazines and books can be useful resources. Choose
sources that target your age and fitness needs. I read Prevention
magazine because it is practical, motivating and easy to carry
around with me. Many communities and employers offer groups
and classes. The Internet has informative sites. Try doing
a general search using "exercise" or "physical
fitness" as key words. Information about The President's
Council on Physical Fitness and Sports and the President's
Fitness Challenge can be found at the end of this article.
Information for people with disabilities is provided on The
President's Challenge web site.
We have access to a coach 24 hours a day. It is the one we
carry with us. Most of us respond to a supportive coach. Skip
the criticism. Show up, suit up and keep a positive attitude.
The effort is worth it, especially when fitness becomes fun.
The President's Council on Physical
Fitness and Sports
www.fitness.gov
The President's Challenge
501 N. Morton, Suite 104
Bloomington, IN 47404
Phone:1-800-258-8146
Fax:1-812-855-8999
www.presidentschallenge.org
Back to top
The Importance
of Water
Kara Wright, PA-C
Water is one of the most important things we take in on a
daily basis. We all know we could live a few days without
food, but without water, we are sure to suffer quickly. Our
bodies are made up of about 70% water. That tells you how
important the nutrient rich substance is. Water is especially
important for people who have liver disease—whether
on or off interferon treatment. It provides many important
functions, which we will discuss here.
Water can actually help decrease fluid retention. At first
glance, this seems counterintuitive. It doesn’t seem
like you should drink more water when you are retaining water,
but it is true. When the body gets less water, it perceives
this as a threat and begins to hold on to all the water it
can. When this happens, the body tends to store water outside
of our cells, which often causes swollen feet, legs and hands.
Drinking more water will decrease the threat and allow the
body to release the excess stored water, which decreases the
swelling. Increases in salt intake can also cause water retention.
In order to alleviate the symptoms, you should drink more
water to dilute the effects of the salt. If this occurs often,
you should be cautious with your salt intake. Some people
are on restricted water and sodium intakes due to specific
disease states. Please talk with your provider before changing
any dietary recommen-dations.
One of our liver’s primary functions is to rid the body
of toxins. Water can help the body get rid of waste products
and toxins as well, which helps the liver be more efficient.
By staying hydrated, we can help the body efficiently shed
all of the extra metabolized products and toxins.
Water suppresses the appetite. Many people feel hungry when,
in fact, they are actually thirsty. Drinking a glass of water
will often satisfy that sensation and decrease the desire
for unnecessary calories. It also helps the body metabolize
stored fat. Some studies show that a decrease in water intake
will cause fat deposits to increase while an increase in water
intake can reduce fat deposits.
Water can help the GI tract function better. When we are dehydrated,
the body tries to keep all the water possible. As waste is
going through the colon to be eliminated, water is absorbed
to form solid stool. When we are dehydrated, too much water
is absorbed causing very hard, dry stool, or constipation.
By giving the body an adequate supply of water, we can prevent
this from happening.
Dry skin is a common problem, particularly in patients on
interferon treatment. Drinking water can help to moisturize
the skin naturally and decrease the side effects, such as
itching and flaking.
Water can also help regulate body temperatures. During the
hot summer months, it is even more important to drink water
in order to keep the body cool. We tend to dehydrate much
more quickly in hot temperatures, and most people don’t
even realize it. You don’t have to be sweating to get
dehydrated, so be aware and drink more water. You should increase
the amount you drink if you exercise since this is another
source of dehydration.
Patients on interferon monotherapy or combination therapy
should be very aware of the body’s need for water. Simply
drinking more water can decrease many of the side effects
experienced on treatment. Many patients find it helpful to
drink the highest volume of water for 1-2 days after the injection
of interferon and then to continue to keep hydrated through
the rest of the week.
As you can see, water is very important. How can you determine
your body’s water needs? There are many different ways
to calculate this, but one formula is to divide your weight
in pounds by 2 to determine the number of ounces you need
to drink in a day. For example, if you weigh 180 pounds you
will need to drink 90 ounces of water. That converts to eleven
8 oz glasses a day or ¾ of a gallon a day. (To help
you convert ounces to cups or gallons, please follow this
link.
Another way to tell if you are adequately hydrated it to check
the volume and color of your urine. The urine should be clear
or pale yellow in color, and there should be lots of it. The
darker and less frequent your urine, the more dehydrated you
are.
It is easy to keep track of your water intake. Purchase a
sport bottle with the amount of fluid already measured for
you. For example, most store bought water bottles tell you
how many ounces of water they contain. Just keep filling up
the water bottle and keep track of how many bottles you went
through. It is a good idea to keep a bottle at home, one at
work, and one in the car.
Don’t wait until you feel thirsty to drink water. At
that point, you are already slightly dehydrated and you will
have to drink extra water just to catch up. The body does
not have a strong thirst mechanism to tell you when you are
dehydrated, so you must consciously drink water all day to
ensure you are hydrated. Drink before you get thirsty.
Most people will feel that they are using the restroom very
frequently. This is healthy. You should decrease your water
intake 1-2 hours prior to bed, so you don’t disturb
your rest by having to get up to urinate throughout the night.
If you know you will be somewhere in which a restroom is not
easily accessible, you may wish to stop drinking water about
1 hour before your trip.
It is very important to avoid caffeinated drinks such as coffee,
tea and cola. These beverages act as dehydrators by pulling
water out of your system. Also, sodas and coffee can cause
headaches and diarrhea. If you are sick of drinking water,
you can substitute other clear liquids. Be leery of sports
drinks as they typic-ally contain lots of sugars and sodium,
which can cause dehy-dration as well. Drink these in small
amounts.
If you have congestive heart failure, kidney disease, decom-pensated
liver disease or ascites (fluid accumulation in the abdo-men),
it is very important that you speak to your medical provider
before increasing your water intake. Patients with these illnesses
are often on restricted water protocols due to the disease
state.
Back to top
News Briefs
Alan Franciscus, Editor-in-Chief
Schering Announces Availability of Oral Ribavirin
Solution
On January 20, 2004 Schering-Plough announced
the launch of Rebetol (ribavirin) oral solution for use in
combination with Intron A (interferon) for treating pediatric
chronic hepatitis C.
Oral Rebetol will come in a bubble gum flavor and is dosed
according to body weight (15 mg/kg daily divided into a.m.
and p.m. doses). Intron A is dosed according to the child’s
size measured in body surface area (3 MIU/m2 three times a
week). Treatment duration for pediatric patients is the same
as for adults: 48 weeks for genotype 1; 24 weeks for genotypes
2 and 3.
Roches Announces FDA Approval of
Pre-filled Syringes
On January 08, 2004 Roche issued a press
release announcing that the U.S. Food and Drug Administration
(FDA) approved pre-filled syringes of Pegasys for the treatment
of hepatitis C.
Roche expects the pre-filled syringes to
be available in pharmacies by the end of January 2004. Pre-filled
syringes will be packaged four per box and the price is expected
to remain the same as the currently priced vials.
The combination of Pegasys plus Copegus
(ribavirin) was approved in December 2002 for the treatment
of chronic hepatitis C. Since then, Pegasys plus Copegus has
captured the majority of the hepatitis C drug market in the
United States.
Currently, Roche is evaluating the combination
therapy in special populations, including African Americans
and people coinfected with hepatitis C and HIV.
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