August 30, 2013

Hey Grandma, Let's Get You Checked for Hep C

Medscape Family Medicine > Best Evidence Review

Charles P. Vega, MD

Aug 30, 2013

Best Evidence Review of the USPSTF Screening Recommendations for Hepatitis C

The Study

Moyer VA; US Preventive Services Task Force. Screening for hepatitis C virus infection in adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013 Jun 25. [Epub ahead of print]


The prevalence of chronic hepatitis C virus (HCV) infection in the United States may have peaked over a decade ago, but there is convincing evidence that middle-aged and older adults born between 1945 and 1965 are at increased risk for infection. The most significant risk factor for chronic HCV infection is prior injection drug use, but the majority of adults with infection do not have this risk factor. Therefore, in additional to regular screening among high-risk groups, the US Preventive Services Task Force (USPTSF) now recommends 1-time screening for chronic HCV infection for adults born between 1945 and 1965.

While this recommendation may seem preposterous when thinking of your own Nana, do you really know what she was up to in 1968? There is good merit for the recommendation, which is discussed below.

Background to the Study

HCV infection is one of the most common chronic infections in the United States. Data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2002 indicated that the overall prevalence of HCV infection was 1.6% among adults aged 20-59 years.[1] This figure includes over 3 million adults with active infection, as defined by a positive HCV RNA test. Moreover, this testing probably underestimated the total prevalence of HCV infection because high-risk populations, including homeless and incarcerated adults, were not included in the research. In a study of over 400 homeless war veterans, the prevalence of HCV infection was 44.0%.[2]

Evidence of HCV infection is twice as common among women than men and among African Americans than white adults.[3] The most important risk factor for HCV infection is intravenous drug use. Nearly one half of the cohort that was positive for HCV infection in the NHANES study had this risk factor.[1] Other significant risk factors for HCV infection include receipt of blood transfusion before 1992, receipt of other blood products before 1987, and other drug use.[3] Sexual behavior is a less powerful risk factor HCV infection compared with HIV infection, but there is evidence that a history of multiple sexual partners is associated with a higher risk for HCV infection. Many individuals with HCV infection have overlapping risk factors for infection.

Why Screen All Baby Boomers?

Although the authors of the recommendations regarding screening for HCV infection note that the prevalence of HCV infection in the United States appeared to peak in 2001, there is another clear trend in the epidemiology of HCV infection that merits close attention. Persons born between 1945 and 1965 comprise approximately 27% of the total population of the United States, but they account for a disproportionate share of cases of HCV infection.[4] The prevalence of HCV infection in this age group is 3.25%, and approximately three quarters of active HCV infection cases are encountered among persons born between 1945 and 1965.

Moreover, and more important, persons who are currently in the fifth through seventh decades of life at this time are at the highest risk for complications from HCV infection. They account for 73% of mortality due to HCV infection, and this group is also at the highest risk for hepatocellular carcinoma and cirrhosis.[4] Therefore, the number of patients needed to treat with anti-HCV therapy in order to prevent additional cases of mortality is lower in this specific older cohort of adults compared with younger adults.

Therefore, it is not only the epidemiologic data that drive the new HCV screening recommendations from the USPSTF, but also an expectation that treatment of heretofore undiagnosed HCV infection can put a substantial dent in the broad clinical impact of HCV. The new recommendations call for 1-time screening for all adults born between 1945 and 1965 (B recommendation: high certainty that the net benefit is moderate, or moderate certainty that the net benefit is moderate to substantial). The anti-HCV antibody is test the best screening tool for these adults.

Limitations and Benefits of Age-Based Screening


The authors identify the limitations of the new recommendations. Although age-based screening should identify more patients with HCV infection, they admit that this method may be less efficient than risk-based screening. The potential harms of screening include stigmatization, but also the more tangible and serious complications of the diagnostic work-up of liver disease.

The rate of major complications after percutaneous liver biopsy ranges between 0.09% and 2.3%, with a trend toward higher complication rates in older studies.[5] Use of ultrasonography to guide liver biopsy may reduce the risk for complications by 30%. However, the authors of the current review note that overall use of liver biopsy is declining with greater reliance on laboratory testing alone to guide treatment. This will reduce the potential harms of screening for HCV infection.

A more serious complication of a large screening campaign for HCV infection among older adults is overdiagnosis, meaning the discovery of infections which would have no impact on the course of the patient's life. Up to 25% of acute infections with HCV may be cleared and do not progress to chronic HCV infection.[6] Despite the high numbers of patients with chronic HCV infection, only 10%-15% develop cirrhosis. The mean interval from infection to cirrhosis is a matter of debate but is approximately 20 years, and patients without other cirrhosis risk factors, such as chronic alcohol misuse or hepatitis B infection, are less likely to develop cirrhosis.

Benefits of Screening

Nonetheless, acquiring HCV infection at an age older than 40 years is also associated with a higher risk for cirrhosis, making overdiagnosis less of an issue among older adults.[6] In addition, treatment of chronic HCV infection has resulted in significant improvements in morbidity and mortality outcomes.

In research from 5 large tertiary hospitals in which 530 patients were followed for over 8 years for mortality outcomes, patients with a sustained virologic response (SVR) experienced a 74% reduction in all-cause mortality and a 94% reduction in the risk for liver-related mortality or transplantation compared with patients who did not have an SVR to anti-HCV therapy.[7] The mean age of participants in this research was 48 years, meaning that many patients included in the new screening recommendation might receive these substantial benefits of anti-HCV treatment.

Furthermore, treatment of chronic HCV infection reduces the risk for hepatocellular carcinoma. In a meta-analysis of 18 studies, SVR reduced the relative risk for hepatocellular carcinoma to 0.24 compared with no SVR.[8] SVR was similarly effective in reducing the risk for hepatocellular carcinoma in an analysis confined to patients with advanced liver disease.

The new screening methods also appear to be cost-effective. In an analysis of the proposed birth-cohort HCV screening plan proposed by the USPSTF, researchers found that screening would result in over 800,000 new cases of HCV infection identified, at the cost of $2874 per case.[9] Subsequent treatment for HCV would result in costs of $15,000-$35,000 per quality-adjusted life-year gained, a favorable sum compared with other health interventions. In fact, another analysis found that age-based screening for HCV was more cost-effective than risk factor-based screening, although the authors stress that this is true only if all new cases receive standard triple therapy for their infection.[10]

Adding to the PCP Tasks

Primary care physicians are asked to do many things. The average number of patient requests of physicians per clinic visit was 5.5 in one study, and this information is now 14 years old.[11] These requests exclude other important elements of the office visit, such as addressing severe anemia or demonstrating empathy and patience when the patient bursts into tears upon being asked, "So, how's it going?"

Primary care physicians are also the stewards of preventive healthcare, which is a wonderful opportunity and distinct challenge. We need to get screening tests ordered on time for the right patients, and practice shared decision-making each step of the way as we do so.

At first glance, the new screening recommendations from the USPSTF may seem superfluous. However, after reviewing the epidemiology, treatment outcomes, and even cost-effectiveness data, this screening certainly appears to be prudent and beneficial. It should be embraced by primary care physicians. It should also evolve. As the demographics of HCV infection shift, the age-based screening approach will almost certainly need to change as well. An eventual move away from HCV screening will indicate a great victory for the public's health.

Clinical Pearls

  • Between 1% and 2% of the adult population in the United States has been found to have chronic HCV infection, although this may be an underestimation once high-risk groups are added to the equation.
  • Persons born between 1945 and 1965 bear a disproportionate share of the disease burden of chronic HCV infection, both in terms of higher prevalence and increased rates of complications.
  • Treatment that results in SVR among patients with chronic HCV infection substantially reduces the risks for cirrhosis, hepatocellular carcinoma, and mortality.
  • The new recommendations from the USPSTF support traditional screening for HCV among high-risk groups but also call for 1-time screening using anti-HCV antibody testing among adults born between 1945 and 1965. If used widely, this screening program should have a positive effect on morbidity and mortality among older adults.


  1. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144:705-714.

  2. Desai RA, Rosenheck RA, Agnello V, et al. Prevalence of hepatitis C virus infection in a sample of homeless veterans. Soc Psychiatry Psychiatr Epidemiol. 2003;38:396-401.

  3. Rustgi VK. The epidemiology of hepatitis C infection in the United States. J Gastroenterol. 2007;42:513-521.

  4. Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012;61:1-32.

  5. Sporea I, Popescu A, Sirli R. Why, who and how should perform liver biopsy in chronic liver diseases. World J Gastroenterol. 2008;14:3396-3402.

  6. Chen SL, Morgan TR. The natural history of hepatitis C virus (HCV) infection. Int J Med Sci. 2006;3:47-52.

  7. van der Meer AJ, Veldt BJ, Feld JJ, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA. 2012;308:2584-2593.

  8. Morgan RL, Baack B, Smith BD, et al. Eradication of hepatitis C virus infection and the development of hepatocellular carcinoma: a meta-analysis of observational studies. Ann Intern Med. 2013;158:329-337.

  9. Rein DB, Smith BD, Wittenborn JS, et al. The cost-effectiveness of birth-cohort screening for hepatitis C antibody in U.S. primary care settings. Ann Intern Med. 2012;156:263-270.

  10. Liu S, Cipriano LE, Holodniy M, Goldhaber-Fiebert JD. Cost-effectiveness analysis of risk-factor guided and birth-cohort screening for chronic hepatitis C infection in the United States. PLoS One. 2013;8:e58975.

  11. Kravitz RL, Bell RA, Franz CE. A taxonomy of requests by patients (TORP): a new system for understanding clinical negotiation in office practice. J Fam Pract. 1999;48:872-878.


Gilead Sues Merck Saying New Drug Won’t Infringe Patents

By Karen Gullo - Aug 30, 2013 9:16 PM ET

Gilead Sciences Inc. (GILD), the world’s largest maker of HIV medicines, sued Merck & Co. (MRK) seeking a court order that the experimental hepatitis C drug sofosbuvir won’t infringe patents.

Merck, which sold $502 million of its Victrelis hepatitis C drug last year, contacted Gilead this month requesting it license two patents Merck says are related to sofosbuvir, Gilead’s attorneys said a complaint filed today in federal court in San Francisco.

Merck, based in Whitehouse Station, New Jersey, asked Gilead to pay a 10 percent royalty on the net sales of the medicine until the patents expire, a request “meant to threaten Gilead” on the eve of U.S. regulatory approval of sofosbuvir, according to the complaint. Gilead seeks a judge’s declarations that the patents aren’t enforceable or infringed so it won’t have to license them to sell the medicine.

Gilead, based in Foster City California, said June 7 that sofosbuvir will receive a priority marketing review by U.S. regulators with a target review date of Dec. 8.

Hepatitis C attacks the liver and can lead to liver cancer. The virus affects about 150 million people worldwide and the market for new pills such as sofosbuvir is estimated at $20 billion.

Lainie Keller, a Merck spokeswoman, didn’t immediately respond to an e-mail after regular business hours seeking comment on the lawsuit.

The case is Gilead Sciences v. Merck, 13-04057, U.S. District Court, Northern District of California (San Francisco).

To contact the reporter on this story: Karen Gullo in San Francisco at

To contact the editor responsible for this story: Michael Hytha at


Yes, Gilead Did It Again

Aug 30 2013, 14:39 | by: Prohost Biotech | about: GILD

Biotechnology accomplishments as we see them and love to write about them are those that act as rings in the chain of the fast advancement in the management of condemning diseases, not just developing and marketing more me-too drugs.

Here is a story told by the National Institute of health and posted in JAMA about an all-oral hepatitis C drug regimen where a majority of hepatitis C viral (HCV) infected patients with liver damage were cured following a six-month course of all-oral treatment. The combination therapy comprised the investigational drug sofosbuvir, with the antiviral drug ribavirin. The company behind the treatment is Gilead Sciences. (GILD).

The results were remarkable considering the fact that the patients had advanced disease with scarred liver and most were from a category known to be resistant to current treatments. The results were announced by the National Institutes Of Health (NIH), as scientists from the National Institute of Allergy and Infectious Diseases (NIAID) and the NIH Clinical Center, which are parts of the National Institutes of Health, have led the trial.

The findings, which appeared in the Aug. 28 issue of the Journal of the American Medical Association ((JAMA)) demonstrate that the regimen was highly effective in clearing the virus and was well tolerated in a group of patients who historically have had unfavorable prognoses.

The study involved 60 volunteers with genotype-1 HCV, which is less responsive to interferon-based treatment.

Fifty of the 60 participants were African-American. NIAID researcher Shyam Kottilil, M.D., Ph.D., the principal investigator of the trial said, "While African-Americans make up about 13 percent of the U.S. population, they represent more than 22 percent of people with chronic HCV infection and, compared to whites, have lower cure rates with traditional HCV therapy."

Dr. Kottilil tried to draw attention to the fact that several recently completed studies testing interferon-free regimens have yielded promising results, but unlike this study, most volunteers in those studies were white. Also, the new study enrolled people with severe liver damage as well as those with mild or moderately scarred livers.

The first part of the two parts study enrolled ten people with mild or moderate liver fibrosis. Volunteers received oral ribavirin at a dosage based on their weight along with the experimental drug sofosbuvir, also in pill form developed by Gilead Sciences taken daily for six months.

Nine of the ten volunteers completed the course of therapy. The hepatitis C virus was undetectable in all nine volunteers 12 weeks after the end of therapy and continued undetectable when they were tested again 24 weeks after finishing therapy.

Dr. Kottilil explained, "HCV does not integrate itself into human DNA. If the virus cannot be detected for a period of 12 weeks after stopping therapy, the patient is considered cured."

The second part of the study enrolled 50 volunteers, Thirteen had liver damage rated serious. Twenty-five received ribavirin based on their weight, and 25 received a low dose (600 milligrams per day). All received sofosbuvir.

At four, 12 and 24 weeks after the end of treatment, HCV levels were undetectable in 24 of the volunteers in the high dose arm when treatment ended. Of those, 17 continued to have undetectable virus levels 24 weeks later and were considered cured of infection. In the low-dose arm, three volunteers dropped out of the study. Of the remaining 22, all responded to the treatment, but only 12 were considered cured at 24 weeks after the end of treatment.

Commenting on the result in general, Dr. Kottilil said, "We saw an overall cure rate of about 70 percent using regimens that did not include interferon," He added, "This is an encouraging result, especially considering the proportion of volunteers who had characteristics such as being male, having HCV genotype-1 infection, being African-American and having advanced liver damage - all are recognized as predictors of poor response to treatment."

Additional trials are underway to further determine if regimens without interferon or ribavirin can help people with chronic HCV infection, particularly those who have both HIV and HCV infections, said Dr. Kottilil. These trials include two studies in which volunteers with or without HIV infection take a combination of HCV drugs (but no interferon or ribavirin) for periods of three months or less.

Information about these trials is available at using the identifiers NCT01805882 and NCT01878799.

Prohost Comments: This story might partially explain the reason why we consider Gilead as the model of firms that we seek to find and invest in. The firm specialized in Viral diseases and began by creating what amounted to miraculous achievement, turning a deadly killer disease, AIDS, into a chronic disease. It courageously paid a huge amount of money, over $11 billion, to put its hands on molecules for HCV infection, knowing in fact that it will develop these molecules in a way that extracts the best out of them, including treating hopeless cases with poor prognosis.

We agree with the NIAID Director and study co-author Anthony S. Fauci, M.D. that there is a pressing need for hepatitis C virus treatments that are less burdensome to the patient, have fewer side effects and take less time to complete.

The number of patients suffering from HCV infection is overwhelming. More than 3 million Americans suffer this liver infection - a major cause of cirrhosis, a leading cause for liver transplantation and in many cases end with liver cancer. People die from HCV and it seems that HCV claims the lives of 15,000 people every year in the U.S.

Gilead's success and fame is based on its strong scientific fundamentals, excellent management abilities and, more important, its persistent efforts towards improvement. Gilead is ready to spend enormous time and money and do whatever it takes to perfect its specialized treatments. It is one of the few largest biotech firms in spite of the fact that it is still at the beginning of the road towards fulfilling its ambitious goals.

Disclosure: Long GILD.

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Chimp-free labs are bad news for fight against hepatitis C

by Elizabeth DeVita-Raeburn @devitaraeburn August 29, 2013 6:30AM ET

Vaccine researchers say an end to testing on chimpanzees would be a major setback

Topics: Disease, Science


A NIH researcher studies DNA map of the hepatitis C virus

Richard T. Nowitz/Science Source

Earlier this summer, Francis Collins, the director of the National Institutes of Health, announced that the agency would significantly reduce the use of chimpanzees in scientific research. The Fish and Wildlife Service is now deliberating whether to add captive chimpanzees — a category that includes the 50 chimps the NIH set aside as a safeguard for research that could not be done any other way — to the endangered species list.

If that happens, it would mark the end of medical research using chimpanzees in the United States. Animal activists have long sought the end of chimp research, and many medical researchers also celebrated the NIH decision, saying research on the animals had become obsolete. For HIV studies, the chimps’ utility is nil; with research on malaria and other diseases, better approaches exist.

But the decisions have troubled a small number of scientists struggling to develop a vaccine for hepatitis C, a serious liver disease most common in intravenous drug users, but also found in baby boomers, veterans, health-care workers and babies born to hepatitis C–infected mothers. They say ending use of chimps will dramatically slow their research.

Hepatitis C researchers think one reason they failed to win their case with the NIH is because so many of the victims are, or have been, intravenous drug users. Some of the doctors who see patients say that the stigma associated with this disease is reminiscent of the early days of the AIDS epidemic, when research and patients suffered because of the perception that it was a "gay" disease that people had brought on themselves.

Hepatitis C, which six years ago surpassed AIDS as a cause of mortality in the United States, may have taken up the niche that AIDS once occupied. "It's stigmatized and totally lacks the advocacy and cachet of HIV," says David Thomas, director of the division of infectious disease at Johns Hopkins University. That's largely, he says, because of its link to drug use.

'A screeching halt'

In announcing the NIH decision, Collins said the chimps' "likeness to humans has made them uniquely valuable for certain types of research, but also demands greater justification for their use. After extensive consideration, with the expert guidance of many, I am confident that greatly reducing their use in biomedical research is scientifically sound and the right thing to do." A NIH spokesperson declined to comment on the specific concerns of hepatitis C researchers.

Those researchers say they have few alternatives. Chimps are the only creatures, other than humans, susceptible to the hepatitis C virus. Because of this, chimps have long been considered essential for studying the disease and potential treatments — particularly a vaccine.

Francis Chisari, a virologist with the Scripps Research Institute who has been working on a vaccine, said that more than 20 years of research came "to a screeching halt" with the NIH decision. The consequences for researchers who've devoted careers to this endeavor are devastating, says Chisari. Many, he says, are considering leaving the field.

But more troubling for researchers are the consequences for people who have the disease or are at risk. Hepatitis C afflicts between 3 and 4 million Americans, most of whom don’t know they have it until its later stages. Unchecked, the disease is a serious risk factor for liver failure and liver cancer. Experts attribute a recent spike in incidence of liver cancer in the U.S. directly to this virus.

Devon Nicholson, 30, who has had the virus since 2009, called the NIH decision "sad" for patients. "I’m an animal lover; I have a lot of empathy for them," he says, "but I do think our own species should be a priority. This is a widespread, infectious disease. The treatment is hard to take, it's expensive, and from what I understand, the number of people infected is growing. This is a serious health concern for the future."

Nicholson, a former wrestler, was on the verge of realizing his life's dream — a lucrative professional wrestling contract — when a blood test, given as part of the required physical for obtaining a license to wrestle professionally, turned up positive for hepatitis C. The deal was canceled. He suspected that he’d been infected when another wrestler "bladed him" — nicked him with a concealed razor — during a match to make it bloodier and more exciting.

Self-blading is not an uncommon practice for wrestlers who want to put on a good show. "It just produces a trickle of blood, and it seals up pretty easily," says Nicholson. But you don’t nick someone else without permission, he says. His theory was proved true, he says, when he watched a videotape of one of his matches and saw his opponent, who has since tested positive for the disease, take out a razor, blade himself, and then blade Nicholson four or five times on the forehead. "It was just the same as sharing a needle," says Nicholson.

New drugs

The last few years have seen an explosion of new and better drug options to treat hepatitis C, which may also be part of the reason hepatitis researchers lost their case with the NIH. Two new drugs, designed to be used in combination with existing therapies, were approved in 2011, and there are six more in the pipeline. This has led some to believe that researchers have conquered hepatitis C and a vaccine is no longer necessary.

But vaccine researchers say this isn’t true. The drug regimens may be capable of clearing the virus, but they don’t protect people from being reinfected, says Andrea Cox, a physician and researcher at Johns Hopkins University who is currently working on a trial of the one hepatitis C vaccine that was tested in chimps before the NIH decision. And the treatments themselves, at this point, are hard to take and quite expensive, about $88,000, according to Cox.

Nicholson has gone through two painful rounds of extensive drug treatment to try and get rid of the virus. The first round had to be stopped at 19 weeks, when he suffered a mild stroke. He doesn’t know yet if the second attempt, an arduous 37-week regimen that he documented via a blog and his Facebook page, has worked. He’ll be tested in mid-September to see if the virus is still in his system.

Predictions of an epidemic

Not all people with hepatitis C are drug abusers. Baby boomers are designated high risk because of potentially risky behavior experimenting with drugs in the era of sex, drugs and rock and roll, and their potential exposure to tainted blood before screenings for the virus became possible. Hepatitis C has even struck some celebrities, including Natalie Cole, Steven Tyler, Naomi Judd and Pamela Anderson. Though they have been open about their infection, their celebrity has, thus far, not changed perception of the disease.

Vets are at risk because of exposure to blood on the battlefield and transfusions before screening. Studies by the Department of Veterans Affairs have shown a hepatitis C prevalence rate of between 5 percent and 22 percent among military veterans.

And some experts, like Marian Major, a research microbiologist at the Food and Drug Administration who works on hepatitis C, predict another “sadly massive epidemic” coming in the form of young suburbanite teens casually experimenting with injectable drugs. “They think they’re safe as long as they’re with people they know,” says Major.

A vaccine could head off a lot of that. But not having chimps to test hepatitis C vaccines will “severely retard” the process, say Chisari and others. Without the chimp, researchers will have to conduct trials on humans earlier, with less assurance of efficacy. "You could end up recruiting patients for a vaccine that has no effect," says Major. And one large question is: will drug companies, faced with this inconvenience, bother with vaccine research when drug options are easier to produce?

The most likely alternative to chimps would be to create mice genetically engineered to be susceptible to the virus — a difficult and time-consuming project that has seen progress recently but by all accounts is nowhere close to being a stand-in for the chimp.

Meanwhile, patients are muddling through their options. Nicholson, who is Canadian, said he called researchers at the University of Alberta to see if a vaccine would be available after he completed his treatment. If he tests negative for the virus, he says, he wants the vaccine "to ensure I never get this disease again, no matter what." He was told it would be at least another 10 years.


Studies: Marijuana May Help Hepatitis C Sufferers

Posted on August 30, 2013 at 9:14 am by David Downs in Health

Hepatitis C is an often-fatal viral disease of the liver afflicting about four million Americans. Chronic hepatitis C infection causes fatigue, depression, joint pain and liver impairment, including cirrhosis and liver cancer. There is no cure.

Interestingly, patients diagnosed with hepatitis C often report using cannabis to treat both symptoms of the disease and the nausea associated with antiviral therapy, and there’s some science to back it up.

“An observational study by investigators at the University of California at San Francisco (UCSF) found that hepatitis C patients who used cannabis were significantly more likely to adhere to their treatment regimen than patients who didn’t use it,” writes today. is co-sponsored by The Massachusetts Medical Society, publisher of the New England Journal of Medicine, as part of their continuing medical education of physicians.

“Preclinical data indicate that the endocannabinoid system may moderate aspects of chronic liver disease and that cannabinoids [– the active ingredients in pot -] may reduce inflammation in experimental models of hepatitis,” writes.

“Cannabis use improves retention and virological outcomes in patients treated for hepatitis C,” one study concludes.

“Writing in the October 2006 issue of the European Journal of Gastroenterology, investigators from Canada and Germany concluded that cannabis”potential benefits of a higher likelihood of treatment success [for hepatitis c patients] appear to outweigh [its] risks.’

“Nevertheless, no clinical trials assessing the use of cannabinoids for this indication are available in the scientific literature,” TheAnswerPage writes, and “some experts discourage the use of cannabis in patients with chronic hepatitis, until further studies are performed.”