Hepatitis C - The Silent Killer
Can Medical Cannabis Help?

Jay R. Cavanaugh, PhD

Hepatitis C (HCV) is a blood borne pathogen that presently infects some four to eight million Americans making it the leading blood borne virus in America. HCV is the primary cause of liver cancer and cirrhosis and kills over 10,000 Americans each year. Hepatitis C is the leading factor in patients who require liver transplant. Some 80% of those who contract HCV will go on to develop chronic infection and 20% of these will develop cirrhosis, liver cancer, or liver failure. A slim 20% of those infected will eliminate the virus from their body on their own.

Patients can contract Hepatitis C from using shared needles, accidental needle stick injuries, blood transfusions (prior to 1990), and to a minor degree from unprotected sex. HCV can be transmitted from an infected tattoo needle, dental instruments, or tools used in commercial nail care. Anything that assists the transfer of HCV infected blood from one person to another can be a vector. The blood of a patient with HCV can be highly contagious and precautions should be taken to not come in contact with it.

Hepatitis C usually produces no early symptoms. The disease can go unrecognized for decades. This is why HCV is termed a "silent killer". During the decades of quiescence the virus can continue to slowly destroy liver cells without the patient having any idea this is happening. The following groups are considered "high risk" and should be tested for the virus:

1. IV drug users who have shared needles
2. Sexual partners of HCV patients
3. Family members of HCV patients
4. Individuals receiving a blood transfusion prior to 1990
5. Patients who undergo dialysis
6. Individuals with tattoos or who have their nails frequently done
7. Individuals who have suffered a needle stick incident
8. Patients who have been diagnosed with any liver disease

Symptoms:

While patients are generally unaware of HCV infection for many years, some 80% may eventually develop symptoms which can include:

1. Fatigue and malaise
2. Loss of appetite
3. Weight loss
4. Jaundice
5. Joint pain and headache
6. Fluid retention in the abdomen (ascites)
7. Nausea and vomiting
8. Itching

Diagnosis:

Diagnosis begins with a simple history and blood test. The history looks at risk factors and symptoms. The blood test is generally to measure both liver enzymes (produced when the liver is damaged) and to detect antibodies to the Hepatitis C virus and/or to quantify the amount of virus present in the blood stream. The amount of virus is called the "titer" and is determined using the polymerase chain reaction (PCR) with HCV "primers". Additional blood tests can determine the specific strain of virus present (some strains are more pathogenic than others). A physical examination will be conducted that includes probing the liver for enlargement and looking for other possible factors such as swelling in the legs and feet and jaundice.

Prior to the initiation of treatment, it is common practice to conduct additional tests to more closely ascertain the status of the liver and the need for treatment. A liver scan using radioactive isotopes and X-ray can highlight liver structures and blood flow. A CAT scan may be conducted to look for tumors or blockage. The definitive diagnostic procedure is a liver biopsy where small samples of the liver are extracted through an office surgical procedure and examined for pathology. A liver biopsy taken from different quadrants of the liver can reveal hepatocarcinoma (liver cancer), fatty deposits, and cirrhosis (scarring).

Why is the liver important?

The liver is the largest internal organ. It is within the liver that medications and toxins are neutralized, metabolized, and eliminated (with the help of the kidneys). The liver is the site of sugar storage (glycogen) and plays a vital role in maintaining normal blood sugar along with the pancreas. The body’s fluid balance and blood clotting are largely controlled by the liver as is the processing of proteins. Bile produced in the liver aides in the digestion of food. Most noticeable is the role of the liver in energy production which is why fatigue is so common in liver disease.

Treatment for Hepatitis C:

Current therapy focuses on the subcutaneous administration of a combination of Interferon alpha (an immunomodulator) and the anti-viral drug Ribavirin. Depending upon the type of Interferon used, dosing can be one to three times a week for six to 18 months. Approximately 50% of those treated respond although it is not yet known how long the response might last. Combination drug therapy is usually not attempted when there is no sign of liver damage as determined by histopathology following biopsy. Drug therapy is also contraindicated when patients have long standing problems with depression or heart disease. The major side effects of the therapy include flu like symptoms, joint pain, nausea, anemia and depression. The decision to undergo combination therapy is a very serious one and should be done only under the supervision of a qualified and experienced physician. HCV patients with liver impairment must avoid hepatotoxins, particularly alcohol and acetaminophen (Tylenol).

Alcohol is a key toxin that damages the liver. Normal healthy adults are advised to drink no more than two drinks a day for men and one for women. With liver disease that recommendation drops to zero. Yet, many in the general population and the HCV population are heavy drinkers. Cannabis can be an effective harm reduction agent for those with alcohol problems along with therapy and self help.

Long term Complications of Hepatitis C:

Cirrhosis - As liver cells are destroyed by virally induced inflammation, they can be replaced by scar tissue (hence the name) which does not function to conduct normal liver functions. Cirrhosis is chronic and progressive. Cirrhosis occurs in approximately 20% of all HCV cases and may lead to cancer. The course of cirrhosis is variable but usually includes fluid build up in the abdomen (ascites), portal hypertension, and esophageal varices (swollen blood vessels). Treatment is limited to alleviating symptoms. Fluid may be periodically drained and medicines provided to reduce hypertension and fluid imbalances. Cirrhosis can cause uncontrolled bleeding, coma, and death.

Hepatocellular carcinoma (liver cancer) - Constant cell death and division caused by HCV can lead to tumors in 1-5% of all patients. Liver cancer is curable only in its earliest stages if it is contained within the liver in an area approachable by surgery. In other cases various treatments can be used including cryotherapy (freezing) and ethanol ablation. Chemotherapy, at present, is not usually effective with liver tumor. Liver cancer is generally terminal with treatment limited to symptomatic relief and improving the quality and length of life.

Liver failure and transplantation - As HCV destroys liver tissue; liver function can be increasingly compromised leading to failure. As the liver fails toxins can circulate that harm other organs and effect perception and behavior. Medications are not metabolized normally and have an increased risk of side effects and adverse reaction. Essential clotting factors may not be produced leading to uncontrolled internal bleeding. Complete failure results in coma and death. Patients with cirrhosis, cancer, and/or liver failure can sometimes be helped by a liver transplant. Hard to come by, transplants are usually restricted to those cases where they may materially help. Patients who continue to abuse alcohol or drugs are often excluded from transplant waiting lists as are those whose cancer has spread beyond the liver. Others excluded are surgical risks (usually those with cardiac disease) and those with compromised immune systems. Patients survive transplantation in nearly 80% of trials although continued use of immunosuppressants is needed.

Can medical cannabis help?

The short answer is yes. The primary role of cannabis is to stimulate appetite, reduce nausea and vomiting, and treat joint pain. This role is applicable to HCV patients undergoing chemotherapy, those with cancer or cirrhosis, and those with joint pain and headache. Cannabis is far less toxic than other medications that might be prescribed for these conditions and where liver impairment is concerned, it is vital to avoid toxicity. Cannabis may help alleviate the depression often produced by chronic illness and by combination drug therapy. Additionally, cannabis based food products may provide needed extra nutrition without taxing the liver. Using cannabis in place of alcohol is an established harm reduction technique particularly important when liver disease is present.

Perhaps more important but still unknown is the possibility that some of the chemical components of cannabis (the Cannabinoids) may actually reduce liver inflammation and slow the progression of both cirrhosis and Hepatocellular carcinoma. The cannabinoids have been shown to be powerful anti-inflammatories and anti-oxidants. They have also been shown to have anti-neoplastic activity, at least in gliomas (a form of brain cancer). Cannabinoids both slow programmed cell death (apoptosis) in normal cells while accelerating apoptosis in cancer cells.

Since cannabis is nontoxic it might as well be tried, particularly in patients who have chronic progressive disease that is likely to result in death. It is important to point out that whole cannabis (whether smoked, vaporized, elixir, or in food products) is preferable to Marinol. The prescription drug Marinol contains only one cannabinoid (THC) and lacks the other healing properties of the whole herb and its extracts. Dosing is up to the physician and patient. Usually patients "self-titrate" or use only what they feel they need for symptomatic relief. This may be a mistake as the protective effects of cannabis are best achieved with a steady state minimal blood level of Cannabinoids. It is recommended that a base line level of Cannabinoids be maintained with regular doses of oral cannabis products and the smoked or vaporized form of cannabis used for acute symptomatic relief.

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