The opioid abuse crisis plaguing Kentucky and the United States at large has had widespread and damaging effects on public health that extend beyond the spread of drug addiction. One of the most significant aspects of the crisis that is prevalent in Kentucky is the rise in cases of Hepatitis C.
Hepatitis, which is an inflammation of the liver, can be caused by a variety of reasons. Most cases are self-limiting, and the patient will have a complete recovery. However, in recent years there has been a large increase of Hepatitis C cases among intravenous drug users – and for many of those patients, the disease is chronic and can have serious, and even fatal, complications.
In this episode of Kentucky Health, host Dr. Wayne Tuckson speaks with a Louisville-based gastroenterologist about the various types of hepatitis, the aspects of Hepatitis C that make it an urgent public health concern, and the effectiveness of drug therapies in curing Hepatitis C.
Dr. Matthew Cave, M.D., practices with University of Louisville Physicians. He is an associate professor at U of L and has specialties in internal medicine, gastroenterology, and hepatology, and is also involved in several other departments.
Cave says that hepatitis has many different causes and can be both acute and chronic. Acute hepatitis is comparatively rare but is very grave and can lead to death if not treated quickly, and it may require a liver transplant.
Chronic hepatitis is more common, and occurs when the constant inflammation of the liver leads to scarring, or cirrhosis. Cirrhosis is often associated with alcoholism, and that is one cause, but Cave says that it can also be caused by being overweight, having diabetes, or by viral hepatitis.
Viral Hepatitis: Types and Treatment
Many people are aware of the longstanding medical advice relating hepatitis to alcohol intake and also to the effects of acetaminophen (Tylenol) on the liver. Cave says that consuming 2-3 alcoholic drinks per day for men and slightly less for women will not result in liver damage, and he also reaffirms that taking about 2,000 milligrams of acetaminophen per day (about four Extra Strength Tylenol) is generally safe for patients who use the drug to treat mild pain.
Cave also briefly discusses hepatitis caused by autoimmune factors, which occurs when the body’s immune system attacks healthy cells. He says autoimmune hepatitis occurs in a manner similar to rheumatoid arthritis or autoimmune diseases of the gastrointestinal tract such as Crohn’s Disease or ulcerative colitis. Many people are unaware of autoimmune hepatitis, which can’t be cured but can be managed.
Most hepatitis cases are caused by viruses, Cave says, and these are grouped in an alphabetical system. “These are distinct viruses,” he says, “but they have one thing in common, and that is that they infect the liver.
“The main ones that we see are Hepatitis A, B, and C,” he continues. “One difference between these is how they are transmitted. Hepatitis A is a water-borne disease; you can get that from contaminated water or food, for example. Whereas Hepatitis B and C, these are blood-borne pathogens, and one may be exposed to those through similar ways to HIV, for example.”
Cave says that there are vaccines in the U.S. for Hepatitis A and B, but not one for C. He says that Hepatitis B is more infectious than Hepatitis C – there have even been reported cases of Hepatitis B being transmitted through sharing toothbrushes and nail clippers. However, he says that Hepatitis C is more stable in the environment and can remain longer on a physical surface, such as a drug needle. It can also be passed on from an infected mother to a newborn, Cave says, although he believes that more research is needed on this method of transmission.
Hepatitis D is relatively rare and requires the presence of Hepatitis B to replicate. Hepatitis E, Cave says, is an emerging virus; he reports that during the recent International Liver Conference, a speaker discussed an outbreak in Germany linked to the use of pork products.
With the aid of several slides, Cave shows how Hepatitis C cases have surged in many regions across the country, with incidence rates exploding in the rural pockets of Appalachia.
“Kentucky is the highest in the nation for acute Hepatitis C cases, and the rates are about four times the national average,” he says. “These are new cases, and most of these are believed to be related to injection drug use, particularly opiates.
“The demographics are changing, and the story is changing a little bit,” he explains. “If we did this talk four years ago, what we would be talking about is the so-called baby boomer generation. If you look at the national prevalence of Hepatitis C, it’s about 3.5 million Americans, and most of those infected were born between 1945 and 1965. And the thing that is changing is the spike in new Hepatitis C cases that we are seeing. What’s scary to me is that they are occurring in young Kentuckians, those that are aged 20 to 29.”
Turning the Tide of Hepatitis C Cases
Cave says that most commonly, the new cases of Hepatitis C from the recent upsurge are chronic cases, and many people are asymptomatic and don’t know that they have it.
“Hepatitis C can be damaging the liver, and for 20 or 30 years people don’t know that they are infected, and don’t feel any pain in their liver, and then they present to me in the hospital with decompensated cirrhosis, variceal bleeding, hepatic encephalopathy,” he says. “And so you may not get a clinical manifestation until it’s too late. But if someone does have an early symptom, it’s usually fatigue.”
In acute cases, patients will present with the symptoms such as severe fatigue, nausea, and jaundice and require immediate hospitalization. But many people will just feel bad for a week or two and go untreated, Cave says.
About 25 percent of patients with acute hepatitis are cured at the outset, Cave says, but the rest will develop a chronic inflammation, and the only way to cure that is through medications. And the underlying cost of these medications is a big part of why the current spread of Hepatitis C is so worrisome, according to Cave.
“Really, Hepatitis C treatment in my mind, and at least from the perspective of internal medicine, is the biggest story, and that’s probably true for all of medicine over the past 3-5 years,” he says. “The Hepatitis C virus has gone from discovery to cure in about 30 years. This is one of the, maybe the only, chronic, life-threatening viral infections that we can actually cure.
“The barrier that we face – and this is what we deal with on a daily basis with our patients – is that the medications are very expensive, and obtaining access for our patients is a big problem,” he adds. “And we work daily with the third-party payers, meaning the insurance companies, to see if they can get access to these medications.”
As it stands now, Cave says that all of the insurance companies that he deals with do cover medications for Hepatitis C, but that each company has different standards that patients must meet to qualify for reimbursement. He says that clinical guidelines for Hepatitis C state that all patients with a reasonable life expectancy should receive drug treatment, but that those guidelines are in conflict with some insurance companies’ pre-authorization policies. Given that there is not yet a vaccine for Hepatitis C, the current high expense of Hepatitis C drugs is limiting the ability of doctors to fully treat the disease and curtail its spread.
“These are the conundrums that we deal with on a daily basis, and I think it’s all cost driven,” Cave says. “If the medications were cheap, I think everybody would get treated. And so it’s really a huge public health problem right now, and the cost of the Hepatitis C medications actually consumes now a significant amount of our health care budget.”