What to Expect After Hepatitis C Treatment
So you’ve completed treatment for Hepatitis C (HCV). If you can make it through the next 12 weeks without the virus being detected in your body, you’ll achieve what’s called a sustained virologic response, or SVR. That’s a fancy way of saying (drumroll) you’re cured! “This virus will not come back,” says Norah A. Terrault, M.D., chief of gastroenterology and hepatology at the Keck School of Medicine of USC in Los Angeles. “It’s not like it’s in remission, it truly is gone.” (You're not immune though, so you still need to be smart about prevention.) What happens next? Check out these answers to all your post-HCV questions.
I'm Cured of Hepatitis C. Now What?
OK, big sigh of relief. Now, a few housekeeping items to address. These three should top your list:
- Figure out follow-up care. The amount of fibrosis, or scarring, of your liver from HCV will determine the kind of care you’ll need.
- Get re-tested. Your liver tests should now be normal, otherwise you might have a different problem, says Robert Brown, M.D., director of the Center for Liver Disease and Transplantation at New York-Presbyterian Hospital and Weill Cornell Medicine in New York City.
- Be vigilant about your health. Without a liver, you can’t survive for long. Make smart decisions to prevent damage and re-infection.
I'm Not Cured of Hepatitis C. Now What?
Let’s address this right away, because while almost everyone achieves SVR with direct-acting antivirals (DAAs), a very small percentage (1% to 3% or so) of people do not. For instance, you might have had to stop treatment due to adherence problems or other reasons.
What happens then? You’ll likely have follow-up blood work every six to 12 months that includes a liver function panel, complete blood count, and international normalized ratio (INR), to monitor your HCV. As new treatments become available, your doctor will re-evaluate your health, to see if you’re a good candidate for another therapeutic option.
What Is a Fibrosis Stage?
Everything post-treatment hinges on the level of damage HCV did to your liver pre-treatment. The scarring is referred to as stage 0-4, preceded by the letter F:
F0: No scarring
F1: Mild scarring
F2: Moderate scarring
F3: Advanced scarring
F4: Severe scarring, considered cirrhosis, a condition where your liver is permanently damaged from scar tissue that’s replaced healthy tissue. Cirrhosis can lead to liver failure and a liver transplant. Advanced liver damage is also a risk factor for liver cancer, Dr. Brown says.
How Did Hep C Damage My Liver?
In one word: Inflammation. You’ve probably heard how damaging inflammation can be in the body—the liver is no different. Inflammation leads to scar tissue that impacts the organ. The inflammatory response in HCV is slow but progressive, happening on different timelines from one person to the next. “There are lots of factors that play into what the likelihood is that over 10, 20, or 30 years, your liver disease will move from being an F0 to an F4,” Dr. Terrault explains. These include sex (men progress faster, typically), age at time of infection, behavior, and genetics.
What Happens Post-Treatment If I'm Stage F0-F2?
Generally, if you have no scarring to moderate scarring from HCV, as long as you maintain good liver health (tips on that to come!), you won’t need specific liver follow-up care. Your doctor will give you the quantitative HCV RNA test during and after treatment to monitor levels of HCV in your blood, as well as your response to therapy, to make sure you’ve achieved SVR. Then that’s it, you’re done! “I tell patients with limited scarring, you’re cured,” says Dr. Terrault. “Get on with your life, be good to your liver, and no further follow-up is needed.” High five!
What Happens Post-Treatment If I'm Stage F3-F4?
If your liver damage was more extensive, especially if you’ve progressed to F4/cirrhosis, you’ll likely need liver-specific follow-up care for life because of the potential for complications. Namely, you’ll need an abdominal ultrasound every six months and lab work to monitor for liver cancer. “We have good therapies if we detect it early—all the more reason to do screening,” Dr. Terrault says. You’ll also need a baseline upper endoscopy. Make sure you discuss post-treatment care with your doctor if you have advanced liver disease, and stick with your regularly scheduled appointments to stay on top of any new developments.
Who Will I See for Post-Hepatitis C Treatment?
Say you have more severe damage to your liver from HCV. Do you need to see a specialist for your follow-up care? Answer: Not necessarily. Hepatitis C used to be treated by specialists before the DAA days when treatment was a little more complicated (and not nearly as effective). But now more primary-care physicians are treating and following patients with advanced fibrosis who need long-term surveillance, Dr. Terrault says. And that’s totally fine—your regular doctor can treat you if you have F3-F4 liver damage. Just make sure you adhere to the six-month follow-up schedule.
What If My Liver Tests Remain Abnormal?
While you’ll have HCV antibodies forever, the infection is gone so post-treatment your liver enzymes should return to normal. Even a slight abnormality is significant: “Know your test results,” says Dr. Brown. “Have an explanation for abnormal ones—and that explanation should not be, ‘They’re not that abnormal.’ There’s a reason for a normal range. You should be in it.”
Abnormal blood-test results could indicate another problem, like excessive alcohol use or non-alcoholic fatty liver disease (NAFLD). Or you could have a genetic or autoimmune disorder, which, while rare, occurs in about 1% of the population.
What Happens to Fibrosis After HCV Treatment?
Here’s an amazing fact: Once you’re cured of Hepatitis C, liver damage stops. And over time (different for everyone, but possibly five years or more), your liver can heal itself through regeneration. That’s right, the thing grows back! While the mechanisms of liver regeneration are still being studied, avoiding a second injury to the organ prevents further stress and may aid in its ability to regenerate, Dr. Terrault says. These “secondary insults” can be alcohol-related (like alcoholic hepatitis), weight-related (NAFLD), or genetic (like hemochromatosis). It could also be an autoimmune disease-related injury such as primary biliary cirrhosis.
How Can I Protect My Liver After HCV Treatment?
Here are three ways to take charge of your liver health:
- Drink responsibly. Excessive alcohol use can cause additional fibrosis. If you’re stage F0-F2, aim for no more than one drink a day for women, and two drinks for men. Abstinence is safest for more advanced liver scarring, says Dr. Terrault.
- Maintain a healthy weight. NAFLD is directly linked to being overweight or obese, and having type 2 diabetes, high blood pressure, and high triglyceride levels, Dr. Brown says.
- Monitor your meds. Certain medicines are toxic to your liver. Be sure to share everything you take with your doc.
How Can I Reduce My Risk of NAFLD?
- Exercise. Being active on a regular basis can boost your metabolism, says Dr. Brown. Shoot for 20 minutes of brisk daily walking.
- Practice moderation. No extreme dieting, no binge-eating. Moderation in meal planning and food choices is important to starting—and sticking to—a healthy lifestyle that will reduce your NAFLD risk.
- Track data. Today’s technology makes it easy to keep a log of your steps, weight, calories, and plate portions. “The more data you have about your behavior, the more likely you are to keep on track,” says Dr. Brown. “You don’t have to become obsessed with it.”
What Should I Know About Post-Treatment Medications?
It’s a good idea to avoid drugs containing high doses of acetaminophen (found even in some cold and flu meds) if you have more extensive fibrosis. Excessive amounts of acetaminophen are known to cause severe liver damage; since your liver is already compromised, there’s no reason to raise your risk higher.
Also make sure to let any new doctors know about your prior HCV infection, including those at urgent care facilities or the emergency room, so they can choose drugs that don’t add a toxic burden to your liver, Dr. Terrault says.
What If I Want to Get Pregnant After HCV Treatment?
You should be OK, Dr. Terrault says. If you have mild fibrosis, pregnancy after HCV treatment should be “very straightforward.”
If you have stage F4 scarring, or cirrhosis, you do have potential risks of increased complications during pregnancy, but it’s pretty rare. If this is you, you might want to see a high-risk obstetrical group during your pregnancy. “Not that the Hep C is causing any issues—it’s gone and it’s not going to be at any risk to the baby—but you have underlying liver disease and do need a higher level of monitoring,” says Dr. Terrault.
Can I Be Re-Infected With HCV After Treatment?
For sure. Whatever contributed to you getting Hepatitis C the first time, if you do it again, you’ll probably have the same outcome. Injecting drugs and unsafe sex practices (particularly for men with HIV who have unprotected sex with men) are among the most common ways that people are infected and re-infected with HCV. If you’re doing either, it’s important to have an annual HCV RNA screening to check for re-infection. You can lower your risk by using clean needles (including for things like tattoos) and condoms for sex.
- HCV Cure Statistics: U.S. Department of Veteran Affairs. (2015). “FAQs about Sustained Virologic Response to Treatment for Hepatitis C.” hepatitis.va.gov/pdf/sustained-virological-response.pdf
- Not Achieving SVR: Hepatitis C Online. (2019). “Monitoring During and After HCV Treatment.” hepatitisc.uw.edu/go/treatment-infection/monitoring/core-concept/all
- Cirrhosis Facts: National Institute of Diabetes and Digestive and Kidney Diseases. (2018). “Definition & Facts for Cirrhosis.” niddk.nih.gov/health-information/liver-disease/cirrhosis/definition-facts
- Liver Cancer and Hepatitis C: American Cancer Society. (2019). “Liver Cancer Risk Factors.” cancer.org/cancer/liver-cancer/causes-risks-prevention/risk-factors.html
- Info on Autoimmune Conditions and the Liver Impact: World Journal of Hepatology. (2016). “Cirrhosis and autoimmune liver disease: Current understanding,” ncbi.nlm.nih.gov/pmc/articles/PMC5055585/
- All About Non-Alcoholic Fatty Liver Disease: American Liver Foundation. (2017). “NASH Causes & Risk Factors.” liverfoundation.org/for-patients/about-the-liver/diseases-of-the-liver/nonalcoholic-steatohepatitis-information-center/nash-causes-risk-factors/
- Use of Acetaminophen: U.S. Food and Drug Administration. (2009). “Acetaminophen: Avoiding Liver Injury.” fda.gov/consumers/consumer-updates/acetaminophen-avoiding-liver-injury