Side Effects and Management Strategies
The side effects from hepatitis C (HCV) treatment can be difficult, and, rarely, even life-threatening, and occur more often in people who are HIV-positive. The information in this section includes ways to manage these side effects.
With the right planning and support, the impact of side effects can be reduced. Ask your doctor how he/she will treat your side effects. Support from other people with HCV, friends, and family before and during HCV treatment plays a key role in coping with this difficult aspect of treatment.
"It is difficult to consider taking a treatment that, in the long term, may help me -- but it's going to make me very sick in the present."HIV meds and liver toxicity
Many HIV drugs are cleared from the body by the liver, and have the potential to cause liver toxicity, and hepatitis C coinfection increases the risk by 2-3 times. This could be through the direct action of the drugs themselves.
This is largely a concern with nevirapine (an NNRTI), tipranavir and higher doses of ritonavir (both PIs) -- which can be managed by choice of alternative HIV drugs. The use of low dose ritonavir to boost other PIs does not seem to increase this risk.
It could also be through an indirect action related to higher drug levles of NNRTIs and PIs, especially if you have serious liver damage. Because a damaged liver is working less efficiently, drug levels can be higher and take longer to clear from your body.
Therapeutic drug monitoring (TDM) is a blood test that checks blood levels of a protease inhibitors, NNRTIs, and possibly T-20.
Doses for HIV-drugs are worked out for an average person. However, individual differences in absorption can vary considerably in real life. In people whose liver is seriously damaged, drug levels can be much higher. This can increase the risk of side effects.
Even if your clinic has to pay for a test, it will only cost around £60 per drug. TDM in the UK is available from Delphic: www.delphicdiagnostics.com
TDM is recommended in UK BHIVA guidelines for management of dosing in people with moderate or severe HCV-related liver damage.
Depression and anxiety are commonly reported side effects of interferon.
In rare cares, people have reported that they have felt like taking their own lives, and a few people have committed suicide during their hepatitis C (HCV) treatment.
If you have a history of depression you may be at greater risk for developing these side effects during HCV treatment, although depression and anxiety are also common in people who have not experienced them before. Interferon can also cause irritability, difficulty sleeping, mood swings and psychosis.
It's important to have access to mental health care before and during (and sometimes after) HCV treatment, so that psychiatric side effects can be treated promptly and appropriately.
Some experts think that starting an anti-depressant before going on HCV treatment can help to prevent depression from the interferon.
However, as anti-depressants and other psychiatric drugs have their own side effects, other experts think it is better to provide these drugs only if and when people need them.
Being prepared to consider using an antidepressant if you get these side effects is important, as depression is one of the main reasons that people abandon treatment before finishing the full course.
Your own history and how you feel about this are important. If you have never suffered depression or mental illness you may not identify the symptoms. It is important to correctly diagnose and properly treat psychiatric symptoms of HCV treatment.
Flu-like symptoms (fever, aches and pains, headache, chills, nausea) are common side effects of interferon. They usually appear 2 to 24 hours after an injection, and tend to lessen over time.
Taking the PEG interferon injection in the evening helps, as does a low dose of paracetamol (or ibuprophen or aspirin -- not recommended for people with cirrhosis) and anti-nausea medication. Warm baths can help with muscle pain.
Drinking plenty of water and juice helps to reduce flu-like symptoms and keep you hydrated.
Weight loss often occurs during hepatitis C (HCV) treatment, because people may lose their appetite, have diarrhoea, and/or feel nauseated.
If possible, eat many small, light meals to keep energy up.
Fatigue is also common. Napping and regular but light exercise, when possible, can help.
Some doctors treat fatigue with methylphenidate (Ritalin).
Fatigue can be a sign of anaemia.
HIV-positive people with a low CD4 count may have low white and/or red blood cell counts.
Regular monitoring of white and red blood cell during HCV treatment is especially important for people with coinfection, since there is a greater risk for anaemia, neutropenia and thrombocytopenia.
Anaemia (an abnormally low red blood cell count) is a side effect of ribavirin. Interferon can also cause anaemia because it suppresses the growth of bone marrow, where blood cells develop.
The most common symptom of anaemia is fatigue.
Anaemia is a common problem for HIV-positive people, and can be caused by AZT and ribavirin. If possible, use an alternative HIV drug to AZT as combining AZT with ribavirin increases the risk. Combivir and Trizivir both contain AZT.
There are two ways to treat anaemia from ribavirin. One strategy is to lower the dose of ribavirin, but hepatitis C (HCV) treatment may not work as well. The other is to treat anaemia with injections of epoetin-alpha (EPO), which improves fatigue and helps people to stay on ribavirin. Severe anaemia is treated by blood transfusions, but reducing the ribavirin dose or starting EPO if anaemia develops during HCV treatment can avoid this.
Neutropenia is an abnormally low amount of neutrophils, a white blood cell that fights bacterial infections.
Interferon can cause neutropenia. The risk of developing bacterial infections is increased in people with neutropenia.
Thrombocytopenia is a low platelet count, and can be caused by serious liver damage (because the hormone that stimulates platelet production is made in the liver).
It can also be caused by other medical conditions, including HIV itself, and by pegylated interferon.
Thrombocytes or platelets stop bleeding by clotting blood. Serious thrombocytopenia can have life-threatening consequences, such bleeding inside of the brain. If severe thrombocytopenia develops, HCV treatment is usually stopped.
Not sleeping well adds to the impact of other side effects, especially those related to your mood and how you feel. Your doctor should know if this is a serious problem, so that sleeping pills can be an option.
Hepatitis C treatment can cause a rash, which is usually mild and 'non-itchy'. Tell your doctor about this, and if it becomes more serious, ask to be referred to a skin specialist.
Interferon can make your mouth dry, and this can cause dental and gum problems. Visit the dentist before, during, and after treatment. Using a soft tooth-brush reduces risk of bleeding gums, and brushing after each meal may help.
If your feel breathless or develop a cough, again, tell your doctor. Common treatments for cough are appropriate -- drink more water, avoid smokey places and try over-the-counter cough syrups.
Irritability can be common on hepatitis C treatment -- which is not surprising of you feel bad and have other side effects, so it is important that these are treated, especially if they affect your sleep. Preparing your friends, family and support network can help. Avoiding stress and using relaxation techniques including exercise, meditation and deep breathing help some people.
Hepatitis C treatment can also cause other diseases including thyroid (hormone regulating) or visual problems (blurred vision). It is important to tell your doctor about any symptoms, and that the doctor pays attention to them.
This article was provided by HIV i-Base. It is a part of the publication Hepatitis C for People Living With HIV. Visit HIV i-Base's website to find out more about their activities, publications and services.