August 2004  Volume 2   Number 1


...a series of interviews by Medical Advocates
for Social Justice with the people who are shaping
our responses to infectious diseases and to the
marginalized affected by these diseases.

Gordon Nary interviews Melissa Palmer, MD

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Thoughtleaders © 2004 by Medical Advocates for Social Justice


Gordon Nary interviews Melissa Palmer, MD
on her book,
Dr. Melissa Palmer's Guide to
& Liver Disease.

Melissa Palmer, MD is an internationally renowned
hepatologist who maintains a private practice devoted to
liver disease on Long Island, New York.

Dr. Palmer is a sought-after medical expert and regularly
speaks to the medical community, general public, and media
about liver disease. She has written numerous scientific articles
on liver disease, and she sits on the medical advisory board of
the New York chapter of the American Liver Foundation (ALF)
and on the nutrition education subcommittee of the national chapter
of ALF.



MASJ:   Dr. Melissa Palmer's  Guide to Hepatitis & Liver Disease received exceptional reviews from both the medical and consumer media.  Your writing style makes the material accessible and interesting to the lay person and provides clinicians and other healthcare professionals with a refreshing update and overview on many of the clinical management challenges of hepatitis C and a wide spectrum of liver diseases. Are some of your colleagues using the book as part of their patient education programs?

Palmer: Thank you.  Many of my colleagues have given the book to their physician extenders- i.e. nurse practitioners, physician assistants, nurses, and medical assistants to assist them in the care of patients with hepatitis and other liver diseases.  The feedback that I have received is that my book is extremely helpful, especially when dealing with the side effect management of interferon.  I have devoted an entire chapter to this specific issue. Other doctors have either given the book or suggested the purchase of the book to their patients to use as a reference guide.  For example, if a patient is suffering from hair loss on interferon therapy – they may use the index to look up “hair loss interferon induced” and then refer to the chapter for management.

MASJ:   The chapters ‘Herbs and Other Alternative Therapies’ and “Diet, Nutrition and Exercise’ provide an important professional assessment of adjunct therapies that are often not well integrated into some medical practices.  As you point out, recent surveys indicate that more people are visiting alternative medicine professionals than those who practice conventional medicine. What are the obstacles to physicians discussing and possibly monitoring these alternate therapies with patients who may choose to supplement traditional medicine with some of these alternatives?

Palmer:  While the amount of information and research concerning herbs is increasing, there are still two important matters that have not been clearly defined as to herbs. First, due to the lack of controlled research on herbal remedies, the exact extent of drug-herb interaction is not entirely known. Thus, an herb that a person may be taking in an attempt to prevent liver damage may have a negative interaction with the medication that he or she is taking to control high blood pressure. For example, licorice—proclaimed to be beneficial in the treatment of viral hepatitis—might cause fluid retention and worsen high blood pressure. Furthermore, licorice may cause a decrease of libido in men, which is a potential side effect of interferon therapy, in addition to being a side effect of many antidepressants which are often used during interferon therapy for hepatitis C. Many herbs may increase or decrease the action of conventional medicines. For example, the herb cannabis sativa (marijuana) has been demonstrated to diminish the effectiveness of interferon and to suppress the immune system. Though potential adverse drug-herb interactions can be looked up in the PDR for Herbal Medicines, this list may be incomplete. An example of such an interaction includes the death of women who was taking St. Johns Wort at the time she underwent anesthesia with the drug Demerol.  Due to an adverse drug-herb interaction, this patient experienced fatal cardiac arrest.  This also resulted in the filing of a large lawsuit against the herb manufacturer.

Furthermore, the noted side effects of an herb, in general, may be incomplete. This is due to the fact that it can be very difficult to trace side effects to a particular herb. It may take weeks, months, or even years for problems to show up. By that point, people don’t always remember that they have taken an herbal remedy or they have become so accustomed to a particular side effect that they dismiss it. Complicating matters even further, many natural remedies contain dozens of active ingredients depending on exactly how they were prepared by the manufacturer. The composition of these ingredients may vary greatly (even among bottles of the same type of herb). Finally, there are no regulatory laws mandating that the manufacturer or distributor of an herbal preparation report possible adverse reactions of the herb to the FDA or other government agency. So, in all likelihood, all the possible drug-herb interactions and other side effects associated with a given herb are not listed in the PDR for Herbal Medicine.  This is made clear by reports which appear on a regular basis alerting the public to the danger of an herb that was once thought to be safe.  Usually the herb –in-question has caused some unsuspecting consumer to suffer severe, or even fatal, side effects including cancer, kidney failure and liver failure, thereby necessitating the removal of the herb from the market or at least stronger warning labels on the bottle.  Examples of such herbs include kava and ephredra respectively.

Second, there is a lack of standardization among herbal products. It is important to be aware that not all parts of the herb contain the active ingredient proclaimed to produce the beneficial effect. For example, one study compared ten different brands of the herb ginseng and found that the active ingredient ginsenoside varied drastically among different brands, although all were essentially similar in their descriptions of ingredients contained in the bottle. In fact, some pills or capsules contained almost none of the active ingredient. A different study found that up to one-quarter of the products on health food store shelves did not contain any of the listed ingredients.

Due to the absence of regulation, it is possible that a totally different herb can be substituted for the one on the label. Furthermore, there have been reports that some herbs have been spiked with steroids, painkillers, tranquilizers, thyroid extracts or other substances to improve their effectiveness. Toxic metals, including lead and arsenic and even powerful heart stimulants (such as digitalis), the blood thinner warfarin, and the diabetic medication glyburide have been discovered mixed in with herbal preparations. And, some herbs have been found to contain dangerous microorganisms, such as staphylococcus aureus, escherichia coli (E. coli), salmonella, and shigella, each of which can make a person quite ill.  Of course, the product labels, did not mention the addition of any of these adulterants, and all labels claimed to contain only “natural” ingredients.    

MASJ:     The chapter ‘Pregnancy, Sex, Medications, and Prevention” includes a comprehensive discussion of drug-induced liver disease that appears to be alarmingly high in my age category - with 40 percent of hepatitis cases in people over fifty years old. Would you comment on the factors contributing to this high incidence and what actions physicians and patients can take to reduce the incidence of drug-induced hepatitis in general and especially in this age group?

Palmer:   Since all medications are processed through the liver at least to some degree, people with liver disease must become aware of which medications can cause liver damage, which medications can worsen preexisting liver disease, and which medications are safe to take. It is the liver’s job to detoxify any substances that are potentially harmful to the body. An already damaged and weakened liver must work much harder than a healthy liver in order to accomplish this task. When a person with liver disease ingests a potentially hepatotoxic drug, this puts an additional strain on the liver and can result in further liver injury or possibly even liver failure. Even people with a healthy liver can develop liver disease as a consequence of ingesting a toxic medication or drug.

In general, people with liver disease should avoid medications known to be hepatotoxic. People who must be treated with a medication that is potentially hepatotoxic should have their LFTs closely monitored by their doctors. If a person’s LFTs become greater than three times baseline values, the medication causing these elevations should be discontinued. Also, it is essential that people with liver disease inform their liver specialists of every medication or drug that they are taking—including herbs, over-the-counter drugs and/or recreational drugs. There is no reason for the patient to expect the doctor to be judgmental. Her goal is the same as the patient’s. Therefore, complete information should be provided to the doctor concerning prescription medications, over-the-counter medications, and herbal and alternative therapies. Remember, a doctor’s objective is to help her patient get better and to help protect her patient from unintentional additional liver damage. 

People with cirrhosis must be particularly aware of which drugs are hepatotoxic, as they are typically more sensitive to drugs side effects due to the inability of the liver to clear the drug from the body (excretion rate).  Even drugs that are not known to be hepatotoxic may have a prolonged excretion rate.  This means that the drug and its metabolites will stay in the body longer.  Therefore, usual dosages of these drugs should not be taken - the dosage of these drugs should be decreased.  Examples of such drugs that require a decrease in the dosage when used for a prolonged period of time in people with cirrhosis include Benadryl (diphenhydramine), morphine, Demerol  (meperidine) and methadone.


A person’s susceptibility to a potentially hepatotoxic drug is enhanced by many factors. Some of these factors may be within the person’s control, such as cigarette smoking , excessive alcohol intake, and obesity.  So, it is important for all individuals with liver disease, especially older people to discontinue cigarette smoking, alcohol use and to loose weight when required. 


MASJ:    With IV drug use accounting for 70 percent of new HCV infections, could you comment on the options for and obstacles to accessing appropriate treatment for HCV in this population?


Palmer:  Recent studies have demonstrated that people with HCV who actively use intravenous drugs - a condition previously considered to be a contraindication to treatment with interferon, may be successfully treated with interferon.  Since intravenous drug use is currently the most common mode of transmission of new HCV infections, treatment of these individuals is important as it may potentially reduce the spread of HCV.  Ideally, these individuals should be enrolled in a methadone maintenance drug treatment program.  The use of methadone is not a contraindication to interferon treatment.  Furthermore, the decision of the NIH Consensus Statement of 2002 concluded that active intravenous drug use should not be considered a contraindication to treatment with interferon. 


MASJ:   What is the risk of organ transplants as a potential source of HCV transmission?


Palmer: Since 1992, extremely accurate testing for HCV has been available. Thus the current risk of infection with HCV from a transplant is probably less than that of receiving a blood transfusion -  less then 0 .001 percent – i.e. miniscule. The reason that a small risk still may exist is that when a person initially becomes infected with HCV, there is a short period of time that neither HCVRNA or HCVAb is detectable. Once somebody has tested positive for HCV he or she is prohibited from donating organs ( see exception to this rule in question 13).  Anyone who received an organ transplant prior to 1992 and especially prior to 1990, are advised to be checked for HCV.

A recent article by Stramer et al in the August 19, 2004 New England Journal of Medicine (NEJM) states that the risk of transmission of HCV by a blood transfusion is now only 1 in 2 million blood units.  Another article by Zou et al. in the same issue of NEJM states that the prevalence rates of HBV, HCV, and HIV are lower in individuals who donate organs compared with the prevalence in the general population, but may be higher compared to first-time blood donors. 

MASJ:    Has HCV superinfection with multiple HCV genotypes been noted in this population as has HIV superinfection?


Palmer:  Interesting question. HCV superinfection with multiple HCV genotypes may occur, however, the predominant genotype will prevail.  This predominant genotype will typically be the only genotype to appear on blood test results – usually being genotype 1a or 1b.


MASJ: .  Your book provides a comprehensive overview of the principal drugs used in the management of the various forms of hepatitis and other liver diseases, their side effects, and the management of these side effects. Please comment on the current standard of care for people coinfected with HIV and HCV and the impact of the APRICOT (AIDS PEGASYS  Ribavirin International CO-infection Trial) data reported in the July 29, 2004 New England Journal of Medicine on such care?


Palmer:   Approximately 200,000 people in the United States are infected with both HCV and HIV.  The incidence of death for people with HIV has dramatically declined since 1996 due to the implementation of highly active antiretroviral therapy.  Since this time, hepatitis C has emerged as a major cause of illness and death in coinfected people. People infected with both viruses have been shown to have a more a rapid progression to cirrhosis, liver failure and liver cancer.  Thus, people in whom HIV infection is well-controlled should undergo treatment for HCV.  Two studies recently published in NEJM  (Chung et al and Torriani et al) confirm that the current standard of care for coinfected people is the combination of peginterferon plus ribavirin[. Sustained virological responses were reported as 40% (APRICOT) and  27% (Chung et al.) In fact, in the Chung study, even in patients who did not clear HCV with this regimen, histological improvement was seen on repeat liver biopsy specimens in 35%.  Thus, therapy should not be discontinued prematurely in patients with advanced liver disease (stage 3 or 4) even if an early virological response is not achieved.


MASJ:    What current trials of investigational drugs hold significant promise for the management of hepatitis?

Palmer:  Newer improved drugs with a similar structure to ribavirin (known as ribavirin analogues) but less side effects are in the process of being developed.  The most promising of these analogues is viramidine. The major advantage of these ribavirin analogues is their decreased incidence of associated anemia.  

Thymosin alfa-1 is a group of linked amino acids that is produced by the thymus gland, a gland located in the neck. Thymosin alfa-1 is an important component of the body’s immune system and helps fight off viral infections. Studies have shown that synthetic thymosin alfa-1 (known as Zadaxin) manufactured by SciClone Pharmaceuticals, can stimulate the immune system to fight off viruses.  Used by itself to treat people with chronic hepatitis C, Zadaxin, produces no significant improvements. However, preliminary studies suggest that when used in combination with pegylated interferon, Zadaxin may lower or eradicate hepatitis C viral levels, in addition to improving inflammation and damage in the liver. Preliminary studies pairing Zadaxin with pegylated interferon alpha 2a (Pegasys) for those who fail to respond to interferon/ribavirin combination therapy look promising. In a recent study, 20-36 percent of people with hepatitis C who failed previous interferon treatment experienced significant decreases in viral load after 3 months of Zadaxin/Pegasys combination therapy. Therefore, Zadaxin used in combination with Pegasys may be of benefit to people with chronic hepatitis C who were nonresponders to previous interferon regimens. Further studies involving larger groups of people are underway. Zadaxin is administered at a dose of 1.6 mg, twice a week, by subcutaneous injection. So far, it appears that Zadaxin causes little, if any, side effects.

A major advance for potential future treatment strategies for hepatitis C was the discovery of the actual structure of two of the key enzymes involved in HCV replication by researchers from Vertex Pharmaceuticals. These enzymes are known as the NS3 protease and the NS3 helicase.  Vertex is attempting to develop a drug that will inhibit these specific enzymes—an HCV-protease and a HCV-helicase inhibitor. The development of a drug that would inhibit these enzymes in the HCV life cycle would be a powerful weapon in the treatment of hepatitis C.

Clinical trials are ongoing to evaluate the drug VX-497 (merimempodib), which is manufactured by Vertex Pharmaceuticals. VX-497 is an inhibitor of the enzyme inosine mono­phosphate dehydrogenase (IMPDH). This enzyme is essential for the production of a nucleotide—a compound that forms the building blocks of DNA and RNA. Therefore, blocking the production of IMPDH may slow or block HCV viral replication. In experimental trials, VX-497 has shown to be a potent antiviral, much more potent than ribavirin. And, VX-497’s antiviral activity appears to be even greater when it is combined with interferon.

Mycophenolate mofetil is another inhibitor of the enzyme IMPDH. This drug is currently used to prevent rejection of a newly transplanted liver (see chapter 22).  In one study it was combined with Pegasys and some patients achieved sustained eradication. Further study is needed on this combination therapy before it can be recommended.

Histamine is a natural substance made by the body.  It may reverse the oxidative stress and free radical damage to the liver caused by HCV.  Furthermore, and may enhance the body’s response to interferon.  When histamine (manufactured by Maxim pharmaceuticals as Ceplene) is combined with interferon, additional antiviral effects occur.  Histamine is in combination with peginterferon and ribavirin is being studied in ongoing trials.

Vaccines  given to treat chronic hepatitis C – known as therapeutic HCV vaccines, and HCV antibody immunoglobulins given - alone or in combination with interferon, are in the preliminary stages of investigation.

Heptazyme (Ribozyme Pharmaceuticals, Inc.) is a type of ribozyme—a kind of RNA molecule with the unique ability to cut targeted genetic material. In the case of Heptazyme, the targeted genetic material is contained within HCV. Thus Heptazyme seeks to incapacitate HCV so that it can no longer replicate. When part of its key genetic material is severed, HCV dies and, therefore, no further virus particles can be produced. Unfortunately initial studies have shown that blindness may be a possible side effect of Heptazyme. Further study is currently ongoing to determine if the benefits of this drug outweigh its risks.  Other less toxic ribozymes are in the process of being developed.

The enzymes that are essential to HCV’s replication - proteases, polymerases and helicases, are all potential targets for drug therapy. So far, the protease inhibitor BILN 2016 appears to be the most promising investigational drug utilizing this approach. Preliminary results in people with genotype 1 have been impressive.  Further studies on this promising new drug are ongoing, and the results are being eagerly anticipated.

ISIS-14803 is a synthetic antisense oligonucleotide that binds HCVRNA thereby resulting in decreased viral replication.  Initial studies have shown that ISIS-14803 (given intravenously) significantly reduces the level of HCV RNA in people who did not respond to previous interferon therapy.  Studies are underway combining ISIS -14803 with peginterferon and ribavirin in people with genotype 1 who failed previous combination therapy.     

MASJ:    You included information in your book on the cost of drugs, blood tests, medical care, and medical insurance including Medicare. Are there any programs for the medically indigent to access any of the current drugs?


Palmer:   Yes. Reimbursement assistance programs exist for both pegylated interferons. The PegAssist program (1-877-734-2797) is sponsored by Roche and the Commitment to Care program is sponsored by Schering-Plough to assist patients with HCV receive Pegasys or PegIntron (respectively) free of charge or at a significantly reduced fee.  Forms do need to be filled out and some tax information also needs to be submitted.   Also, both pharmaceutical companies are conducting phase four or “post-marketing” trials of Pegasys and PegIntron.  When a patient enters into a trial study, all medication, blood testing and medical visits are typically free-of-charge.  Finally, Medicaid typically covers the cost of these medications.


MASJ:   Please explain the factors contributing to the increased prevalence of HBV and HCV in African-Americans and the impact of this higher prevalence data on screening recommendations.


Palmer:  African Americans with HCV appear to have poorer prognostic factors than Caucasians.  They have a higher prevalence of hepatitis C than Caucasians.  In fact, the prevalence among AA is approximately 2X as great as that of Caucasians.  AA, especially males, are more likely to progress to chronic disease than are Caucasians (86% versus 68%). Approximately 90% of AA are infected with genotype 1 as compared to 70-75% of Caucasians.  While African Americans appear to have a slower rate of progression of HCV, once cirrhosis develops they are more likely to suffer from complications such as liver cancer and death.  Finally, the response rate to treatment is poorer for AA than for Caucasians.  Factors that have been suggested to contribute to this decreased response rate include – genotype 1, viral kinetics, interferon resistance and body mass index.  African Americans  have been found to have a lower neutrophil count than Caucasians, which has traditionally excluded them from enrolling in many trials and from maintaining a therapeutic dose of interferon.  An abundance of research is currently ongoing concerning these issues in African Americans .


African Americans  with HBV have been found to have higher rates of fibrosis and cirrhosis than Caucasians in spite of having lower levels of hepatitis B viral replication (HBVDNA).  Currently, this higher prevalence data has not effected screening recommendations.  However, with greater amounts of research specifically targeting these issues in AA, guidelines for screening may be impacted in the future. 


MASJ:  How effective are the current treatment options for Non-Alcoholic Fatty Liver Disease (NAFLD) and what have been the obstacles to the development of effective drugs for the management of NAFLD?

There is no specific therapy for NAFLD that has clearly been proven effective.  Treatment has focused on weight reduction and hepatoprotective medications. As with all liver diseases, avoidance of alcohol, before, during, and after treatment, is essential. This is especially true for people with NAFLD, as alcohol may worsen the severity of fat deposits, fatty inflammation, and fatty scarring in the liver. NAFLD is an evolving disease and much research is going on in connection with it. Thus, there is some disagreement within the medical community as to the characteristics of NAFLD, which may have been an obstacle to the development of effective drugs for management.  

MASJ:   Could you provide a brief summary of some of the more promising investigational drugs for NAFLD?

Palmer: The most promising medication for the treatment appears to be ursodeoxycholic acid (UDCA). UDCA, also known by the brand names Actigall, URSO, and Ursodiol, is a naturally occurring bile acid, that, unlike many other bile acids in the body, is not toxic to the liver. It is found in a small quantity in the human body, but in a large quantity in a bear’s body. UDCA was initially used to dissolve gallstones, but is now commonly used to treat many different liver diseases, specifically primary biliary cirrhosis. Initial studies involving people with NASH have shown that treatment with UDCA can lead to improvements in liver enzymes and to a reduction in the severity of fatty deposits in the liver. UDCA may possibly decrease the risk of developing gallstones during weight reduction. Further studies are ongoing as to the effects of UDCA on NAFLD.

Metformin (Glucophage) and rosiglitazone (Avandia) are oral glucose-lowering (also known as hypoglycemic) medications used to treat type II diabetes.  These medications work by correcting insulin resistance.  Therefore, these types of drugs may potentially benefit people with NAFLD and insulin resistance. In fact, preliminary studies have shown that treatment with metformin can improve liver enzyme elevations in people with NAFLD.  However, improvement in the amount of fat and inflammation in the liver have thus far been established only in studies involving animals. Studies on humans will be required before these medications can be recommended for people with NAFLD.

Clofibrate, a triglyceride-lowering drug, has been tested as a treatment but has not shown to be beneficial. Gemfibrozil, another triglyceride-lowering medication was able to improve liver enzyme elevations in a small group of people with NAFLD, but its effects on liver fat and scarring was not tested.  Further study is needed on gemfibrozil. Polymixin B is an antibiotic that can reduce the amount of bacteria in the intestines. This medication may be characterized as a form of “bowel decontaminate.” Studies have shown that administering polymixin B to people on intravenous feedings (total parenteral nutrition (TPN)) can reduce the amount of fat in their livers. This treatment option needs further study before definite conclusions can be drawn about its effectiveness in treating people with NAFLD.

Betaine is a precursor of S-adenosyl methionine (SAMe), a derivative of the amino acid methionine.  S-AMe is purported to promote the health of the liver.  In two studies, some patients who were treated with betaine experienced decreased liver enzyme elevations and a decreased amount of fatty deposits in their livers.  The mechanism by which betaine exerts its beneficial effect on the liver, is not clear, but it is believed that it may assist in transporting fat away from the liver. More research is needed in this area.

Certain nutritional deficiencies which are common among people with NAFLD may provide a clue in the search for a successful treatment. Some people who receive intravenous feedings for prolonged periods of time develop fatty liver in addition to a choline deficiency. (Choline is a B vitamin.) Correcting the choline deficiency in these people has been shown to resolve the fatty liver as well. Choline supplementation in people with NAFLD is a promising treatment option, but is one which requires further study. Coenzyme A is a substance that is essential for the metabolism of carbohydrates, fats, and certain amino acids. It contains pantothenic acid, a B vitamin which is necessary for growth.  In some studies, people with NAFLD were supplemented with a form of coenzyme A, and this caused the extent of fat deposits in the liver to decrease. More research must be done to confirm the efficacy of this type of nutritional supplementation. Preliminary studies have shown that another B vitamin - , may decrease insulin resistance.  Thus, biotin supplementation may be beneficial for people with nonalcoholic fatty liver disease (NAFLD).  However, this needs to be confirmed by further studies.

One preliminary study has indicated that vitamin E (alpha-tocopherol) supplementation may be a beneficial adjunctive treatment for people with NAFLD, but more research is needed in this area.  Biotin, a B vitamin has been shown to decrease insulin resistance.  Studies on people with NAFLD have not been conducted at this time, but biotin supplementation would be an interesting area of exploration for people with NAFLD. 

MASJ:   There are more than 17,000 people in the US on waiting lists for liver transplants.

What steps are being taken to increase liver donations?  

Palmer:  In an effort to increase the number of suitable donor livers available for transplantation some of the criteria for donation have become less stringent. Livers from donors over the age of fifty, and sometimes from those as old as seventy, are now being used – and generally with favorable results. Livers from donors who have hepatitis C are being utilized in cases where the patient undergoing the transplant also has hepatitis C. Similar with hepatitis B.

Living liver donation involves the removal of one lobe of the liver from a donor, (typically the right lobe in adult-to-adult transplantation), and its transplantation into the recipient with liver disease. This technique offers an additional means of expanding the existing liver donor pool. Furthermore, waiting time on the transplant list is eliminated, and transplantation may be performed at a time when the patient is not exceedingly ill.  And, not only does living donor transplantation diminish the waiting time for the living donor recipient, it also reduces the waiting time for those on the transplant list.


Sometimes, one viable donor liver is split in two, with each half being transplanted into a separate person. This procedure, known as split-liver transplantation, obviously has the capacity to double the number of livers available for donation. Usually, an adult receives the larger right side of the liver, and a child or small adult receives the smaller left side of the liver. However, new techniques are enabling a more even split, so that one donor liver can be utilized for two adult patients. Some experts are lobbying to have liver-splitting mandated as the first option in the transplantation of cadaver livers.

Hepatocyte transplantation involves the infusion of a small number of liver cells (hepatocytes) from a donor liver into a person who has either a genetic defect of the liver (such as Crigler-Najjar syndrome) or fulminant liver failure. The use of hepatocyte transplantation might even eliminate the need for transplantation in some people with fulminant liver failure by promoting spontaneous recovery. While there have been only limited attempts to implement this procedure in humans, the results in animal-based studies appear promising.

Another exciting procedure that is still in the experimental stage is one that involves taking samples of one’s liver cells, altering the genetic and then reconstituting it back into the person’s genetically defective liver. Known as gene therapy, this procedure is also being evaluated for use in preventing the rejection of a transplanted liver, thereby eliminating the need for post-transplant immunosuppressant medications. This promising technique is undergoing extensive testing. 

MASJ:  Thank you for insights into the challenges in the management of hepatitis C and other liver diseases which will be of great interest to physicians, other healthcare professionals, and those affected by these diseases.


Gordon Nary is executive director of Medical Advocates for Social Justice


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