Liver Awareness Month: What pain medication can Liver Disease patients take? Is milk thistle good for my liver?

Liver Awareness Month, Nana and Zombies
October has been busy around here folks, fall is one of our favorite times of the year. Nana and the little people finally completed our little Halloween horror movie, a family tradition since 2013. I am hoping this isn't the last year, but it could be.

People are saying (my daughter) that I went a bit too far this year. Note to self; during lunch never film a bloody zombie attack - especially at Taco Bell.

Who knew our blood curdling screams would offend so many people. I ask you, how scary can a four and eight year old be? After the manager explained the situation, I somewhat understood. Manager Frank made a special appearance in "Zombies Eat Tacos - Not People" I love the title too, brainchild of the baby!

Liver Awareness Month
Moving on to something more important, as most of you know October is both Liver and Liver Cancer Awareness Month. Yes, because of my movie career I almost missed it. Not to worry, the wonderful website of the American Liver Foundation (ALF) just published their E-Newsletter "LIVERLOWDOWN" chock–full of great information about the causes, symptoms and risk factors associated with liver disease.
Begin here....

ALF Mayo Nutrition and Wellness Liver Chat
In addition, last month ALF along with experts from the Mayo Clinic and University of Florida Health hosted a Q&A on Twitter about liver wellness and nutrition. Below I condensed the chat highlighting the questions and answers, or view the Liver Chat on Twitter here. Enjoy.

Panelists Weigh in on Liver Nutrition
Is milk thistle good for my liver? How about the Paleo diet? Leading experts from the Mayo Clinic and University of Florida Health answered these questions and more at ALF’s September Nutrition Tweet Chat. Three transplant hepatologists and a dietician weighed in on wellness and nutrition.

American Liver Foundation (ALF) - The first topic we will be covering is liver disease and diet

Q1. Why do people who have never consumed alcohol get Liver Disease?
A1. Many causes besides alcohol. Your doctor will check to see if you have a condition requiring specific treatment.

Q2. What kinds of processed or salty foods should patients with ascites/edema limit?
A2. Patients should read nutrition labels. Common culprits include frozen meals, deli meats, chips, fast food

Q3. Is it healthy to skip meals or try to drastically decrease calorie intake to lose weight?
A3. Patients with cirrhosis can often suffer from malnutrition. The key to losing weight: healthy diet and exercise.

Q4. For patients with issues such as nausea or lack of appetite, are smaller meals better than 3 meals/day?
A4. Smaller, frequent meals can be beneficial. Especially to those with slow gastric emptying and decreased appetite.

Q5. Next, what are some smart snacks to pack or have on hand, instead of reaching for candy or chocolate?
A5. High protein stacks are always favorable: nuts, seeds, yogurt, protein bars, or high protein shakes.

Q6. Patients often ask, you recommend the DASH diet to all patients?
A6. Despite limited data showing the benefits of DASH for Fatty Liver Disease, I recommend discussing with your dr.

Q7. What foods should I be eating if I have liver disease and low platelets? Or what if I'm anemic?
A7. Drink 1.5-2 L water per day, but avoid all fruit juice. Make sure you eat 3-4 servings vegetables, 2 servings fruit. Fruit juice contains significant amounts of fructose sugar- metabolized like fat. Also eat 4 servings whole grains/day, 3 servings low fat dairy. Try eating 1-2 servings ocean fish weekly, 2 egg yolk. Finally, avoid meats/sausages/butter/vegetable oil. And limit sodium (<2g daily), as well as processed and restaurant foods!

Q8. If I have fatty liver disease- are there good fats I should consume or should all be eliminated for your diet?
A8. Avoid fried foods, pizza, and sausage. Choose ocean fish, which are good sources of Omega-3 fatty acids.

Q9. The Paleo diet is popular- but is it a good choice for overall wellness?
A9. No, too much saturated fat and minimal whole grains. It's easy to develop Vitamin B deficiencies

Q10. If I have too much iron in blood- are there foods I should avoid or limit consumption of?
A10. Avoid red & processed meats, fatty foods, supplemental Vitamin C, sugary foods/beverages. DO eat nuts, grains, rice & beans.

Q11. Very popular question: Is coffee OK to consume? How many cups a day is OK?
A11. 2-3 6-8oz cups of coffee daily are fine.

Q12. If you have ascites/edema (water retention), what kinds of processed or salty foods should you limit consumption of?
A12. Avoid processed foods, salty foods, sausage, pizza, and baked goods like muffins. Minimize restaurant foods.

Q13. For patients w/issues such as nausea or lack of appetite- are smaller meals better than 3 square meals per day?
A13. 4-6 meals per day helps meet your calorie and protein needs. Remember to included a good source of protein w/ every meal.

Q14. Is the DASH diet one that you would recommend for all liver patients?
A14. DASH diet benefits most patients except for those on a low potassium diet.
Basic DASH Diet includes 7 day meal plan with 2000 calories, 100 gram protein, 1500 mg sodium-(link) As the responses from the experts keep coming in, we're moving onto our next topic- supplements, liver function, and medication

Q15. What is the best test to assess liver function?
A15. No single test. Blood tests + imaging assess functions and complications of Liver Disease. Liver biopsy can also provide valuable diagnostic info.

Q16. What pain medication can Liver Disease patients take?
A16. No more than 2gm acetaminophen (Tylenol and its related medications) in 24 hrs. Avoid NSAIDs if you have cirrhosis

Q17. Is it ok for patients with Liver Disease to take statin meds?
A17. Yes, statins may be taken to treat high cholesterol. Recent studies suggest statins may help patients with cirrhosis.

Q18. Is milk thistle okay to take?
A18. We usually refer people to speak with their nutritionists/providers/pharmacists to double check out supplements. Clinical evidence for milk thistle isn't established but may benefit some types of liver disease. Studies are inconclusive. However, available evidence suggests that milk thistle is likely harmless with minimal minor side effects.

Q19. Should you be consuming large amounts of protein? Are protein shakes ok? What are ways to consume protein w/o added sugar?
A19. A good guide is 25-30 g of protein per meal, unless you have chronic kidney disease. Focus on fish, chicken, dairy, and vegetable proteins. Protein shakes or bars may help if you can't eat enough.

Q20. Our last question before answering some from the chat: Are probiotics OK for someone to take if they have liver disease?
A20. Yes, but make it a food source like Greek yogurt or kefir. Speak to you doctor before taking any supplements.

Liver Chat participants
Q Is jogging safe for someone with stage 3 liver disease?
A There is no reason not to consider jogging with stage 3 fibrosis. Enjoy!

Q Should I expect my MELD score to drop after hepatitis c treatment?
A Generally yes, we do see improvements in MELD after treatment for HCV

Q At what bilirubin range should a patient get listed? Or is it MELD 15?
A Patients are evaluated for liver transplantation generally at meld15 or with symptoms of liver decompensated (confusion, ascites)

Q What causes liver to produce high HDL even though eat healthy all life?
A You're lucky if you have HDL cholesterol. Patients with low HDL and high LDL are at greater risk of heart disease.

Q Vitamin B12 shots post transplant?
A b12 shots should be provided if patients are deficient

Q Any advice on naturally reducing a FNH liver mass?
A There is no diet or natural therapy to reduce FNH.

Q Any specific suggestions for someone with Autoimmune Hepatitis?
A Would AIH require any specific requirements on diet or just good liver nutrition as highlighted in chat. Autoimmune hepatitis requires assessment with blood tests + liver biopsy. Rx with prednisone + azathioprine usually effective.

Q Are there specific risk factors for African American men and Liver disease?
A Actually fatty liver disease in African Americans, has a better prognosis.

More From ALF
October is big for the liver community. It's Liver Awareness Month- and it's also Liver Cancer Awareness Month, so we've teamed with Bayer to help raise awareness about the risk factors for this deadly disease. Learn more about liver cancer here.

Questions about liver disease? Need support or resource info? Call our helpline at 1-800-465-4837, 9am-7pm ET Mon-Fri.

Hope you all have a wonderful week and Halloween, until next time.
Bad Grandma - AKATina

Scotland - Liver cancer death rate rises by 52%

Liver cancer death rate rises by 52%
Death rates from liver cancer increased by 52% in the last 10 years, with the disease killing 572 Scots last year.

But new figures from the NHS showed that the cancer mortality rate for all forms of the disease fell by 11% over the decade to 2015.

The mortality rate for breast cancer - the most commonly diagnosed cancer for women - fell by 21%
Lung cancer death rates were down by 15.1% and there was a 16.4% decrease for bowel cancer.

A total of 16,011 deaths in 2015 were caused by cancer, with the report noting that "although the rate of deaths due to cancer has decreased over this period, the actual number of deaths due to cancer has not".

This is thought to be due to the increase in older age groups within the population and the fact that cancer is a relatively common disease among the elderly.

Cancer mortality rates have fallen by 14% among men over the last 10 years. The decrease in the mortality rate for females was lower at 6%.

Deaths from liver cancer were up from 320 in 2005, with the mortality rate increasing by 45.6% in males and by 68.6% for females.

"The increase in the mortality rate of liver cancer over the last 10 years by 52% reflects the increase in incidence of this type of cancer," the report said.

"Survival from liver cancer is poor in most cases. The main risk factors for liver cancer are alcohol and infection with hepatitis B and C."

Continue reading....

Complex Pattern of Resistance-Associated Substitutions of Hepatitis C Virus after Daclatasvir/Asunaprevir Treatment Failure

Complex Pattern of Resistance-Associated Substitutions of Hepatitis C Virus after Daclatasvir/Asunaprevir Treatment Failure
Jun Itakura , Masayuki Kurosaki , Chitomi Hasebe, Yukio Osaki, Kouji Joko, Hitoshi Yagisawa, Shinya Sakita, Hiroaki Okushin, Takashi Satou, Hiroyuki Hisai, Takehiko Abe, Keiji Tsuji, Takashi Tamada, Haruhiko Kobashi, Akeri Mitsuda, Yasushi Ide, Chikara Ogawa, Syotaro Tsuruta, Kouichi Takaguchi, Miyako Murakawa, Yasuhiro Asahina, Nobuyuki Enomoto, Namiki Izumi

Full Text Article -View Online Or Download PDF

Backgrounds & Aims
We aimed to clarify the characteristics of resistance-associated substitutions (RASs) after treatment failure with NS5A inhibitor, daclatasvir (DCV) in combination with NS3/4A inhibitor, asunaprevir (ASV), in patients with chronic hepatitis C virus genotype 1b infection.

This is a nationwide multicenter study conducted by the Japanese Red Cross Liver Study Group. The sera were obtained from 68 patients with virological failure after 24 weeks of DCV/ASV treatment. RASs in NS5A and NS3 were determined by population sequencing.

The frequency of signature RASs at position D168 of NS3 was 68%, and at positions L31 and Y93 of NS5A was 79 and 76%, respectively. The frequency of dual signature RASs in NS5A (L31-RAS and Y93-RAS) was 63%. RASs at L28, R30, P32, Q54, P58, and A92 in addition to dual signature RAS were detected in 5, 5, 1, 22, 2, and 0 patients, respectively. In total, triple, quadruple, and quintuple RASs in combination with dual signature RAS were detected in 35, 10, and 1.5% patients, respectively. These RASs were detected in patients without baseline RASs or who prematurely discontinued therapy. Co-existence of D168 RAS in NS3 and L31 and/or Y93 RAS in NS5A was observed in 62% of patients.

Treatment-emergent RASs after failure with DCV/ASV combination therapy are highly complex in more than 50% of the patients. The identification of complex RAS patterns, which may indicate high levels of resistance to NS5A inhibitors, highlights the need for RAS sequencing when considering re-treatment with regimens including NS5A inhibitors

Continue to full text article...

Scientists uncover why Hepatitis C virus vaccine has been difficult to make

Scientists uncover why Hepatitis C virus vaccine has been difficult to make

LA JOLLA, CA -- Oct. 24, 2016 -- Researchers have been trying for decades to develop a vaccine against the globally endemic hepatitis C virus (HCV). Now scientists at The Scripps Research Institute (TSRI) have discovered one reason why success has so far been elusive.

Using a sophisticated array of techniques for mapping tiny molecular structures, the TSRI scientists analyzed a lab-made version of a key viral protein, which has been employed in some candidate HCV vaccines to induce the body's antibody response to the virus. The researchers found that the part of this protein meant as the prime target of the vaccine is surprisingly flexible. Presenting a wide variety of shapes to the immune system, it thus likely elicits a wide variety of antibodies, most of which cannot block viral infection.

"Because of that flexibility, using this particular protein in HCV vaccines may not be the best way to go," said co-senior author TSRI Associate Professor Mansun Law.

"We may want to engineer a version that is less flexible to get a better neutralizing response to the key target site and not so many off-target responses," said co-senior author Ian A. Wilson, TSRI's Hansen Professor of Structural Biology and a member of the Skaggs Institute for Chemical Biology at TSRI.

The report, published online ahead of print by the Proceedings of the National Academy of Sciences the week of October 24, 2016, is likely to lead to new and better HCV vaccine designs.

A Great Need

A working vaccine against this liver-infecting virus is needed desperately. HCV infection continues to be a global pandemic, affecting an estimated 130 to 150 million people worldwide and causing about 700,000 deaths annually from liver diseases including cancer. Although powerful antiviral drugs have been developed recently against HCV, their extremely high costs are far beyond the reach of the vast majority of people living with HCV infection. Moreover, antiviral treatment usually comes too late to prevent liver damage; HCV infection is notorious for its ability to smolder silently within, producing no obvious symptoms until decades have passed.

The Law and Wilson laboratories have been working together in recent years to study HCV's structure for clues to successful vaccine design. In 2013, for example, the team successfully mapped the atomic structure of the viral envelope protein E2, including the site where it binds to surface receptors on liver cells.

Because this receptor-binding site on E2 is crucial to HCV's ability to infect its hosts, it has an amino-acid sequence that is relatively invariant from strain to strain. The receptor-binding site is also relatively accessible to antibodies, and indeed many of the antibodies that have been found to neutralize a broad set of HCV strains do so by targeting this site.

For all these reasons, HCV's receptor-binding site has been considered an excellent target for a vaccine. But although candidate HCV vaccines mimicking the E2 protein have elicited high levels of antibodies against the receptor-binding site, these antibody responses--in both animal models and human clinical trials--have not been very effective at preventing HCV infection of liver cells in laboratory assays.

Enormous Flexibility

To understand why, the Law and Wilson laboratories teamed up with TSRI Associate Professor Andrew Ward and used electron microscopy and several other advanced structural analysis tools to take a closer look at HCV's E2 protein, in particular the dynamics of its receptor binding site. Their investigations focused on the "recombinant" form of the E2 protein, produced in the lab and therefore isolated from the rest of the virus. Recombinant E2 is a prime candidate for HCV vaccine design and is much easier to purify and study than E2 from whole virus particles.

One finding was that recombinant E2, probably due to its many strong disulfide bonds, has great structural stability, with an unusually high melting point of 85°C. However, the TSRI scientists also found evidence that, within this highly buttressed construction, the receptor binding site portion is extraordinarily loose and flexible in the recombinant protein.

"It adopts a very wide range of conformations," said study first author Leopold Kong, of TSRI at the time of the study, now at the National Institutes of Health.

Prior studies have shown that HCV's receptor binding site adopts a narrow range of conformations (shapes) when bound by virus-neutralizing antibodies. A vaccine that elicited high levels of antibodies against only these key conformations would in principle provide effective protection. But this study suggests that the E2 protein used in candidate vaccines displays far too many other binding-site conformations--and thus elicits antibodies that mostly do nothing to stop the actual virus.

Law and Wilson and their colleagues plan to follow up by studying E2 and its receptor binding site as they are presented on the surface of the actual virus. They also plan to design a new version of E2 or even an entirely different scaffold protein, on which the receptor binding site is stabilized in conformations that will elicit virus-neutralizing antibodies.


In addition to Law, Wilson, Ward and Kong, authors of the study, "Structural flexibility at a major conserved antibody target on hepatitis C virus E2 antigen," included Rameshwar U. Kadam, Erick Giang, Travis Nieusma, Fernando Garces and Netanel Tzarum, all of TSRI; and David E. Lee, Tong Liu, Virgil Woods and Sheng Li, of the University of California, San Diego.

Support for the study was provided by the National Institutes of Health (AI079031, AI123861, AI106005, AI123365, GM094586, AI117905, GM020501 and AI101436) and TSRI's Skaggs Institute for Chemical Biology.

About The Scripps Research Institute

The Scripps Research Institute (TSRI) is one of the world's largest independent, not-for-profit organizations focusing on research in the biomedical sciences. TSRI is internationally recognized for its contributions to science and health, including its role in laying the foundation for new treatments for cancer, rheumatoid arthritis, hemophilia, and other diseases. An institution that evolved from the Scripps Metabolic Clinic founded by philanthropist Ellen Browning Scripps in 1924, the institute now employs more than 2,500 people on its campuses in La Jolla, CA, and Jupiter, FL, where its renowned scientists -- including two Nobel laureates and 20 members of the National Academy of Science, Engineering or Medicine--work toward their next discoveries. The institute's graduate program, which awards PhD degrees in biology and chemistry, ranks among the top ten of its kind in the nation. For more information, see

Credit: Illustration by Christina Corbaci and Leopold Kong

Short-duration Treatment With Elbasvir/Grazoprevir and Sofosbuvir - HCV GT1 or GT3 with or without cirrhosis

Short-duration Treatment With Elbasvir/Grazoprevir and Sofosbuvir for Hepatitis C: A Randomized Trial
Eric Lawitz,1 Fred Poordad,1 Julio A. Gutierrez,1 Jennifer T. Wells,1 Carmen E. Landaverde,1Barbara Evans,2 Anita Howe,2* Hsueh-Cheng Huang,2 Jerry Jing Li,2 Peggy Hwang,2 Frank J.Dutko,2 Michael Robertson,2 Janice Wahl,2 Eliav Barr,2 and Barbara Haber2

This clinical study is the first to examine the treatment of patients infected with HCV GT1 or GT3 with or without cirrhosis with short durations of a novel regimen of EBR/GZR + SOF. Our data confirm that cirrhotic and noncirrhotic patients with HCV GT1 infection can be cured with 6–8 weeks of treatment, and that an 8–12 week regimen of EBR/GZR + SOF is safe and effective in cirrhotic and noncirrhotic patients with HCV GT3 infection, commonly regarded as one of the
most challenging patient populations to treat..
View Article - Download PDF

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/hep.28877

Future role of gastroenterologists in HCV therapy

LAS VEGAS — In this exclusive video from ACG 2016, Tram T. Tran, MD, FACG, medical director of liver transplantation, Liver Disease and Transplant Center, Cedars-Sinai, Los Angeles, discusses the role of gastroenterologists in future hepatitis C virus treatment, and how they will play a role in assisting primary care physicians in treatment

ACG American College of Gastroenterology
October 14, 2016 - October 19, 2016

Meeting Coverage
Healio brings you the highlights from the American College of Gastroenterology Annual Scientific Meeting. Refer back to this page often for the latest news from ACG, perspectives and interviews with leading researchers and clinicians, and to review archives of past meetings.