For Patients Caregiver Tips and Advice For Medical Professionals

Support for patients with Hepatic Encephalopathy

If you’re living with HE or caring for a loved one with HE you’ll likely need emotional, physical or financial support at certain points in your journey.

In this section, we cover how and where you can get that support – from finding resources to help pay for the cost of medications to learning how to talk about your diagnosis with friends and family. In addition, many people find it helpful to talk with others living impacted by HE. By attending support groups you can meet other people who have similar issues and may learn from their experience.


As a service, the American Liver Foundation provides information about local Support Groups. Find one near you…

Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey (Northern Area)
New Jersey (Central/Southern Area)
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma


Online Support Groups

Visit the American Liver Foundation online support group at Inspire…


Phone Support Help Line

Questions about liver disease? Need support or information about our resources? Call our helpline at 1-800-465-4837, 9am – 7pm ET, Monday – Friday.

The American Liver Foundation provides many resources and support services for people with HE and their family, friends and caregivers. An outline of these services and where to access them follows below:

There are other advocacy groups and professional associations that can also be valuable sources of information for learning more about your condition, connecting with other people who have HE and their caregivers, and finding doctors who specialize in treating this condition.

  • National Organization for Rare Disorders (NORD)
    55 Kenosia Avenue
    Danbury, CT 06810Web: www.rarediseases.org
    Phone: 203-744-0100
    Fax: 203-798-2291
    Email: orphan@rarediseases.orgNORD provides information about rare diseases, patient assistance programs, and resources for patients and their families, medical professionals and the public.
  • American Gastroenterological Association (AGA)
    4930 Del Ray Avenue
    Bethesda, MD 20814Web: www.gastro.org
    Phone: 301-654-2055
    Fax: 301-654-5920
    Email: member@gastro.orgThe patient center section of this Web site offers information about digestive conditions, procedures, diet and medications, and a gastroenterologist (GI) physician locator service. In addition, it rates the accuracy of information provided on certain patient-oriented Web sites.
  • American College of Gastroenterology (ACG)
    6400 Goldsboro Road
    Bethesda, MD 20817Web: www.gi.org
    Phone: 301-263-9000
    Email: info@acg.gi.orgThe patient section of this Web site helps you to locate a physician liver expert in your area, provides information about digestive health topics and procedures, and has the latest news and updates on GI health.

In addition, pharmaceutical companies have support services for people taking their medications.

  • Salix Pharmaceuticals, makers of rifaximin (Xifaxan®), has a program that offers a variety of resources to help you understand and manage your condition, called Hepatic Encephalopathy Living Program (H.E.L.P.). It includes:
    • Educational materials
    • 24-hour access to a toll-free patient hotline staffed by registered nurses
    • Support to help you stay on treatment including prescription and appointment reminder calls

    Visit them on the Web at www.xifaxanhe.com for more information.

If you need help to pay for your prescription medications, you may be eligible for patient assistance programs. The following organizations provide programs that directly reduce the cost of prescription drugs or can assist you in finding programs for which you are eligible.

The American Liver Foundation’s Financial Assistance Resource Support Guide is available for more information. The American Liver Foundation’s Free Drug Discount Card can be used for prescription medications, over-the-counter medications and medical supplies. The card is available with no charge.


Pharmaceutical Patient Assistance Program

Salix Pharmaceuticals, makers of rifaximin (Xifaxan®), has a program that offers a variety of resources to help you with cost and insurance support regardless of whether or not you have prescription coverage. Find out about the Xifaxan 550 mg Access Helpline, Instant Savings Card, and Patient Assistance Program. Contact them at 1-866-282-6563 or visit them on the Web at http://www.xifaxan550.com.

To apply for drug assistance programs you will likely be asked for the following information, so it’s helpful to have it handy before contacting these organizations:

      • State of residence and zip code
      • Estimated gross annual household income
      • Number of people living in the household
      • Brand name of the prescription medicines you have been prescribed
      • Type of health insurance and/or prescription coverage, if any
      • Name and contact information of your doctor who prescribed the medication

All information discussed with people staffing patient assistance help lines is strictly confidential.


Needy Meds

NeedyMeds is a nonprofit organization whose mission is to help people who cannot afford medicine or health care costs.

NeedyMeds offers resources that are helpful to uninsured and underinsured patients:

Contact Information
Needy Meds
P.O. Box 219
Gloucester, MA 01931
Phone: 1-800-503-6897
Website

Partnership for Prescription Assistance

The Partnership for Prescription Assistance helps qualifying patients without prescription drug coverage to access the medicines they need.

The Partnership for Prescription Assistance has an online prescription assistance program finder
Contact Information
Partnership for Prescription Assistance
Phone: 1-888-477-2669 Website

State Pharmaceutical Assistance Programs

Many states offer subsidies to provide pharmaceutical coverage or a discount program for prescriptions to eligible individuals.

Programs are listed by each state. For more details…
Eligibility requirements vary from state to state. For more details…
Contact information varies by state. For more details…

Additional Organizations

      • RxAssist offers a comprehensive database of patient assistance programs, as well as news and practical tools. Visit them on the Web at http://rxassist.org
      • RxOutreach is a mail order pharmacy for people with little to no health insurance coverage. Visit them on the Web at http://www.rxoutreach.org
      • Patient Access Network Foundation is a non-profit organization that provides assistance to under-insured people for their out-of-pocket expenses for life-saving medications. Visit them on the Web at www.panfoundation.org
      • Chronic Disease Fund is a non-profit charitable organization that helps people with chronic disease, cancer and other life-altering conditions obtain the life-savings medications they need. Visit them on the Web at http://www.cdfund.org/
      • HealthWell Foundation is a non-profit organization that educes financial barriers to care for underinsured patients with chronic or life-threatening diseases. Visit them on the Web at http://www.healthwellfoundation.org

If you’re living with HE you’re likely to need support from family and friends who might accompany you to medical appointments, make sure you take your medications on a regular basis, help with household chores such as cleaning or preparing meals, and provide for your safety when your symptoms are more severe.

It’s important to keep in mind that the person giving care and the person receiving care are in this together – sometimes referred to as “care partners.” You as the person with the disease may be the one requiring assistance, but the needs and concerns of both partners must be addressed for the relationship to stay healthy.

The person giving care – the caregiver – often experiences many of the same emotions that you might experience: anger, fear, isolation, depression. As the caregiver takes on more responsibilities it can be overwhelming for him or her to balance assisting you, along with their job, the kids, household duties and so forth. This can lead to the caregiver feeling burned out.

It’s very important for the caregiver to take steps to ward off burnout. One of the biggest mistakes that caregivers make is to think that they can – or should – handle everything themselves. They start to neglect their own needs, both emotional and physical, and the strain begins to take a toll. It’s important for you to remember that your loved ones need a break too – not from you – but from the disease and the toll it can take.

There are many support services for caregivers and you should encourage your loved ones to take advantage of them. Your “care partner” can get more information by referring to the section specifically for caregivers of people with HE.

The liver is the seat of our overall health and wellness and the health of nearly every organ is intimately connected with our liver. A healthy liver is essential to a fully functioning body, but our modern sedentary lifestyles and unhealthy eating habits can truly damage the liver and damage our health overall.

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Genetic Dissection of Hepatitis C Virus Entry in Vivo

At least 130 million people worldwide are chronically infected with hepatitis C virus (HCV). Infection frequently leads to advanced liver disease, including fibrosis, cirrhosis and hepatocellular carcinoma. Despite substantial efforts to develop antivirals directly blocking replication, treatment options remain limited.

The current standard of care is only partially effective. A therapeutic or preventative vaccine does not exist. Currently, HCV associated liver transplantation is merely a palliative procedure due to universal infection of the graft after transplantation, often resulting in rapid fibrosis progression and subsequent graft failure.

Even transient therapies inhibiting HCV cell entry could prevent graft reinfection and greatly improve the effectiveness of liver transplantation. Such therapeutic advances targeting this stage of the viral life cycle will require a much more solid understanding of HCV cell entry than is currently available. The development of treatment and prophylactic options has been hampered in part by the lack of immunocompetent, cost effective, robust, and reproducible small animal models for the virus.

Besides humans, chimpanzees are the only species that is naturally susceptible to HCV infection. While experimentation in these large primates has yielded valuable insights, ethical considerations, limited availability, genetic heterogeneity, and cost limit their utility.

To overcome roadblocks to HCV research in vivo, Dr. Ploss’ group has engineered an immunocompetent mouse model with genetically encoded susceptibility to the virus. Generation of HCV permissive mice was facilitated by his recent discovery that species tropism at the level of entry is defined by two human molecules: CD81 and occludin (OCLN).

Dr. Ploss has demonstrated that transient or stable expression of these entry factors in vivo renders mice susceptible to infection with diverse HCV genotypes. He has shown that viral uptake can be blocked by passive immunization strategies and that immunization of these animals induces humoral immunity and confers partial protection to heterologous challenge. He has also shown proof-of-principle for combining this system with gene knockout analysis to begin to dissect viral entry. He is now proposing to apply this system to genetically dissect HCV infection in vivo.

Dr. Ploss aims to take advantage of existing repositories of mutant mouse strains to assess the impact of targeted gene disruptions on HCV infection. Combining mouse knockout technology with his genetically humanized mouse models therefore offers a unique opportunity dissecting HCV infection in the 3 dimensional context of the liver.


Alexander Ploss, PhD
Gregg Allman and Tune In to Hep C Liver Scholar Award winner
The Rockefeller University


Liver Dendritic Cell Recruitment and Differentiation During Chronic HCV Infection

Eighty percent of individuals infected with HCV fail to clear their infection on their own, largely as the result of weak, narrowly targeting or waning antiviral T cell responses. One possibility is that the observed defects in HCV immunity are a direct result of inefficient T cell priming by professional antigen presenting cells (APCs).

Unfortunately, progress in understanding potential defects in antigen presentation during chronic HCV infection has been impeded by the lack of a small animal model in which to study the host response. Using a large cohort of patients undergoing liver transplantation for chronic HCV infection and non HCV-related liver disease, Dr. Best has observed that a number of professional APCs, including dendritic cells (DCs), reside within the human liver microenvironment that have the potential to shape HCV-specific immunity. Among six identified populations of liver APCs, a novel population of CD34+ myeloid ”progenitors” was also discovered.

Interestingly, chronic HCV infection was characterized by a drastic reduction in the frequency of “progenitor” cells and a significant increase in the frequency of intrahepatic myeloid DCs. Moreover, intrahepatic myeloid DCs revealed the HCV-induced expression of numerous maturation markers, including CD80, CD83, CD40 and PD-L1, and were responsive to antigenic stimulation in vitro through the secretion of IL-12.

Using various immunological techniques developed by her laboratory, Dr. Best proposes to test the hypothesis that the chronic HCV liver microenvironment promotes the differentiation of myeloid liver DCs, and that these DCs regulate HCV-specific T cell responses through B7-mediated pathways and the secretion of effector cytokines. Phenotypic analysis of liver “progenitor” cells, and the use of in vitro and in vivo stem cell differentiation assays also allow Dr. Best to determine the recruitment and DC differentiation fate of these cells during chronic HCV infection.

Comparisons of immunomodulatory receptor expression, cytokine secretion potential and antigen presenting capacity of mature liver APCs from uninfected and HCV-infected patients will allow Dr. Best to identify mechanisms of immune system modulation by these cells in the context of chronic HCV infection. Together, the experiments proposed will reveal potential mechanisms underlying HCV chronicity, and will serve useful for the development of novel therapeutic strategies.


Victoria Velazquez Best, PhD
Emory University


Investigating a Protective Role for miR-122 in the Life Cycle of Hepatitis C Virus

Hepatitis C virus (HCV) infection is a rapidly increasing global health problem with over 170 million people infected worldwide. HCV is a hepatotropic, positive-sense RNA virus of the family Flaviviridae. MicroRNA-122 (miR-122) is a highly abundant, liver-specific human microRNA that interacts with two sites in the 5’ end of the HCV RNA genome.

Sequestration of miR-122 leads to a loss of viral RNA in cell culture and in vivo. Curiously, miR-122 does not affect viral translation and has a minimal affect on the rate of RNA synthesis. Dr. Sagan has recently demonstrated that miR-122 binds to the 5’ terminus of the HCV genome, suggesting that miR-122 may protect the terminus of the HCV RNA from attack by nucleases or cellular sensors of RNA.

In this study she will investigate the character of the 5’ terminus of the viral genome during infections. Dr. Sagan will also directly investigate specific gene candidates for their role in HCV RNA recognition and turnover by carrying out short-interfering RNA (siRNA) knockdown during miR-122 sequestration of specific nucleases and cellular sensors of RNA. Finally, a genome-wide siRNA screen will identify genes mediating HCV RNA accumulation during miR-122 sequestration.

The proposed research is highly significant as it examines the mechanism by which miR-122 modulates HCV RNA abundance and will help to identify novel host-virus interactions, defining new targets for therapeutic intervention.


Selena Sagan, PhD
Stanford University


Identification of a Novel Host Innate Immune Factor that Regulates HCV

Current antiviral therapy against HCV consists of a combination of pegylated IFN-? (PEG-IFN)
and Ribavirin. However, Dr. Saito recognizes this treatment eradicates HCV in only 40-50% of patients following 48 weeks of treatment and has severe adverse effects. Therefore, improvement of IFN based therapeutic strategy is desperately needed for better therapeutic outcome and relief of medication-related toxicities.

IFN induces antiviral effects through the induction of approximately 200 interferon stimulated genes (ISGs). It is known that HCV proteins block induction and function of some of critical ISGs, leading us to hypothesize that those ISGs are critical to inhibit the HCV life cycle.

In this proposal, Dr. Saito has established a cell line stably expressing the interferon stimulated gene 56 (ISG56) promoter fused to a firefly luciferase reporter gene. Dr. Saito applied the cells to high throughput cDNA screening to identify novel antiviral host factors. The screening identified more than forty genes as potential candidates of antiviral gene inducers including tyrosine kinase, non-receptor, 1(TNK1).

Preliminary experiments suggest that the TNK1 pathway promotes the expression of antiviral genes that suppress HCV replication. Moreover, virus infection and interferon (IFN) treatment each regulate TNK1 abundance, suggesting a regulatory feedback mechanism. These observations indicate that TNK1 is involved in the host response against virus infection and the antiviral action of IFN.

In this proposal, Dr. Saito will focus on defining the mechanism of antiviral gene induction by TNK1 including investigation of the phosphorylation of candidate substrates of TNK1, determination of the signaling cascade of the TNK1 pathway, structure and function analysis of TNK1 to identify its signaling and substrate binding motifs. Furthermore, Dr. Saito will also assess how the antiviral activities of TNK1 control HCV in hepatocytes as a potential novel anti-HCV therapeutic target.

Finally, Dr. Saito will examine the effect of TNK1 combined with pegylated IFN-? (PEG-IFN) and Ribavirin or HCV NS3/4A protease inhibitor as a basis to investigate potential novel anti HCV treatments. Dr. Saito’s study stands to identify novel anti-HCV therapeutic strategies through the identification and characterization of TNK1 mediated antiviral signaling pathways.


Takeshi Saito, MD, PhD
USC Keck School of Medicine


Development of Novel Host-Factor-Based Antivirals for Hepatitis C

The hepatitis C virus (HCV) forms a structure called the “membranous web” in order to replicate. One component of the cellular membranes that are hijacked to form the membranous web is phosphatidylinositol 4,5-bisphosphate (PIP2), a particular membrane lipid molecule. The enzyme that synthesizes PIP2, PI4K III?, is required for HCV to replicate. The nonstructural 5A protein (NS5A) of HCV binds specifically to PIP2.

This binding appears to take place at the N-terminal amphipathic helix (AH, an alpha-helix with one charged face and one hydrophobic face) of NS5A. Mutating the AH or sequestering the PIP2 with neomycin disrupts the binding and prevents HCV replication.

Dr. Gelman’s hypothesis is that a novel class of anti-HCV therapeutics that disrupt the PIP2-NS5A interaction can be discovered. One way to disrupt the interaction is to bind either NS5A AH or PIP2. Another approach is to inhibit PI4K III?.

Dr. Gelman will pursue both of these approaches. His specific aims are (1) to develop a fluorescence polarization (FP) assay for inhibition of binding of fluorescence-tagged PIP2 to NS5A (AH peptide, full length protein, or biotin-tethered AH peptide), (2) to use this assay to screen thousands of compounds in the Stanford High Throughput Biosciences Center, (3) to validate compounds identified in the screen for activity against HCV replication using luciferase-reporter and focus-reduction assays in cell culture based on the Huh7 or Huh7.5 cell lines, and (4) to screen known and candidate inhibitors of PI4K III? to identify compounds that inhibit HCV replication without unacceptable cytotoxicity.

Dr. Gelman expects to identify lead compounds both for disruption of the PIP2-NS5A interaction and for inhibition of PI4K III?. Further work will focus on application of organic chemistry expertise to these compounds to synthesize and evaluate promising structural analogues. Since PIP2 is a host factor and PI4K III? is a host enzyme, the barrier to development of resistance may be high.


Michael Gelman, MD, PhD
Stanford University


Role of Lipid Droplets in Hepatitis C Virus Infection and Liver Damage

The goal of Dr. Camus’s proposal is to characterize molecular mechanisms controlling Hepatitis C Virus (HCV) replication at lipid droplets (LDs) and leading to liver damages in infected patients. LDs have emerged as central cellular organelles in HCV replication. Triglycerides stored in LDs can be generated by two diacylglycerol acyltransferase (DGAT) enzymes.

Recent results from his laboratory indicate that HCV exclusively replicates at LDs generated by DGAT1. To define the role of DGAT1 in HCV replication, Dr. Camus will 1) characterize proteins interacting specifically with DGAT1 or DGAT2 in hepatoma cells to identify factors that favor or disfavor HCV particle production associated with DGAT1 or DGAT2 respectively. 2) His preliminary results show that two HCV proteins, core and NS5A, interact physically with DGAT1. He will perform a mutagenesis study of DGAT1 and these viral factors to elucidate the role of their interactions in viral assembly. 3) Transgenic mice expressing core develop fatty liver/steatosis, a frequent symptom in HCV-infected individuals. To examine whether DGAT1-generated LDs play a role in core-induced steatosis, he will generate core-transgenic mice in a DGAT1-/- background.

Dr. Camus anticipates that these studies will provide important new insight into the HCV life cycle at LDs and will determine whether DGAT1 is a novel antiviral drug target in HCV infection.


Gregory Camus, PhD
Gladstone Institutes

Hepatic Encephalopathy Webinar Presented by the Duke University Transplant Team

Hepatic Encephalopathy Webinar Presented by the Duke University Transplant Team

Ask the Experts Duke University Transplant Team
  • Dr. Andrew Muir, Chief, Division of Gastroenterology
  • Debra Bernardina, Liver Transplant Coordinator
  • Elizabeth Goacher, Physician Assistant
  • Jennifer Gommer, Clinical Pharmacist
  • Karli Pontillo, Clinical Social Worker
...
Hepatic Encephalopathy Webinars

Hepatic Encephalopathy Webinars

Webinar series offers patients and caregivers valuable information ALF's VP of Programs Lynn Seim, Director of Education and Training Phil Scarfo, and patient advocate Lynette Kozelenko at our HE Webinar on 1/23. On January 23, 2014, more than 300 people tuned in to the American Liver Foundation’s webinar on ...

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