A silent, damaging virus

New drug holds promise for hepatitis C patients

Deana Stokes Sullivan dss@thetelegram.com
Published on April 19, 2011
Dr. Kevork Peltekian

Many people think of alcohol use as the primary cause of cirrhosis of the liver.

Think again, says Dr. Kevork Peltekian, a full-time liver disease and transplantation specialist in Nova Scotia.

“I can guarantee you, that is not the case,” says Peltekian, who’s also an associate professor at Dalhousie University.

The hepatitis C virus (HCV), which often causes no symptoms in its early stages, can damage the liver and is known to cause cirrhosis if left untreated.

An estimated 250,000 Canadians are infected with the virus, and Peltekian said 3,200 to 5,000 are newly infected each year.

The exact number of people infected in Atlantic Canada isn’t known, but Peltekian said there are estimates of anywhere from 4,500 to 7,000. He figures one-third of cases haven’t been identified yet.

“Every week,” he said, “I have at least another patient that gets referred to me with newly diagnosed Hepatitis C.”

In Newfoundland and Labrador, according to a communicable disease report, 88 HCV cases were reported in 2009 and 99 in 2008. The highest number of cases were diagnosed within Eastern Health, which reported 71 cases in 2009 and 84 in 2008.

Peltekian says there are communities in this province where many people have genetic bleeding disorders, and many of these people were infected with HCV through blood transfusions before the early 1990s, when blood donations were not properly screened for the virus.

People addicted to injected drugs are also at increased risk, Peltekian said, explaining that HCV is transmitted through contact with blood through intravenous blood products, sharing of needles and drug paraphernalia. Body piercings, tattoos, mother-to-child transmission and accidental needle sticking in medical settings are also known risk factors.

Peltekian said reviewing a patient’s possible risk factors is important in making a diagnosis as early as possible.

If a patient received blood products prior to 1992, there’s a two to five per cent chance they’ve been infected with HCV. If they’ve shared needles for drugs or tattoos, or instruments for using cocaine even once, Peltekian said, “we know that up to 50 per cent are infected with hepatitis C.”

Peltekian tells his patients and family physicians that the liver is not an organ that “whines,” and that’s why in most cases, HCV causes no symptoms in the early stages.

“If you were having any troubles with your heart, with your stomach, with your bowels, you’d know right away,” he said. “But with the liver, until the damage is extensive, there’s very little symptoms.”

Sometimes, he said, “you can figure this thing out by just doing blood tests.”

If left untreated, HCV can lead to fibrosis, cirrhosis, liver cancer and liver failure. The liver fails when damage to the liver is extensive, Peltekian said. Symptoms can include fever, fatigue, reduced appetite, stomach pain, dark urine, jaundice or yellowing of the skin and eyes, nausea, vomiting, aching muscles and joints and poor concentration.

There are very few options for survival when the liver fails, with the exception of a liver transplant. However, Peltekian said if HCV is treated in a timely manner, the virus can be eradicated.

When HCV is no longer detected in blood testing, the term used is sustained virologic response (SVR), Peltekian said. It’s not a virus that stays dormant and can reactivate, he said, explaining that some patients who got rid of HCV have been tested seven years later and continue to have no signs of it. Liver biopsies also show an improvement in the amount of scarring and inflammation, he said.

HCV reoccurs in only about two per cent of those who get rid of the virus, he said, but it’s always from a new exposure to the virus.

There are six families or subgroups of HCV, with the most common one in Canada being genotype 1. That subtype is the one that affects 65 per cent of HCV patients in Atlantic Canada, Peltekian said, and it’s a more difficult strain to treat.

However, a new oral drug, boceprevir, has shown promise in eradicating the virus over a shorter time period, compared to the current standard treatment over 48 weeks. Peltekian has administered boceprevir to patients in one of two recent investigational studies, which have been published in the New England Journal of Medicine.

Peltekian said one study dealt with people with HCV who never had treatment before, and the other involved people who didn’t respond to previous treatment.

“I elected to go with the second study only and the reason why that was, I felt that we have a large proportion of individuals who had made that effort to get treatment but had not responded,” Peltekian said.

“Can we find a solution for these individuals?”

The patients he worked with were divided into three groups — one receiving, for the second time, the standard treatment they had previously for 48 weeks, with the other groups receiving the new drug, boceprevir, or a combination of boceprevir and two standard medications, peginterferon alfa-2b and ribravirin (PR).

Peltekian said the virus was eradicated in only 21 per cent of the group that received the standard treatment for the second time, compared to 59 and 66 per cent in the other groups that had boceprevir incorporated into their therapy.

“We basically improved the outcomes by giving the combination of three drugs, compared to the combination of two drugs by 68 per cent,” Peltekian said. “So, instead of only one in five responding to the treatment, now two-thirds have responded to treatment and got rid of the virus in a group that had been treated before.”

He’d like to see the drug available right away to patients considering this outcome, but said it has yet to be approved by Health Canada.

After studies are done to prove a drug works and the information is published, the manufacturer has to apply to Health Canada for approval. That process may take some time, Peltekian said.