Understanding Hepatitis C

compiled by John G. Connor, M.Ac., L.Ac., edited by Barbara Connor, M.Ac., L.Ac.

  • Introduction
  • Assessment of Liver Fibrosis
  • Examples of Mediators & Pathways Involved in the Progression of Liver Inflammation, Fibrosis & HCV Replication
  • Examples of Natural Compounds that Inhibit HCV Replication or are Liver Protective
  • Novel Treatments for Hepatitis C
  • Reducing Inflammation with Natural Compounds
  • Regulating the Immune Response with Natural Compounds
  • Examples of Natural Compounds that Target Growth Factors Involved in HCV
  • Nutritional Support for Glutathione & Optimal Liver Detoxification
  • Blood Tests in Hepatitis C
  • Natural Strategies in Treating Hepatitis C
Introduction

At present, about 3% of the human population are infected with Hepatitis C virus (HCV). The first, acute stage of the disease is usually asymptomatic. However, only 15-25% of the infected eliminate the virus, while the remaining patients develop chronic hepatitis C (CHC). After 10-30 years of CHC, cirrhosis occurs in 20-30% of patients; 5-10% of this group eventually suffer from hepatocellular carcinoma. Unfortunately, up till now no effective methods protecting against HCV or allowing for efficient CHC treatment have been elaborated. This is primarily because not much is known about the mechanism of CHC emergence and the factors affecting anti-HCV therapy. (Jackowiak et al 2011)

Hepatitis C virus (HCV) is a member of Flaviviridae family and one of the major causes of liver disease. There are about 175 million HCV infected patients worldwide that constitute 3% of world’s population. The main route of HCV transmission is parental however 90% intravenous drug users are at highest risk. Standard interferon and ribavirin remained a gold standard of chronic HCV treatment having 38-43% sustained virological response rates. (Munir et al 2010)

The first step in a virus life-cycle is the attachment of the infectious particle to the host cell, for which a specific interaction between a receptor on the cell surface and a viral attachment protein on the surface of the particle is required. Recently, CD81 was identified as a putative HCV receptor based on its strong interaction with E2 as well as with virus particles in vitro (Pileri et al., 1998). Furthermore, preincubation of the HCV-containing plasma used for the binding studies with sera from chimpanzees that were protected from HCV challenge by vaccination with recombinant E1 and E2 also blocked in vitro binding of HCV to CD81 (Pileri et al., 1998).

However, whether virus binding to CD81 is followed by internalization of the virus particle is not known. (Bartenschlager & Lohmann 2000)Apart from this route, HCV as well as other members of the Flaviviridae family may enter the cell by binding to low-density lipoprotein (LDL) receptors. Based on the observation that HCV particles are associated with beta-lipoproteins. (Bartenschlager & Lohmann 2000)

Hepatitis C is transmitted mainly by blood.  This occurs through sharing of equipment to inject drugs, needle stick injuries in health care workers and unsafe techniques of body piercing and tattooing.  Only a tiny quantity of virus is necessary for the virus to become established .  Razor blades and toothbrushes can become contaminated with blood, so it is important not to share them.  Nowadays the risk of catching hepatitis C from a blood transfusion is extremely low, because blood banks now screen all donated blood.The risk for developing cirrhosis 20 years after initial HCV infection among those chronically infected varies between studies, but is estimated at around 10%-15% for men and 1-5% for women. Once cirrhosis is established, the rate of developing HCC (hepatocellular carcinoma) is at 1%-4% per year. Approximately 280 000 deaths per year are related to HCV infection. (Yu & Chuang 2009)

The high HCV replication rate provides sufficient chance of mutation that occurs in the viral population inside an infected person. Production of virus has been estimated at 1012 (one trillion) new HCV virions per day. It has also been reported that envelop protein E2 has highly mutated sites known as hypervariable region HVR1. High variation in E2 causes immune escape mutants of the virus as of the neutralizing antibodies and therefore describes the constant viremia. In addition to E2 gene, P7 region has also been shown with increased variability. (Munir et al 2010)

Currently the standard therapy for HCV is pegylated interferon (PEG-INF) with ribavirin. This therapy achieves 50% sustained virological response (SVR) for genotype 1 and 80% for genotype 2 & 3. As pegylated interferon is expensive, standard interferon is still the main therapy for HCV treatment in under developed countries. On the other hand, studies showed that pegylated IFN and RBV therapy has severe side effects like hematological complications. Herbal medicines (laccase, proanthocyandin, Rhodiola kirilowii) are also being in use as a natural and alternative way for treatment of HCV but there is not a single significant report documented yet. Best SVR indicators are genotype 3 and 2, < 0.2 million IU/mL pretreatment viral load, rapid virological response (RVR) rate and age <40 years=”” munir=”” et=”” al=”” 2010=”” b=””>Interferons (IFNs) are cytokines with species-specific, but nonvirus- specific antiviral, immuno-modulatory and anticellular activities. PegIFN derives from attachment of an inert polyethyleneglycol (Peg) chain – a unique polymer that does not have a definite tertiary structure – to conventional IFN-alfa. This confers an improved pharmacokinetic profile for the drug, by slowing subcutaneous absorption, reducing degradation and clearance and prolonging its half-life. PegIFN maintains high sustained plasma IFN levels that allow for weekly dosing (compared with 3 times weekly administration of standard IFN),while also reducing its adverse side effects (AEs) and immunogenicity. (Cernescu et al 2011)

HCV Genotype is a major predictor of treatment response. HCV genotypes can be ranked, in a decreasing order of susceptibility to IFN-based treatment, as follows: genotypes 2, 3, 4 and 1. Furthermore, subtype 1b rather than 1a and subtype 2b rather than 2a are likely to respond poorer to IFN-based therapy. Permanent viral eradication (SVR) can be achieved in up to 80% of individuals infected with ‘favorable’ or “easy-to-treat” HCV genotypes (G2/3), but only in approximately 40% of those infected with ‘unfavorable’ or “difficult-to-treat” HCV genotypes (G1/4). (Cernescu et al 2011)

A large proportion of patients with genotype 1 chronic hepatitis C will not respond to standard of care treatment. (Cernescu et al 2011)

Insulin resistance (IR) is one of the strongest negative predictors of response to HCV therapy.
Improved insulin sensitivity may be associated with better treatment response and even with HCV clearance. It is important to control diabetes before starting PegIFN/RBV therapy, because IFN induces a decrease in glucose uptake by peripheral tissue and the liver. New HCV protease inhibitors can restore insulin sensitivity in patients chronically infected with G1 HCV. HCV G3 has a direct steatogenic effect independent of IR. (Cernescu et al 2011)

Chronic hepatitis C may progress to cirrhosis (in approximately 20% of patients, with a mean duration of 20 years) and subsequently, decompensation and complications, including HCC, develop in about 30% of cases over a period of approximately 4 years (DiBisceglie 2008 ).

Assessment of Liver Fibrosis
Liver biopsy (LB) is the gold standard for (i ) liver disease staging, (ii ) treatment decisions and (iii ) prognostication, as it may reveal advanced fibrosis or cirrhosis that necessitates surveillance forHCC and/or screening for varices.  However, LB is invasive and has a number of drawbacks:–  substantial sampling error (extracts only 1/50,000 of the liver) –  variability in interpretation –  potential serious adverse outcomes (bleeding) –  high cost (approximately $1000–$1500 per biopsy) –  low patient’s  acceptability/reluctance to undergo repeated biopsies. (Cernescu et al 2011)

Transient elastography (FibroScan™) uses ultrasound and low frequency elastic waves to measure liver elasticity/stiffness in kilopascals (kPa). With a cutoff value of about 7-8 kPa, it can identify about 70% ofpatients with histological signs of moderate to severe fibrosis. With a cutoff of 14-15 kPa, it can identify about 85% of patients with histological signs of cirrhosis. Transient elastography is less reliable in ruling out moderate fibrosis. The results are less certain in patients with a thick chest wall, hepatic congestion of cardiac origin and acute exacerbations of hepatitis. However, it has improved the ability to define the extent of fibrosis without a LB, particularly when combined with other noninvasive markers. (Cernescu et al 2011)

Nucleic acid testing, genotyping and assessment of the level of hepatic fibrosis are invaluable tools in the diagnosis of HCV infection, treatment guidance and monitoring. (Cernescu et al 2011)

Examples of Mediators and Pathways Involved in the Progression of Liver Inflammation, Fibrosis & HCV Replication
Patients should have serum transaminases (ALT and AST) levels monitored at one month, and then every 3 months, following initiation of therapy. Mild to moderate fluctuations in liver enzyme levels are common in persons with chronic HCV infection, and in the absence of signs and/or symptoms of liver disease they do not require interruption of antiviral therapy. Significant elevation in liver enzymes levels – more than 5 times the upper limit of normal – should prompt careful evaluation for liver insufficiency and for alternative causes of liver injury. Eventually, withdrawal of antiviral treatment may be required. A high baseline viral load correlates with higher fibrosis and necrosis-inflammation scores. (Mallet 2008 )

Aspartate amino transferase (AST) and gamma-glutamyltransferase (GGT) were most correlated with METAVIR staging (a system to quantify the degree of inflammation and fibrosis of liver biopsy), followed by platelet counts and alpha2-macroglobulin. The negative predictive value was 77% and 83% and the positive predictive value was 100% and 84% for the Forns score and the Fibrotest, respectively. In multivariate analysis AST, GGT and alpha2-macroglobulin had independent predictive power. (Mossong et al 2011)

The progression of fibrosis and other HCV-associated histopathologic changes may also be related to coagulation cascade activity and hepatic accumulation of iron, which have been associated with mutations in factor V and hemochromatosis genes, respectively. (Cernescu et al 2011)Cellular stress response pathways also modulate HCV replication, including the UPR, dsRNA activation of IFN signaling (PKR/EIF2AK2), oxidative stress (NF-κB/RELA, STAT3), and heat shock (Hsp70/HSPA1A). Numerous groups have observed the activation of these pathways during HCV replication, so it is likely that these pathways are responding, at least in part, to HCV infection. (Randall et al 2007) C-reactive protein (CRP) belongs to pentaraxin family.  It is produced by the liver in response toseveral inflammatory mediators, the most important of which is interleukin-6 (IL-6).  C-reactiveprotein is a sensitive but nonspecific inflammatory marker.  During inflammation, levels of CRPcan be increased up to 1000 fold,  and as soon as inflammation subsides it comes to normallevels.  Recently, CRP has been documented as a predictor of cardiovascular disorders,  myocardialinfarction, stroke, and sudden heart attack. (Afzal et al 2011)

In the present study, D-dimer, a marker of fibrin degradation products, was found to be increased with increasing severity of hepatocyte damage. (Gursoy et al 2005)Ferritin – Increased hepatic iron deposition may be associated with more advanced hepatic fibrosis in patients with chronic hepatitis C virus infection. The serum ferritin value, an independent predictor of severe hepatic fibrosis in patients with chronic hepatitis C virus infection, may predict hepatic iron deposition and severity of fibrosis. (Metwally et al 2004)Hepatitis C virus Core protein is thought to be involved in the disruption of lipid metabolism leading to the production of the pro-inflammatory cytokine TGF-ß1. Hyaluronic acid (HA) is synthesized and distributed throughout the extracellular space by HSC (hepatic stellate cells), therefore its serum levels reflect the activity state of these cells. Tissue inhibitor of matrix metalloprotein inhibitor-1 (TIMP-1) protects collagen from MMP fibrolysis and also inhibits the apoptosis of HSC. On the other hand, initiating events in HSC activation are occurring on a background of progressive disease changes in the surrounding ECM. Over the time, the subendothelial matrix composition changes from one comprised of type IV collagen, heparan sulfate proteoglycan, and laminin to one rich in fibril-forming collagen, like collagen type III. (Valva et al 2011) 

Examples of Natural Compounds that Inhibit HCV Replication or are Liver Protective
Alpha-lipoic acid –
A randomized double-blind trial of thioctic acid (alpha-lipoic acid) in chronic hepatitis patients showed that 55% patients have significant improvements in mean ALT levels, and 77% patients have histological improvements on liver biopsy. (Bustamante et al 1998 and Houglum et al 1997)

Antioxidant therapy has a mild beneficial effect on the inflammatory response of chronic HCV infection patients who are non-responders to interferon. Combined antiviral and antioxidant therapy may be beneficial for these patients. (Gabbay et al 2007)

Blueberry leaves – More recent studies regarding herbal treatment provoke a hope for HCV patient that is based on a chemical known as proanthocyandin, extracted from blueberry leaves. It has been reported that proanthocyandin can stop HCV replication in infected patients. According to another study rhizomes of the Chinese medicinal herb Rhodiola kirilowii may also act as possible inhibitor of HCV. (Munir et al 2010) Protanthocyandins are found in Fruit Anthocyanins.

Curcumin – The reduced severity of hepatitis in curcumin pretreated mice correlated with decrease in numbers of liver CD4(+) T cells but not CD8(+) T cells by immunohistochemical analysis. Furthermore, the expression levels of intercellular adhesion molecule-1 (ICAM-1) and the interferon-inducible chemokine CXCL10 in hepatic tissue were significantly decreased by curcumin pretreatment. In conclusion, curcumin pretreatment protects against T cell-mediated hepatitis in mice. (Tu et al 2011) 

Glutathione – Indices of free radical-mediated damage, such as the increase of malon-dialdehyde,  4-hydroxynonenal, protein-adducts, peroxynitrite, nitrotyrosine, etc., and/or decrease of glutathione, vitamin E, vitamin C, selenium, etc., have been documented in patients with viral or alcoholic liver disease. These markers may contribute to the monitoring the degree of liver damage, the response to antiviral therapies and to the design of new therapeutic strategies. (Loguercio & Federico 2003)

Eicosapentaenoic acid (EPA) – These findings suggest that EPA supplementation may be useful in therapy for chronic hepatitis C. (Kawashima et al 2008) 

Green Tea polyphenol epigallocatechin-3-gallate (EGCG) – The green tea molecule EGCG potently inhibits HCV entry and could be part of an antiviral strategy aimed at the prevention of HCV reinfection after liver transplantation. (Ciesek et al 2011) 

Lactoferrin – Hepatitis C virus envelope 2 glycoprotein (E2) binds several cell-surface molecules that act as receptor candidates mediating hepatitis C virus entry into hepatocytes. Peptides derived from human lactoferrin have been shown to bind hepatitis C virus-E2 protein thereby preventing hepatitis C virus entry in cultured hepatocytes. These results have provided new lead peptides for future investigations of hepatitis C virus entry inhibitors that may provide an interesting approach to prevent hepatitis C virus infectivity. (Beleid et al 2008) 

Oyster mushroon laccase (Pleurotus ostreatus) – Incubation of peripheral blood cells PBCs and hepatoma HepG2 cells with laccase which were then infected with HCV did not protect the cells from HCV attack and entry, while direct interaction between HCV and the laccase at the concentrations of 2.0 and 2.5 mg/ml led to a complete inhibition of virus entry after seven days of incubation. Meantime, the laccase at the concentrations of 1.0 and 1.5 mg/ml did not display any blocking activity. The potential activity of the laccase on intracellular HCV replication in infected HepG2 cells has been examined. The laccase was capable of inhibiting HCV replication at the concentrations of 1.25 and 1.5 mg/ml after first dose of treatment for four days and at the concentrations of 0.75, 1.0, 1.25 and 1.5 mg/ml after the second dose of treatment for another four days. (El-Fakharany et al 2010)

Phyllanthus amarus (PA) (Bahupatra) – Results suggest the possible molecular basis of the inhibitory activity of PA extract against HCV which would help in optimization and subsequent development of specific antiviral agent using P. amarus as potent natural source. (Ravikumar et al 2011)

Schizandrae chinensis, a potent anti-oxidant, lowers ALT levels in patients with chronic viral hepatitis. (Liu GT 1989)

Silymarin (standardized extract of milk thistle seeds) – Oxidative stress has been associated with all stages of chronic HCV liver disease (Jain et al., 2002) and recent data from the HALT-C trial suggest that silymarin use among patients with advanced HCV liver disease may be associated with reduced progression to cirrhosis. (Freedman et al 2011) 

Vitamin D – This study demonstrates for the first time a direct anti-viral effect of vitamin-D in an in-vitro infectious virus production system. It proposes an interplay between the hepatic vitamin-D endocrine system and HCV, suggesting that vitamin-D has a role as natural anti-viral mediator. Importantly, our study implies that vitamin-D might have an interferon sparing effect thus improving antiviral treatment of HCV-infected patients. (Gal-Tanamy et al 2011)

Vitamin D – In conclusion, vitamin D deficiency predicts an unfavourable response to antiviral treatment of RHC. Vitamin D supplementation improves the probability of achieving a SVR following antiviral treatment. (Bitetto et al 2011)

Zinc – The contents of zinc (Zn), and selenium (Se) in plasma and erythrocytes were significantly lower in hepatitis C patients than in the controls. On the contrary, copper (Cu) levels were significantly higher. Furthermore, plasma and erythrocyte malondialdehyde (MDA) levels, and the superoxide dismutase (SOD) and glutathione reductase (GR) activities in erythrocytes significantly increased in hepatitis C patients compared to the controls. However, the plasma glutathione peroxidase (GPX) activity in patients was markedly lower. Plasma Se (r = -0.730, P<0.05), Cu (r = 0.635), and GPX (r = -0.675) demonstrated correlations with HCV-RNA loads. Significant correlation coefficients were also observed between HCV-RNA levels and erythrocyte Zn (r = -0.403), Se (r = -0.544), Cu (r = 0.701) and MDA (r = 0.629) and GR (r = 0.441). The levels of Zn, Se, Cu, and oxidative stress (MDA), as well as related anti-oxidative enzymes (GR and GPX) in blood have important impact on the viral factors in chronic hepatitis C. The distribution of these parameters might be significant biomarkers for HCV. (Ko et al 2005)

Novel Treatments for Hepatitis C
Teprenone (Selbex) and coenzyme A reductase inhibitors – Previously we reported that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, statins, inhibited hepatitis C virus (HCV) RNA replication. Furthermore, recent reports revealed that the statins are associated with a reduced risk of hepatocellular carcinoma and lower portal pressure in patients with cirrhosis. The statins exhibited anti-HCV activity by inhibiting geranylgeranylation of host proteins essential for HCV RNA replication. The anti-ulcer agent teprenone inhibited HCV RNA replication and enhanced statins’ inhibitory action against geranylgeranylation. This newly discovered function of teprenone may improve the treatment of HCV-associated liver diseases as an adjuvant to statins. (Ikeda et al 2011)

Metformin – Compound C induced further suppression of HCV replication when the cells were cultured under the shortage of glucose or with metformin. These results suggest that glucose shortage and metformin have anti-HCV effect independently of AMPK activation. (Nakashima et al 2011)

Ozone therapy – significantly improves the clinical symptoms associated with chronic hepatitis C and is associated with normalized ALT and AST levels among a significant number of patients. Ozone therapy is associated with disappearance of HCV RNA from the serum (-ve PCR for HCV RNA) in 25%-45% of patients with chronic hepatitis C. (Zaky et al 2011)

Reducing Inflammation with Natural Compounds
Many patients with chronic hepatitis caused by hepatitis C virus (HCV) infection develop liver fibrosis with high risk for hepatocellular carcinoma (HCC), but the mechanism underling this process is unclear. These results indicate that chronic inflammation associated with HCV infection shifts hepatocytic TGF-beta signaling from tumor-suppression to fibrogenesis, accelerating liver fibrosis and increasing risk for HCC. (Matsuzaki et al 2007)

An inflammatory response is typically accompanied by the generation of free radicals, the stimulation of cytokines, chemokines, growth and angiogenic factors. Free radicals, capable of both directly damaging DNA and affecting the DNA repair machinery, enhance the genetic instability of affected cells, thus contributing to the first stage of neoplastic transformation also known as “initiation”. Cytokines and growth factors can further promote tumor growth by stimulating cell proliferation, adhesion, vascularization, and metastatic potential of later stage tumors. (Dobrovolskaia & Kozlov 2005) While the use of synthetic agents, especially those targeting molecules, is an attractive and reasonable approach to prevent carcinogenesis, it should be noted that traditional herbs and spices also exist along with their active constituents, which have been demonstrated to disrupt inflammatory signal transduction pathways. (Murakami & Oshigashi 2007)

The following is a list of some of the natural compounds that are effective at reducing inflammation:
Boswellia – Initially, it was found that Boswellic acids (BAs) inhibit leukotriene biosynthesis and 5-lipoxygenase. BAs, in particular AKBA, directly interfere with COX-1 and may mediate their anti-inflammatory actions not only by suppression of lipoxygenases, but also by inhibiting cyclooxygenases, preferentially COX-1. (Siemoneit et al 2008) Boswellia targets LOX-5, 12, 15, TOPO I & II; suppresses brain cancer and brain metastasis.

Curcumin – targets PGE2 – Curcumin is a polyphenol present in the spice turmeric, which can directly scavenge free radicals such as superoxide anion and nitric oxide and modulate important signaling pathways mediated via NF-kappaB and mitogen-activated protein kinase pathways. Polyphenols also down-regulate expression of pro-inflammatory mediators, matrix metalloproteinases, adhesion molecules, and growth factor receptor genes and they up-regulate HDAC2 in the lung. Thus, curcumin may be a potential antioxidant and anti-inflammatory therapeutic agent against chronic inflammatory lung diseases. (Biswas & Rahman 2008) 

EPA/DHA/GLA-rich fatty acids reduce PGE2 and pro-inflammatory cytokines.  EPA and DHA upregulate PG3 which suppresses cancer.  GLA upregulates PG1 which suppresses cancer. Arachidonic acid is converted into PGE2 and LTB4 by COX-2 and lipoxygenase, respectively.  Since fish oil suppresses arachidonic acid levels, it reduces the precursor to both PGE2 and LTB4. 

Ginger – targets PGE2.  Ginger treatment resulted in inhibition of NF-kB activation as well as diminished secretion of VEGF and IL-8 in ovarian cancer cells. (Rhode et al 2007) 

Magnolol suppresses inflammation by inhibiting NF-κB activation and NF-κB regulated gene expression via inhibition of I-κB kinase activation.

Regulating the Immune Response with Natural Compounds

Natural Killer (NK) cells are effectors of the rapidly acting antiviral innate immune system. They kill virally infected cells and are an important source of antiviral cytokines such as IFNγ. Their activation is the net result of signals emanating from a panel of inhibitory and activating receptors, among which the NKG2D activating receptor plays a major role. NKG2D ligands, the MHC class I related Chain (MIC) molecules, are induced on HCV-infected hepatocytes. We show that NKG2D expression is decreased on NK cells from chronically infected HCV patients. As a consequence, NK cell cytolytic and IFNγ-producing functions are impaired. We show that this phenomenon is mediated by TGFβ produced by monocytes upon stimulation by the non-structural HCV-NS5A protein. NS5A could bind to TLR4 on monocytes, thus inducing the production of IL-10 and TGFβ, while inhibiting the production of IL-12. We further showed that TLR4-dependent IL-10 production by monocytes upon NS5A stimulation was mediated through the p38 and PI3 kinase pathways. In addition, we demonstrated that IL-15 could inhibit the TGFβ-mediated effects on NKG2D expression and NK cell functions. (Sene et al 2010)

Ashwaganda – Total extracts of and alkaloid-free polar fractions of Withania somnifera resulted in protection towards cyclophosphamide-induced myelo- and immuno-suppression as evidenced by significant increase in white cell counts and humagglutinating and hemolytic antibody titers. (Diwanay et al 2004) 

Astragalus polysaccharides (APS) – might induce the differentiation of splenic dendritic cells (DCs) to CD11c(high)CD45RB(low) DCs followed by shifting of Th2 to Th1 with enhancement of T lymphocyte immune function in vitro. Also, the effect of APS on T-cell differentiation to Th1 was not associated with the inhibition of IL-10 production in CD11c(low)CD45RB(high) DCs.(Liu et al 2011)  Nourishes the bone marrow. 

Glutamine – is necessary for the production of Interferon gamma and Natural Killer cells. A precursor of glutathione.  Protects the structural and functional integrity of intestinal mucosa.  GALT (Gut Associated Lymphoid Tissue) requires glutamine for optimal immune response.  GALT is the tissue that B and T cells are primed against intestinal antigens, thus forming a healthy immune defense of memory cells.  It maintains or augments cellular immune function, especially those associated with cell-mediated immunity.

Lactoferrin – is a natural forming iron-binding glycoprotein with antibacterial, antioxidant and anti-carcinogenic effects. Lactoferrin also has the capacity to induce apoptosis and inhibit proliferation in cancer cells as well as restore white and red blood cell levels after chemotherapy. (Gibbons et al 2011) Colostrum is the richest source of lactoferrin. Lactoferrin stimulates IL-18, IL-α & IL-γ which stimulates NK cells. 

Propolis – Propolis activated macrophages to stimulate interferon (IFN)-gamma production in association with the secondary activation of T-lymphocytes, resulting in a decrease in IgG and IgM production. Cytokines released from macrophages in mouse peripheral blood after Propolis administration activated helper T-cells to proliferate. In addition, activated macrophages in association with the secondary T-lymphocyte activation increased IFN-gamma production and stimulated proliferation of cytotoxic T-cells and suppressor T-cells, indicating the activation of cell-mediated immune responses. (Takagi et al 2005) 

Vitamin D – is crucial to activating our immune defenses. Without sufficient intake of the vitamin, the killer cells of the immune system — T cells — are not be able to react to and fight off serious infections in the body. For T cells to detect and kill foreign pathogens such as clumps of bacteria or viruses, the cells must first be ‘triggered’ into action and ‘transform’ from inactive and harmless immune cells into killer cells that are primed to seek out and destroy all traces of a foreign pathogen. It was found that the T cells rely on vitamin D in order to activate and they would remain dormant, ‘naïve’ to the possibility of threat if vitamin D is lacking in the blood. (von Essen et al 2010)

Natural Compounds that Target Growth Factors and Genes Involved in HCV
COX-2 (Cyclooxygenase-2) – is up-regulated in practically all cancers (75%).  COX-2 is a key enzyme that catalyses the biosynthesis of prostaglandins from arachidonic acid and plays a critical role in some pathologies including inflammation, neurodegenerative diseases and cancer. (Weber et al 2010)COX-2 – The activation of factor-κB (NF-κB) and cyclooxygenase-2 (COX-2) signalling pathway has particular relevance to HCV-associated HCC. SHXT-frC treatment also caused a concentration-dependent decrease in the induction of COX-2 and NF-κB expression caused by either HCV replication or HCV NS5A protein. Collectively, SHXT-frC could be an adjuvant treatment for patients with HCV-induced liver diseases. (Lee et al 2011)

Examples of Natural Compounds that Inhibit or Down-Regulate COX-2:
Baicalein, from Chinese skullcap (Chiu et al 2010) 
Curcumin (Lin et al 2010) (Moon et al 2010) (Leite et al 2009) 
Curcumin & n-3 fatty acids – inhibited pancreatic cancer by down-regulating COX-2. (Nutr. Cancer 2008) 
Diosgenin – in fenugreek seeds – inhibits COX enzymes. (Wargovich et al 2010)
EGCG – has been shown to inhibit the COX-2 pathway. (Roomi et al 2010)
EPA and DHA in n-3 fatty acids from fish oils (Lee et al 2009) (Lim et al 2009) 
Honokiol – Nitric oxide (NO) and COX-2 are the key targets of honokiol in the inhibition of breast cancer cell migration, an essential step in invasion and metastasis. (Singh & Katiyar 2011) 

Natural COX inhibitory
curcuminoid components of curcumin are active in the regulation of COX-2, EGFR, VEGF, PI3K/Akt, MEK/ERK, p53, c-Myc, NF-kappaB, Bcl-2, e-cadherin, and apoptotic pathways all known to be critically involved in breast carcinomas in general and in triple negative disease in particular, as well as HER2 (ErbB2), and some of which are also regulated by the activity of the EGCG (epigallocatechin-3 gallate) component of green tea. (Kaniklidis 2007)

Cyclin E – is one of the key regulators of the G1/S transition in the cell cycle. Overexpression of cyclin E has been observed in several malignancies and is associated with high proliferation, aberrant expression of other cell cycle regulators and chromosomal instability in vitro. Overexpression of cyclin E is associated with an aggressive tumor phenotype and specific types of p53 mutations. (Lindahl et al 2003)

The cell cycle is divided into four sequential phases. G1 is the first gap phase in which cells prepare for deoxyribonucleic acid (DNA) replication; S (synthesis) phase is the period of DNA synthesis for the reproduction of the whole genome; G2 is the second gap phase in which cells prepare mitosis; and M (mitosis) phase in which cell division occurs for the generation of two genetically identical daughter cells. Quiescent cells that have not entered the cell cycle are referred to as being in G0. (Bassiouny et al 2010)

Natural Compounds that Inhibit or Down Regulate Cyclin E

Baicalein – Cell cycle analysis demonstrated that baicalein-treated HUVECs were arrested in the G1/S phase. Baicalein also induced a decline in the expression of G1-related proteins that normally promote transition from the G1 phase to the S phase, including cyclin D, cyclin E, cdk-4, cdk-6 and p-Rb. In contrast, several proteins upstream of cdks and cyclins, including p16, p21, p27 and p53, were upregulated by baicalein, indicating that baicalein may inhibit angiogenesis, at least in part, by effects on the p53/Rb signaling pathway. Baicalein could exert antitumor effects by inhibiting VEGF-induced angiogenesis and endothelial cell proliferation. (Ling et al 2011) 

Bitter melon – We observed that prostate cancer cells treated with BME (bitter melon extract)
accumulate during the S phase of the cell cycle, and modulate cyclin D1, cyclin E and p21 expression. Together, our results suggest for the first time that oral administration of BME inhibits prostate cancer progression in TRAMP mice by interfering cell cycle progression and proliferation. (Ru et al 2011) 

MAPK (Mitogen-Activated Protein Kinase)Cancer can be perceived as a disease of communication between and within cells. The aberrations are pleiotropic, but MAPK pathways feature prominently. (Dhillon et al 2007) MAPK – The pathogenesis of hepatitis C virus (HCV) infection involves a complex interaction between viral factors and host immune responses. A major component of the latter involves oxidative stress. Oxidative stress has been attributed to both host inflammatory processes and induction by viral proteins, with the two mechanisms possibly acting in synergy. HCV non-structural proteins have been shown to induce activation of STAT-3 via oxidative stress and Ca2+ signaling. This induction is influenced by the activation of cellular kinases, including p38 mitogen-activated protein kinase (MAPK), JNK, JAK-2 and Src, and inhibited in vitro in the presence of antioxidant 3. (Gabbay et al 2007)

Natural Compounds that Regulate MAPK
Andrographis – downregulates p38-MAPK. 
Betulinic acid activates the proapoptotic MAPK cascade in human melanoma cells. (Tan et al 2003) 
Curcumin – downregulates MAPK. (Ajaikumar 2008) 
Guggul – downregulates the MAPK pathway.
ITCs – inhibit MAPK signaling pathways.

mTOR 

The mammalian target of rapamycin (mTOR) is a protein kinase of the phosphatidylinositol 3-kinase (PI3K)/Akt signalling pathway with a central role in the control of cell proliferation, survival, mobility and angiogenesis. Dysregulation of mTOR pathway has been found in many human tumours; therefore, the mTOR pathway is considered an important target for the development of new anticancer drugs. (Fasolo & Sessa 2008)

mTOR – The HCV core protein interferes with in vitro insulin signalling by genotype-specific mechanisms, where the role of suppressor of cytokine signal 7 (SOCS-7) in genotype 3a and mammalian target of rapamycin (mTOR) in genotype 1 in IRS-1 downregulation play key roles. Steatosis and insulin resistance have been associated with fibrosis progression and a reduced rate of sustained response to peginterferon plus ribavirin. (delCampo & Romero-Gomez 2009)

Natural Compounds that Inhibit mTOR
Silimarin – (Singh et al 2006)
Curcumin has been shown to inhibit the growth of rhabdomyosarcoma cells.  The data suggest that curcumin may execute its anticancer activity primarily by blocking mTOR-mediated signaling pathways in the tumor cells. (Beevers et al 2006)
Honokiol can decrease PI3K/mTOR pathway-mediated immunoresistance of glioma, breast and prostate cancer cell lines. (Crane et al 2009) 

NF-kappaB

NF-kappaB is an important transcription factor that is up-regulated in practically all cancers.  It up regulates inflammation, angiogenesis, metastasis and tumor promotion. NF-kappaB activates TNF, IL-1, IL-6, IL-8, Chemokines, VEGF, COX-2, iNOS, MMP-9, uPA and Telomerase. It is hyperactive in many cancers raising the resistance of cancer cells to chemotherapy drugs and chemo radiation.NF-κB – The activation of factor-κB (NF-κB) and cyclooxygenase-2 (COX-2) signalling pathway has particular relevance to HCV-associated HCC. SHXT-frC treatment also caused a concentration-dependent decrease in the induction of COX-2 and NF-κB expression caused by either HCV replication or HCV NS5A protein. Collectively, SHXT-frC could be an adjuvant treatment for patients with HCV-induced liver diseases. (Lee et al 2011)

Examples of Natural Compounds that Inhibit or Down-Regulate NF-kappaB:
Andrographis paniculata – (J Immunol 2004) 
Boswellia – (Br. J. PHarm 2006) (J. Immunol 2006) (Mol Pharm 1995) 
Carnosol has been evaluated for anti-cancer property in prostate, breast, skin, leukemia, and colon cancer with promising results. These studies have provided evidence that carnosol targets multiple deregulated pathways associated with inflammation and cancer that include nuclear factor kappa B (NFκB), apoptotic related proteins, phosphatidylinositol-3-kinase (PI3 K)/Akt, androgen and estrogen receptors, as well as molecular targets. (Johnson JJ 2011) 
Chinese skullcap (Scutellaria) (Piao et al 2008) (Peng et al 2008) 
Curcumin – (Rafiee et al 2010) (Kamat et al 2009) .
DIM – significantly inhibited Akt activation, NF-kappaB DNA binding activity and PSA targeting multiple pathways involved in prostate cancer. (Bhuiyan et al 2006) (Banerjee et al 2009)

PDGF
– (Platelet-Derived Growth Factor)
PDGF down regulates IGF-1 which acts as an anti-apoptotic hormone (Biochem Biophys Res Comm. 2008) (Endocrinology 2008)TGF-β is the central mediator of fibrogenesis, while PGDF stimulates proliferation of the HSCs (hepatic stellar cells). Activation of HSCs is associated with a gradual replacement of the basement membrane-like extracellular matrix (ECM) within the space of Disse by the collagen rich fibers and the production of fibrous bands. (Baranova et al 2011)

Natural Compounds that Suppress PDGF
Baicalein, in Chinese skullcap, one of the most powerful anti-cancer agents, induces apoptosis of cancer cells.  One known mechanism is by down-regulating 12-LOX – reducing PDGF.  
Curcumin causes an interruption of the PDGF and EGF signaling pathways by stimulating gene expression of PPARγ.  Curcumin, also decreases the proportion of S phase cells after PDGF stimulation.
EGCG, from GTE, inhibits PDGF-induced VEGF expression via blocking PDGF receptor and Erk-1/2. 

PPAR alpha and gamma
peroxisome proliferator-activated receptors –  are a group of nuclear receptor proteins that function as transcription factors regulating the expression of genes. PPARs play essential roles in the regulation of cellular differentiation, development, metabolism and tumorigenesis. Activation of PPARs reduces the expression of AP-1 which is a transcriptional regulator of COX-2 and VEGF.  Stimulation of PPAR gamma interrupts the PDGF and EGF signaling pathways. PPAR alpha – The core protein component of HCV is known to contribute to hepatic steatosis, hepatic fibrosis, and hepatic carcinogenesis. Some studies suggest that HCV core protein causes hepatic steatosis through inhibition of microsomal triglyceride transfer protein (MTP) activity and very low density lipoprotein (VLDL) secretion, and impairment of the expression and transcriptional activity of peroxisome proliferator-activated receptor (PPAR)α. (delCampo & Romero-Gomez 2009)

Natural Compounds that Activate or Enhance PPAR α and gamma
Carnosic acid, carnosol and ursolic acid (Phenolic diterpene compounds from rosemary and sage.) 
Curcumin (Ajaikumar 2008) 
EGCG 
Grape Seed Extract 

STAT-3
signal transduction and transcription proteins – regulate many aspects of cell growth, survival and differentiation. The transcription factors of this family are activated by the Janus Kinase JAK and dysregulation of this pathway is frequently observed in primary tumors and leads to increased angiogenesis, enhanced survival of tumors and immunosuppression.  STAT3 activation is associated with various human cancers and commonly suggests poor prognosis.  It has anti-apoptotic as well as proliferative effects.  STAT signals are triggers or switches for angiogenesis.Cellular stress response pathways also modulate HCV replication, including the UPR, dsRNA activation of IFN signaling (PKR/EIF2AK2), oxidative stress (NF-κB/RELA, STAT3), and heat shock (Hsp70/HSPA1A). Numerous groups have observed the activation of these pathways during HCV replication, so it is likely that these pathways are responding, at least in part, to HCV infection. (Randall et al 2007)

Natural Compounds that Inhibit STAT-3
Curcumin – (Ajaikumar 2008) 

Parthenolide – sensitizes hepatocellular carcinoma cells to trail by inducing the expression of death receptors through inhibition of STAT3 activation. (Carlisi et al 2011)
Ursolic Acid – in Basil and Sage – is the most powerful natural STAT-3 inhibitor. 

TGFβ1
(Transforming Growth Factor Beta) – is a secreted protein that performs many cellular functions, including the control of cell growth, cell proliferation, cell differentiation and apoptosis. Over-expression of the immunosuppressive cytokine TGFbeta1 stimulates IL-17 and is another strategy that tumors have developed to evade effective immune surveillance. (Cancer Res 2008) TGF-1 indirectly down-regulates the cell adhesion molecule E-cadherin. (Loss of E-cadherin expression is predictive for metastatic cancer.) (Quershi et al 2006 & Li et al
2006)

TGF-ß1 –
Hepatitis C virus Core protein
is thought to be involved in the disruption of lipid metabolism leading to the production of the pro-inflammatory cytokine TGF-ß1. (Valva et al 2011)

We show that NKG2D expression is decreased on NK cells from chronically infected HCV patients. As a consequence, NK cell cytolytic and IFNγ-producing functions are impaired. We show that this phenomenon is mediated by TGFβ produced by monocytes upon stimulation by the non-structural HCV-NS5A protein. NS5A could bind to TLR4 on monocytes, thus inducing the production of IL-10 and TGFβ, while inhibiting the production of IL-12. We further showed that TLR4-dependent IL-10 production by monocytes upon NS5A stimulation was mediated through the p38 and PI3 kinase pathways. In addition, we demonstrated that IL-15 could inhibit the TGFβ-mediated effects on NKG2D expression and NK cell functions. (Sene et al 2010)

Natural Compounds that Suppress TGF-β1 
Astragalus and Salvia extract suppressed cell invasion triggered by TGF-beta(1) in HepG2 cells. (Liu et al 2010)
Curcumin (Ajaikumar 2008) 
Green tea extract (40% EGCG) 

TNF-α – Tumor necrosis factor-alpha –
is a cytokine involved in systemic inflammation and is a member of a group of cytokines that stimulate the acute phase reaction.  The primary role of TNF is in the regulation of immune cells. TNF is able to induce apoptotic cell death, to induce inflammation, and to inhibit tumorigenesis and viral replication. Dysregulation of TNF production has been implicated in a variety of human diseases, as well as cancerTNF alpha – HCV core protein inhibits PPAR α and γ expressed in hepatocytes and adipocytes promoting IRS-1 degradation and insulin resistance. HCV core protein induces the over production of TNFα, responsible for phosphorylation of serine residues of IRS-1 (insulin receptor-1) and IRS-2 (insulin receptor-2) and down-regulation of glucose transporter gene expression. TNF correlates with the hyperinsulinemic state and the blockade of TNF production by anti-TNF drugs like infliximab inhibits the development of insulin resistance. Thus, TNF promotes hyperinsulinemia and hyperglycaemia and has been linked to an increased risk of diabetes development. (delCampo & Romero-Gomez 2009)

Examples of Natural Compounds that Suppress TNF-α
Andrographolide (J. Immunol 2004) 
Curcumin 
Feverfew 
Green Tea 
ITCs downregulate TNFα (Nitric Oxide 2007) 

Nutritional Support for Glutathione & Optimal Liver Detoxification
Raising glutathione levels through direct supplementation of glutathione is difficult.  Research suggests that glutathione taken orally is not well absorbed across the GI tract.  However, plasma and liver glutathione concentration can be raised by administration of certain supplements which follow that serve as glutathione precursors. 
Andrographolide was found to be even more potent than silymarin. (Visen et al 1993) In .. 
Milk thistle (Silymarin) – spares glutathione degradation. Milk Thistle has also demonstrated an ability to replenish glutathione levels. (Lucena 2002)  Milk Thistle binds tightly to the receptors of liver cell membranes that allow toxins in thus locking them out.
NAC (N-acetyl cysteine) – increases the level of glutathione produced in the body. (NAC) is the most bioavailable precursor of glutathione.  NAC helps with natural chelation. 
Non-denatured whey protein concentrate – the best protein-rich source of glutathione precursors. 
Phytic acid – in IP-6 (inositol hexaphosphate) by Phytopharmica – is a binder of heavy metals.  Need 2-5 grams of the IP-6 powder to be useful. Phytic acid is in any unleavened grain.  

Blood Tests Specific to Hepatitis C

AFP
(alphafetoprotein)
HCV RNA Quant Hepatic Panel – especially AST and GGT (Mussong et al 2011)
hs CRP (
Afzal et al 2011)
D-Dimer & fibrinogen
(Cernescu et al 2011) (Gursoy et al 2005)
Fasting Insulin –
(Cernescu et al 2011) (Cross et al 2010)
Fasting Glucose –
(Cernescu et al 2011) (Cross et al 2010) (Nakashima et al 2011)
CBC –
especially neutrophils, lymphocytes, monocytes, platelets (Mossong et al 2011)
Ferritin –
(Metwally et al 2004)
Iron – (
Cernescu et al 2011)
Copper –
(Ko et al 2005)
Vitamin D – (Bitetto et al 2011)
Zinc –
(Ko et al 2005) 
Glutathione – (Loguercio et al 2001)(Loguercio & Federico 2003)
Selenium –
(Ko et al 2005) IL-6 – (Afzal et al 2011)
VLDL –
(delCampo & Romero-Gomez 2009)

Natural Strategies in Treating Hepatitis C
Following a diagnosis of Hepatitis C there is a need for nourishing and building (adaptogenic and anabolic) herbs and nutrients – in order to nourish and rebuild the damaged liver cells and tissues.  Hepatitis C is a destructive condition, so the concept of anabolic restoration is essential.  We also need to look at protection and immune modulation with botanicals and nutrients. We need to establish a good foundational therapy. We can also target any blood work abnormalities that may be revealed in the blood work such as AFP, HCV RNA Quant, Hepatic Panel, etc.

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Compassionate Acupuncture and Healing Arts, providing craniosacral acupuncture, herbal and nutritional medicine in Durham, North Carolina. Phone number 919-309-7753.


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