Living With Coinfection

• Overview
• Stress
• Alcohol
• Alcohol and liver damage
• Tips for reducing or avoiding alcohol
• Recreational drugs
• Smoking
• Body fat and body weight
• Body mass index
• Diet
• Herbal medicine
• Research on herbal medicine

Overview

Some of these lifestyle changes can also reduce the risk for hepatitis C progression, especially cutting down or avoiding alcohol. General things like stopping smoking, eating and resting properly, cutting down stress, and taking exercise are important for everyone.

• Alcohol
• Recreational drugs
• Smoking
• Body fat, body weight and diet
• Herbal medicine

Probably the most important aspect of dealing with any medical condition includes having the time and support to become better informed about choices that affect your health.

Another common experience is to look at aspects of your life in order to reduce stress and improve both quality of life and general health. Some of these lifestyle changes can also reduce the risk for HCV progression, especially cutting down or avoiding alcohol. General things like stopping smoking, eating and resting properly, cutting down stress, and taking exercise are important for everyone.

Stress Many of the symptoms of hepatitis are very similar to those of stress and one can enhance the other. More information about recognising and reducing stress is included on the Hepatitis C Trust website. www.hepctrust.org.uk

Alcohol

Heavy drinking is known to be harmful to the liver. Alcohol intake in amounts over 50 grams per day for men and over 30 grams per day for women accelerates HCV progression. Fifty grams is equivalent to four or five glasses of wine, beer or mixed drinks. Binge drinking is more harmful for your liver than regular drinking.

Alcohol harms the liver by increasing both inflammation and scarring. Generally, the less you drink, the better for your liver, since no one has determined what amount of alcohol is safe for people with chronic HCV. Drinking less -- or not at all -- may be more important than treating HCV.

Alcohol increases hepatitis C viral load, which makes HCV treatment less effective. This may be why studies of treatment with interferon (since replaced by a combination of pegylated interferon and ribavirin) reported that HCV treatment was not very effective for people who drink alcohol.

A few more recent studies have not reported much difference in HCV treatment outcomes among drinkers vs. non-drinkers. Nonetheless, many doctors will not treat people who consume alcohol.

Heavy drinkers are not eligible for HCV treatment in the UK.

Alcohol and liver damage

Alcohol is mainly broken down by the liver, but during this process bi-products are produced that damage the liver more than the alcohol itself.

Prolonged inflammation from long-term alcohol use results in the over production of molecules called "free radicals" that can destroy healthy liver tissue and subsequently impair liver function.

Alcohol can also disrupt the production of antioxidants, which defend the body against free radical damage. The combination of over-production of free radicals and loss of antioxidants can lead to liver damage.

Women may be more vulnerable to the damaging effect of alcohol than men.

Drinking less -- or not at all -- can be very difficult. Some people cut down or quit on their own, others find that support groups, counselling, and/or pharmacotherapy works best for them.

Tips for reducing or avoiding alcohol

Alcohol support organisations Alcoholics Anonymous has over 3,000 regional meeting places. AA phoneline 0845 769 7555 (10am-10pm, everyday). www.alcoholics-anonymous.org.uk Alcohol Concern can provide a wide range of information and advice. 0207 395 4000. www.alcoholconcern.org.uk Drinkline national helpline. 0800 917 8282 (24 hour service) Your doctor or clinic may also be able to refer you for help with drinking. Other sources of direct help or information for other organisations include your GP, your local Drug and Alcohol Service, your HIV specialist and your heptatitis specialist.

The following suggestions may help, whether you decide to drink less or quit drinking altogether.

If you decide to cut down

• Monitor how much alcohol you drink. Be honest, even if the total seems unreasonable. Once you know where you are starting from it will be easier to measure or monitor improvements.
• If you are drinking alcohol, drink slowly and drink plenty of water or juice as well.
• Drink with or after food as this slows down the absorption rate.
• It is better to spread your alcohol intake over the whole week, rather than drinking heavily in one session.

If you decide to stop completely

• Don't keep any alcohol at home.
• Avoid people, places or circumstances that trigger alcohol use, or develop a plan so that you are prepared and able to deal with the situation without alcohol.
• Remind yourself regularly about why you are giving up alcohol and the benefits it will bring.
• Try to keep your mind off alcohol, by involving yourself in other things, particularly at times when you usually have a drink.

Recreational drugs

Drug interactions Some recreational drugs may have interactions with HIV drugs: Toronto General Hospital HIV drug interaction tables Drug Interactions: HIV Medications, Street Drugs and Methadone Delivering HIV care and treatment for people who use drugs

The liver is the organ that processes most recreational drugs.

Some are more toxic than others, but all will stress your liver to some extent.

They are also likely to contain impurities and unspecified ingredients that are also toxic and difficult to assess. In general, injecting drugs is more dangerous as this bypasses the filtering system of the stomach.

If you are injecting drugs, using sterile equipment (syringe, cooker, filter, water, tie and measuring syringe) will protect you from reinfection with hepatitis C and other infections.

You may want to consider reducing your intake of recreational drugs, or stopping. If so, there are places where you can get help.

Drug support organisations National Drugs Helpline 0800 776600 (24 hrs) www.ndh.org.uk Narcotics Anonymous 0845 3733366 (24 hrs) www.ukna.org Cocaine Anonymous 0800 6120225 (10am-10pm) www.cauk.org.uk Drugscope 0870 7743 682 (10am-1pm, Mon- Fri) www.drugscope.org.uk Other sources of direct help or information for other organisations include your GP, your local Drug and Alcohol Service, your HIV specialist and your heptatitis specialist.

Smoking

Smoking is not good for your health. There is some weak data to suggest that smoking may encourage the progression of hepatitis C, but most people in the studies also drank alcohol.

Some Primary Care Trusts run "quit smoking" programmes that incorporate group therapy.

Stopping smoking is not easy, and probably not recommended during HCV treatment, if you feel it gives you support.

While quitting may be an important goal in the long-term, it may not be your most important short-term priority.

Help with quitting QUIT is a UK charity that provides assistance to those who wish to quit smoking. Freephone number 0800 002200. 1-2-1 email counselling. www.quit.org.uk Your doctor or clinic may also be able to refer you to a smoking cessation service.

Body fat and body weight

Liver abnormalities are more common in people who are overweight. This is usually defined as having a Body Mass Index (BMI) that is over 25.

These may include fatty deposits found in the liver and fatty inflammation or fatty liver. This is more common in people who have diabetes. Fat in the liver can cause it to become enlarged and can lead to raised liver enzymes.

People who are overweight and who have a fatty liver, and who subsequently reduce their weight, are likely to have an improvement in fat-related liver abnormalities. Loosing weight increases the chance of a better response to hepatitis C treatment.

If you do find it hard to maintain lower weight, ask to see a dietician for specialist advice.

Body Mass Index (BMI) A calculation using someone's height and weight that is used to determine if they are over or under weight. There are many online calculators.

Diet

A healthy and balanced diet is important for general good health. With advanced liver disease, avoiding or reducing certain foods may become more important.

This includes avoiding or reducing:

• Fried foods
• Fatty foods especially saturated and hydrogenated fats
• Very high protein diets
• Foods with high iron content
• Processed food and fast food
• Caffeine in coffee, tea and some carbonated drinks
• Salt, especially with advanced liver disease (people with ascites are recommend to use less than 500mg/day)
• Foods containing additives and pesticides
• Iron supplements (unless advised by your doctor).
• Protein -- guidelines for daily protein consumption for those with liver disease recommend 1 to 1.5 grams of protein per kilogram of body-weight.
• Sugar levels -- a link between hepatitis C and risk of diabetes may be improved by reducing processed sugars and keeping sugar levels more constant by switching from white bread and pasta, that quickly raise blood sugar levels, to whole wheat bread and pasta.

Herbal medicine

Herbal remedies have been used for centuries to treat liver disease, but they cannot cure hepatitis C. So far, no clinical trials have demonstrated that herbal remedies are effective against hepatitis C (HCV), but many people use these nonetheless.

Some people use them because conventional treatment has not worked for them, or because of concerns about side effects of HCV therapy.

• Milk thistle (silymarin) is often used by people with hepatitis C, although clinical trials have not found any benefit. Research on milk thistle in HCV is ongoing.
• Licorice root (glycyrrhizin) has been used, although it has no effect on hepatitis C viral load. Some studies have shown that it can lower liver enzyme levels and may decrease the risk of liver cancer. However, longterm use can cause side effects, such as high blood pressure and fluid retention, which are especially serious for people with cirrhosis.

Many other combinations of herbs are being sold to treat HCV or benefit the liver. Unfortunately, these products are unregulated, and differ in purity and strength.

Some herbs actually be harmful to the liver, and others may interact with HIV drugs and other medications.

It is important to discuss the use of any herbs or supplements with your doctor.

Research on herbal medicines

There is some research on the therapeutic use and drug interactions of herbs:

General

• Hepatitis C and complementary and alternative medicine: 2003 update (National Center for Complementary and Alternative Medicine, US Dept of Health and Human Sciences)

Milk thistle

• Milk thistle: effects on liver disease and cirrhosis and clinical adverse effects (Agency for Healthcare Research and Quality, US Dept of Health and Human Sciences)
• Milk thistle (Silybum marianum) (Medline Plus)
• A warning about milk thistle and drug interactions (HCV Advocate article)
• Milk thistle can reduce levels of indinavir in the blood (HIV Treatment Bulletin report)

Licorice root

• Licorice (Glycyrrhiza glabra L.) and DGL (deglycyrrhizinated licorice) (Medline Plus)
• Licorice root (National Center for Complementary and Alternative Medicine, US Dept of Health and Human Sciences)

Traditional Chinese medicine

• Introduction to traditional Chinese medicine in relation to hepatitis C (Hepatitis C Trust)

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