Chronic Hepatitis C
Roderick Remoroza, MD, and Herbert Bonkovsky, MD
Although most patients with chronic hepatitis C are asymptomatic, an appreciable number will experience symptoms that are due to the liver disease and/or extrahepatic manifestations of HCV infection. Recognition of these symptoms will lead to early diagnosis and treatment of hepatitis C. Fatigue is the most common symptom of chronic hepatitis C and is most often mild. Intermittent right upper quadrant pain, anorexia and nausea occur less commonly.
Chronic hepatitis C infection predisposes patients to the development of diseases involving other organ systems including the kidneys, the skin, eyes, joints, immune system, and the nervous system. There are many extrahepatic manifestations of hepatitis C: some are relatively common (e.g., cryoglobulinemia), whereas others are infrequent and their association with hepatitis C has not been clearly defined. Only the common extrahepatic manifestations with clear association with hepatitis C will be discussed in this review.
CRYOGLOBULINEMIA
KIDNEY MANIFESTATIONS
SKIN LESIONS
RHEUMATOLOGIC and AUTOIMMUNE MANIFESTATIONS
LYMPHOMA
EYE MANIFESTATIONS
Mike
Ron update
Man when Copyman speaks people listen LOL
THANKS Copyman..............the thing i like about Copy
is that you get no BS From him, he simply tells it like it is...
no sugar coating just honest opinions based on good info
..................Ron update...
i just did TX #14 last night (friday night)
so in ten weeks i will get that VL blood work done in week 24....
249lbs at start, im down to 218lbs now
no beer, no cheeseteaks, no chicken wings, no hoagies...
nothing taste that good any ways..
1600mg of Riva per pay (800 2x per day)
PEGINTRON 2B, hightest does 5ml
i would like to test by week 16
im am seing my PRIMARY CARE physician on Wed
i will ask him to do the test..........(i dont know what his response will be)
2nd opinion............i have a friend who will help me get an appointment
for an evaluation from a top HEP doctor at the UNIVERSITY OF PA
Im hoping for an evaluation from him...
My doctor did not elabortate on why he was pleased with my 12 week VL
Count..............we discussed so many things in this short visit,,,thats it
hard to remember exactly how he phrased this comment..
but now he is optimistic i will be UD no later than week 24
and he seems to think 48weeks will be enough for...
..
...............This was music to my Ears............IF however there is 72weeks
TX in my future, i wont even think about til week 24 or until after the new year..
The doc is dangling a carrott and im gonna chase that HOPE..
by week 24 im shooting to be UD, and hopefully down to 200lbs..
im not sure which of the two will be harder to accomplish ..lol
i want to thank ALL of you for taking the time to help me with my HEPATITIS
situation..........you people are the greatest THANK YOU ALL
and a special thanks to my friend Copyman
Ron (pokerron)
ps I PLAY in poker tourneys at ULTIMATEBET every night
its great for keeping my mind off of this hep stuff
small stakes no big deal
Sincebirth switched pegs and went on to finish 72 weeks of treatment recently.
Sincebirth's stats:
Viral load count - Geno type 1
Week 0 - 1,780,000
Week 8 - 353,000
Week 12 - 488,000 (went up)
(Changed from PegIntron to Pegasis at week 16)
Week 20 - 15,300
Week 24 - 317
Week 28 Undetectable (below 10)
Week 36 Undetectable (below 10)
Finished week 72 a week or so ago.
Here is a fairly recent abstract of a study of very difficult to treat geno 1s who were divided into four groups that took regular doses of pegasyis and riba or high doses, all four groups for 48 weeks. It found that higher doses of peg and riba get better results than the lower doses for difficult to treat groups.
http://www.natap.org/2006/AASLD/AASLD_43.htm
Group A: Peginterferon alfa-2a (40KD) 180 _g/week plus ribavirin 1200 mg/day (n=46).
Group B: Peginterferon alfa-2a (40KD) 180 _g/week plus ribavirin 1600 mg/day (n=47).
Group C: Peginterferon alfa-2a (40KD) 270 _g/week plus ribavirin 1200 mg/day (n=47).
Group D: Peginterferon alfa-2a (40KD) 270 _g/week plus ribavirin 1600 mg/day (n=47).
A very tough to treat group here: "Mean bodyweight was 97 to 101 kg, that's 200 to 230 lbs, heavy. Body mass index (BMI) was 31.7 to 33.3 kg/m2, big. 9-13% were Black, 62-74% Caucasian. Mean HCV RNA was 4.9 to 6.2 logs. 17-19% had cirrhosis." The mean viral load each group ranged between 4.9 million and 6.2 million iu/ML.
Note that almost 20% of each group had cirrhosis.
Some of the findings:
Only one patient of 46 in Group A achieved UND by week 4. 6 of 47 were UND by week 4 in Group D.
"Among groups A, B and C, respectively, the relapse rates between week 48 (end of treatment for all groups) and week 72 were 40% (8/20), 42% (11/26), and 46% (12/26). In comparison, the relapse rate in patients treated with the most intensive regimen (group D) was only 19% (5/26)."
Only 28% of Group A achieved svr; 47% of Group D achieved svr.
peg-intron is full dosed @ .5/150. He's getting the full load.
i'm not sure about the peg intron dosage, i will let poker answer that but i think it is the standard max dose. from what it sounds like his doc is very conservitive and would never prescribe 2000mg of riba. how do you feel about switching pegs? do you have any studies on that, does it work? or perhaps infergern? thanks again
PS, LOL that was funny what you said about me in the first response above. you got a great sense of humor to go along with your vast knowledge of this disease.
I don't think it changes anything about continuing, however it's possible that even 1600 mg/day of ribavirin isn't enough, as different people metabolize ribavirin differently -- and for that reason, some here I believe are on 2000 mg/day of ribavirin.
But again, whether or not to further increase riba depends on a number of factors including pre-tx and current hgb levels, side effects, other medical conditions, etc. It's certainly a strategy worth exploring with his doctor in a methodical and cautious way. If riba is increased beyond 1600 mg/day, I think weekly (or even more often) CBCs would be in order until hemoglobin levels off.
Sorry, not that familiar with Peg Intron. Is "5ml" the standard dose for Poker's weight?
-- Jim
I did read that some doctor(s) recommend switching Pegs if response does not meet certain requirements, but don't remember anyone here posting they did so (mid treatment), nor am I aware of any studies. Keep in mind that Poker is definitely responding to the Peg Intron -- just not as completely as would be ideal -- that's why I suggested reviewing his riba dose with the doc. Again, he's a big guy, and even in spite of size, some people metabolize riba slower than others.
-- Jim
thanks jim for responding, i forgot a very important factor to mention, poker is on a high dose of riba & peg , 1600 riba & 5ml pegintron. and still did not go unde at 12. does this change anything about continuing?
hey Ron, glad your feeling well and that you are responding. i am a little ahead of you on tx and have similar stats as you. me- 50 yo M, 1a, 200 lbs. start VL 3 mil, 12 week VL 55 , 15 week VL UND. tonight is shot # 21. i know exactly where you are coming from on tx options. the more i read the more i am inclined to extend to 72 weeks. i will see my Dr. in 2 weeks and ask him. i really trust my Dr. and probably will feel ok with whatever he suggests. however, from all i've been reading lately, recent data does suggest extending if still detectible at 12 weeks. you and i have plenty of time to sort that out. just keep up with your meds and take care of youself. and of course, drink lots of water!
Paragraph 2 should read in part:
"...That said, some recent studies suggest that it's *undetectible* we're really looking for by week 12 or earlier. They further suggest/recommend that those that still show virus at week *24* have a better chance of SVR (cure), as opposed to treating the standard 48 weeks...."
Paragraph 3 should read in part:
"...Right now, your first 'job' is to get non-detectible by week *24*..."
Paragraph 5 should read in part:
"...That said, at *249* lbs..."
I was going to ignore the post when read you were a friend of "Copyman", but you got me in a good mood tonight -- Just kidding of course, "Copy" is one of the good guys here who always has time to help out.
It's understandable that your doctor is happy with your viral response, as you did have a two-log drop during the initial 12-week period. That said, some recent studies suggest that it's *undetectible* we're really looking for by week 12 or earlier. They further suggest/recommend that those that still show virus at week 12 have a better chance of SVR (cure), as opposed to treating the standard 48 weeks. And even the 72-week scenario assumes that the patient will be non-detectible by week 24, and if not, then the recommendation is often for treatment to simply stop because the odds of SVR are simply too low.
Right now, your first 'job' is to get non-detectible by week 12. And while there are no stats on differences between being UND at week 16 vs 24, for example, testing monthly (or even every two weeks at this point) until non-detectible should provide useful data in terms of viral response. In other words, why wait till week 24, if you can get interim data that might suggest some change(s) in medications.
One change -- and something you might talk to your doctor about right now -- would be to increase your ribavirin. This is hypothetical/discussional because I don't know your daily dose of riba, don't know your pre-tx and post tx hemoglobin levels, don't know how you're tolerating the tx drugs -- plus I'm not a doctor, etc.
That said, at 245 lbs. you're a big boy, and the weight-based studies suggest you should be on at least 1400 mg/day of ribavirin. So, if you're not taking 1400 mg/day, you might speak to your doctor about increasing the dose to 1400 or more, depending again on how much of a drop in hemoglobin you've had since starting treatment and how you're tolerating the side effects. Another strategy, might include also increasing the amount of Peg until non-detectible. But in any case, interim testing between weeks 12 and 24, should help guide you and your doctor in terms of progress toward non-detectible.
Assuming you reach non-detectible by week 24, then the question becomes how long to treat, I don't have the studies at hand, but at that point I'd personally want to do some more research including ordering the FULL-TEXT studies (not just abstracts) and discussing them with my doctor. If I didn't feel my doc was up (or motivated) to the task, then I'd arrange for a consultation with another doctor. Best doctor to consult with would be a hepatologist (liver specialist), and frankly, if logistics and insurance allows, you might even want to get that consult now, as it appears you're seeing a gastro.
Regarding the 72-week studies mentioned, keep in mind that some of them did not use weight-based riba dosing but used a flat 800 mg of riba a day. This must be factored into the results. Another factor is your stage 2 status, which means you do not have significant liver damage. So the question here is how long do you want to expose yourself to the treatment drugs, i.e. balancing the risks of the tx drugs themselves against a better chance of SVR by staying on those drugs longer. A lot here has to do with how you're tolerating treatment, how much better the odds would be with 72-weeks, and the analysis of the aforementioned by both you and your doctor. (Some doctors and some patients are just more agressive than others(I consider 'Sonic' to be agressive btw as is my own doc) and to be clear I'm not using 'agressive' in either a positive or negative way).
Lastly, did your doctor elaborate why he was positively "surprised" at your results. Little confused on this.
Hope this helps some.
All the best,
-- Jim
hi jim & sonic, was wondering if you could help pokeron with this post, he is a friend of mine and i told him that you guys and others here will give him some great advise. as you see he just found out he is still detectable at 12 weeks and his doc tells him he will not test again until 24 wks. please tell him what the protocols are for tx'ing and odds for SVR being detectable at 12 weeks. not sure if i was right but i told him to test no later then 16 weeks and if still detectable stop tx and either wait for better meds, try a different peg or maybe Infergen. thanks