In contrast to hepatitis B, hepatitis C is a curable disease in many patients. This is referred to as a sustained virologic response rate (SVR) and ranges between approximately 20% to 90% (i.e., it is a measure of virus suppression). Length and success of HCV treatment are dependent upon a variety of factors (see Box 171-2). Pegylated interferon (PI) administered subcutaneously once a week, along with oral ribavirin (RBV) pills daily for 24 to 48 weeks, is the current standard of care (SOC) treatment for patients with chronic hepatitis C genotypes 2 and 3, and was the SOC for patients with genotype 1 (G1), the most common and most difficult to cure genotype worldwide. In May 2011, a major advance in the field of hepatology occurred. With the addition of a protease inhibitor, either telaprevir (Incivek, manufactured by Vertex) or boceprevir, (Victrelis, manufactured by Merck), to SOC treatment, SVRs jumped from approximately 42% to as high as 86% for many G1 patients. And, between 44% and 60% of treatment naïve G1 patients are now capable of being cured in just 24 to 28 weeks as opposed to 48 weeks. However, numerous adverse events (AEs), complex treatment regimens, exorbitant costs, and the potential for the development of drug-resistance, may decrease their therapeutic usefulness. This underscores the need for clinicians to be aware of the effects of natural and integrative therapies on the progression of HCV, and of the potential benefits of these therapies either with or without SOC treatment for chronic hepatitis C.

BOX 171-2 Factors Impacting Hepatitis C SVR Rates

Host Factors

• Ethnicity

• BMI

• Age

• Insulin resistance/DM

• Gender

• Alcohol use

• Nutritional factors

Viral Factors

• Genotype

• Viral load

• Interleukin-28B polymorphism

Disease Factors

• Degree of fibrosis

• HCV/HIV coinfection

Adherence Factors

• Patient education

• Response-guided therapy

• Management of AEs

• Alternative RBV formulations

• Support team – medical and personal

Several nutrients and herbs, discussed later, have been shown to inhibit viral reproduction, improve immune system function, and stimulate regeneration of the damaged liver cells.

Lifestyle Recommendations

Sleep

Experimental studies have demonstrated that sleep deprivation results in poorer immune function, such as reduced natural killer cell activity, suppressed interleukin-2 production, and increased levels of circulating proinflammatory cytokines.^6,⁷ A recent study showed that survival was inversely associated with sleep disturbance among 156 patients with cirrhosis. The study’s authors suggested that tailored behavioral interventions might help to improve overall health-related quality of life and could potentially improve patient outcomes.⁸ Sleep problems have been reported in patients with chronic hepatitis C, with about 60% to 65% of individuals reporting such complaints. Subjects administered IFN-α demonstrated increased waking after sleep onset, decreased sleep efficiency, and reduced stage 3 and/or 4 sleep.⁹ Evidence also suggests that impairments in sleep quality exist independent of antiviral therapy with IFN-α and prior to the advanced stages of liver disease.¹⁰ Sleep deprivation has also been found to attenuate antibody response to hepatitis A immunization.¹¹ In terms of sleep duration, individuals with less than 7 hours of regular sleep are approximately three times more likely to develop a cold when exposed to nasally introduced rhinovirus than those with 8 hours or more of sleep.¹² It may therefore be prudent to encourage proper sleep habits and a duration of 8 hours or more in order to optimize immune and antiviral benefits in the hepatitis patient as well.

Exercise

The benefits of exercise for people with liver disease are numerous. Studies of patients with hepatitis C incorporating exercise as part of their therapy with SOC show that they can safely participate in an exercise program, create clear changes in the way they perceive their bodies and its capacities, as well as improve their self-confidence, all of which can lead to far-reaching changes in the way this disease and the constraints of treatment are perceived.¹³ Because fatigue is probably the most common as well as one of the most bothersome symptoms affecting people with chronic hepatitis, exercise can provide a boost of energy and also improve cardiovascular function. Exercise leads to a reduction in total body fat, which is important to all people with liver disease. When total body fat is reduced, the fat content of the liver is also reduced, often resulting in a significant reduction in elevated liver enzymes.¹³ Thus, it is recommended that all patients with chronic hepatitis incorporate an exercise program combining weight training and aerobics into their daily routine as tolerated once they have been medically cleared by their physicians.

Diet

Nutritional treatment decisions for those with acute viral hepatitis should be symptom directed. In general, the focus should be on replacing fluids through consumption of vegetable broths, diluted vegetable juices (diluted with 50% water), and herbal teas in order to avoid dehydration, especially if diarrhea is present. Alcohol should be completely avoided because it can trigger a relapse of acute hepatitis.

Nutritional treatments for chronic viral hepatitis have been shown to have a significant impact on disease progression (e.g., obesity, alcohol consumption, and iron overload) and can worsen the disease, whereas the consumption of caffeine may be helpful. A diet low in saturated fats, simple carbohydrates (e.g., sugar, white flour, fruit juice, honey), oxidized fatty acids (fried oils), sodium, and animal products may be beneficial in patients with decompensated cirrhosis complicated by ascites (fluid retention) and/or hepatic encephalopathy (HE) (brain fog). A diet focused on plant foods (i.e., a high-fiber diet) has been shown to increase the elimination of bile acids, drugs, and toxic bile substances in some patients with decompensated cirrhosis complicated by HE. Alcohol should be completely avoided.

Fruit and Hepatitis C

Blueberries have been found to inhibit the replication of HCV,¹⁴ and rats fed diets high in blueberries were protected from developing acute hepatitis.¹⁵ This effect may be due to the antioxidant properties of the flavonoid proanthocyanidin that is a component of blueberry leaves.

Naringenin, a flavanoid contained in grapefruit and other citrus fruits, has been found to have antiinflammatory, antioxidant, and lipid-lowering properties and may act as a promoter of carbohydrate metabolism. Naringenin has been found to lower very low density lipoprotein cholesterol. It is suspected that the hepatitis C virus may “hitch a ride” on cholesterol—a theory that has held up in test tube experiments. Studies have demonstrated that naringenin can inhibit or reduce steatosis, (the deposition of fat in the liver),¹⁶ in addition to inhibiting HCV viral replication.¹⁷ It is important to remember that grapefruit contains furanocoumarins and flavonoids, which can inhibit components of the cytochrome P450 drug metabolism pathway leading to toxic levels of many medications.^18,¹⁹

Caffeine and Hepatitis C

The mechanism by which caffeine exerts its hepatoprotective effect is under investigation. Data from two population-based studies found that people consuming more than 2 cups of coffee a day were less likely to have elevated serum liver enzymes and were less likely to have chronic liver disease when compared with those who did not drink coffee.^20,²¹ The protective effect of coffee drinking on the development of cirrhosis and its complications, including HCC, has also been shown.²²^–²⁵

Higher coffee consumption was associated with less hepatic steatosis, a lower ratio of serum aspartate (AST)/alanine aminotransferase (ALT), and lower α-fetoprotein levels in patients with hepatitis C. Patients who drank more than 2 to 3 cups of coffee a day had a lower incidence of disease progression and less fibrosis on histologic evaluation compared with HCV patients who drank less coffee.^22,²⁶ Similar results were not seen in patients who got caffeine from other sources or who consumed decaffeinated coffee. Caffeine may also reduce the fatigue associated with HCV and/or chronic liver disease. Although the exact coffee intake necessary to obtain benefits is unclear, it appears reasonable for patients with hepatitis C to drink 2 to 4 cups of regular coffee daily.

Whey Protein

A product of the milk curding process, whey may boost immune function, protect against free-radical damage, and improve cellular glutathione levels. A preliminary trial found that 24 g of whey protein daily reduced serum ALT levels and increased plasma glutathione levels in people with hepatitis B but not those with hepatitis C.²⁷

Nutrient Therapeutics

Vitamins C and E

Patients with hepatitis C treated with pegylated interferon and ribavirin were found to have higher SVRs and to be less likely to experience ribavirin-associated anemia when they supplemented this antiviral treatment with vitamins C and E.^28,²⁹ It should be kept in mind that vitamin C increases iron absorption and many patients with hepatitis C already have elevated iron stores.

Vitamin E levels have been shown to be low in both serum ³⁰ and liver tissue³¹ in people with hepatitis as well as in those who later develop liver cancer from chronic hepatitis. In one preliminary trial of adults with hepatitis C, administering 1200 IU/day of vitamin E for 8 weeks appeared to reduce liver damage.³² In another study, 544 IU of vitamin E/day for 24 weeks improved the response to interferon/antioxidant therapy, although the results did not reach statistical significance.³³

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