Anemia and Hepatitis C

-by Morris Sherman, MD, FRCPC, FACP
Department of Gastroenterology, Toronto General Hospital

What is hepatitis C?

Hepatitis is an inflammation of the liver, causing soreness and swelling. When the liver is inflamed, it cannot do a good job of ridding the body of waste products. One of the causes of hepatitis is infection with a virus. For most people, the hepatitis C virus (HCV) causes no symptoms at first, sometimes not for 10 to 30 years. However, the virus usually remains in the blood stream. In some cases, hepatitis C can lead to serious liver damage, including scarring of the liver and even liver failure.

Why do persons with hepatitis C develop anemia?

Persons with hepatitis C can become anemic for two reasons. First, ribavirin, one of the drugs used to treat hepatitis C, often causes anemia. In many cases, anemia is mild and no treatment may be required. For persons who develop severe anemia, the ribavirin dose may need to be reduced. The use of recombinant erythropoietin, a medication that treats anemia and would allow ribavirin dose to be maintained, is being investigated.

The second cause of anemia is liver cirrhosis. The complications of cirrhosis can cause the spleen to remove too many red blood cells from circulation or decrease production of red blood cells. It can also cause gastrointestinal bleeding which may lead to anemia.

What is the treatment for hepatitis C?

The recommended treatment for HCV is medication to reduce the amount of virus in the body. The goal is to achieve a “sustained viral response”, that is, the amount of virus in the body remains at a very low level for a long period of time after treatment has been completed . Interferon (or pegylated interferon) may be given alone (also called monotherapy) or in combination with ribavirin (also called combination therapy). For most persons with hepatitis C, combination therapy is more effective, but it also causes more side effects. Side effects include flu-like symptoms, depression, increased risk of infection, and anemia.

What is anemia?

Anemia is a condition in which the body has too few red blood cells. Red blood cells contain the hemoglobin that carries oxygen to all parts of your body. If you do not have enough oxygen, your organs and tissues cannot function properly. As a result, you may feel tired, weak, or dizzy. You may have shortness of breath, rapid heartbeat, and difficulty sleeping. If anemia is not treated, it can affect a person’s quality of life and ability to carry out daily activities.

How do you know if you have anemia?

The experience of anemia varies depending on the individual. In the beginning, you may not notice any symptoms. As anemia progresses, people often report feeling fatigued and weak. You may look pale and may experience other symptoms such as shortness of breath, headaches, or loss of concentration.

If you have symptoms that suggest you have anemia, tell your doctor or nurse. The only real way to know if you have anemia is to have a blood test to check your red blood cells and, specifically, your hemoglobin. Depending on your hemoglobin level, your doctor will determine if you have anemia. Normal hemoglobin levels are between 120 and 160 g/L for women and between 140 and 180 g/L for men. Not everyone experiences the symptoms of anemia at the same hemoglobin level.

Why is it important to treat anemia for persons with hepatitis C?

Sustained viral response—In order to achieve a sustained viral response (maintenance of a low level of virus long after treatment has been completed), it is important to treat with a sufficiently high dosage of interferon and ribavirin. Treating anemia allows the patient to continue the combination therapy, as planned.

Quality of life—By increasing hemoglobin levels, patients experience improved energy, activity level, and overall quality of life. Even mild anemia can result in extreme fatigue and can interfere with your ability to work, perform daily tasks, or participate in family and social activities.

How is anemia treated?

Treatment for anemia depends on correctly identifying its cause.

Increase nutrient intake—If you have too little iron, vitamin B12, or folic acid to make your red blood cells work effectively, your doctor will likely suggest that you change the foods you are eating, or take specific vitamins or iron pills.

Improve hemoglobin production—If your anemia is due to too few red blood cells, in selected cases, your physician may prescribe a medication called recombinant erythropoietin, a synthetic form of the naturally occurring hormone that stimulates red cell production

Blood transfusion—If you red cell count falls rapidly too low, you may require a blood transfusion in addition to erythropoietin.