1.1 Definitions
Hepatitis C is a viral disease that leads to swelling (inflammation) of the liver. [1]
Hepatitis C is inflammation of liver by hepatitis C virus (HCV). [2]
Hepatitis C is the pathogeneses of hepatocytes involving replication and distraction. [3]
Hepatitis C virus an envelope, plus strand RNA virus in the family Flaviviridae that causes serious liver disease. [4]
HCV infection is asymptomatic which leads to scarring of liver and ultimately leads to cirrhosis. Cirrhosis is a term used for the final stage of fibroses. Liver fibroses is the presence of scar cell in the liver tissue. It varies in location. The liver scar uniformly distributes represent an excess of extracellular matrix (ECM) and a shift in quantity of that matrix. [5]
1.2 Virology
HCV is classified as a flaviviridae and contain a single strand of RNA. The genome consists of single open reading frames that encode a poly protein of about 3000 amino acids. The transcript is cleaved into a single protein including three structures protein (one core and two envelop) and form non structural protein. The virus is structurally unstable which leads to multiple genotype and subtype. Six different type of genotype are recognized, type 1, 2, and 3 the most common. Genotype 2 and 3 are more responsive to antiviral therapy than is type 1. In individual patient many mutant HCV strain arises, which likely account for several features of infection including.
i- The inability of anti-HCV lg-G antibiotics to clear the infection.
ii- Persisting and replacing infection (chronic Hepatitis).
iii- Lack of progress in developing vaccines.
1.3 Epidemiology
The presence of HCV is variable less from 1% in Canada, 1.8 % in U.S and 22% in Egypt. It is estimated that 200 hundred million people are infected worldwide. HCV is the most common indicator of liver transplantation. Accounting for up to 50 % of patient a variety list HCV infection is transmitted by contact with infected blood and is particularly associated with intravenous drug abuse, high risk sexual behavior and alcoholism. Vertical transmission of HCV from mother to her new born baby is infrequent (about 5 %) [7]
1.4 Pathogenesis
HCV is not directly cytopathic as evidence by the fact that many chronic carriers of virus often have no evidence of liver cell injury despite of active hormonal and cellular immune response directed against all viral protein, most patients display persistent viremia. Liver cell injury has been attributed to cytotoxic T-cell responses to virally infected hepatocytic. The mechanism by which HCV persist has not been clarified. In additional to mutational escape, defect in HCV specific cellular immunity have been described. [8]
1.5 Clinical Features:-
The incubation period for acute HCV is 2-3 months but not less than 2 weeks and greater 6 months. Elevated serum aminotransferase activities are usually detected 1-3 months of exposure to virus. The presence of HCV RNA in the serum can be detected by polymerase chain reaction (PCR) within two week of infection.
Anti-HCV antibodies are usually detectable 7-8 weeks after HCV infection and persist during the chronic phase of infection. [9]
1.5 Causes, incidence, and risk factors
Hepatitis C infection is caused by the HCV. Peoples at risk for hepatitis C are
o Have been on long term kidney dialysis.
o Have regular contact with blood at work.
o Have unprotected sexual contact with a person who has hepatitis C (this risk is less common than hepatitis B (HBV). But the risk is higher for those persons who have many sex partners, already have a transmitted disease, or infected by HIV).
o Inject street drugs or share a needle with someone who has HCV.
o Received a blood transfusion before July 1992.
o Received a tattoo or acupuncture with contaminated instruments (the risk is very low with licensed, commercial tattoo facilities).
o Received blood, blood products, or solid organs from a donor who has HCV.
o Share personal items such as toothbrushes and razors with someone who has HCV.
1.7 Signs and Symptoms
Most people who were recently infected with hepatitis C do not have symptoms. About 1 in 10 has yellowing of the skin (jaundice) that gets better. Of people who get infected with hepatitis C, most develop a long-term (chronic) infection. Usually there are no symptoms. If the infection has been present for many years, the liver may be permanently scarred. This is called cirrhosis. In many cases, there may be no symptoms of the disease until has develop. The following symptoms could occur with HCV infection.
o Right upper abdomen pain.
o Abdominal swelling (due to fluid called ascites)
o Dark urine.
o Clay colour or pale stool.
o Fatigue.
o Fever.
o Itching.
o Jaundice.
o Loss of appetite.
o Nausea.
o Vomiting.
1.8 Tests
The following tests are used for the diagnosis of HCV
Blood tests are done to check for HCV.
EIA assay to detect hepatitis C antibody.
HCV RNA assays to measure virus levels (viral load).
Genetic testing is done to check for the HCV genotype. Six genotypes exist. Test results can help your doctor better choose your treatment.
Most Americans have genotype 1 infection, which is the hardest to treat.
Genotypes 2 and 3 are also common, and respond better to treatment.
The following tests are done to identify and monitor liver damage from HCV.
· Albumin level.
· Liver function tests.
· Liver biopsy can show how much damage has been done to the liver.
· Prothrombin time.
1.9 Treatment
The goals of HCV treatment are to remove the virus from the blood and reduce the risk of cirrhosis and liver cancer that can result from long-term HCV infection.
o Many patients with hepatitis C benefit from treatment with medications. The most common medications are a combination of pegylated interferon alfa and ribaviren, an anti viral medication.
o Most patients receive weekly injections of pegylated interferon alfa.
o Ribaviren is a capsule taken twice daily. Ribaviren can cause birth defects.
o Women should avoid getting pregnant during, and for 6 months after treatment.
o . Treatment is given for 24 - 48 weeks.
o Telaprevir and boceprevir are newer drugs which may be used for patients with genotype 1.
o These medications have a number of side effects, and patients must be watched closely. See: cirrhosis for information about treating more severe liver damage caused by HCV.
o Patients who develop cirrhosis or liver cancer may be candidates for a liver transplant.
o People with hepatitis C should also
· Be careful not to take vitamins, nutritional supplements, or new over-the- counter medications without first discussing it with their health care provider.
· Avoid any substances that are toxic to the liver, including alcohol. Even moderate amounts of alcohol speed up the progression of hepatitis C, and alcohol reduces the effectiveness of treatment.
· Get vaccinated against HAV and HBV.
Another treatment is to know early viral response.
1.10 Prevention
o Avoid contact with blood or blood products whenever possible. Health care workers should follow precautions when handling blood and bodily fluids.
o Do not inject illicit drugs, and especially do not share needles with anyone. Be careful when getting tattoos and body piercings.
o Sexual transmission is very low among stable, monogamous couples. A partner should be screened for hepatitis C. If the partner is negative, the current recommendations are to make no changes in sexual practices.
o People who have sex outside of a monogamous relationship should practice safer sex behavior to avoid hepatitis C as well as sexually transmitted diseases, including HIV and HBV.
Currently there is no vaccine for HCV.[11]
1.11 Aims and Objectives
The knowledge that has been learned in five year Pharm-D program that is knowledge of Pharmacology and therapeutics, Clinical Pharmacy, Hospital Pharmacy and therapeutic drug monitoring utilization is the basic aim of my clinical clerkship, and in order to implement and use this knowledge practically in the hospital at ward level setting for the rationalization of the drug therapy is the basic objective of my clinical clerkship. Besides of these mentioned other aims and objectives include the following;
· To know about the definitions, virology, epidemiology, pathogenesis, clinical features, causes, incidence and risk factors, Signs and symptom, tests, treatment and prevention steps of HC.
· To check the rationality and irrationality in the prescriptions.
· Monitoring the patient response to the current medications.
· To recognize the problems and benefits arising from the medication given to the HC patient.
· To get knowledge of drugs their class, indication, mode of action, recommended dose, dose frequency, adverse reactions and drug reactions.
· To learn dose calculation in specific patients with concurrent disease or with their age.
· Give presentations about the drugs and share information to other health care providers of the ward.
· Preparation of patient medication history charts monitoring their blood pressure and chest examination and correlate with patient conditions.
· To note patient prescription and non-prescription drugs, allergic disorders and drug interactions.
· Also to record patient compliance to their medication and guide the patient about proper use of drug.
· Give knowledge about the disease and it management to the patient to improve the self-care.
· Giving advice to the patient about the preventive strategies so to minimize the risk of getting HC.
