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Pegasys mono or combo?
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Pegasys mono or combo?

I've been on Pegasys monotherapy since April 2008. My doc did not want to put me on combo therapy because he said he would follow only approved lines of treatment.
So far, the meds have reduced the viral load to below detectable levels. But I'm still HBsAg+ and BHeAg+.
Are any of you on combo therapy with Pegasys? If so, what? And how is it working for you?
Tags: hbv
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23 Comments Post a Comment
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Avatar_m_tn
If you are already responding to Pegasys in DNA UND, why do you want to add more drugs?  HBsAg and HBeAg changes may take time, and adding drugs may add side effects.
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751470_tn?1268502109
Thank you for responding, cajim.
Why do I want to add more drugs? I want to do all I can to get rid of this. If I have to use more drugs, so be it.
I agree about the side effects, but I already monitor my WBC, platelet and hemoglobin levels every week before administering the peginterferon -- because in my case, these three have gone below normal levels. Even if I have to monitor a couple of other factors, it's not such a big deal.
It's a pity I can't edit my question and fix my typo of HBeAg :-)
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Avatar_m_tn
It is not proven that adding more drugs is easier to get rid of HBV.  In general, anitviral drugs try to control the replication of HBV, not clearing of HBV.  And there is always the worry of resistance.
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751470_tn?1268502109
I agree with all that you wrote. One thought that nags me once in a while: there were some studies done for peginterferon alfa-2a+LAM, across various genotypes of HBV. One study for HBeAg- concluded that Genotype D _may_ possibly benefit from the combo, but the sample size was too small to draw conclusions. [ http://www.natap.org/2007/HBV/052507_01.htm ]
I did not want to go on combo with LAM exactly for the reasons you mentioned. I was wondering if there were other doctors or patients who go with PEG-IFNa-2a+something else.
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751470_tn?1268502109
Latest labs:
HBsAg (MEIA) - positive
HBeAg (ELFA) - negative
ALT                - 39.0 U/L

I guess the next step would be to get the HBeAb status. And I guess the results will sink in only if I re-do the HBeAg test at a different lab.
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Avatar_m_tn
Also test to find out your HBV DNA status.
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751470_tn?1268502109
Sounds like a good idea! Thanks!
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751470_tn?1268502109
Latest labs:
Parameter_______Value ___Ref. Range
AST (SGOT) _____ 20 _____15 - 37 U/L
ALT (SGPT) _____ 36 ______ 30 - 65 U/L

HBeAb ----------------- Non-reactive
HbeAg ----------------- Reactive

Does not look good.
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181575_tn?1250202386
The "e" flops happens.  I remember that my eAb was positive one time and it went back negative.

It's important to remember that the "eAb" and "eAg" is not a light switch where one turn on and the other off.  It's a balance between the two.  Eventually, it will stablize.

If you are responding well to pegasys, then try tostay on it as studies have shown that the longer you stay on the better (for the chance of "e" and "S" seroconversion).  But if the sides of staying on is getting worse, then perhaps, you could switch to a newer antiviral to hold DNA UND.  Although this is a good strategy, it is not "an approved line of treatment".
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751470_tn?1268502109
Hi Steven,
Thank you for your response. I can't continue with PEG-IFN any longer. It is not approved for more than a year's course. They (researchers) are doing trials with HCV... to figure out if it is safe and/or effective to continue a lower-dose treatment beyond the standard recommended period. But they are trying nothing of the sort with HBV, as far as I know.

There are two different criteria for calling treatment with PEG-IFN a success:  'e' seroconversion, and sustained low DNA count. I guess the next step is to get my DNA count done. I am not clear about what I should do if it turns out to be UND. The reason: 'e' positive means that the viral load is going to go high sooner or later, right?

This might mean the best course of action is to continue with something else right away. I guess I'll to start with entecavir right away, keeping in mind that the longer I stay in UND, the better.
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751470_tn?1268502109
I forgot to add... I was never eAb positive :-(
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181575_tn?1250202386
Since you didn't "e" seroconvert after 1 year of pegasys (which actually is not too surprising), transitioning to an antiviral now is still very good strategy.  Your current UND DNA will help enhance the resistance profile of antivirals.

And yes, if you do nothing and being eAg+, your DNA will like climb back up.  So start antiviral quickly..and you may be able to stay with mono treatment until you "e" seroconvert.

Be patient and good luck.
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751470_tn?1268502109
My updates:
After checking my VL 3 months after finishing my course (IDIOT!!!) of pegasys, I discovered that I had developed a thriving colony of viruses all over again - 3.6 million copies/ml. I am back HBeAg+. LFT was still quite normal.

Why did I wait for 3 months to check my VL? That is what my doc asked me to do, and that is the period that all the medical lit I have read recommend. Moral: don't assume even medical journals and international guidelines have all the best answers.

Started baraclude (entecavir) 0.5 mg now. Why monotherapy again and not some sort of combo, given that my VL is quite high: I will quit my job and become a student again (hopefully, if my german visa gets approved). I will not be able to afford 2 meds. Starting with one for now, and will keep testing often for a while. Will decide on combos based on what the tests reveal.

The medicine costs INR 6849 for a pack of 30 ~ €100. Or €3.35 per tablet. BMS and its associates here offer some discounts as long as I use their meds: 50% discount on VL tests, 3 free HBsAg tests for 3 family members or friends. Quite nice of them!

Roche was a bit more generous, though still a lot more expensive: Roche paid for all my VL tests, as long as I had the doc's prescription for each test.
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751470_tn?1268502109
Forgot to add one strange thing that happened to me, that I think I can primarily ascribe to pegasys. I had developed a need for eye glasses! I have never seen this documented as a side-effect of pegasys. The power was not much... just a bit of astigmatism: -0.25 L and -0.75 R. I began wearing it approx 9 months into the treatment. I discovered about a month ago that my vision is better without specs. I don't need it at all now.

I told this to my doc and asked him if we should report this to Roche as one of the possible side-effects. He said there was no need: this is known to happen. I'm slightly irritated that he did not tell me that when I called him up and told him that I have trouble seeing things clearly, and I see double images. In addition to that, Roche does not list this as one of the possible side-effects. I think he may have been BSing me.
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181575_tn?1250202386
As you case indicates, current treatment is too conservative.  It's reactive rather that proactive.  Well you can't dwell on the past and past decisions.  Make sure you monitor your LV with monotherapy.  If you have a limited response, try to combo it even if it means going back to mono shortly thereafter.  With antiviral, you need to go UND to minimize the risk for resistance.  Don't be reactive on this one.  Don't let the doctors say oops, we weren't agressive enough to bring you UND and now it looks like there's antiviral resistance, but it's okay, we just just bring you up to combo now.  
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751470_tn?1268502109
Thank you, Steven! I'll monitor closely this time.

Good to see that you are active here again :-)
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751470_tn?1268502109
Updating my thread again with my latest labs:
Parameter_______Value ___Ref. Range
AST (SGOT) _____ 20 _____49 IU/L
ALT (SGPT) _____ 32 ______ 49 IU/L
HBV DNA VL_____ UND_____ <100 copies/ml

Seems like the VL dropped from 3.6 million to undetectable with entecavir for about just 7 weeks. Methinks this is awfully quick. Mesuspects one of the lab results -- either this one or the previous one!
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948882_tn?1270557407
Wow - 3.6  million to UND in 7 weeks with Baraclude ? That is unbelievable!!

What about you eAg and eAb status ?
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751470_tn?1268502109
did not check recently. the last time I checked, a few months ago, it was eAg+ and eAb-. I'll check it again soon.
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948882_tn?1270557407
I looked at your orginal post on this thread and you went UND with Pegasys and end of July it was 3.6 mil.

Seems your July test is suspicious - you may have been UND then too. Another test might clear things up ? just a thought...

Also the eAg flop does not happen that often.

BTW - how are you feeling in general ? Once you confirm yourself that viral load is UND (I think (and hope) your latest result is correct), are you going to continue Baraclude ?



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751470_tn?1268502109
Yeah... what ***** is that I do not know which test to doubt. Even if the test equipment worked perfectly in both cases, it may still be the case that they fed someone else's blood sample one of the times! (things like this happen)

eAg flop happened because I was never eAb+: a clear sign that it is going to come up again. In any case, in hindsight, I probably should not have used pegasys given that I have genotype D.

I feel fine... as always :-). I intend to continue baraclude until I become eAb+. No combo now because the VL is undetectable (gotta confirm).
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Avatar_m_tn
Hi,

I noticed from your pega experience that it was relatively the same as my results after the 1 years course. Unlike you, however, i never managed to get my VL UND after the years treatment and therefore was then put onto combo treatment. I think this procedure is often see as the correct way of managing aggressive HBV simply because Pega is used to decrease the VL and the combo lowers it further (i reached UND 10 months after going on combo treatment of Adevoir + Lum).

I must admit it was quite disheartening to basically be told Pega hadn't done the job it should have and therefore combo was the next option. However, looking back it made me realise that these steps were all leading up to a decrease in my VL, enabled me to seroconvert and also to maintain a steady ALT result....

I believe the way you are going abouts your treatment is definately the right way to limit the damage your liver was incurring.

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Avatar_m_tn
... check out my experience with pega monotx ... I quitted it after 7 months and not having had any serocoversion.. so I'm still eag +.

The positive side is that I've not ha any side effect along the tx despite I was very scare of them.. so go for it.. Just try!
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