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Newly diagnosed? See our Hepatitis Health Center to learn more about it. Exercise & Liver Disease? Our expert tells you how.

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Cost of Med's if you have Insurance

Hello - I am getting ready to start the triple-drug therapy and am having no luck finding out a ballpark...

Posted by EnochTwo

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Purisis, MILD Rash with severe itching TIPS

I am a Pegasys/Teleprivir patient. End of week one. I went to the hospital because I just could not...

Posted by JesusFeedsMeCure

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1 Reply | ReplyReport This| Share this:Purisis, MILD Rash with severe itching TIPS I am a Pegasys/Teleprivir patient. End of week one. I went to the hospital because I just could not...

Knowing your vitamins

As many of you have heard pro-biotics are extremely important to good intestinal health. As is Zinc. I...

Posted by JesusFeedsMeCure

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1 Reply | ReplyReport This| Share this:Knowing your vitamins As many of you have heard pro-biotics are extremely important to good intestinal health. As is Zinc. I...

My 2cents,on Hep C, For what its worth

Hello Everyone, I have recently joined a couple support groups for Hep C suffers and those that have tried...

Posted by CipsaroP

Hello Everyone, I have recently joined a couple support groups for Hep C suffers and those that have tried treatments or are currently being treated. As expected there are many different side effects that can appear. Since 1991 when I was first diagnosed with Hep C I have tried three different trial studies without success. Each time I was closley monitored by my GI doctor. In none of these instances did I go to my PCP. Since there are so many different things that can show up I would highly recommend that you do this through a GI MD. In particular one that sees patients that are being treated with these meds. They know the details and will know what you should do to ease the side effects or can tell you if and when you should stop the treatment. In all three trial studies I did not suffer much from the side effects other than depression. I attribute this mostly to the fact that the monthly blood test were not showing signs of improvment.
I am now one week away from completing the 48 week TX treatment and can now say that I can see the light shinning brightly at the end of the long tunnel. The depression seems to be a non factor this time as I have been testing negative for the virus since week 6. In addtion I was helped along by seeing Physchiatrist from time to time during the process. I found it better to talk to someone face to face rather then reading and typing on the computer. Crying is ok and having someone there to cry to is a great relief. I have also been lucky or forntunate in that I was still able to maintain a rigours workout program of bicycling and walking without any problems. I must say that most of this is done as early in the day as possibe. Fatigue is still a factor but I am able to maintain by going to bed by 8-9pm. Of course not everyone is the same. Just do what you can try to have a postive attitude. I wish everyone could be as lucky as me but my advise is to do what you can and try to maintain a postiive attitude. Most of all do what the MD tells you and do not drink alchohol or take any meds other then what is allowed. Even some over the counter meds can be a no no. If you are unsure about anything ask. If I can help anyone who is having issues please feel free to ask. I do not know everything but certainly can relate my personal experiences to possibly help ease your mind. Good Luck to everyone and may you all have MANY MANY more Happy New Years.
BTW. I will be 60 years old this May. I keep telling anyone who will listen that "My next 30 years will be the best years of my life" now that I have rid my body of the virus that has occupied my mind for the last 20 plus years.... God Bless you all CIPView Thread

Posted by CipsaroP

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1 Reply | ReplyReport This| Share this:My 2cents,on Hep C, For what its worth Hello Everyone, I have recently joined a couple support groups for Hep C suffers and those that have tried...

Hep C for Boomers

Please listen up all Baby Boomers - this disease is not a laughing matter. If you were doing drugs back in the...

Posted by chestn

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Greatest Healer of All

Hello friends, this isn't a question just a positive and encouraging story. Like some of you I had used drugs...

Posted by Grace1337

Hello friends, this isn't a question just a positive and encouraging story. Like some of you I had used drugs and shared needles, was very reckless in the past. I've been clean for 5 years and since then had two beautiful boys. I was told about a month ago that I had antibodies for Hepatitis C, and this scared me to death. I was overcome with guilt, shame, anger for what I exposed myself to when I was younger. I needed help, and just not from healthcare professionals, I needed God to heal me. I prayed and opened my heart to God begging Him to heal me, asking Him for forgiveness of my sins for being so destructive in the past. I started going to church and reading the Bible, I gave my burdens, worry, pain, fear and doubt to Him and did my best to give Him control of the situation. When I started to feel worry and doubt that this was the end, I turned to him and asked Him for strength because I couldn't do this on my own. I had faith that He would heal me because He loves me unconditionally and despite of my transgressions, He would heal me if I boldly asked Him to. Less than a week ago I went to the specialist, had my blood drawn to see if I actually had the virus. I prayed for the best and reminded myself that God will protect me no matter what the outcome may be. A couple of days ago I got a call and was told that I do NOT have Hepatitis C. Friends, I truly believe God will heal us if we just believe in Him and open our hearts to Him. God wants us to give Him our burdens because we are too weak to carry it ourselves. He can heal us because He loves us unconditionally and is the greatest Healer there is. Please pray to Him for healing, He will heal you. Also, when talking to the specialist I was told that in 3yrs there will be a new treatment that will have an 80% cure rate even for genotype 1. The specialist sounded quite optimistic about this new treatment so don't lose faith or become discouraged. Open your hearts and minds to the power of prayer and God, He'll always listen to you for we have a merciful, God full of grace and love. Thank you for taking the time to read this and God bless you.View Thread

Posted by Grace1337

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5 Replies | ReplyReport This| Share this:Greatest Healer of All Hello friends, this isn't a question just a positive and encouraging story. Like some of you I had used drugs...

Exercise and Liver Disease part 7 Putting Together...

Putting Together an Exercise Program Nobody expects a person beginning an exercise regimen to run...

Posted by Melissa Palmer, MD

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Exercise and Liver Disease part 6 Weight-bearing E...

Weight-bearing exercises build up both bones and muscles. For many reasons, it is important for all...

Posted by Melissa Palmer, MD

Weight-bearing exercises build up both bones and muscles. For many reasons, it is
important for all people with liver disease to incorporate weight-bearing exercises into
their daily exercise routines. First, people with liver disease need good strong bones
because they are prone to osteoporosis. Weight training is the best way to fight against
this, as stronger muscles equal stronger bones. Second, in advanced stages of liver
disease, the body is forced to recruit muscle as a source of energy, and people are at risk
of developing severe muscle wasting and greatly diminished strength. However, if a
person has a reserve of muscle built up on her body, it will take a much longer time for
this complication of liver disease to develop. Third, people who have too much fat on
their bodies are at risk of worsening their underlying liver condition by developing
nonalcoholic fatty liver disease (NAFLD). Weight training reduces the amount of fat on
the body and increases muscle mass. Therefore, the chance of developing NAFLD will be
reduced. Finally, since muscle weighs more than fat, weight training is the perfect means
of gaining lean healthy weight for those people who are underweight.
One exception to weight training should be mentioned. People with cirrhosis
complicated by esophageal varices should avoid weight training. This is because wall
tension in the esophagus may drastically increase with weight training which puts this
group at increased risk for esophageal variceal rupture and hemorrhage.
Once again, there are lots of self-help books and videotapes that describe how to
create a personalized weight-bearing exercise routine. It's a good idea to hire a personal
fitness trainer, who can design a personalized routine specific to an individual's needs. It
is important that the trainer be aware of the client's liver disorder, and that consequently,
the client will not always be able to exercise to her fullest capacity. A person with liver
disease should never push herself excessively, nor should she allow herself to be pushed
by a trainer. If she feels too tired or if a body part feels strained, she should stop
exercising until she feels better. Fitness training has become a field that requires
certification, so make sure that the trainer is certified.
It is important to remember to work out every part of the body evenly. Did you know
that there are eleven distinct body parts to work out! In that way, the chances of injury are
decreased. A few stretching exercises should always be performed first to warm up the
muscles before doing weight-bearing exercises. The amount of weight being lifted should
allow for eight to twelve repetitions. Each repetition (rep) is defined as one full and
individual execution of a particular lifting exercise. A set is a distinct grouping of
repetitions, followed by a brief rest interval. Three sets of a given type of exercise should
be performed. Aim to work out each body part at least once a week. Twice a week is ideal.View Thread

Posted by Melissa Palmer, MD

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1 Reply | ReplyReport This| Share this:Exercise and Liver Disease part 6 Weight-bearing Exercise Weight-bearing exercises build up both bones and muscles. For many reasons, it is important for all...

Exercise and liver Disease part 5 -Aerobic Exercis...

Aerobic exercise trains the heart, lungs, and entire cardiovascular system to process and deliver...

Posted by Melissa Palmer, MD

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Exercise and Liver Disease part 4 -The Types of Ex...

People with liver disease should take up both aerobic and weight-bearing exercises, as they each...

Posted by Melissa Palmer, MD

People with liver disease should take up both aerobic and weight-bearing exercises, as
they each play a different role in fighting liver disease. It is fortunate that there are an
abundance of books, videotapes, and television programs that teach, step by step, both
types of exercises. It is important to use these self-help materials prior to starting any
exercise regimen. Other helpful ideas include scheduling a few appointments with a
personal trainer to design a fitness routine that personally meets the needs of a person
with liver disease. Many fitness trainers will even work in their clients' or the trainer's
homes. And recently, one-on-one fitness training facilities have become widespread.
They offer both privacy and personalized attention. This is important, as many people are
too self-conscious or too shy to exercise in a crowded gym, and/or lose self-motivation
after the first few sessions at a gym. A welcome development has been the appearance
very recently, of gyms geared specifically to individuals who are not in good shape. In
these facilities, embarrassment is mitigated and the convergence of similarly situated
clientele creates an environment akin to a combination support group/health club. Finally,
the likelihood of success is increased if a person adopts an exercise program that she
already enjoys and that can easily be adhered to with consistency at least three times a
week.
Timing is also important. It is fine to exercise at any time of the day that is personally
convenient. However, by the end of the day, most people are usually too mentally and
physically tired to do anything, least of all, run on a treadmill! That is why most people
with liver disease find that they need to do their exercises first thing in the morning.
While some people may find it difficult to get up in the morning in the first place, once
they get started with an exercise regimen, it will become easier and easier. And people
usually find that exercising in the morning helps give them an extra boost of energy to
make it through the day. Finally, don't overdo it. It's more important to maintain a regular
routine than to set any records.
Aerobic Exercises
Aerobic exercise trains the heart, lungs, and entire cardiovascular system to process and
deliver oxygen more quickly and efficiently to every part of the body. It's the kind of
exercise that gets the heart pumping. As one becomes more aerobically fit, the heart
won't have to work as hard to pump blood to the rest of the body, including the liver. The
pulse will begin to slow down, making it easier for the liver to send back to the rest of the
body the blood it has just filtered. The benefits of being an aerobically fit person include
an overall improved energy level, which translates into decreased fatigue. Fortunately, a
person does not have to purchase high-fashion workout clothes or go to a fancy gym to
get aerobic exercise. Walking briskly, bicycling (either stationary or regular), swimming,
or using a treadmill all provide solid aerobic benefits. Many people start off with
something easy, such as walking around the block. A helpful hint is to start by walking up
and down the street close to home. In that way, if a bout of fatigue suddenly occurs, it won't take long to get home.View Thread

Posted by Melissa Palmer, MD

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0 Replies | ReplyReport This| Share this:Exercise and Liver Disease part 4 -The Types of Exercise for Liver Disease People with liver disease should take up both aerobic and weight-bearing exercises, as they each...

Exercise and Liver Disease part 3 - osteoporosis

Exercise is essential in order to decrease the incidence of potentially detrimental bone disorders....

Posted by Melissa Palmer, MD

Exercise is essential in order to decrease the incidence of potentially detrimental bone
disorders. Osteoporosis is a bone disorder frequently associated with liver disease. It
results in decreased bone density, thereby leading to fragile, easily fractured bones. While
osteoporosis is a disease that most frequently affects postmenopausal women, it can also
affect premenopausal women and men with liver disease. Postmenopausal women are
particularly susceptible to osteoporosis because, as estrogen production stops, bone loss
accelerates. Furthermore, women naturally have a lower percentage of muscle and bone
mass than men. This further increases their risk of developing osteoporosis. Other risks
for osteoporosis in people with liver disease include excessive alcohol use, primary
biliary cirrhosis, advanced cirrhosis from any liver disease typically resulting in muscle
wasting, and the use of prednisone. Fortunately, people can reduce the likelihood of
developing osteoporosis by making exercise and a healthy diet part of their lifestyle.
Just as muscles grow in response to muscle contractions, bone strength and density
increase when the muscles attached are contracting. Studies have shown that muscle and
bone growth promoted by frequent weight-bearing exercise is vital to the prevention of
osteoporosis. Supplementing the diet with at least 1,000 to 1,500 milligrams per day of
calcium in combination with vitamin D is also important. If a person already has
osteoporosis, it needn't keep her from exercising, but she will have to use more caution
so as to keep from breaking any bones. High impact aerobic exercises, which involve
jumping and twisting, can increase the risk of injury and should be avoided. Low impact
exercises, such as swimming and walking, are the safest choices for aerobic exercise.
Weight-bearing exercises with light weights can generally be safely performed. Close
attention should always be paid to proper form. Running on a hard surface, such as
concrete pavement, should be avoided. Soft surfaces, such as specially designed running
tracks, a treadmill or a sandy beach, are preferable.View Thread

Posted by Melissa Palmer, MD

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0 Replies | ReplyReport This| Share this:Exercise and Liver Disease part 3 - osteoporosis Exercise is essential in order to decrease the incidence of potentially detrimental bone disorders....

Exercise and Liver Disease part 2 - Some of the Be...

The benefits of exercising are numerous. First, exercise gives people a general sense of well-being...

Posted by Melissa Palmer, MD

The benefits of exercising are numerous. First, exercise gives people a general sense of
well-being and an improved self-image. It is a known fact that if a person feels well
mentally, her immune system will be stronger and give her that extra edge needed in the
fight against disease.
Second, as previously discussed, exercising gives a person a boost of energy. Fatigue
is probably the most common as well as one of the most bothersome symptoms that
plagues people with liver disease. Many people with liver disease frequently feel like
they don't have enough energy to make it across the room, let alone around the block.
However, the best way to fight this seemingly relentless exhaustion is to exercise. Yes,
the notion of exercising when you are fatigued may seem counterintuitive- like a vicious
cycle, but most people find that it actually works. In part, fatigue may have to do with the
fact that both the heart and the liver are working overtime to keep a good supply of
filtered blood circulating throughout the body. Adding a regular exercise routine enables
both organs to work more efficiently. Over time, this will boost energy levels. While most
people find it tough going at first, they eventually realize that the benefits make it well
worth it.
Third, exercise improves cardiovascular function. As the body gets stronger and more
aerobically fit, the cardiovascular system will be able to work more efficiently. Less
effort will be required of the heart to pump blood to the liver and other body organs. Less
effort on the heart equals stronger cardiovascular function and an increased overall
energy level for a person with liver disease. It is extremely important to attempt to do
some exercise while on interferon treatment, as this will decrease the fatigue, irritability,
and depression often associated with this medication.
Fourth, exercise results in a reduction of total body fat. While nearly everyone knows
that being overweight places a great deal of stress on the heart, most people don't realize
that it also makes it harder for the liver to do its job. When total body fat is reduced, fat
content in the liver is simultaneously reduced. This often results in a significant reduction
of elevated liver enzymes, no matter what the underlying liver disorder is. Eating right
and getting plenty of exercise is undoubtedly the slowest way to lose weight known to
humanity, but it's also the safest and surest. This is especially true for people with liver
disease. Even intermittent exercise has been shown to be beneficial in obese women.
Combining a healthy diet with regular exercise is also the best way to keep from
regaining the weight.View Thread

Posted by Melissa Palmer, MD

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Exercise and Liver Disease part 1

Regular exercise is an important component in the fight against liver disease. This isn't something...

Posted by Melissa Palmer, MD

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Hepatitis C

I currently have Hep-C and went thru the pills and shot once a week.To get to the point I go to University...

Posted by ChaoticNytZ

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i have a niece with hepatitisc. How can i buy her ...

She was treated with a localy made interferon in egypt,with no results.My wife was treated here inUSA with...

Posted by akazzoun

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1 Reply | ReplyReport This| Share this:i have a niece with hepatitisc. How can i buy her interferon to send her for treatment She is in Egypt now? She was treated with a localy made interferon in egypt,with no results.My wife was treated here inUSA with...

New treatments for hepatitis C

I'll be appearing on Sirius Radio, channel 114 (on XM, channel 119) on Monday April 14, from 9-9:30...

Posted by Melissa Palmer, MD

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Sexual Transmission of hepatitis B

HBV is 100 times easier to transmit sexually than HIV ( the virus that causes AIDS). HBV has been...

Posted by Melissa Palmer, MD

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7 Replies | ReplyReport This| Share this:Sexual Transmission of hepatitis B HBV is 100 times easier to transmit sexually than HIV ( the virus that causes AIDS). HBV has been...

Liver OK

I think I have had Hep C for about 25 yrs - I got it experimenting with IV drugs in my early 20's - went to the...

Posted by chuml

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6 Replies | ReplyReport This| Share this:Liver OK I think I have had Hep C for about 25 yrs - I got it experimenting with IV drugs in my early 20's - went to the...

Viral Hepatitis: 8 Self-Defense Tips for Travelers

Are you planning on any holiday travel abroad? In the U.S., the risk of contracting viral hepatitis...

Posted by Andie_WebMD_Staff

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What is a Hemangioma?

Hemangiomas are the most common benign tumors of the liver. They have no malignant potential and may...

Posted by Melissa Palmer, MD

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TYPES OF BENIGN LIVER TUMORS

There are many types of benign liver tumors and I will discuss five of the most common types:...

Posted by Melissa Palmer, MD

There are many types of benign liver tumors and I will discuss five of the most common types: hemangioma, hepatic adenomas, focal nodular hyperplasia (FNH), the solitary liver cyst, and nodular regenerative hyperplasia (NRH). For a discussion of malignant liver tumors please refer to www.liverdisease.com.

In general, they occur more frequently in women than in men. They are usually discovered by chance during the evaluation of nonrelated symptoms. Liver function tests (LFTs) are usually normal in people with benign liver tumors. In rare circumstances, these benign tumors can become so massive that a person may go to the doctor for abdominal discomfort caused by an enlarged liver. In these uncommon circumstances, results from blood tests occasionally reveal mildly elevated AP or GGTP levels.

There are no blood tests that specifically indicate that a tumor is in fact benign. Thus, the doctor may be uncertain as to whether the tumor is, in fact, benign. While malignant liver tumors may metastasize (spread to other organs, most commonly the lungs), benign liver tumors are always confined to the liver. Diagnosing the specific nature of the tumors can generally be done using a variety of radiological techniques (imaging studies) combined with the patient's medical history. When the diagnosis remains uncertain, a liver biopsy is generally performed. Since many of these tumors have an abundance of blood vessels, liver biopsy in some cases carries an increased risk of bleeding. A smaller than normal needle, or an aspirate of liver fluid, can be used to decrease the occurrence of this potential complication.
Treatment of benign lesions is generally conservative. Surgery is considered primarily in cases where the tumor is causing significant abdominal pain, or if there is a high risk of rupture of the tumor. Furthermore, surgery should be done if the benign nature of the tumor cannot be confidently established, or if it is felt that the tumor has a risk of progression to a malignancy.View Thread

Posted by Melissa Palmer, MD

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2 Replies | ReplyReport This| Share this:TYPES OF BENIGN LIVER TUMORS There are many types of benign liver tumors and I will discuss five of the most common types:...

What type of doctor should treat your liver diseas...

There are many different kinds of doctors who evaluate and treat people with liver disorders. A...

Posted by Melissa Palmer, MD

There are many different kinds of doctors who evaluate and treat people with liver disorders.

A gastroenterologist is an internist who has completed specialty training in the treatment of digestive disorders. Digestive disorders include disorders of the esophagus, stomach, small and large intestines, pancreas, gallbladder, and liver. In order to become board certified in gastroenterology, the doctor must first become board certified in internal medicine. In order to become eligible to even take the examination for board certification in gastroenterology, a gastrointestinal (GI) fellowship lasting an additional two to three years beyond an internal medicine residency must be completed.

During the course of their two to three years of training in gastroenterology, some gastroenterologists have little exposure to patients with liver disease. On the other hand, some gastroenterologists have a great deal of exposure to patients with liver disease during the course of their gastroenterology specialty training. Thus, the level of experience and expertise among gastroenterologists in diagnosing and treating liver disease varies greatly. It is important for the patient to determine the gastroenterologist's level of expertise in liver disease prior to establishing a long-term medical relationship with this type of doctor.

A hepatologist is the most experienced and qualified type of doctor to treat people with liver disease. There are specialized training programs for doctors who are focused solely on liver disease, - known hepatology fellowships and typically last from one to two years. Over the course of a hepatology fellowship, a doctor receives comprehensive training in the diagnosis and treatment of liver disease. This specialty training typically includes extensive exposure to all liver diseases, including those that are rare and infrequently seen. This intense training in liver disease is rarely matched in a gastroenterology fellowship.

A physician who successfully completes a hepatology fellowship is considered a hepatologist. Most hepatologists, although not all, are also gastroenterologists. These doctors have successfully completed both a hepatology and a gastroenterology fellowship. Occasionally, gastroenterologists who have not completed a fellowship in hepatology nonetheless focus their medical practice primarily on the diagnosis and treatment of people with liver disease.

For many reasons, it is to the patient's advantage to choose a hepatologist to treat his liver disease. The patient can be virtually assured that the hepatologist will have substantial experience in the diagnosis and treatment of the full range of liver diseases. Furthermore, hepatologists are likely to be the first to learn about the most up-to-date therapies—both FDA-approved and experimental—and to incorporate them into their practices. However, whether someone chooses to see a gastroenterologist or a hepatologist, it is important to find a doctor who is willing to work with him or her as an equal partner in the healing process.

The full article can be located at
http://www.liverdisease.com/liverspecialist_hepatitis.html View Thread

Posted by Melissa Palmer, MD

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Email Digests Are Back!

Don't get to your favorite boards every day? We're all busy, so sometimes it is nice to have your...

Posted by Andie_WebMD_Staff

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MANAGED CARE AND NEW TEST FOR HCV TREATMENT RESPO...

10/27/2010 - Time gap could appear between protease inhibitor approval and creation of new AASLD...

Posted by Melissa Palmer, MD

10/27/2010
- Time gap could appear between protease inhibitor approval and creation of new AASLD practice guidelines, committee member says - Managed care might ask for testing at week 4 and 12, may interrupt treatment regimens - IL-28B genotype testing to possibly play a role in reimbursement algorithms - If a patient displays eRVR, then SOC would likely be sufficient, some physicians said Merck's (NYSE: MRK) boceprevir and Vertex's (NASDAQ: VRTX) telaprevir, first generation protease inhibitors in development for HCV, will necessitate both professional treatment algorithms to be updated and managed care reimbursement algorithms to be created to define eligibility criteria for triple therapy, physicians said. The current treatment regimen for the treatment of hepatitis C (HCV) involves a 24 or 48-week course of a combination of pegylated alpha interferon and ribavirin. There is concern that there will be a disconnect between the time when these protease inhibitors become available, the next annual review of the American Association for the Study of Liver Diseases (AASLD) practice guidelines, and the implementation of managed care reimbursement algorithms, according to Dr Nancy Reau, a member of the AASLD Practice Guidelines Committee and associate professor of medicine at the University of Chicago. The annual review is typically not a complete overhaul, said Reau, but there is concern that the association will have to change the whole algorithm. This might include four week viral load testing, which the European Association for the Study of Liver (EASL) guidelines currently indicate, she said. In practice, this means that the current EASL guidelines are set up to "use week four as a decision making point, but ours are not," she said. The lack of a four week testing point conflicts with the four week assessment to see if a patient has achieved early rapid virologic response (eRVR), which might indicate that a patient is eligible for response guided therapy as is done in some clinical study protocols, according to Reau. "We don't think our practice guidelines are going to mirror [clinical> practice the day this becomes available. We think these are going to come out, and our guideline review will lag a bit," said Reau. However, she said she remains confident that academic institutions will be able to adequately treat patients with triple therapy until the guidelines are updated. Although there are currently guidelines for the use of interferon and ribavirin, use is not uniform - as it is tailored to an individual patient, Reau said. The lag time in the guideline review will be most difficult for physicians who are less experienced in the treatment of HCV, like virologists and gastroenterologists, she said. Reau has previously had to show 12 week viral load data to managed care companies demonstrating sufficient viral load in order for them to continue authorizing even SOC treatment, she said. "That's probably going to become more common with triple therapy, because it's going to be so much more expensive," she said. "You could see some treatment interruptions," as a result of possibly needing four week or 12 week data, she said. The appropriate tests need to be performed and analyzed, with results then sent to a managed care company to review. The company then needs to reauthorize treatment and appropriately notify the physician, who will then need to reorder the proper therapy. It will be "nearly impossible" for this to happen in a timeline
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which will not interrupt the proper time course of therapy, said Dr Paul Gaglio, medical director of the Liver Transplant Center at Montefiore Medical Center and professor of clinical medicine at Albert Einstein College of Medicine. Gaglio said he would like to use protease inhibitors in all of his patients - regardless of whether an individual presents with a positive prognostic profile who would likely achieve SVR with SOC. The improved SVR results in a patient like this would merit use of triple therapy, he said. Another option outlined by Gaglio was the use of a four week SOC lead-in and subsequent viral load test to then determine if a patient should receive triple therapy, which is the protocol used by Merck in its boceprevir trials. If a patient displays eRVR, then SOC would likely be sufficient, whereas if the viral load still remained high, the patient would be eligible for triple therapy, he said. If managed care mandates these four week and 12 week decision making points, it might "mandate a minimum standard," said Reau, with practitioners ordering these tests because they have to for reimbursement purposes. The IL-28B genotype test may also be used to guide treatment selection, said Gaglio. Dr Andrew Muir, director of gastroenterology and the hepatology research program at Duke, and co-author on the article in Nature which reported on the predictive value of the IL-28B genotype and a patient's likelihood of responding to the SOC, said "IL-28B appears to be the strongest predictor of your response to standard of care." The test is available from LabCorp (NYSE: LH) after it licensed the technology from Merck. Current turnaround time on the test is usually around 10 days, said Muir. Gaglio outlined a possible scenario of how IL-28B genotyping could be used in a managed care algorithm. If IL-28B testing is favorable, a patient will get SOC first, he explained. If patients have a lack of response or an unfavorable genotype to start, then they will start on triple therapy, he added. "I think IL-28B testing might be the way that companies stratify which way patients are treated," he said. The "worst case scenario," according to Gaglio, would be one in which managed care only pays for triple therapy if a patient is a null responder or relapser, he said. Muir also cautioned, however, that IL-28B is neither the only predictor of response, nor always a predictor of response. Other predictive indicators beyond IL-28 genotype include race, viral load, and degree of fibrosis. "As with many other tests, it could be misused," said Dr Melissa Palmer, medical director of hepatology at New York University Hepatology Associates. Virologic response to treatment is still a stronger indicator than IL-28B, Reau added. IL-28B data could be used to truncate the treatment window of patients with an unfavorable genotype if they do not demonstrate a reduced viral load on therapy, she said. Additional studies are currently being done to verify that the IL-28B genotype is also predictive of a patient's response to therapy with a protease inhibitor, said Muir. This data is expected around EASL next year, said Reau. "Boceprevir seems like it will cost more because in trials it was in continuous therapy for longer than telaprevir," said Dr Silvia Degli Esposti, director of the Center for Women's Gastrointestinal Services at Women and Infants Hospital of Rhode Island. Additionally, the side effect profile associated with boceprevir, namely anemia, may limit the extent of its managed care reimbursement and thus use in patients, as a patient may require erythropoietin stimulating agents (ESAs) in addition to their triple therapy regimen, she said. This could confer an advantage to the use of telaprevir, she noted. "I have the feeling it is too complicated for managed care to tackle, because it's too complicated for us, as individualized therapy is very difficult," said Degli Esposti. "I don't think they want to know about patient details to decide what should be reimbursed. I think they will just go for a general guideline," she said.
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When historically presented with only guidelines, patients have a hard time receiving reimbursement without a defined algorithm, as there is often no rationale behind an insurance provider's choice for wView Thread

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Treatment of Insomnia and Other Sleep Disturbances

The average person requires between 7-8 hours of sleep per night. However, some people require as...

Posted by Melissa Palmer, MD

The average person requires between 7-8 hours of sleep per night. However, some people require as much as10 hours of sleep per night and others require only 4 hours of sleep per night. No matter what your personal requirement is, the main objective is to feel rejuvenated upon awakening. People with liver disease often suffer from sleep disturbances. In fact, approximately 35 to 50 percent of people with cirrhosis report having sleep-related difficulties. Some people have trouble falling asleep and others have difficulty staying asleep. Many people complain of being tired all day and awake all night. Others complain of erratic sleeping habits characterized by days of excessive sleep (a condition known as hypersomnia) alternating with days of lack of sleep (a condition known as insomnia). Still others state that they experience delays of their usual bedtimes and wake-up times. For most people suffering from these sleep disorders, the sleep they do get is not refreshing. Sleep disturbances may cause decreased concentration, poor coordination, excessive fatigue, anxiety and depression. It may affect personal relationships, work performance, and physical appearance. These symptoms and consequences of sleep disorders are magnified in people with liver disease as they may already be suffering from one or more of the aforementioned symptoms.
The cause of sleeping disorders in people with liver disease is unclear, but most likely it relates to alterations in the body's production of melatonin—a hormone that is produced by the pineal gland and is involved in the sleep cycle. Sometimes, sleep disturbances stem from medications used for the treatment of liver disease. For example, interferon, ribavirin, prednisone, and propanolol all may cause insomnia. Pruritus (itching) can sometimes cause a sleeping disorder. People suffering from intense itching (discussed on page xx) may find themselves awake half the night scratching. People on interferon therapy for chronic hepatitis may be drinking up to a gallon a day of water to diminish the side effect of dehydration. Therefore, they may be awakening throughout the night to go to the bathroom. Discontinuation of water or fluid intake 2-3 hours prior to retiring, along with urinating before bedtime, may alleviate this problem. Caffeine, nicotine, and alcohol consumption may disturb sleep habits. Abstaining from these substances will likely assist in the quest for a good night's sleep. Note that sleep disturbances may also be a sign of impending encephalopathyView Thread

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Sex and HCV

Since this is understandably such a frequent question, I am leaving up this information. Sexual...

Posted by Melissa Palmer, MD

Since this is understandably such a frequent question, I am leaving up this information.

Sexual contact, whether it is genital, oral, or anal, appears to be an extremely inefficient means of HCV transmission. In fact, many studies evaluating this route of transmission have failed to detect the presence of HCV in either the saliva, semen, or urine of HCV-infected people—except when these body fluids have been contaminated by the person's blood. However, it is important to emphasize that HCV has the potential to be transmitted through intimate contact if there are breaks in the skin or in the lining of the mouth, vagina, or anus. This may occur for a variety of reasons including the presence of active, bleeding herpes sores; an inflamed and infected prostate gland, known as prostatitis; or as a result of traumatic or rough sex, especially anal intercourse.
HCV has been detected with greater-than-average frequency among people who have a history of sexual promiscuity. While there is no exact definition for sexual promiscuity, one study published in the New England Journal of Medicine defines it as a "history of a sexually transmitted disease, sex with a prostitute, more than five sexual partners per year, or a combination of these." Of interest is that it appears to be easier for a man to transmit HCV to a woman than vice versa.
A person who is in a long-term monogamous relationship with an HCV-infected person rarely contracts this virus. Only approximately 2 percent (a range of 0 to 6 percent) of sexual partners of HCV-infected people also test positive for HCV. However, it is important to note that this statistic is based on indirect evidence only. Therefore, whether these people became infected through a sexual act or by another route is unclear. For example, people in long-standing relationships generally care for one another in times of illness or injury. During such times, HCV may be transmitted to the spouse or partner as blood-barrier precautions may not always be taken into consideration—even among the most cautious of couples.
Household Contact
Transmission of HCV among family members or other people living together may occur. This potentially can happen through the sharing of razors, toothbrushes, or any sharp instruments that carry HCV-infected blood. Therefore, it is crucial to keep all personal items, such as toothbrushes, in a separate part of the bathroom or specifically labeled. In this manner, the accidental use of a potentially HCV-infected household item will be decreased. The incidence of contracting HCV from accidental household contact in the United States is unknown. However, data from other countries indicate that it is low—approximately 4 percent.View Thread

Posted by Melissa Palmer, MD

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Just found out I have Hep/C I'm a bit scared I don'y really know what to expect I believe I've had this for a...

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