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A review by AHCS Researcher & Editor/Administrator, Linda McInnes.
Most people I know with hepatitis C worry about what they can do to slow down the progress of their illness. Very few studies have looked at this issue and of those that I could find only one looked at it in great depth. (Riley, 2001- part 1 & 2). The article was intended to be used as a reference for GPs, however I feel this information should also be made available for people with hepatitis C.
The article looks at the hepatotoxic (toxic/damaging to the liver) effects of herbal remedies, vitamins, vaccinations, alcohol, and medications for other disorders and diet. I have selected only what is relevant to people with hepatitis C and have not included some of the more technical information. The article is in two parts; the first section containing strategies to slow down the progression towards cirrhosis, the second, strategies for people with cirrhosis to slow down end stage liver disease.
Strategies for slowing progression to cirrhosis:
In this section we look at abstinence from alcohol, vaccinations, hepatotoxic medications, vitamins and supplements, diet and exercise. In Australia the progression rate to cirrhosis is 7% in 20 years and 20% in 40 years. (HCCNSW Medical Research & Advisory Panel, 2005).
Alcohol:
Alcohol consumption is associated with a faster progression towards cirrhosis and it can result in hepatocellular carcinoma (liver cancer) and death. Even small amounts of alcohol can cause damage to the liver, and where possible people with hepatitis C should be encouraged to stop drinking completely.
The author notes that in one study they found that alcohol in patients with Hepatitis C can cause cirrhosis to develop faster, can cause the virus to replicate, can affect the immune system and can interfere with iron content and regeneration of the liver.
Alcohol also decreases the response to interferon. It has now been found that alcohol increases the toxicity of Vitamin A; vitamin A can cause steatosis (fatty liver), perisinusoidal fibrosis (a vascular lesion found in the liver of type 1 diabetics), chronic hepatitis and cirrhosis (Riley 2001 – part 1).
Vaccinations:
If you are not immune to Hepatitis A or Hepatitis B it is recommended that you be vaccinated against these. All patients who are hepatitis C positive should be checked for “hepatitis A total antibody” and ”hepatitis B surface and core antibodies”. To not be vaccinated against these is to put oneself at risk. In one study of co infected people the mortality rate was 35% (Riley, 2001 – part 1).
Toxic Medications:
Many people with hepatitis C also suffer from other illnesses or disorders which require them to take medications. Many medications both prescription and over-the-counter drugs can be quite toxic to the liver (see list below).
The author notes that for example; taking paracetamol (acetaminophen in the USA) on an empty stomach or with alcohol can be harmful.
Eating regularly will help avoid this as well as help you absorb any other medications or supplements you are taking. But, if you are in pain, paracetamol is the best option with a safe dosage being 500mg four times a day or 2g daily (Riley, 2001 - part 1).
List of Toxic Medications:
• Muscle relaxants.
• Psychotropics (a drug which alters the mind) e.g. antidepressants.
• Anticonvulsants (a drug or agent that prevents or reduces the severity of convulsions).
• Lipid-lowering drugs.
• Oral antidiabetic agents (therapy for type 2 diabetes).
• Estrogens are any of various steroid hormones developing and maintaining female characteristics of the body; this hormone produced artificially for use in oral contraceptives etc.
• Anabolic steroids are any of a group of synthetic steroid hormones used to increase muscle size.
• Antituberculous agents (Riley, 2001 – part 1).
Hepatotoxic (toxic to the liver) Vitamins and Supplements:
Many vitamins and supplements can cause damage to the liver depending on the dose. One study in the USA found that up to one third of the patients in a liver clinic used herbal remedies. One of the most hepatotoxic vitamins is Vitamin A and anyone taking vitamin A supplements should be aware that doses higher than 25,000 IU (international units) per day may be dangerous. Most multivitamin preparations contain 4,000 IU vitamin A, which is well within the safety range. One of the few supplements which has been shown to be beneficial to the liver but without any toxic effects is Milk Thistle (Silybum Marianum) and there is no evidence of toxicity related to the pure form of milk thistle. It is known to protect cells in our liver that is not damaged (Riley, 2001 – part 1).
List of Toxic Vitamins, Supplements and Herbal Remedies:
• Amanita species – wild mushrooms.
• Asafetida – plant, comes in powder, tablet or oil form.
• “Bush” Herbal teas
• Chaparral – The active ingredient of chaparral is a potent antioxidant.
• Comfrey - is an important herb in organic gardening, having many medicinal and fertiliser uses.
• Echinacea - The above ground parts of the plant and roots of echinacea are used fresh or dried to make teas squeezed (expressed) juice, extracts, or preparations for external use. There are 9 known species. Used in various herbal remedies.
• Gentian - their roots were harvested for the manufacture of tonic liquor, also used as flavouring, for example in ‘bitters’.
• Germander or Teucrium – has garlic like aroma, is a genus of perennial plants, of the family lamiageae, used as a herb.
• Iron - Patients with chronic liver disease tend to accumulate excessive iron amounts in their liver parenchyma. 30% of patients with liver disease have high serum iron levels and 10% have excessive amounts of iron in their liver tissue.
• Jin bu huan tablets - is a traditional Chinese herbal product used as a sedative and analgesic.
• Mistletoe - for treating circulatory and respiratory system problems, and cancer.
• Nicotinic acid (niacin; Nicolar) - is a form of vitamin B. Niacin is available over the counter as vitamin B3.
• Pennyroyal oil – Comes in oil form or tea. Can cause serious liver and kidney problems.
• Senna fruit extracts - is used as a laxative.
• Valerian - has uses in herbal medicine as a sedative.
• Vitamin A - Consuming less than 25,000 IU is recommended and most multivitamins contain 4,000 IU which is within safety range. If you are taking multi vitamins, vitamin A might already be included in this, make sure that you are under the recommended limit (Riley, 2001 – part 1).
Diet & Exercise:
If you are a diabetic or are overweight you need to be particularly careful especially if the lipids (fats) in your liver account for more than 5% of the weight. It has been shown that following a supervised low fat diet and exercise program can minimise the risk of fatty liver (Riley, 2001 – part 1).
Strategies for slowing progression to end stage liver disease: In this section we look at varices and bleeding, screening for liver cancer, vaccinations, toxic medications, diet, ascites and spontaneous bacterial peritonitis, with a list of some preventative measures (Riley, 2001 – part 2). In Australia the progression rate to end stage liver disease is 1% in 20 years, and 4% in 40 years (HCCNSW Medical Research & Advisory Panel, 2005). Varices and Bleeding: Varices (swollen veins in the esophagus and stomach) can be found in 60% of patients with cirrhosis, an endoscopy (a procedure using a lighted, flexible instrument to observe the esophagus, the swallowing part of the throat, stomach and intestines) is recommended to detect varices or bleeding. If this shows no varices this procedure should be repeated in one or two years to assess the risk of bleeding. As a preventative treatment propranolol and nadolol (beta blockers) have been used and shown to reduce the risk of variceal bleeding from about 45% to 22%. Other preventative treatments may also involve esophageal banding (a band is used to tie off the bleeding portion of the vein) or sclerotherapy (a drug injected into the bleeding vein causing it to narrow), (Riley, 2001 – part 2). Screening for Hepatocellular Carcinoma (liver cancer): Patients with cirrhosis should also be screened for liver cancer. This can be done by ultrasound with serum alpha-fetoprotein testing - in order to detect early detection these should be performed together. This should be done on a regular basis as this is the leading cause of death in patients with cirrhosis (Riley, 2001 – part 2). Vaccinations: Patients with cirrhosis are advised to have vaccinations against infections such as peritonitis and pneumonia, also yearly vaccinations against influenza (Riley, 2001 – part 2). Toxic Medications: See list in part 1 of this article. Diet: Diet is very important once you have cirrhosis. It is important to reduce salt intake as failure to do so can cause development of ascites. It is important that people with cirrhosis follow a sodium restricted diet, that is, less than 2grams per day. Apart from developing ascites, people with cirrhosis can develop malnutrition and it is advised to have 1 to 1.5 grams of protein per kg body weight a day. However, if you have advanced cirrhosis you can develop encephalopathy (inflammation of the brain) if you eat too much protein at one time, therefore at this stage you have small servings of protein throughout the day to bring the level up to 1 gram per kilo body weight daily (Riley, 2001 – part 2). Ascites and Spontaneous Bacterial Peritonitis: Cirrhosis can lead to portal hypertension which is an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver) due to blockage of blood flow throughout the liver, low Albumin (water soluble proteins found in blood), and increased sodium retention, which can culminate in the development of Ascites (accumulation of fluid in the abdominal cavity causing swelling). Ascites is the most common form of clinical deterioration and complications such as peritonitis (inflammation of the abdomen) and renal (kidney) insufficiency can worsen the long term outcome. Once you develop ascites it is recommended that there be an evaluation done for liver transplantation. Patients with new-onset ascites or clinical deterioration may have an operation called paracentesis where an incision is made to remove fluid or gas. Peritonitis is usually treated with antibiotics. Treatment should be ceased after 6 months to avoid the development of antibiotic resistance (Riley, 2001 – part 2). List of Preventative measures: • Complete abstinence from Alcohol. • Avoid toxic medications, especially nonsteroidal anti-inflammatory drugs, paracetamol (acetaminophen in USA) at 2 grams a day is sufficient. • Avoid Iron supplements unless you have anemia, multi-vitamins without iron should be used. • Assessment of vitamins and herbal remedies for safety. • A low-fat, ‘heart-smart’ diet. • Have an endoscopy once yearly to screen for esophageal varices. • Alpha-fetoprotein testing every six months and ultrasonography once yearly to detect early hepatocellular carcinoma (cancer of liver). • Avoid elective surgery once signs of liver decompensation develop (Riley, 2001 – part 2). I hope this article will be of some benefit to all readers. I would like to thank Wanda Dillon from the Department of Human Resources Library for her assistance with this research, and Doug Mellors for his valuable help in setting out this article. Thank you to Doug Mellors for his assistance with this article. Thanks Doug! REFERENCES: HCCNSW Medical Research & Advisory Panel, 2005 in report “Estimates & Projections of the HCV Epidemic in Australia 2002. Riley, T.R. & Bhatti, A.M. Preventative Strategies in Chronic Liver Disease Part 1. American Family Physician (2001) Vol. 64(9):1555-60. Riley, T.R. & Bhatti, A.M. Preventative Strategies in Chronic Liver Disease Part 2. American Family Physician (2001) Vol. 64(10):1735-40.
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