Hepatitis C plus alcohol or marijuana: Which is worse?

Despite advances in hepatitis C therapy and better knowledge of viral/host factors related to disease progression, the hepatitis C virus remains the leading cause of chronic liver disease, causing progression to end-stage liver disease (ESLD) as well as the development of hepatocellular carcinoma. Because hepatitis C virus acquisition is linked to an addictive behavior (ie, injection drug use), any perceived dependence has been a major reason for treatment denial as well as exclusion from clinical trials. Of special interest are two such dependences: drinking alcohol and smoking marijuana (cannabis). We review the available evidence for the effects of alcohol and cannabis on liver disease progression in chronic hepatitis C, and conclude with recommendations regarding the use of these two substances in the setting of chronic hepatitis C.