COMMENTARY

New Reason Your Patients With HCV Will Say 'Thanks a Latte'

David A. Johnson, MD

Disclosures

October 17, 2016

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Hello. I am Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Unfortunately, chronic liver disease is not an uncommon process in this country. We do not have great management strategies for drug modification, particularly as it relates to nonalcoholic fatty liver disease (NAFLD), but there are a variety of these patients who might benefit from the addition of coffee.

A recent meta-analysis of 11 studies[1] looked at the effect of caffeine consumption in patients with chronic hepatitis C. This is a very interesting study that built on animal data, and one which I think is worthy of some discussion with your patients.

There are growing data on [caffeine use in] metabolic-related disease and NAFLD, and [results of this study were] impressive for hepatitis C. The [investigators] did an excellent job of extracting, scoring, and assessing the quality of the studies [comprising the meta-analysis]. Six studies [evaluated] liver enzymes, and five studies used [advanced] hepatic fibrosis as an endpoint. Three studies looked at hepatitis C viral load, and two studies looked at the effects on hepatocellular carcinoma.

All of these studies came back with the same message—that caffeinated brewed coffee reduces risk for these endpoints. Why might that be?

The mechanisms are still not entirely clear, but there are several potentials. There is a potential hepatoprotective effect of caffeine. Caffeine has been known to alter liver signaling pathways and inflammatory pathways. In the fibrotic liver, hepatic stellate cells are activated and function in myofibroblastic differentiation, [which] leads to laying down of collagen and fibrosis. Caffeine not only represses the activation of these myofibroblasts, but also expression of a connective tissue growth factor.[1] The potential for decreased fibrosis in the matrix of the liver suggests that [caffeine] may be particularly helpful.

The effect of caffeine is interesting. A study found that animals pretreated with coffee had reduced hepatic necroinflammation and fibrosis after thioacetamide-induced hepatocellular injury.[2] When they tried to do the same model with nonfiltered coffee, there was no effect on the aggravation of liver injury induced by carbon tetrachloride. It appears to resonate across all of these studies that filtered brewed coffee [has the most effect].

Consistent across all these studies is that brewed caffeinated coffee, and not just caffeine, [is effective]. Green tea, sodas, and what have you seemed not to have the same protective effect as brewed caffeinated coffee.

Coffee has a tremendous number of ingredients. A number of alcohols, potassium, niacin, magnesium, and antioxidants are part and parcel of coffee. We know that when coffee is brewed, there is a reduction of organic compounds, particularly cafestol and kahweol, that can potentially raise serum cholesterol[3] and may actually be associated with increased cardiovascular risk. These get filtered out somewhat with the brewed filtered coffee, which may move toward a better outcome. The amount of brewed caffeinated coffee [needed to be effective] seems to be about three or more cups a day.

When you talk to your patients with any fibrotic liver risk (I have opened this up now to hepatitis C and NAFLD), it is very important not to miss the primary message. Patients with hepatitis C should get treated for their primary disease. Patients with NAFLD should lose weight, control diabetic glycemic index, and control lipids. If patients are drinking and they are an alcoholic, they need to stop drinking. Then they can consider three or more brewed cups of coffee a day.

Always bounce this off the primary care provider as well, to make sure there are no contraindications for the patient. But if they like their coffee, they can really take it up a notch. This is something that may add tremendous value. And again, do not miss the primary message here: It should never be something that would take the place of another therapy.

I guarantee that you will not get a prior authorization request from any of the coffee shops in your area or the grocery stores. Coffee tastes good, and it is something that we are not taking away from patients. This time we are telling them, "Bottoms up." Think about it, and add it to your armamentarium. The data are pretty exciting and extensive. If you like your coffee and your patients like their coffee, they are going to love you when you tell them this.

Thank you very much. See you next time.

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