Diagnostic testing to determine the presence of HCV viremia and the extent of liver pathology should be completed as early as possible in the care of a patient infected with HCV. Liver biopsy is useful in evaluating liver damage and deciding type of treatment; elevation in serum transaminases in the absence of inflammation or fibrosis typically is not an indication for treatment. Patients with active HCV infection or evidence of chronic liver disease should be referred to a specialist with experience in treating hepatitis C for evaluation and guidance regarding possible treatment. Treatment recommendations should be individualized, and not all patients with HCV should receive treatment.
Factors to be considered in the selection of patients for treatment include the patient’s immune status; the presence of moderate to severe inflammation and/or fibrosis, which predicts the likelihood of progression to cirrhosis in the absence of treatment; the likelihood of a favorable response to therapy, which varies with HCV viral load (lower viral load predicts better response) and genotype; HIV viral load if co-infected; the patient’s commitment to therapy; and the risk of adverse effects of treatment, particularly for those with underlying psychiatric illness (National Digestive Diseases Information Clearinghouse 2003).
In those who are also HIV positive, antiretroviral therapy may need to be modified, delayed, or interrupted in order to complete an adequate course of therapy for HCV. The effectiveness of treatment is assessed by following HCV viral load.
The goal of HCV treatment is cure of the infection, manifested by reduction in hepatitis C viral load to undetectable, normalization of transaminase (ALT and aspartate transaminase [AST]), and cessation of liver disease progression. Combination therapy with daily, oral ribavirin and once-weekly subcutaneous peginterferon-alpha-2b given over 6 to 12 months (depending on genotype and response) is emerging as the standard therapy for HCV and is clearly indicated in patients 18 to 60 years of age who have persistently abnormal ALT levels, HCV RNA in serum, and evidence on liver biopsy of chronic hepatitis with either fibrosis or moderate degrees of inflammatory activity (National Institutes of Health Consensus Development Conference Panel 1997).
HIV and Hepatitis C in Patients With Schizophrenia
Psychiatric symptoms during interferon therapy for viral hepatitis have been a crucial concern in consultation-liaison psychiatry. Interferon and ribavirin have potential neuropsychiatric side effects, including apathy, cognitive changes, irritability, depression, and suicidal thoughts. However, there have been few studies of this problem, and those that exist are not focused on people with schizophrenia. Nonetheless, it is worth noting that at least one study of nonschizophrenic patients suggests that the risk of serious psychiatric symptoms during interferon-alpha treatment may not be high, and that psychiatric illness or the possibility of psychiatric complications should not be used as a reason to refuse this treatment to patients with hepatitis C (Mulder et al. 2000).
Nevertheless, psychiatric disorders may influence the course of treatment of HCV infection, and clinicians as well as internists should be aware of the substantial psychiatric comorbidity in these patients. Although neuropsychiatric complications of HCV itself are not a significant problem, some of the symptoms of liver failure, such as fatigue, loss of appetite, loss of sexual drive, and impotence, can overlap with the complications of interferon treatment, the symptoms of psychiatric disorders, and the side effects of psychotropic drugs.
Milton L. Wainberg, M.D.
Francine Cournos, M.D.
Karen McKinnon, M.A.
Alan Berkman, M.D.
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