Module 7: Managing side effects and optimising treatment strategies - section 1

In this document:

Side effects and implications for treatment

Activity: Small group work and supporting presentation
Section Time: Approximately 35 minutes

The purpose of this section is to help participants develop a basic awareness of the side effects associated with antiviral therapy and how these can be managed to improve outcomes.

Introduce this section by showing Slide 7.2 (Side effects and treatment disruption) outlining how treatment side effects are common and can undermine treatment adherence and so, treatment effectiveness:

Ask small groups to form and consider the following questions shown on Slide 7.3 (Group work) and record their answers on flip chart paper:

After 5 minutes ask each group in turn to feedback their understanding and encourage discussion to support learning. Slide 7.4 (Minor side effects) and Slide 7.5 (Major side effects) can be referenced to support feedback:

Once feedback on both minor and major side effects has been received and processed, establish groups for small group activity. Provide Handout 7.1 Hepatitis C treatment side effect tips (worksheet) to all participants and ask them to review, discuss and complete the worksheet.

Allow 15 minutes for this activity then reconvene the large group and allow 5 minutes for participants to offer areas that might require further discussion and clarification. Provide Handout 7.2 Hepatitis C treatment side effect tips (answer sheet) to participants to aid clarification.

Supporting content:

The side effects from hepatitis C treatment, typically interferon (pegylated or standard) with or without ribavirin can be uncomfortable, sometimes debilitating, and, rarely, life-threatening. The toxicity of antiviral drugs present significant challenges to those receiving antiviral therapy. Not everyone experiences side effects but it is rare to have none at all, particularly at the beginning of treatment. In general, side effects are worse for people who have more serious liver damage, and/or are HIV/HCV co-infected.

With the right planning and support, the impact of side effects can be reduced and treatment adherence and outcomes improved. Discussions with the health care provider before starting HCV treatment can establish plans on how side effects can be treated. Support from other people with HCV, friends, and family before and during HCV treatment can play a key role in coping with this difficult aspect of treatment. Additionally, the negative impacts of treatment experienced by some people, particularly emotional changes, can place additional demands on family members and carers who should have access to support networks.

Common side effects

Depression, anxiety, and other features such as despair, irritability, mild cognitive impairment and mood swings are commonly reported side effects of interferon which disappear with cessation of such treatment. However, physical side effects disappear sooner than mental health related ones which can linger for several months post treatment. Severe depression and psychotic disorders are a rare complication of treatment and usually resolved with discontinuation of treatment. Access to mental health care and psychiatric consultations before and during HCV treatment is essential so that risk of psychiatric side effects can be identified and treated promptly.

Flu-like symptoms (fever, aches and pains, headache, chills, nausea) are common side effects of interferon. They usually appear 2 to 24 hours after an injection, and tend to lessen over time. Taking PEG-IFN in the evening helps, as does a low dose of paracetamol, drinking plenty of water and anti-nausea medication.

Weight loss often occurs during HCV treatment, because people may lose their appetite, have diarrhoea, and/or feel nauseated. Medical advice, anti-diarrhoea medication, and diet advice (eating frequent, smaller, lighter meals throughout the day to boost energy levels) can help.

Fatigue is also common. Napping and regular but light exercise, when possible, can help. Doctors may prescribe methylphenidate or bupropion to help with extreme tiredness.

Anaemia (an abnormally low red blood cell count) is a side effect of ribavirin. Interferon can also cause anaemia because it suppresses the growth of bone marrow, where blood cells develop. Anaemia related fatigue is a significant issue for many receiving treatment and is a common cause of premature treatment exit – many find that day to day living is significantly compromised by feelings of extreme lethargy, breathlessness, palpitations and headaches and tinnitus. Sore mouth and gums and brittle nails may also cause problems. Anaemia can be treated by lowering ribavirin dose but this may compromise HCV treatment. It can be treated with weekly subcutaneous injections of epoetin-alpha (EPO), a red blood cell growth factor, which improves fatigue and helps people to stay on ribavirin. Severe anaemia is treated by blood transfusions.

Neutropenia is an abnormally low amount of neutrophils, a white blood cell that fights bacterial infections that can be caused by interferon. The risk of developing bacterial infections is increased in people with neutropenia. If the neutrophil count drops during HCV treatment, the dose of PEG- IFN is reduced, or neutropenia is treated with injections of white cell growth factor called filgrastim.

Thrombocytopenia is a low platelet count, and can be caused by serious liver damage (because the hormone that stimulates platelet production is made in the liver). It can also be caused by pegylated interferon. Thrombocytes or platelets stop bleeding by clotting blood and can, rarely, have life-threatening consequences such as bleeding inside of the brain. If severe thrombocytopenia develops, HCV treatment is usually stopped.

HIV-positive people with a low CD4 count may have low white and/or red blood cell counts. Regular monitoring of white and red blood cell during HCV treatment is especially important for people with co-infection, since there is a greater risk for anaemia, neutropenia and thrombocytopenia requiring specific variations in treatment regime.

Rash, dry and itchy skin can be caused by HCV treatment. It tends to be mild but may require support from health care professional or specialists if it becomes serious. Dry mouth can be caused by interferon and this can cause dental and gum problems. Maintaining good dental hygiene and regular dental check-ups can help.

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