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August 2012 HCV Advocate

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In This Issue:

Cure: Really?
Alan Franciscus, Editor-in-Chief

HCV Snapshots
Lucinda K. Porter, RN

Disability & Benefits: What Happens When COBRA Ends
Jacques Chambers, CLU


HealthWise: Medically-Acquired Hepatitis C
Lucinda K. Porter, RN


HCV Increases the Risk of Non-Liver Deaths
Alan Franciscus, Editor-in-Chief

Curing Fatigue with Treatment
Alan Franciscus, Editor-in-Chief


HCV Advocate Eblast
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Cure: Really?
—Alan Franciscus, Editor-in-Chief

The word “cure” or “viral eradication” has always been hotly debated.  Study after study has shown that for most (>99%) the HCV virus is eradicated once someone has achieved a sustained virological response (SVR) or in those who spontaneously (naturally) clear the virus.  There is some evidence, however, that  the virus might still be in the body hiding out in so called reservoirs in organs and certain blood cells and that HCV could re-assert itself if a person becomes immunocompromised by an illness (i.e., cancer) or by taking immunosuppressive drugs (i.e., Enbrel).  

Two of the most common theories are that the virus could be lurking in the liver or in certain components of blood cells, such as peripheral blood mononuclear cells (PBMC)—this is the basic component of red blood cells that have one nucleus.  If there is a reservoir for a virus this is the type of cell in which a virus like hepatitis C could be “hiding out.”  A recently released journal paper reported on testing whether HCV can be found in PBMC’s and/or in the liver and more importantly if it is in a form that can replicate.     

The recently published study by K. Fujiwara and colleagues included 11 people who spontaneously cleared the virus, 48 people who achieved an SVR with HCV treatment, and two chimpanzees that had been inoculated with hepatitis C, but resolved acute infection.  First the authors proved that the hepatitis C virus could infect non-infected PBMC’s in a cell culture and that the virus was found to be in a form that could not replicate—this is a really important part of the study.  Next the researchers tested the PBMC’s of people who spontaneously cleared an acute infection and people who achieved an SVR.  The blood was checked for the hepatitis C virus using an HCV RNA test that had a lower level of detection of 2 IU/mL’s.  What they found was that while certain parts of the hepatitis C virus could be detected, it was not the entire virus and could not replicate.  Additionally, the chimpanzees’ blood was tested and in one chimpanzee that had died (not related to HCV) the organs were tested and no traces of the hepatitis C virus were found—this included blood cells and tissues as well as the liver of the dead chimpanzee.  

The authors concluded that, “Residual HCV was not detected in the plasma or PBMCs of any spontaneous or treatment-recovered subjects or in chimpanzee liver, suggesting that the classic pattern of recovery from HCV infection is generally equivalent to viral eradication.”

So the question is what does this mean?  The study indicates that the virus is effectively eradicated from the body.  However, the authors conceded that there might be a very low level of the virus in the body that the body’s immune system can control naturally.  This is in contrast to a chronic infection state where the virus produces very high levels of HCV RNA and the high levels of the virus overwhelm the body’s immune system thus preventing the body from naturally clearing the HCV.

Article:
Investigation of residual hepatitis C virus in presumed recovered subjects. Fujiwara K. Hepatology. 2012 Jun 23. doi: 10.1002/hep.25921. [Epub ahead of print]


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HCV Snapshots
—Lucinda K. Porter, RN

Article: Reduction in Hepatic Inflammation Is Associated with Less Fibrosis Progression and Fewer Clinical Outcomes in Advanced Hepatitis C – Morishima C, Shiffman M, Dienstag J, et al.
  Source: The American Journal of Gastroenterology June 2012; Advance online publication, doi: 10.1038/ajg.2012.137

One of the most frequently cited studies is the HALT-C or Hepatitis C Antiviral Long-term Treatment against Cirrhosis Trial.  This trial enrolled 1,050 chronic hepatitis C (HCV) patients who were interferon nonresponders with advanced fibrosis or cirrhosis. Participants randomly received either half-dose peginterferon therapy or no treatment for 3.5 years.

Previously, it was reported that maintenance therapy did not affect chronic hepatitis C (HCV) progression, measured by fibrosis. In this study, the researchers reanalyzed the data and found new and important elements.

The Bottom Line: Previously reported was that HCV treatment can reduce inflammation in the liver and that viral suppression is associated with improved clinical outcomes but not decreased progression of fibrosis. The new findings are:

  • Patients in the peginterferon therapy arm, who had dramatic HCV suppression but had recurrent HCV RNA, had decreased liver inflammation for as much as 3.5 years.

  • Reduced progression of fibrosis was associated with decreased inflammation of the liver—not with suppression of HCV RNA.

  • Improved clinical outcomes were associated with decreased liver inflammation, lasting for at least 8.5 years (the length of current data).

  • Reducing inflammation of the liver may be the vital ingredient for reducing HCV progression.

Editorial Comment: This is good news as it gives a potential solution for how to manage HCV patients in advanced stages of liver damage who don’t eliminate the virus with current medications, and who are waiting for the next round of FDA approvals of HCV treatment. Perhaps half-dose peginterferon will become a holding pattern for these more advanced patients. Time will tell…

Article: Insulin Resistance Is Associated with Progression to Hepatic Fibrosis in a Cohort of HIV/HCV Coinfected Patients – Hull M, Rollet K, Moodie E, et al.
  Source: AIDS June 2012 Advance online publication, DOI:10.1097/QAD.0b013e32835612ce

HCV patients have an increased risk for insulin resistance. This study analyzed factors associated with higher insulin levels in patients who were co-infected with HIV/HCV, particularly looking at the relationship between insulin resistance and liver fibrosis. The study enrolled 158 non-diabetic, Canadian participants with HIV/HCV co-infection.

The Bottom Line: More than half (56%) of the subjects were insulin resistant. A Body Mass Index (BMI) greater than 25 was associated with increased insulin levels. The greater the insulin resistance, the greater the likelihood of progressed liver fibrosis.

Editorial Comment: This study shows one of the potential consequences of insulin resistance, a condition that may lead to severe health problems. Initial symptoms include fatigue and brain fog, and if left untreated, can deteriorate to diabetes and related problems. Insulin resistance is treatable. Lifestyle changes, such as diet, weight loss, and exercise are usually recommended, and medication may be prescribed to treat insulin resistance. 

Article: Impact of Ribavirin Dose on Retreatment of Chronic Hepatitis C Patients – Stern C, Martinot-Peignoux M, Ripault MP, et al.
  Source: World Journal of Gastroenterology 2012 June 21; 18(23): 2966-2972

The goal of this research was to evaluate various factors associated with sustained virological response (SVR) in chronic HCV. Patients who relapsed after treatment with peginterferon plus ribavirin were retreated with the same form of peginterferon they had previously used, along with higher levels of ribavirin.

The Bottom Line: SVR was more likely in younger patients (< 50 years = 61%) than older patients (27%) and for patients with genotypes 2 or 3 (57%) than in those with genotype 1 or 4 (28%). SVR rates were improved for longer treatments (an additional 24 weeks more than the previous length of therapy (53% vs 28%). Improved SVR rates were noted in those taking higher ribavirin doses (70% vs 35%). The increased ribavirin doses were mostly well-tolerated with some dose reductions due to anemia.

Editorial Comment: The most recently approved HCV medications are strictly for genotype 1 patients. This study offers the potential for retreatment for relapsed genotype 2 or 3 patients, particularly if they are younger than 50 years of age.

Article: Prevalence, Distribution, and Correlates of Hepatitis C Virus Infection among Homeless Adults in Los Angeles – Gelberg L, Robertson M, Arangua L, et al.
  Source: Public Health Reports July/August 2012; Volume 127 pages 407-421

In the U.S., approximately 1.6% of the population has chronic HCV. This Los Angeles-based study interviewed 534 homeless adults from 41 facilities, testing them for HCV and HIV.

The Bottom Line: Nearly 27% of this homeless population tested positive for HCV antibodies; 4% were HIV-positive. Less than 1% tested positive for HIV/HCV. About 46% were unaware of having HCV. Injection drug use was the highest predictor of HCV risk. Prison stays and multiple tattoos were other predictors of HCV.

Editorial Comment: In the original HCV prevalence surveys, homeless individuals were not included in the data. In fact, many high risk groups of people were not counted, such as the military, those who were undocumented, and those in prison and other institutions. Accurate HCV data is long overdue.


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Disability & Benefits: What Happens When COBRA Ends
—Jacques Chambers, CLU

COBRA is an excellent law that allows people to stay on their employer’s plan if they lose their employer’s health coverage, including related benefits such as dental, vision, and prescription drug plans, due to termination or reduction in hours. However, the extension is normally only available for 18 months. Once that is ended, people still need health coverage and people with HCV are “uninsurable” in the open health insurance market.

There are two additional laws that can extend the period you can have health insurance. OBRA is a federal law that allows disabled persons to extend their COBRA coverage until Medicare starts. HIPAA contains a provision that allows a person to purchase an individual health insurance policy when their COBRA finally ends, regardless of their health history or medical condition.

OBRA – If you leave work due to disability……
COBRA has been amended to allow people, who had to stop work due to disability, to extend the time they can keep COBRA Continuation. Under this law, someone who qualifies may stay on their employer’s COBRA Continuation until they become eligible for Medicare, which is normally 29 months after they leave work due to disability. This disability extension lasts for up to 11 months, which, in addition to COBRA’s 18 months, is enough to last until Medicare.

However, to qualify for this extension of COBRA, you must meet several requirements:

  1. You must apply for Social Security Disability Insurance (SSDI) benefits.

  2. Social Security must approve your benefits during your initial 18 month COBRA period.

  3. The Onset Date of your disability, as determined by Social Security, must be within 60 days of the start of your COBRA coverage.

  4. Finally, you must provide a copy of your Social Security Notice of Award letter to your COBRA administrator within 60 days of receiving it AND within the initial 18 month COBRA period.

Now, for a practical look at each of these requirements:

  1. COBRA is letting Social Security decide who was disabled when they stopped working with this requirement. If you didn’t pay into Social Security because you were a public school teacher or government employee and are therefore not “financially eligible,” Social Security is still required to review your medical records to see if you are disabled enough to qualify for SSDI benefits if you were otherwise qualified. When you first apply for Social Security Disability, you need to tell them you are applying in order to extend COBRA.

  2. The SSDI claim must be approved during the original 18 months of COBRA. If there is a denial and you have to wait to appeal before an Administrative Law Judge, and it goes beyond 18 months, you lose your chance to extend COBRA even if your claim is later approved.

  3. Social Security will determine the onset date of your disability. That is the date they believe you became disabled and the date from which they start counting the five calendar-month waiting period of benefits. Even if the approval letter comes in the last few months of your COBRA Continuation, you can still qualify for the extension if the Onset Date given in your approval letter is within 60 days of the COBRA Qualifying Event.

  4. The rule requiring you to give notice has unfortunately cost many people their right to extend their COBRA. The COBRA administrator is usually your old employer but they may have contracted with an outside firm to administer their COBRA’d people. A good rule of thumb is that the copy of the Social Security Notice of Award letter should go to the same place that you pay your COBRA premiums to. Be sure to ask for a receipt or otherwise confirm that the letter was received.

This is a good way to stay insured since it allows you to stay on your employer’s health insurance plan until you become eligible for Medicare.

Drawback – The primary drawback is that during the months after the first 18 months of COBRA, the employer can (and will) charge you the actual premium PLUS 50%. If you were paying $400 per month on COBRA, the extended months will cost $600 per month.

An Alternative to OBRA in Some States
Many states have enacted their own mini-COBRA plans, primarily directed at small groups that don’t come under the federal law. Many or these laws also extend the length that a person can stay on COBRA beyond the federal 18 months. If the state you live in has such a law, it may be less expensive than the 50% surcharge the federal disability COBRA extension requires.

You must be careful, however, as these mini-COBRA laws are state insurance laws. Large employers don’t purchase health insurance, they self-fund their employees’ health plan and hire an insurance company or other third-party administrator to process the claims. Because these are not insurance plans, they are not subject to state insurance laws and therefore not subject to state mini-COBRA laws. This is usually true for employers of more than 1,000 employees, and occasionally happens for slightly smaller groups.

HIPAA – If your COBRA ends and you don’t qualify for the disability extension….
A 1996 federal law, called HIPAA, provides that people have a one-time opportunity, after losing their employer’s coverage, to move to a broad benefit individual health insurance plan.

The rules on qualifying for individual coverage are not complicated:

  1. You must continue your COBRA Continuation as long as possible. You cannot drop COBRA at any time and move to the individual plan.

  2. You must have been continuously covered under health insurance for at least 18 months. That’s easy, since COBRA itself lasts 18 months or longer.

  3. The 18 months does not all have to be COBRA coverage, but the last carrier in the 18 months of coverage must end with either employer provided or COBRA coverage.

  4. You must sign up for the individual coverage within 63 days of the end of your COBRA insurance.

The Coverage
The plans you will have a guaranteed right to buy will change from state to state. Some states require that everyone purchase coverage from one central plan. Other states require every insurance company writing individual health insurance to carry “HIPAA coverage plans” and each person can go with the company of their choice. Either way, the coverage must be broad, and will almost always include prescription drug coverage. Companies offering “HIPAA” plans must offer their two most popular health plans based on premiums written.
To find how your state handles these individual plans, use your browser to search for “HIPAA Options by State,” you should be directed to an excellent pdf file from the Disability Rights Legal Center that shows how each state handles HIPAA individual policies.

The Cost
The insurance lobby wasn’t totally asleep when this law was passed, so there are no limits on what carriers can charge. It will definitely cost you more than buying coverage on the open market. The cost will also vary dramatically by location.

How It Works
Once your COBRA Continuation coverage ends, the insurance company or administrator is required to send you what is called a “Certificate of Creditable Coverage” which is usually simply a letter confirming the starting and stopping dates of your coverage with them. If you work for a company that is small or otherwise doesn’t have to offer a COBRA extension, you can still purchase a HIPAA policy if you meet the other requirements, and purchase it within 63 days of your group coverage ending.

Upon presenting that letter to the HIPAA plan or carrier, the plan is required to let you purchase an individual plan without any health questions.

Thanks to these two laws, now, if you ever become insured under an employer health plan, you will be permitted to maintain health insurance indefinitely, even after your employment terminates.


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HEALTHWISE: Medically-Acquired Hepatitis C
—Lucinda K. Porter, RN

This summer, I happened to be teaching a workshop in New Hampshire as a hepatitis C virus (HCV) outbreak was making headlines. This outbreak was traced to Exeter Hospital, affecting patients seen between October 2010 and May 2012. As I write this, 31 infections were linked to the hospital, a number that could be higher since not everyone has been tested.

The cause is still under investigation, but has been reported as a probable “drug diversion” case. Typical drug diversion situations are employees taking narcotics or other controlled substances that were meant for patients. In the case of injectable medications, syringes are usually refilled with saline. Tragically, if the hospital employee has HIV or viral hepatitis, the needle and everything associated with it are now potentially infectious. To make matters worse, the patient may not receive sufficient medication for sedation or pain control. 

Outrageous? Betrayal? Criminal? Yes, yes, yes.
There have been other HCV outbreaks in the U.S., many due to narcotics abuse. In A Never Event, one hundred cancer patients including Evelyn McKnight were infected with HCV while undergoing chemotherapy. McKnight’s husband, a family physician, helped to uncover the outbreak. Evelyn co-authored A Never Event with attorney Travis Bennington, and the two cofounded HONOReform, an organization committed to safe injection practices.

The largest reported HCV outbreak occurred in Nevada. In 2008, 63,000 patients were notified of possible exposure to HIV and hepatitis B and C after having surgical procedures at an endoscopy center in Las Vegas. At least 116 case of HCV were linked to this center, primarily due to unsafe injection procedures.

Reacting to the New Hampshire outbreak, Steve Langan, director of HONOReform said, “There have been 40 documented outbreaks in the last 12 years in the United States. It’s staggering. It’s unacceptable.”

I agree, sort of. It is staggering. It is unacceptable, largely because these outbreaks were preventable. Outrage is the appropriate response, particularly when someone is seriously harmed or killed by medical error. The problem I have is dwelling too long in the shock and outrage. It is fine to react with righteous indignation, but it is not a good long-term position.

In a recent interview, I disclosed that I contracted HCV via a blood transfusion in 1988. The interviewer was horrified, saying that I did not deserve this, and that I had every right to feel betrayed by a medical system that did not protect me. However, I don’t feel that way at all.

Resentment emphasizes the problem rather than the solution. It makes me a victim, and if I felt that way, I might never trust anyone again. There was no test for HCV in 1988. The blood transfusion saved my life. Moreover, if I hadn’t contracted HCV, I would not be writing this article. I would not be in this worldwide community of amazing people who, like me, are trying to make a difference.

I am not suggesting we take a Pollyanna approach to medical harm, particularly since it is one of the top ten causes of death in the U.S. Saying, “Oh, well, it happens is about as smart as driving without seat belts and hoping there aren’t any bad drivers on the road.” In short, we know our health care system is overburdened and fraught with problems; being sick is risky business.

Hoping that we won’t be the next victim of a medical error is not enough—instead, take steps to reduce the risk. Here are some tips on how to reduce exposure to medical harm:

  • Stay healthy. The bottom line is that you are more likely to be hospitalized for problems that may be avoided by lifestyle changes. For instance, smokers are more likely to need hospitalization than nonsmokers are.

  • Ask a friend or family member to be your advocate and to be at the hospital during medical rounds and nursing shift changes.

  • Bring a list of medications and supplements that you take.

  • Keep a notebook at your bedside. Write down everything that is told to you, the names of your doctors and nurses, medications, the times you took your medications, and all your questions.

  • Bring your cell phone and charger to the hospital.

  • Be sure your wristband is checked or your name is asked before you have a procedure or receive medication.

  • Speak up. Don’t be afraid to ask questions.

  • Trust your instincts. If something doesn’t feel right, mention it immediately.

  • Don’t take medication that doesn’t look familiar to you. Also, don’t take medication you don’t remember your doctor prescribing without first getting a satisfactory explanation.

  • If you have a choice, do not go to the hospital in July when the new medical residents are just getting started.

  • Bring hand sanitizer with you and be sure everyone who enters the room has washed or sanitized their hands. The hospital provides this, but having a bottle nearby serves as an extra cue.

  • Show this list to those close to you, so they know your wishes in case you have an emergency hospitalization.

  • Appoint a trusted friend or family member to act as Durable Power of Attorney for Health Care. This gives written authorization for someone to act on your behalf should you be unable to speak for yourself.

Although these tips may help you, I am not sure they would help in the New Hampshire situation. Most of these HCV outbreaks seem like criminal acts rather than mistakes. One could argue that the abuser should have been discovered, but drug use is easy to hide, and frankly, we rarely suspect those around us as having a problem. A safe injection procedure to prohibit reuse of needles is a potential fix for this problem.

As awful as the New Hampshire outbreak is, there are positive sides to it. During the testing process, at least 12 chronic HCV cases were identified. After recovering from the shock of it, presumably these 12 people will have an opportunity to take their health into their own hands.

Another good thing that could come out of this is that up until now, New Hampshire is the only state that does not have mandatory HCV reporting. If nothing else, this incident is motivating the state public health department to examine its policies.

To those who were infected, my heart goes out to you and your families. Fortunately, HCV is easier to treat in the early stages. I hope you can put HCV behind you. Dealing with HCV is the easy part—dealing with your feelings is the real challenge. Get support and don’t dwell in the land of resentment for too long. There is also goodness in the world and that is a much more comfortable place to live. 

For More Information:



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HCV Increases the Risk of Non-Liver Deaths
—Alan Franciscus, Editor-in-Chief

We all know that infection with the hepatitis C virus (HCV) can lead to serious disease progression and death for some people.  We also know that the key to managing HCV is to identify those who are infected with HCV, to provide access to effective medical management and access to and success with HCV antiviral therapy.  But does hepatitis C contribute to deaths that are not related to the liver?  There have been a few studies that looked at this issue before, but the current study is the largest prospective study and provides some startling insights as to how the hepatitis C virus affects the entire body—not just the liver.   

The journal paper titled “Chronic Hepatitis C Infection Increases Mortality of Hepatic and Extrahepatic Diseases:  A Community-Based Long-Term Prospective Study” by Mei-Hsuan Lee and colleagues included 23,820 adults aged 30 to 65 years old who were enrolled during 1991-2008.  Of those, 18,541 were HCV antibody negative and 1095 were HCV antibody positive.  Of the people who were HCV antibody positive, 69.4% were HCV RNA positive (chronic infection).   The average follow-up period was 16.2 years. 

During the study period, there were 2394 deaths.  The risk of death in people who were hepatitis C RNA positive was increased for all cause deaths compared to those who were negative for HCV RNA.  The following causes of death were found to be higher in the people who were HCV RNA positive:   

  • Liver-related (cirrhosis, liver cancer)

  • Circulatory disease (diseases that affect the heart and blood vessels)

  • Kidney diseases

  • Cancer (esophagus, colon, gallbladder and bile ducts, trachea, bronchus, lung, prostate,  thyroid, leukemia)

In those who were both HCV antibody and RNA negative there were no recorded deaths due to chronic liver disease and cirrhosis, or cancers of the esophagus, prostate or thyroid.  However, deaths were similar between this group and those who were HCV antibody positive but HCV RNA negative, due to resolved infection. 

The authors commented about their study saying that “This suggests that not only hepatic deaths but also extrahepatic deaths could be decreased in anti-HCV seropositives by clearing the virus with efficient antiviral therapy.”

Reference

  • Journal of Infectious Diseases Volume 206, Issue 4 Pp. 469-477



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Curing Fatigue with Treatment
—Alan Franciscus, Editor-in-Chief

The most common symptom that people with HCV experience is fatigue.  Fatigue can range from mild to moderate to severe.   Fatigue in any form can be difficult to live with— mild to moderate fatigue can compromise normal daily activities or it can be so severe that some people find it difficult to get out of bed and start their day.   HCV treatment has been shown to improve overall survival especially in those who achieve a sustained virological response (SVR).  But can treatment improve overall symptoms such as fatigue? 

A recently released paper, “Fatigue Before, During and After Antiviral Therapy of Chronic Hepatitis C: Results from the Virahep-C Study,” by Sarkar et al. (Journal of Hepatology online July 2012), reported on the effect of treatment on fatigue.  The study was originally conducted at 8 U.S. medical centers between 2002 and 2006.  The primary endpoint of the study was to understand the differences (viral kinetics, immune function, genetics and interferon signaling pathways) in treatment response rates of HCV genotype 1—196 African Americans (AAs)and 205 Caucasians (CA).  The treatment consisted of Pegasys and ribavirin.  A secondary endpoint was the effect of treatment on fatigue. 

In the portion that studied treatment and fatigue the participants completed a self-reporting symptom questionnaire that asked the participant “Do you have fatigue?” answered with either a “Yes” or “No” answer.  The severity of fatigue was also self-reported using a visual analogue scale (VAS) by marking a line from 0 to 100 mm with ‘None’ being 0  and “Worst ever” being 100 mm. 

“In those who recorded severe fatigue before treatment and achieved an SVR the decrease in VAS score was the the greatest.”

The VAS has been used to study fatigue in various disease states including liver disease.  The severity of fatigue was categorized as minimal (0 to 10 mm (120 patients)), mild-to-moderate (>10 to 40 mm (115 pts), and severe fatigue (>40 to 100 mm (155 pts)).  The patients were also evaluated for depression in order to rule out depression-related fatigue. The results were available from 390 patients.

At the time of screening it was found that fatigue was more common in women (59%) than in men (48%) and more common in people who had cirrhosis, although the results did not meet statistical significance.  Fifty-four percent of patients reported having fatigue and of those 88% marked a score of more than 10 mm in VAS scores.  The baseline fatigue was similar between AA and CA patients and the groups had similar body mass index (BMI), HCV RNA levels and disease severity.   

The important findings of the study are listed below. 

On-Treatment:

  • Not surprisingly, the percentage of people who reported fatigue increased from 52% before treatment to 78% by week 4 of treatment with the average patient reporting mild to moderate fatigue.

  • Fatigue remained at the higher levels for the duration of therapy. 

  • The severity of fatigue was higher among women than men and among CAs compared to AAs.

  • Interestingly, the frequency and severity of fatigue was greater in those who achieved an SVR compared to those who did not achieve an SVR.

After-Treatment:

  • By 12 weeks post-treatment the number of patients who reported fatigue was lower than before treatment—36% in responders, 42% in non-responders compared to 52% before treatment.  

  • By post-treatment week 24 the recorded fatigue scores decreased to 33% compared to 53% before treatment.   

  • The median VAS fatigue score decreased from 27 mm to 13 mm. 

  • In those who recorded severe fatigue before treatment and achieved an SVR the decrease in VAS score was the greatest—64 mm pretreatment to 21 mm at week 24 post-treatment. 

The researchers commented that they were able to control for depression-related fatigue indicating that it did not affect their findings.  The authors acknowledged that the limitation of the study was the relatively low number of patients.  There was also a potential for bias since some of the patients in the study were motivated to take on a difficult treatment and that part of the motivation may have been the severity of fatigue.  The scores the patients reported were reported before the patients knew if they had achieved an SVR, which means that the self-reported reduction in the severity of fatigue was not due to the patients’ knowledge that they had been cured.   

Fatigue is a well-recognized symptom of HCV.  This study showed dramatic reductions in the level of fatigue in those who achieved an SVR.  We know that HCV treatment can increase long-term survival, lower the chances of liver and non-liver related deaths, and improve liver health.  Now we also know that successful treatment can reduce fatigue, especially in those who suffer from severe fatigue.  All of these benefits from treatment mean that people who have a reduced quality of life due to fatigue should be seriously considered and encouraged to seek HCV treatment regardless of the severity of liver disease. 


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