Hepatitis C

Nutrition, supportive care and complementary therapies

Nutritional interventions

Dietary interventions

Protein energy malnutrition is common in all patients with chronic liver disease and can lead to weight loss. Chronic hepatitis C infection increases basal metabolic rate in non-cirrhotic patients.¹⁶² Malnutrition (either under- or overweight) negatively affects nutritional status, quality of life and survival. Nutritional assessment to identify patients at risk and provision of nutritional support (enteral and parenteral) to improve clinical outcome should play an important role in patient care.¹⁸⁷ 2- 4

Weight loss is commonly reported in patients on antiviral therapy.^{150, 151, 163} This is possibly a result of other side effects, such as fatigue and depression, which may have a negative impact on appetite.^{150, 151} 2- 3

Good practice points

A systematic review of 11 RCTs found no conclusive evidence to support any benefit of branched chain amino acids (BCCA) in patients with cirrhosis and hepatic encephalopathy.¹⁸⁸ It was unclear how many of the patients included in the study were HCV positive. BCCA improve serum albumin levels in the compensated stage of cirrhosis in patients with a branch chain tyrosine ratio (BTR) <4 and serum albumin level between 35-39 g/l.^{189, 190} The methodology used in these studies gave little consideration to confounding variables. 1++ 1-

Coffee may have a protective effect against the development of hepatocellular carcinoma in patients with liver disease when consumed in quantities of three or more cups per day. It is unclear which compound in coffee causes the effect.^{191, 192} 2+

Vitamins and minerals

There is little evidence that individual vitamins and minerals may influence the natural history of CHC.

Zinc supplementation of 34 mg/day may have some beneficial effect on sustained viral response in patients taking interferon therapy; with genotype 1b; with viral load lower than 5x10⁵ copies/ml.¹⁹³ 2-

Vitamin K² may be beneficial in the prevention of development of HCC in patients with hepatitis C.¹⁹⁴ 2-

Vitamin E supplementation had no beneficial effect in patients taking pegylated interferon and ribavirin. It does not appear to prevent ribavirin haemolysis or enhance virological clearance.¹⁹⁵ 1-

Iron restricted to <7 mg/day in conjunction with a controlled calorie intake of 30 Kcals/kg, protein intake of 1.1-1.2 g/kg, and fat at 15% of dietary intake, reduces aminotransferase levels.¹⁹⁶ 4

Vitamin C supplementation of 600 mg/day is not beneficial in the prevention of retinopathy associated with interferon therapy.¹⁶⁵ 1-

Good practice points

Overweight

Studies have identified BMI>25 as being associated with hepatic steatosis, which leads to more severe fibrosis.^{88, 198} Liver fibrosis, steatosis and ALT level decrease with supervised weight loss programmes of diet and regular exercise, aiming at 0.5 kg weight loss weekly.¹⁹⁹ 2+ 3

Good practice points

Specialist nurse interventions

Specialist nursing support is key to maintaining adherence to treatment in patients with neuropsychiatric conditions.²⁰⁰ Specialist hepatology nursing has a significant role to play in helping patients to attain and maintain SVR.²⁰¹ 2-

Good practice points

Psychosocial interventions

Two studies on psychological interventions for patients with hepatitis C showed no evidence for a benefit. One small non-randomised trial showed some benefit, but the other, an RCT which tested individually tailored interventions, showed no difference in outcome from standard care.^{202, 203} 2- 1+

Exercise

Light to moderate exercise programmes have been recommended for patients receiving treatment for hepatitis C.¹⁵⁰ A small cohort study shows that patients on antiviral therapy have a reduced exercise tolerance.²⁰⁴ 4 2-

Complementary therapies

Two meta-analyses have concluded that there is no evidence to support the use of complementary or alternative medicines in the treatment of patients with hepatitis C.^{205, 206} 1++

None of the trials identified ran for a long enough period to show the long term safety or harm of herbal remedies.

No trials were found which specifically examined the use of silymarin (milk thistle) in patients with chronic hepatitis C.

Good practice points

Palliative care

No evidence was identified looking specifically at palliative care for patients with HCV.