People who drink—even heavily—can successfully undergo treatment for hepatitis C virus (HCV) if they're provided with individualized, multidisciplinary care that also addresses their alcohol use, according to a study published in the February 2012 issue of Journal of Hepatology.  

Caroline Le Lan, MD, and her colleagues in Brittany, France, treated 73 alcohol-dependent patients for both hepatitis C and addiction, between September 2002 and February 2008. Their treatment outcomes were compared to a matched group of non-drinkers. Although overall cure rates were similar (48 percent versus 49 percent for non-drinkers), people who drank excessively during HCV treatment—defined as 21 or more drinks per week for men, 14 or more drinks per week for women, or at least four drinks at a time, at least twice—were less likely to be cured than those who drank less or were abstinent.  

Excessive alcohol consumption—50 grams (3.5 glasses of wine) or more a day—is known to worsen liver damage from hepatitis C. Drinking also increases hepatitis C viral load, and it may make adherence to HCV treatment difficult. For these reasons, the American Association for the Study of Liver Diseases (AASLD) recommends that HCV treatment decisions for people actively using alcohol be determined on a case-by-case basis, with an emphasis on patient participation in an alcohol support program.  

According to the AASLD's HCV Practice Guidelines, “[I]t seems reasonable to recommend either the complete suspension of alcohol intake while on treatment or restricting its use to an occasional drink during the course of the treatment.”

There is very little information on HCV treatment outcomes among moderate or excessive drinkers. “Doctors are reluctant to treat alcoholic patients because they fear that these patients may experience more side effects and have poor adherence and that heavy alcohol consumption may worsen antiviral treatment outcomes,” said Lan and her colleagues, noting that it may not be possible for every alcohol-dependent patient to reduce, or stop, alcohol consumption, either before or during HCV treatment.

Before starting treatment, study participants were seen by a hepatologist, counseled about risks and benefits of HCV treatment, and evaluated by an addiction specialist who provided individualized counseling. Although study participants were encouraged to reduce or stop alcohol consumption, they were not disqualified if they continued to drink. Excessive drinking was reported by 62 percent of participants when they started HCV treatment; their alcohol consumption ranged from 30 to 98 drinks per week, and the majority had a history of injection drug use. Only 34 percent had been abstinent for less than three months.

Pegylated interferon and ribavirin were administered for six to 12 months, according to HCV genotype and response to treatment. Most were first-time treatment takers. Thirty-four percent had HCV genotype 3, and 42 percent had a low hepatitis C viral load—both of which are associated with higher likelihood of achieving a sustained virological response (SVR), or viral cure. In contrast, 34 percent had serious liver damage, which reduces the odds of being cured.

Overall, 65 percent of abstinent patients were cured, compared with 52 percent of moderate drinkers and 33 percent of heavy drinkers. People with a low pre-treatment HCV viral load were more likely to be cured, as were study participants with a history of severe drug addiction. “This indicates that difficulties with drugs, such as pursuing injections despite substitution treatment, are not a reason to exclude patients from treatment,” Lan and her colleagues wrote.

A total of six participants discontinued treatment, and another six missed some of their study visits. Treatment adherence was associated with family and social status, and duration of abstinence from alcohol before treatment.

“The paradox is that alcoholic patients, who have the highest potential to progress to severe liver disease, are excluded from treatment without any published evidence,” said the authors. There was an unexpected benefit to combining treatment for HCV and alcohol dependence: a third of patients, half of them heavy drinkers, stopped drinking during HCV treatment and remained abstinent afterward. Lan's group concluded, “Treating alcoholic patients was feasible and led to viral eradication and durable alcohol cessation in a number of them.”