Patients undergoing treatment for hepatitis C require frequent monitoring in order to ensure that the following parameters are well managed:
Figure 3-15: The RGT Algorithm
Genotype test - should be made to determine the duration of therapy, dose of ribavirin, and likelihood of a sustained virological response. Occasionally, a person may be infected by virus of more than one genotype. If mixed infection includes a genotype more resistant to therapy (e.g. genotype 1 or 4), then treatment should be based upon that genotype.
PCR (polymerase chain reaction) test – detects the presence of viral RNA in a blood sample.
Two tests are available:
Two further qualitative PCR tests are run at the end of treatment and at the end of the follow up period (6 months after the end of treatment). The absence of virus at the end of treatment follow up determines whether the patient has had a sustained virological response (SVR). This can be considered a cure, since relapses after this point are very rare (1%).
Liver enzyme testing (ALT, AST)
The correlation between the degree of ALT elevation and the severity of underlying liver disease is poor. Patients with normal ALT levels may actually have significant liver damage. (Bacon, 2002) Pre-treatment ALT level is not a reliable marker of disease severity (eg, fibrosis) and ALT levels can vary over the course of time in HCV-infected individuals.
Liver biopsy – is used to identify disease severity and progression. Because biopsy is invasive and carries a small risk of complication, some physicians are looking to non-invasive biochemical markers of fibrosis which can be measured in the blood. In sum, liver biopsy should no longer be considered mandatory for starting treatment if a solid case for starting treatment can be built without it. (French consensus statement, 2002)
Other tests which are recommended to ensure the patient is not adversely affected by the treatment include:
Blood levels – regular monitoring of haemoglobin, neutrophils and platelets with appropriate reduction of ribavirin and interferon medication respectively.
Psychiatric monitoring – patients should be probed to determine any change, notice should be taken if the patient reports mood swings and increased aggression. Dose modification of interferon and use of anti-depressants can be prescribed but patient should be sent for evaluation if psychological problems worsen. In cases of severe depression/suicidal tendencies, interferon dose should be stopped and the patient referred to a psychiatrist. The need for careful monitoring of the patient’s psychiatric condition emphasizes the importance of regular meetings with the patient throughout treatment.
Thyroid function – TSH or T4 tests should be regularly conducted to determine any change in thyroid function. Patients may also complain of tremors or weight fluctuations which may indicate changes in the thyroid.