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HEPATITIS DOCTOR HOME since October 1998

Welcome to patients with chronic viral hepatitis B or C and to their loved ones. We can cure about half

of the patients with chronic hepatitis C, including some with advanced cirrhosis and liver failure. If you

are cured, your viral level falls to undetectable during treatment and stays undetectable the rest of

your life, after you stop the medications. Some patients who are clinically cured of HCV may still

have tiny amounts of HCV-RNA, but the implications of this are not yet clear. If your HCV-RNA level

becomes detectable (>2 IU/ml) in your blood, you were not cured. If your HCV-RNA is undetectable

6 months after your last injection of interferon, you have a 97-99% chance of permanent cure. I have

only five patients out of many hundreds who turned HCV-RNA positive later than 6 months after their

last injection of interferon one year after completion of treatment. Four turned positive one year after the

last injection, and one turned positive 18 months after the last injection.

I add information to this web site as often as I can, and I want to make it the best possible resource for

patients whom are often incorrectly told that they cannot be helped. The opinions expressed here are

entirely my own, and are based on my experience in treating more than 3,000 patients with hepatitis C.

I am especially interested in developing the best treatment for patients with advanced hepatitis C

cirrhosis. We can avoid the need for transplantation for some of these patients. We can prevent

recurrent HCV in some who must be transplanted if we cure the HCV. The liver and the bone marrow

are the only two organs that can regenerate. Most patients with cirrhosis who are cured of HCV can

expect their liver damage to improve with time. Cirrhotic patients who are cured can greatly reduce their

risk of death, liver cancer and liver failure. Their platelet counts improve. Their enlarged spleens shrink

towards normal size. Patients with HCV cirrhosis who are cured of HCV can live a full life span. They

will be able to avoid death in middle age from liver disease. We ask patients with cirrhosis (F4)

or severe fibrosis (F3) to have blood tests and ultrasounds every six months. We measure their liver

damage with HCV Fibrosure yearly. About half of those with F4 fibrosis (cirrhosis) now have F2 fibrosis

since being cured of their hepatitis C. I am a board certified in internal medicine and

gastroenterology. In addition, I completed 2 years of residency in pathology at Duke

University Medical Center. I have been a physician for 30 years. I spend about 95% of my time treating

patients with chronic viral hepatitis C. I enjoy helping as many patients as possible cure this

infection.

I am very excited about the HCV protease inhibitor from Vertex Pharmaceuticals called VX-950. The

generic name is telaprevir. It is taken by mouth every 8 hours and drops the viral level by about 99.9%

in a week or so. When combined with Pegasys plus ribavirin, it dropped the HCV-RNA level to

undetectable in all 12 of 12 genotype one patients in 28 days. It is now being tested in

phase 2 clinical trials and the company hopes to initiate phase 3 trials in 2008. I expect that it will

allow us to double our success in previously untreated genotype one patients. I hope that it will

especially help with our African American patients who have less success with current treatments.

The only concern is that some patients had a severe rash. The phase 3 studies will demonstrate

how much of an obstacle the rash will be for patients.

My Louisville, KY office: 1009A Dupont Square North, Louisville KY 40207
502-894-9950

If you have previously failed or could not tolerate standard antiviral therapy, you should consider

individualized therapy. Some patients need to start with lower doses of interferon. Some need to take

higher doses. A few respond to one brand of interferon but not another. Many patients need longer

duration of treatment than the standard 48 weeks. I measure the percent fall in HCV-RNA after 2-4

weeks of treatment, and calculate the minimal length of treatment. If the viral level is not falling

quickly enough, (more than 90% per month), the treatment must be changed to obtain success.

The simplest change is to raise the dose of interferon, usually to 150-200% of the normal dose, for

example 270 or 360 mcg Pegasys per week. Many insurance companies will not allow a higher dose.

If higher doses of interferon do not work, switching to a different type of interferon will sometimes

cause a response. Some patients who do not respond to one type are able to respond to another.

We use Pegasys first because patients report less side effects than with PegIntron. If there is no

response, Infergen 15 mcg daily produces a response in 20% and if that is ineffective, PegIntron

will obtain a response in another 5% of patients. Other physicians may start with PegIntron,

and most doctors do not go to the trouble of using more than one or two types of interferon before

Ribavirin does not add much to the fall in the viral level. It is the interferon that is the muscle drug.

Ribavirin does not transform a nonresponder into a responder. What ribavirin does wonderfully is

greatly reduce the chance of viral breakthrough (HCV-RNA falls with treatment, but then rises even

though treatment is continuing) or relapse in patients who respond to interferon. A relapser is a patient

who became undetectable for HCV-RNA on her previous treatment, but the virus came back when the

treatment ended. A relapser is a proven responder and will almost always respond again when retreated.

Relapsers must be treated longer and sometimes stronger to prevent a second or third relapse.

Cirrhotic genotype 1 patients are classic relapsers. The doctors treat for 48 weeks and half of the

responding cirrhotic patients relapse. It is very frustrating for the patient and physician to relapse.

I aim for 2 years of treatment for genotype one cirrhotic patients. By treating longer, the immune

system has more time to remove 100.000% of the virus from pockets of scar tissue in the cirrhotic

800 mg of ribavirin daily is optimal for easy to treat genotype 2 or 3 infected patients. In fact, 400 mg

daily was as good as 800 mg daily in an European study of genotype 2 or 3 patients presented at DDW

Chicago May 2005. Genotype 1 patients do better with 1,000 or 1,200 mg of ribavirin daily. Even higher

doses are being used in very heavy patients. The Roche brand of ribavirin (Copegus) competes with

Rebetol. Three Rivers pharmacy sells generic ribavirin called Ribasphere. They also sell RibaPak which

lowers the number of pills and improves compliance. This is lowering the cost of treatment for

The CDC now recommends that Americans be tested for HIV routinely. They should have also

recommended that all American middle aged persons be tested for HCV and HBV. Their data indicate

that 7.1% of men and 2.3% of women between 45 and 49 are infected with HCV. Identify infected

persons and offer treatment is the logical strategy. We can lower the death rate from HCV if we are

aggressive in identifying infected patients. Cure the curable patients and lower the death toll.

Five million Americansare infected and we can cure TWO MILLION TODAY with currently available

medicine. We have good drugs now and patients do not have to wait like they did in the 1990's for

About half of Americans with HCV have genotype one and high viral load. Standard treatments only

work in about 30% of this large group. The success rate of treatment is especially poor in African

American patients. Many patients fail standard treatments and individualized treatment can help some.

Trying different medications at different doses helps some get cured. The prediction from the Manns

study in 2001 that higher doses (>10.6 mcg/kg) of ribavirin would give 48% sustained viral response rates

in genotype one patients was refuted by the huge Jacobsen trial reported at AASLD, November 2005 in

San Francisco. Only 34% of genotype one patients given 1,000 to 1,400 mg ribavirin daily achieved

sustained response compared to 29% with the 800 mg ribavirin daily. Very heavy patients and African

American patients were the subgroups that particularly benefited from the higher doses of ribavirin.

I am an advocate for patients infected with HCV. The medical insurance companies place too many

obstacles to block patients from going on or staying on the medications. I have seen many curable

patients fail because of this. Medicaid cancels Rx Even though treatment is now less expensive and more

effective, the insurance companies are shifting more of the cost of treatment to patients. Stage 3 and

stage 4 HCV liver disease is life threatening and should be covered like cancer treatment, coronary

artery bypass surgery and kidney dialysis. HCV cirrhosis is just as deadly as these other life-threatening

diseases. Insurance companies should not discriminate against treatment of HCV, just as they are

I can give information, but cannot practice medicine over the internet. Patients with HCV should

consult a knowledgeable medical provider who treats large numbers of HCV infected patients

You can find more HCV information in the links below and the links on the left side of this page.