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Does everyone who gets treated for hepatitis C have side effects during treatment?

Does everyone who gets treated for hepatitis C have side effects during treatment? Treatment of chronic hepatitis C in 2013 involves 2 to 3 medications. The currently used treatment regimen always include the combination of peginterferon (Pegasys or PegIntron), given as a weekly injection, and ribavirin, taken as pills twice a day. Most patients who have the strain of hepatitis C known as genotype 1 now take "triple therapy" which includes the addition of a third medication, either telaprevir (Incivek) or boceprevir (Victrelis). Side effects are common with peginterferon and ribavirin and tend to be more pronounced with triple therapy. It is better to be prepared for the worst when initiating treatment for hepatitis C. You need to know which side effects can be serious, so that you can report them immediately to your medical provider. Community support, either through an organized peer group or the help of family members, friends or co-workers, when combined with the assistance of your medical provider, can help you get through hepatitis C therapy successfully.

What are the common side effects of hepatitis C treatment?

  • Flu-Like Symptoms: Peginterferon frequently causes flu-like symptoms, including fever, chills, aching muscles and joints, fatigue, or a general feeling of being rundown.  These symptoms are usually worse a day or two after the peginterferon injection. The symptoms usually get better over time with each subsequent injection.  Acetaminophen (Tylenol) can make the symptoms better, but you should not take more than 2,000 mg per day (half of the recommended maximum dosage listed on the bottle).  Consider taking acetaminophen 30 to 60 minutes prior to peginterferon injections.  Try to spread out activities during the day, allowing for daily rest periods or plan for lighter activities on days following injections.  Take a hot bath or use a warm compress on the areas that hurt.  Time your injections at night or prior to a weekend, to minimize symptoms that may develop during the day or while at work.  Let your provider know if you have a fever over 101°F for more than a day or if you have any fever that is over 102°F.
  • Headache:  Use acetaminophen as needed with permission from your medical provider.  Get plenty of rest.  Drink a lot of water, juices, and non-caffeinated beverages—at least 8 to 10 glasses per day.  Avoid bright lights and loud noises if they bother you.  For persistent or severe headaches, seek help from your medical provider.
  • Injection Site Reactions: Peginterferon injection almost always causes some redness at the site of the injection and the injection site should be rotated week to week to a different spot on the abdomen or thigh.  If the injection site is itchy or bothering you, an over-the-counter topical corticosteroid, like hydrocortisone 0.1%, can be used for relief. 
  • Rash: Telaprevir can often cause a rash. Because this can sometimes become a severe life-threatening rash, any rash on telaprevir should be taken very seriously and reported to your medical provider right away. Most of the time, the rash with telaprevir is mild and not severe. Rashes usually occur within the first month of treatment with telaprevir and will go away within a month or so of stopping telaprevir. Sometimes ribavirin can also cause a skin rash that is often more widespread over the trunk and back. For mild rashes, oral anti-itch medication, like diphenhydramine (Benadryl) or hydroxyzine (Vistaril), or a topical corticosteroid cream can be used for relief.  Let your medical provider know if you develop a rash and it is more urgent if you also have any of the following danger signs: skin tenderness, peeling skin, fever or involvement of the mucous membranes (the lining of your eyes, mouth, or nose).
  • Dry or Itchy Skin:  To help prevent getting really dry and itchy skin while on treatment, it is important to keep well hydrated and drink at least 64 ounces (8 tall glasses) of water or other non-caffeinated, non-alcoholic beverage a day.  Use a moisturizing unscented soap. Avoid very hot showers, which can dry the skin and worsen the itching.  Apply a moisturizing cream or petroleum jelly right after showering before drying off with a towel; this can help trap some of the moisture in your skin and lessen the itching.  Limit sun exposure and use sunscreen.  Wash clothes in mild unscented detergent and do not use fabric softener.
  • Stomach Upset: Loss of appetite, nausea, and sometimes even vomiting can occur with treatment. Monitor your weight.  Take your ribavirin with food.  If stomach upset becomes a problem, you can try eating more frequent, smaller, snack-size meals throughout the day and pack snacks with you when you are away from the house.  Make a smoothie or drink a liquid supplement (such as Ensure or Carnation Instant Breakfast) if you cannot eat a full meal. Avoid foods that are spicy or strong smelling that might trigger you getting sick.  It may help to eat non-acidic fruit like bananas or applesauce or bland foods, like crackers or toast. If you are not hungry, try to eat whatever sounds best.  Don’t lie down right after eating.  Let your medical provider know if you have a lot of nausea or are vomiting, because they can prescribe something, such as anti-nausea or antacid medication, to help lessen your symptoms.
  • Hair Loss:  Some people notice more hair falls out when they comb or shower while on treatment for hepatitis C.  Generally this hair thinning is temporary and eventually goes back to normal when you stop treatment.  To minimize hair loss while on treatment, use a wide-toothed comb, try to sparingly comb your hair, and avoid harsh hair products or aggressive styling .
  • Depression, Anxiety, Irritability, and Suicidal Thoughts: About 1 in every 4 to 5 people on peginterferon become depressed.  Changes in mood can occur any time while on treatment, but often does not occur until 1 to 2 months into therapy.  Sometimes anxiety can develop or worsen. More commonly, the treatment can cause you to feel more “emotional” and prone to anger or crying. This irritability is generally manageable by just being aware that you are feeling this way because of a medication side effect, but sometimes if it is severe or your mood remains very low you may need psychiatric medication to help.   Exercise, such as regular walking or yoga, can help some people improve their mood.  Schedule activities that you enjoy.  Hepatitis C support groups can also be helpful.  Avoid alcohol or other recreational drugs.  Rarely, suicidal thoughts may occur.  If this happens, you must seek help right away with a medical provider. Rarely, the dose of peginterferon may need to be reduced or stopped altogether to help you feel better, but do not make any changes without the knowledge of your medical provider.
  • Poor Sleep: Some people have trouble falling and/or staying asleep while on treatment; this is a common problem.  Lack of sleep can make other side effects, like fatigue, irritability, depression, and headaches, a lot worse, whereas getting enough sleep can improve side effects.  Practice good sleep hygiene, such as going to sleep at a regular time every night, not taking naps, and not watching television or reading in bed.  If you can, try to get some light to moderate exercise, such as walking outside every day, but don’t do heavy exercise right before bed.  Avoid caffeinated and alcoholic beverages and limit your fluid intake during the evening.  If you are feeling tired, but sleeping well, let you medical provider know, so they can look for other causes, such as anemia or low thyroid function.  Sometimes, over-the-counter diphenhydramine (Benadryl) can help you sleep, but do not take more than 1 to 2 tablets per night and let your medical provider know if you are taking this.
  • Diarrhea: Drink plenty of clear non-caffeinated, non-alcoholic beverages.  Consume bland foods, such as rice and toast, and those high in potassium, like bananas and potatoes.  Avoid spicy, fried or greasy food.  Eat plenty of soluble fiber—which is present in foods like hot cereal, white toast, rice and bananas—or take fiber (psyllium) supplements.  Avoid sugar-free candy with sorbitol, caffeine, and dairy products.  Notify your medical provider if the diarrhea is severe, lasts for more than a couple of days, is associated with significant weight loss or fever, or has blood in it.
  • Anal Itching, Burning or Discomfort: This adverse effect has been associated with telaprevir. Do not rub or scratch your anal region as this may make the symptoms worse.  Consider using over-the-counter topical hydrocortisone cream or medicated pads, like Tucks.  You can also apply a barrier cream like zinc oxide or Desitin.  If this does not help, your medical provider may prescribe a stronger cream or ointment, or give you an oral anti-itch or antacid medication to help. If the symptoms are severe, a topical anesthetic can be used.  Citrus products and caffeinated beverages should be avoided as they can aggravate the symptoms.  Avoid soap in the area, just rinse with water and pat dry.  Wear loose, rather than tight fitting clothes.  Use hot or cold compresses or sit in a basin or tub of warm water as often as you need for relief.  These symptoms will go away after completion of telaprevir.

What are some less common side effects with hepatitis C treatment?

  • Vision Changes:  Peginterferon can result in damage to your eye and if there is a sudden change in vision during treatment, you should consult with your medical provider immediately. 
  • Cough and Shortness of Breath:  The cough associated with ribavirin is usually dry and often will not resolve until therapy is stopped.  It can be annoying, but is usually tolerable.  Drink plenty of fluids and use cough drops as necessary.  Use a humidifier, if you have one.  If you become short of breath, develop a fever, or cough up phlegm, it is important to see your medical provider to find out if you have pneumonia or severe anemia. 
  • Mouth Ulcers: Do not use mouthwash that has alcohol in it and avoid toothpaste with sodium lauryl sulfate.  You should also avoid eating foods that are acidic, spicy, salty, or crunchy. Instead, eat soft or pureed foods; drink using a straw.  You can suck on ice chips or eat a frozen treat to ease the pain.  If the ulcers are very painful, your medical provider may be able to give you a medicine to numb your mouth or treat the ulcers.
  • Change in Taste: Drink plenty of water.  Use utensils not made of metal and avoid canned foods.  Flavor your food with mustard, vinegar, lemon, lime or orange juice to add tartness, which can help overcome the bitter taste.  Cold and crisp foods, such as apples, often will be more tasty than hot, softer foods.  Drink a smoothie or frozen fruit bar if you are unable to tolerate a meal. Suck on lemon drops, zinc lozenges, or mints or chew gum to help get rid of bad tastes after eating.  Your sense of taste will return to normal after completing treatment. 

What common laboratory abnormalities can occur during hepatitis C treatment?

It is pretty common that low blood cell counts develop during treatment. If this happens to you, it may become necessary to lower medication dosages, hold treatment temporarily, or stop treatment completely.

  • Anemia:  Ribavirin can damage the oxygen-carrying red blood cells, causing them to be destroyed faster than they are produced.  Having a low red blood cell count is called anemia, which can cause shortness of breath, fatigue, fast heart rate, and pale skin.  Anemia can usually be managed by lowering your ribavirin dose, but you should only do this under the guidance of your medical provider.  The anemia can be severe, especially in patients with underlying kidney disease.   The addition of telaprevir or boceprevir as a third drug in the treatment regimen usually increases the frequency and severity of anemia seen with hepatitis C treatment.  More severe or persistent anemia may require the addition of epoietin alfa (Epogen or Procrit) or darbepoietin alfa (Aranesp), which are injectable medications that boost your red blood cell production. Rarely, severe anemia may require a transfusion. Your medical provider will be following your blood counts closely, especially during the first several months of therapy.
  • Neutropenia:  At some time during the course of treatment, almost everyone on peginterferon develops a low neutrophil count, a type of white blood cell that helps fight infection.  About 20% of patients on peginterferon develop neutropenia that is severe enough that it may lead your medical provider to lower your peginterferon dose.  In some circumstances, your medical provider may give you an injectable medication filgrastim (Neupogen) or pegfilgrastim (Neulasta) that will help boost your neutrophil count, although it is not clear that this is necessary to reduce the risk of infection.
  • Low Platelets:  Platelets play a critical role in helping you clot your blood when bleeding. Although peginterferon causes a 10 to 50% fall in the platelet count, it rarely causes significant problems.  If, however, you have cirrhosis and already have a low platelet count prior to starting therapy, your medical provider will need to closely follow your platelet count during treatment.
  • Abnormal Thyroid Function: Sometimes your thyroid gland can be affected during the course of treatment.  Hypothyroidism or low thyroid function can be managed with the use of thyroid hormone pills.  Treatment may need to be stopped if you develop hyperthyroidism (or abnormally high thyroid function) and have symptoms that cannot be well controlled. Symptoms of hyperthyroidism include diarrhea, feeling shaky, weak, hot, sweaty, anxious, and losing weight more than you might expect on treatment.
  • Elevated Uric Acid:  Both peginterferon and telaprevir can increase the levels of uric acid in the blood.  In some people this rise in uric acid may lead to a gout attack, especially if you already have a diagnosis of gout prior to starting hepatitis C treatment.

Is it possible to have a baby while on hepatitis C treatment?

Medications used in the treatment of hepatitis C may cause serious birth defects and thus women should not become pregnant while receiving treatment and for 6 months thereafter. The medical provider usually will perform multiple pregnancy tests to confirm that a woman has not become pregnant during treatment. Women should also avoid breastfeeding during treatment and for 6 months after the last treatment dose. Men being treated should avoid getting a woman pregnant during this same time period (on treatment and 6 months thereafter). You must use at least two methods of contraception to prevent getting pregnant, for example: an intrauterine device (IUD) and condoms. If you or your partner gets pregnant during hepatitis C treatment, let your medical provider know immediately.


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