4 week PCR results

Well…I got my 4 week PCR results back today and I only got a one log drop from 848,000 to 38,600. To be honest, I thought RVR was a long shot considering my stats going in, but with the amped up doses, I really thought I’d see more of a drop. So now instead of decreasing the Pegasys down to 1 ½ doses a week, I am to stay at the full 360 mcg a week and stay at 1400 Riba until the 12 week mark and then extend SOC to 72 weeks. I’m almost too disheartened to cry right now, but I’m sure the tears will come at some point. I still wonder if I am getting enough…what do you call it? Saturation?  with the Riba even at 1400 mg since my hgb is hard pressed to budge downward.  But the thought of upping it to 1600 makes me almost physically ill, not that it’s been recommended.

So what do you do? Cuss and cry it out for a day then start putting one foot in front of the other again. I mean, what else can you do?  I want to clear, but I don’t want to nuke myself in the doing…… So I’ll give myself another jab tonite and hopefully kill off a few more of those buggers, Any suggestions of anything more I could try, even if it's outside the norm?

Pam

[zazza]

It is a 1.34 log drop, which is good enough for a geno 1 at week 4. Sure enough, you might be heading for 72 weeks, but at least you are responding. A lot of geno 1s do not respond.´I see you are on a tough regime. Wishing you well, Za

[epiphiny]

You could try increasing the amount of fat you are taking with your riba meal to try and increase your riba absorption, rather than taking more riba.  And make sure you are not taking your riba with fibre or antacids - riba binds to the fibre and moves through too quickly to absorb well, antacids block the absorption.  

Riba likes to bind to fat.  I have really noticed a difference in the sx when I take my riba with more fat...

[justme53]

Thanks for the encouraging words...

Zazza....a 1.34 log drop sounds loads better than a measly 1 log...and it is going down. And an evr at 12 weeks is my new goal!

Epi - I've been taking my Riba with a meal at 8 am and 6 pm and then with a spoonful of VCO..yet my hgb just began a slow decline the past week (4)You said you noticed a difference in sx since you started taking Riba with fat....I'm assuming you mean less of them?

Now if I can get my WBC's and platelets to stabilize.......

[HectorSF]

Pam,

I don’t know your medical history details (liver condition, treated before etc.) but you seem to be on track generally.

RVR (Rapid virologic response) occurs in approximately 15% of patients (SRV rate 90 %) with HCV genotype 1.
Most genotype 1 patients, 35 %, achieve undetectable HCV RNA before week 12. And 66 % of these patients achieve SVR.
15 % achieve undetectable HCV RNA between weeks 12 – 24. SVR rate 35 %.

All is not lost by any means. As long as your viral load becomes undetectable before week 12 you still of a greater than 50 % chance of achieving SVR.

By the way your platelet count is at 95,000 I believe. Which is plenty of platelets. You have a long way to drop to even get close to danger there. (20,000).

Hopefully your next HCV RNA test will be UND or close to it.

Best of luck.
HectorSF


All is not lost by any means. As long as your viral load becomes undetectable before week 12 you still of a greater than 50 % chance of achieving SVR.

By the way your platelets are at 95,000 which is plenty. You have a long way to drop to even get close to danger there. (20,000).

Hopefully your next HCV RNA test will be (848,000 to 38,600) UND or close to it.

Best of luck.
HectorSF

[jmjm530]

To be honest, I thought RVR was a long shot considering my stats going in,
-----------------
Sir if I missed it or forgot, what exactly are your stats and any prior treatment history if any --, and why is it that you already committed to 72 weeks when you still have a chance to be undetectable by week 12? that's a fairly aggressive approach, but again, not sure what your stats are, possibly your stage four?

As to the hemoglobin, you mentioned hasn't budged much. What was your pre-treatment hemoglobin and what is it now? how much do you weigh?

[copyman]

if possible i would do pcr's weekly or at least week 8 (draw blood day of 9th shot but before shot) to see exactly when I became UNDE. If early enough and also unde at 12 & 24 weeks I would only do 48 weeks of tx.  with new drugs in the pipe line no way would I subject my body to 72 weeks of these drugs. Best of luck

[jmjm530]

yes, weekly tests are ideal,  although given the drop, probably no big deal if you skip week five and test from six until undetectable.

[justme53]

I am tx naive, Stage 4, Grade 3, 55 years old, weight 145. The idea to treat until 72 weeks if not clear at 4 weeks is the Dr.s. I do two shots of 180 mcg Peg each week and 1400 Riba per day. Even at the higher dosing, my sx are very few which is why I was wondering if it was working.

[jmjm530]

I thought you might be stage four  and  in that context, the doctor's strategy is quite reasonable. depending on your hemoglobin drop from pretreatment, you still may be under dosed with the ribavirin.

[justme53]

hemoglobin pre tx was 14.4
week 1  14.5
week 2  14.0
week 3  13.6
week 4  13.7

not much of a change

[Trinity4]

I had about the same vl drop you did at 6 wks.  By 12 wks I was at 793.  24 wks UND.  I wish now I had tested more often and knew the exact week I became UND.  I had two peg dose reductions at wks 6 - 7 due to low ANC and platelets.  I would have never dose reduced had I known then what I know now but none the less I did respond and went UND probably somewhere around 15 wks. Hgb was 12 starting out and never got below 11 until recently. I'm taking 1000 mg of riba and lots of fat with it. I'm 115 lbs so it wouldn't be healthy for me to take more than that.  People react differently and the body absorbs, processes and interacts with the interferon differently regardless of what we do.   I'll be doing 72 wks but I would also wait and see what happens at 12 wks before resolving yourself to a 72 wk regime.
Good Luck
Trinity
I was slow coming out of the starting gate but I finally caught up and you are repsonding so keep your eye on that 12 wk target.
Good Luck
Trinity

[jmjm530]

I would have a talk with Dr. about increasing your riba. Some studies suggest that lack of anemia is negatively associated with viral response regardless if you're on weight-based riba or not. sounds like you're probably seeing a hepatologist, but even so, sometimes you have to get their attention before you can get them to deviate much from standard practice. lastly, do you have any insulin resistance issues? if so, they may have to be addressed as well.

[Trinity4]

Sorry about the crazy add on.  I have the attention span of nat and lose my place.

[justme53]

Trinity...yeah seems like I'm a slower starter too. :-)

Well, I am IR and also have cryoglobulinemia...not sure if the latter plays a role in difficulty. So not a whole lotta good going into it except a positive attitude. My glucose was 78 on Wednesday (non-fasting)  but not sure if that means anything while on tx. Also LFT's have not budged down AT all.

[jmjm530]

you might want to send a private message to "cowriter" regarding the IR. If it's not handled correctly, your chances of SVR are significantly diminished.

[justme53]

Yeah, I think the IR on top of the cirrhosis is really a poor combo. I'll give Co a PM tomorrow...right now my Tylenol pm is kicking in big time...Thanks to all for your input.

Pam

[jmjm530]

yes, she is the resident IR maven, and if relevant, can supply you with any necessary studies to share with your doctor.

[epiphiny]

The more fat I take with my riba the MORE side effects I experience ie: generalised weakness, muscle fatigue, and overall tiredness.  

I have interpreted that to mean when I take the riba with more fat I am getting more absorption which is therefore lowering my hb and increasing my anemia.  My Hb dropped to 9 in week 5 and has since stabilized around 10 - 10.4.  I had to reduce my riba to get my hb back.

Sometimes when I'm feeling too kicked about by the riba I alter my fat content with the riba meals to give myself a wee break...

[Kristina538]

Am I missing something?   My riba saturation didn't start affecting my hgb until end of week 5  and did quite a drop between week 4 and 8 (160 to 136).  

I thought it took riba about 5 weeks to reach the optimum level?   Wouldn't taking the extra riba now possibly increase the levels too much over these 'heavy saturation' weeks.

(My concern is that upping the riba could have the detrimental affect of hitting the hgb too hard and therefore forcing a reduction below what you're currently on which wouldn't be the best outcome of the dose increase you're thinking about)....

I agree that it's great that you're responding and decisions about length of tx don't have to be made until further PCRs come back.  Good luck

[geterdone]

Am I missing something also? I would stick with what you are doing right now and get another blood draw at week 8 to see where your Hgb is at and agree it takes riba about 5 weeks or so to start to kick your butt and at 1400 out the gate and then to up that before it has a chance to reach cmax will put you in the hospital for sure. I would, for the next four weeks add more fat to the meals as said above.

jasper

[zazza]

A 1.34 log drop IS loads more than a 1 log drop. It means the certainty that the viral load IS really decreasing. That is something to be truly happy about!

[portann]

At 145 pounds, you're taking 1400mg daily of ribavirin and 360 mcg weekly of interferon, much more than the standard dose. Is this superdosing because of your stage? And you have no side effects after more than four weeks? Wow.

Do you really think it makes sense to INCREASE you riba? After taking 1000 mg riba daily for 36 weeks, I have a VERY healthy fear for how powerful it can be even at normal weight dosing.

Please get in touch with Co about your insulin resistance. I think her view is that IR will seriously impede SVR and she's supersmart to boot. You can probably take more riba until the cows come home (if you survive the brutality of it) but the route that may hold more promise is addressing the IR, not fixating on ribavirin.

[zazza]

With your percentage numbers: 15+35+15=65, the geno 1 non-responders would constitute 35%. The figure I have read for the non-responders is 20%. Could you refer me to a link?

The numbers I have read are:

RVR (approximately 20%) - SVR appr. 90% - Relapse <10%

EVR (appr. 40%) - SVR appr. 70-80% - Relapse <15%

Slow VR (appr. 20%) - SVR appr. 20-30% - Relapse more than 70%

Non response (appr. 20%) - SVR <0-5% - Relapse -

The above numbers are taken from an article by dr Thomas Berg in the magazine Hepatitis&more, 2/2006.

[zazza]

I think your doctors are smart to put you on extended tx when not RVR. This is what often is recommended for geno 3s with cirrhosis: to extend tx to 48 weeks from the standard 24 weeks. So why should not geno 1s with cirrhosis also benefit from extended tx? I would go with the 72 weeks if I were you.

[jmjm530]

what you're missing is that she's a stage four with IR.

Why do you think her doctor is double dosing the peg on her first treatment and and dosing the riba so high? then why do you think the strategy is to treat for 72 weeks if not UND by week four? the reason is that stage fours are more difficult to treat, have more at risk, and therefore warrant more aggressive treatment strategies. All I am suggesting, given aid and very minimal hemoglobin drop -- and it is minimal but what many of us experience by week four --  is that she have a TALK with her doctor about increasing the riba. Apparently, the doctor already feels that a higher dose is warranted, my thought is simply an extension of that concept AND to discuss the entire IR issue with the Dr. IF it has not already been dealt with. That's why brought up "CoWriters" name, what thought might be helpful.

We don't have Kristina's medical history. But what we do know is that she has the hardest to treat genotyped and she is stage four. And we also know that her doctor feels aggressive treatment is necessary. Further, we know that anemia can be used as a marker for riba absorption. just putting in two and two together folks.

[jmjm530]

are these numbers for stage 4's? also keep in mind she has IR? in any event she has to be considered in the "difficult patient population" group. This group has its own stats and is therefore is literally treated differently.

[justme53]

No, no...I DO not want to increase the Riba....it scares me and my Dr. has not even suggested it.They did reneg on halfing a dose during the week so I will stay at the full 360 mcg. The thought of maybe upping the Riba crossed my radar last night then floated off into space.

I did ask if I could use Metformin from the start with info from 2008 AASLD. They were aware of the study but thought it too small. plus a patient of theirs WITHOUT cirrhosis had started tx and also on Avandia for IR, and ended up at the Mayo for an emergency TP. Not to say that comparing Metformin and Avandia are apples to apples,but, it did change my mind about it being a Stage 4.

And I did have some second thoughts about it last night thinking I may have short changed myself, but I really don't think I went into this blindly...just made the best decisions I could based on the info at hand. Just as soon as we think we have come to some conclusion about HCV, it seems it flips us the bird and says, think again, toots!

I KNOW I still have options...decent options. I work at a funeral home where I deal everyday with folks that have run out of options. But yeah, I was a bit bummed last night, but if anything now, I'm more determined than ever! I SO want to nail that 12 week VL.

Pam

[Willy50]

This is only week 4.  I had hoped for better given your aggressive dosing.  I still think you could be on the path.  Your scores are holding up and even may allow a bit more dosing but will really have to be monitored if increased.  It may well be worth it to get that earlier response.  I also agree that a little more proactive PCR sample might be of benefit but wonder if weekly is a bit much.  I know that they are expensive but the could be of immense value when it is to be decided whether to treat for 1 year, to extend or whether to cut ones loses and wait for better treatment.  Unless you have the data you may find yourself flying blind.  I also wonder about a protocol for using cheap PCR's until you hit a certain viral load and then switching.  I don't know what insurance companies will cover and what a high sensitivity PCR will cost you out of pocket if the insurance company won't pay for it.  My thought would be a 600 sensitivity until one clears and then switch but I'm not up on the costs. I wonder what others would recommend?

I agree about checking the IR issues.  Have those threads and studies printed up and forwarded to your doctor so when you ask him he will have had a chance to have read them or even confer with his own group of people he may confide in.  When you are ready for a switch or add on then perhaps they may also be more ready.  
I also wonder if you can have your riba trough levels checked.  

I've read that some people respond to one form of interferon after failing the other.  Anybody ever wonder if adding the other brand since she is double dosing (whether Pegasys or Pegintron) might catch a broader range of virii?  I know it may be splitting infinitives but there is a statistical group that responds to one but not the other.  Might mixing in the first 12 weeks provide a better response rate that one sees switching dosages after one fails one?  Just a wild thought....

Carry on Pam.

Cyber hugs and crossing my cold fingers for ya.

Willy

[Willy50]

By the way I wondered about the implications of having low RBC/WBC and working in a more infectious environment.  Be careful

I'm glad that you already had checked the IR but wonder now that you have response score if Co-writer might have any further suggestions.

best,
Willy

[geterdone]

Ha! rotflmao... good attitude, you got spunk!
jasper

Just as soon as we think we have come to some conclusion about HCV,
"it seems it flips us the bird and says, think again, toots!"  

[jmjm530]

Dr. Cecil sometimes recommends changing the type of interferon, but usually the target is the one log drop in a month which was achieved. Cecil, by the way is somewhat controversial, but that doesn't mean changing interferons is necessarily a bad idea. as to mixing pegs that's been bandied around here before. and frankly I'm surprised it has never been put to a formal trial. my guess here is that the reason is because the trials are funded by the drug companies which would mean less motivation to fund a joint trial

[Willy50]

Jim/ Pam---my point was not to switch but rather make that 2nd interval shot the opposing type of interferon so as to experience a broader band of protection;
say..... I should go into marketing.  : )

(interferon; now with antifreeze)  ; )

Jim, Cecil also suggested tapering into treatment and I question if that is now a well established protocol.  Yes; he is one source I got that idea.

Willy

[justme53]

I'm not totally convinced the interferon is the problem. If I'm correct, the big dips in WBC's and ANC's show that it doing it's thing?? I still think the problem lies with the Riba and watching my CBC's the next couple of weeks will be interesting. The other thing that concerns me is all this high fat with the Riba...is that compounding the IR problem?

[jmjm530]

yes, alternating legs is what has been discussed, but again, it's too bad they're not trials and there probably won't be any for the reason I mention.

As to tapering IN to treatment. This is one of the reasons why Cecil is controversial. In my opinion, and I would assume the opinion of most hepatologist, tapering IN to treatment is a bad idea, and goes against the hit hard and hit it fast principle with the goal of RVR

[Willy50]

Pam, trough levels will answer that.  If I recall not all people absorb the same; Jim would be up on that I'd guess.  It is also a reason that predosing riba is sometimes discussed.

Jim; I'm sure you are on the same page but just for clarity..... when one is near double dosing IFN in early weeks I just want to make it clear that it may look more like *adding* than switching.  I think Pam is adding a second dose mid week or..... how was that again Pam?  : )  

It could also get confusing but after all; who ever said that there were 7 days in a week?

Willy

[jmjm530]

The other thing that concerns me is all this high fat with the Riba...is that compounding the IR problem?
---------------
that's a very difficult question to answerwithout knowing all your numbers in both before and during treatment, plus of course understanding how to interpret those numbers, and then factoring in whatever effect if any treatment drugs might be making. This is something you might want to bring up with your doctor. Personally. I ate a very high-fat diet on treatment, yet all my metabolic numbers improved ( from pretreatment) and the reason no doubt was the interferon. YMMV.

It's interesting you mention a potential danger of these IR drugs, something I hope "CoWriter" addresses, as I have read some cautionary studies myself. that's one of the reasons I always suggest diet and weight loss as a first-line treatment for IR, although in your case -- already on treatment-- drug intervention seemed like a reasonable idea ( you dont want to start a diet and exercise program on treatment)
but still, the risks of the IR drugs to have to be factored in.

[jmjm530]

not sure if I'm following you entirely, but the usual convention with double dosing is to take both shots at the same time. That's how I did it. perhaps Pam is doing it differently.

[portann]

I agree with you that I'd be worried about high fat, given you're already IR.

It's great to hear about people who ate huge amounts of fat with their riba and suffered no ill consequences but they might be in a privileged minority.

I'd tread very carefully in your case and consult even more carefully.

[justme53]

I take 180 mcg on Friday evening and another the same on Tuesday evening. Dr. suggested doing it in two and I think it may have helped keep my sx to a minimum and perhaps a more steady blood level(?). And this is Pegasys I'm using.

Willy, I'm not sure they even do Riba troughs in the US. I think I remember Jim having info on this.

My metabolic numbers have been good for the longest time A1C 4.5 a year ago and metabolic panels normal. All that changed in the past year with glucose holding at 120 trigycerides elevated and HDL seriously tanking. Have not had a HOMA.  GP missed it altogether until I questioned the numbers. When I got insurance and started back with the liver Dr. she said it was hepatic in nature...meaning I needed to fix my liver to fix the metabolic issues. Last glucose was 78 but that was non fasting.

[jmjm530]

as far as I know, there is still no way to accurately measure serum riba levels in this country. In Sweden they use HPLC testing, at least in a trial setting. It's unfortunate, given the studies, that we do not have this tool but that's how it is. Anemia is crude barometer of r Reba absorption but that's all we have.

I'm certainly not an expert in IR, but glucose 78 -- especially non-fasting -- sounds pretty good to me. Like I said, the treatment drugs sometimes improve the metabolic profile while you're on them. curious, you mention that your numbers went south the year before treatment. Did you ever weight change that year? how is your weight coming into treatment?

[Willy50]

Pam may be able to better clarify but I think that she is on single doses but higher frequency than 1/week.....

In my model for instance one might do a pegasys shot on day 1, a pegintron shot day 5, pegasys 5 days later, pegintron 5 days later etc.

The frequency could be adjusted as well as the dose.  One could start in with a tighter frequency and then taper out into a more 6 or 7 day dosing schedule.

The more frequent shots might keep IFN trough levels up; the same reason that IFN was pegalated.  I confess that I didn't know that double dosing was done that way.  ; )

Willy

[justme53]

Off on a tangent a bit...regarding IR...I heartily back anyone waiting to treat if they have minimal damage...I'd be doing the same thing. But in lieu of what we know now, I think it prudent NOT to rely strictly on LFT's for monitoring. More importantly would be to monitor the metabolic panels and adhere to a healthy diet, exercise program and weight loss if needed to minimize this risk. I'd go out on a limb to say that this problem is right up there with heavy alcohol consumption as far as fibrosis progression.....

[geterdone]

Your doing all you can at the moment, 180 peg Friday and Tuesday, and 1400mg riba a day, WOW! you can walk across my pond anytime, you have some tolerance level or very mean virions floating around. Just stay positive moving forward and you’ll be und by wk8.

jasper

[justme53]

Lol, yup, that's what I'm afraid of..........some really wicked viruses (virii?)

[jmjm530]

More importantly would be to monitor the metabolic panels and adhere to a healthy diet, exercise program and weight loss if needed to minimize this risk.
--------------------
amen to the healthy diet and exercise program pre treatment. but as to monitoring some components of the metabolic panel -- such as LDL -- the irony is that high LDL is associated with the SVR, not lower LDL. This does not mean necessarily -- as some have suggested here -- that one should try to raise LDL prior to treatment. But it is an interesting Association, as apparently both the virus in the LDL particles share the same receptors. In my case. My LDL was always relatively high, even with a good diet and exercise program.

[justme53]

My glucose of 78 was from this past week on tx. My weight did not change over the past year. My diet was great to obssesive and I thought I was exercising my a$$ off. (It's still ALL there !) So it was disappointing to get those numbers before tx.

[GreatBird]

Can someone explain what a "metabolic" panel is?

[CoWriter]

I'm glad I got to read your posts before I gave you my answer.  They provided very useful information.

"All that changed in the past year with glucose holding at 120 trigycerides elevated and HDL seriously tanking. Have not had a HOMA.  GP missed it altogether until I questioned the numbers. When I got insurance and started back with the liver Dr. she said it was hepatic in nature...meaning I needed to fix my liver to fix the metabolic issues."
---------------------------

What your doctor means is that insulin resistance caused by HCV is actually hepatic hyperglycemia (it's not the same as the simple antagonism of PPAR gamma of adipose tissue associated with type II diabetes).  In some people, HCV causes the liver to disgorge huge amounts of glucagon and the pancreas has to produce more insulin to control it  (hyperinsulinemia).

So your doctor thinks that because the insulin resistance is caused by the Hep C virus, obtaining SVR will get rid of it.  (Sort of the same concept as with the steatosis (fatty liver) caused by Genotype 3.  Obtaining SVR gets rid of the steatosis).  But even though it is true that SVR improves IR and pancreatic beta cell functioning, being insulin resistant may prevent you from reaching SVR and why.  That's the part your doctor seems to be missing.

You see....when you're insulin resistant (insensitive to insulin), the pancreas compensates by increasing the production of insulin....which leads to hyperinsulinemia...and Hyperinsulinemia induces interferon resistance!

From the Gomez-Romero study....

"Recently, in a replicon model using Huh-7 cells transfected with full-length HCV-RNA, interferon alpha blocked HCV replication. However, WHEN INSULIN (128 µU/ml, similar to that seen in the hyperinsulinemic state in patients with metabolic syndrome) WAS ADDED TO INTERFERON, THE ABILITY TO BLOCK HCV REPLICATION DISAPPEARED"

http://scielo.isciii.es/scielo.php?pid=S1130-01082006000800006&script=sci_arttext


In other words, when you're insulin resistant, it causes your pancreas to make too much insulin - (so much, that it can sometimes make your blood sugar after meals go way down to 78) - and having so much insulin, makes the Peg ineffective.

A fasting blood sugar of 120 means you're pre-diabetic.  Six more points and you would be considered diabetic.  At that point, your pancreas is producing large amounts of insulin (hyerinsulinemia) to be able to keep the blood sugar under control.

"Glucose greater than 100 mg/dl Reduces Interferon/RBV SVR"

http://www.natap.org/2008/HCV/031008_01.htm


2 hours after a meal, your blood sugar should be 140-160 perfect, up to 180 is okay.  The fact that your blood sugar is going down to 78, which is almost hypoglycemia (below 70 is considered hypoglycemia), means you're producing too much insulin then too....So you may have hyperinsulinemia all day.

So if all that insulin is making the interferon ineffective, that may be why you don't feel symptoms from taking 360 of Peg.  So in that case, increasing your dose of Riba would do nothing if the interferon is not working.  And the only thing eating a bunch of fat with the Riba will do, is increase your weight and make the insulin resistance even worse.  

For the interferon to work, your doctor needs to treat the insulin resistance!!!


"Hepatitis C and insulin resistance."    (Sept 2008)

Seirafi M, Negro F.  Service de gastroentérologie et d'hépatologie, HUG, 1211 Geneve 14.

In the course of a chronic infection with the hepatitis C virus, the fibrosis progression rate varies among individuals, and depends on the existence of certain co-factors. In this context, a growing interest has emerged and has focused on insulin resistance. In fact, the hepatitis C virus is now recognized as being responsible for a direct interference with the insulin signalling pathway. This insulin resistance of viral origin, in combination with an eventual insulin resistance associated with an existing metabolic syndrome, can therefore accelerate its evolution to a type II diabetes. Independently of its pathogenesis, insulin resistance occurring in chronic hepatitis C causes a fatty liver, contributes to the progression towards cirrhosis, and narrows the chances of a successful antiviral therapy. It is therefore crucial to recognize it in order to correct it.

http://www.ncbi.nlm.nih.gov/pubmed/18831405?ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

(will continue on next post)
Co

[CoWriter]

"I did ask if I could use Metformin from the start with info from 2008 AASLD. They were aware of the study but thought it too small."
--------------------------------


The TRIC-1 study used 125 patients and the.  The conclusion said...

"Triple therapy with metformin, peginterferon, and ribavirin was well tolerated, decreased insulin resistance and increased SVR in this difficult-to-treat group of patients.

This therapy was especially effective in females, in whom metformin raised significantly the SVR rate.  Our data suggest that triple therapy SHOULD BE the STANDARD OF CARE for females with hepatitis C genotype 1 and insulin resistance."

SVR for females 57.7% in the Metformin group.....vs 28% for females not using Metformin.

SVR for patients with a HOMA greater than 4 and weight greater than 75 Kg.....

Females 60% with Peg/Riba/Metformin  vs 37.5% with Peg/Riba.

Males.....46.7% with Peg/Riba/Metformin vs 27.3% with Peg/Riba.

Breakthrough happened less with Metformin (6.7 % vs 16.7%).

http://www.hivandhepatitis.com/2008icr/aasld/docs/112108_a.html



"plus a patient of theirs WITHOUT cirrhosis had started tx and also on Avandia for IR, and ended up at the Mayo for an emergency TP. Not to say that comparing Metformin and Avandia are apples to apples,but, it did change my mind about it being a Stage 4."
------------------------------

You're talking about two very different products.  Metformin is the only medication recommended by the Americal Diabetes Association for the prevention of diabetes Type 2 in people who are insulin resistant.  It helps with weight loss....Avandia can cause weight gain from fluid retention/edema.  There have been only 4 cases of hemolytic anemia with Metformin.  Drops in hemoglobin between .5 and 1.0gm are more common with Avandia.  There are 14 reported cases of liver failure with Avandia (5 patients were above the age of 70 and 2 were above the age of 80),  none with Metformin.  

The most serious side effect from Metformin is lactic acidosis which has an incidence of 3 in 100,000 patient years.  Plus, lactic acidosis happens as a result of another condition (like trauma, infection, severe dehydration, heart and respiratory failure), not by itself.  So you would know what to watch out for.  

The risk of lactic acidosis is higher for co-infected patients because some of the HIV drugs can also cause lactic acidosis.  However, they use Metformin frequently to treat lipodystrophy (fat atrophy and redistribution), which is associated with IR.


"According to a large population-based study, approximately 25% of patients taking Metformin have at least one contraindication to its use, suggesting that Metformin may be safe in mild renal or liver dysfunction.

Contra-indications to metformin therapy:
1.  Significant hepatic impairment
2.  Renal impairment (serum creatinine >150 µmol/l)
3.  Diabetic ketoacidosis
4.  Conditions predisposing to lactic acidosis like trauma, infection, severe dehydration, heart and respiratory failure."
  
http://qjmed.oxfordjournals.org/cgi/content/full/96/4/315-b


In October 2008, the group Public Citizen, petitioned the FDA  to put a ban on Avandia.  Their petition stated......

"Our petition is based on rosiglitazone's multiple, serious risks, including one just documented by our new analysis of 14 cases of liver failure, of which 12 resulted in death. In addition there is clear previous evidence of increased risk of heart attacks, heart failure, bone fractures, anemia and macular (retinal) edema with vision loss. The evidence for this unique combination of toxicities is compounded by the accompanying lack of evidence of any clinical benefit, compared to other approved drugs for diabetes, such as METFORMIN, insulin and sulfonylureas. Because of a lack of evidence that benefits are outweighed by risks, both the American Diabetes Association and the European Association for the Study of Diabetes, in a statement submerged in a pre-publication consensus article on treatment of diabetes released last week, concluded that for the treatment of diabetes, "given that other treatment options are now recommended, the consensus group members unanimously advised against using rosiglitazone."

http://www.citizen.org/publications/release.cfm?ID=7614


So obviously they don't feel the same way about Metformin.


Bottom line......whether IR is hepatic in nature, associated with the metabolic syndrome (from obesity, etc), or both, the same kind of thing is going to show up on your glucometer, and the treatment for it is the same. But you can't wait for it to treat itself or wait for SVR to get rid of it ....because it's the thing that's preventing SVR.

Talk to your doctor about treating the IR....(do it quickly).  Considering that the TRIC-1 trial underdosed the Metformin for the first 4 weeks....I think you still have a chance at EVR if they start the Metformin right away.

I'll PM you some studies you can show your doctor.  

Co

[CoWriter]

"More importantly would be to monitor the metabolic panels and adhere to a healthy diet, exercise program and weight loss if needed to minimize this risk."
------------------------------

It sounds like you've been doing all the right things.  But missing blood sugars of 120, not checking your insulin or HOMA and missing obvious hyperinsulinemia (blood sugar of 78) means docs need to be educated about the importance of treating IR.

Co

[CoWriter]

" I'm not totally convinced the interferon is the problem. If I'm correct, the big dips in WBC's and ANC's show that it doing it's thing?? I still think the problem lies with the Riba"
-----------------------------

The Riba causes hemolytic anemia...destruction of red blood cells.

But interferon can also cause anemia because it makes the bone marrow production of red cells drop.

Co

[CoWriter]

"I'm certainly not an expert in IR, but glucose 78 -- especially non-fasting -- sounds pretty good to me."
----------------------------------

It would be fine if it was fasting.  You want the fasting to be below 100.

2 hours after a meal, your blood sugar should be 140-160 perfect, up to 180 is okay.  A random test (if you check several hours after a meal) should be below 120.

But below 70 is considered hypoglycemia...and you may start having symptoms (shaky, dizzy, crave sweets, etc)....and it may get so low that you pass out.

Her blood sugar after a meal was only 78.  What could have made it go that low?

Too much insulin....hyperinsulinemia.

Hypoglycemia is undoubtedly a form of hyperinsulinemia that is at least transient. And it may cause people to crave sweets.

Co

[CoWriter]

"riba binds to the fibre and moves through too quickly to absorb well"
--------------------------

That's not true.  Fiber SLOWS down absorption.  That's why we tell diabetics to have lots of fiber....because it slows down the absorption of food  so it won't turn into sugar so quickly.



"The more fat I take with my riba the MORE side effects I experience ie: generalised weakness, muscle fatigue, and overall tiredness.

I have interpreted that to mean when I take the riba with more fat I am getting more absorption which is therefore lowering my hb and increasing my anemia.  My Hb dropped to 9 in week 5 and has since stabilized around 10 - 10.4.  I had to reduce my riba to get my hb back."
-----------------------------

What you're saying doesn't make sense.  If your hemoglobin has remained stable, then that means that the Riba is not increasing the anemia.

Plus.....when you're anemic for a long time like you have been, the body gets used to the anemia, so you wouldn't be feeling increased symptoms on and off....especially since your hemoglobin is staying the same.

I think the FAT intake is what's causing your symptoms of "generalised weakness, muscle fatigue, and overall tiredness".



"Sometimes when I'm feeling too kicked  about by the riba I alter my fat content with the riba meals to give myself a wee break."
------------------------

According to your theory, you're making your levels of Riba go up and down (up with the fat, down when you take a break).  Why would you want to do that?

The object of the game is to keep the levels of Riba even.  That's why we tell people, "If you take the Riba with food, then always take it with food.  If you take it on an empty stomach then always take it on an empty stomach.  

Co

[CoWriter]

"You can probably take more riba until the cows come home (if you survive the brutality of it) but the route that may hold more promise is addressing the IR, not fixating on ribavirin."

"I agree with you that I'd be worried about high fat, given you're already IR."
--------------------------------

I am sooooo proud of you.

You're right.  If you're insulin resistant, the pancreas compensates by making extra insulin.  And if you have large amounts of insulin making the interferon ineffective, then increasing the Riba will not help.  

Co

[epiphiny]

Oookaay....

So where do you stand on the added fat equals better riba absorption theory?  And where do you stand on the added fibre causes the riba to be bound to it and excreted more quickly theory that is OFTEN purported on this forum by many esteemed members?

To be honest, I did my own research on that and found studies that showed Riba absorption WAS affected by fibre by 3% but this was not considered of great clinical significance.  I will admit to not knowing the significance of diabetes, fat, fibre and riba but I was not responding to the IR component of this question.

Also, while I agree ABSOLUTELY with what you say about keeping Riba levels equals, in all honesty I just needed a mental break and didn't want to reduce the riba.

Sometimes doing 'something' can help us mentally break through.  What ever it takes to keep me on the path and moving forward at this stage of the game, whether it's the 'right' way or not.

I have to admit I have taken offense at your statement that I am not making sense. It is a rather insulting. I am sorry that you were not able to understand what I wrote so just to be clear.  Hb dropped to 9,  Riba reduced by 200 per day for 3 weeks, Hb back to 10.8.  Riba reinstated at full dose, Hb dropped to 10.1, stopped eating as much fat, Hb went back up to 10.7 (but that could be hydration issues).  

Since then I have been getting results around 10.1 to 10.4 which I would call hovering but relatively stable.  But then what defines relatively stable when it comes to Hb count?  For me I defined it as not going below 10.

As far as I am concerned it is pretty clear that the riba IS affecting the anemia.  As it is also clear to my med team who monitor it or they would not be ringing me to make sure I am aware of my results... The fat and absorption debate is another issue all together but each to their own on this journey...

I respect the knowledge you have on treatment meds and IR but I would appreciate not being told I am not 'making sense' in a public forum.  It is humiliating and rude.  

Life is better with a little respect, don't you think?

[nygirl7]

"Hb dropped to 9,  Riba reduced by 200 per day for 3 weeks, Hb back to 10.8.  Riba reinstated at full dose, Hb dropped to 10.1, stopped eating as much fat, Hb went back up to 10.7 (but that could be hydration issues).   "

Epiphany - I think you need to find a happy medium and stick with it, upping and downing riba and playing games with your "serum levels" this way by dose reducing and upping - just going off the hgb when in reality you have no idea what your real serum level might be is a bit over the top and dangerous. Anemia is THOUGHT to be a side of the riba but could also be the interferon and it is not always predictive.  Dose 'reducing' is one of the key factors in SVR failure and totally not advised by any hep specialist that i've ever heard of - not this way.  There is always going to be a lag of some sort when you think about it as the bone marrow has a huge job to do and it is not accomplished overnight...you don't have to eat TONS of fat - that wouldn't be healthy to anybody really can you just find a middle ground and just moderate what you are doing so you stay CONSISTENT?

JUSTME - I don't have anything to add to the subject, IR is something I don't know about but I wanted to wish you best of luck. In your case a 1.3 log drop at week 4 is a very good sign and you should be encouraged by that.  Unfortunately I had to treat for 72 weeks myself (not clear by 12 but clear before 24) and while it's not a great amount of fun (I double dosed the riba and only a few times the interferon) it is possible to make it through and get success.

I think you'll be UND by week 12 but still agree extending might be a great idea in your case. Sounds like you have some good aggressive doctors, just what you do need.

[jmjm530]

The object of the game is to keep the levels of Riba even.  That's why we tell people, "If you take the Riba with food, then always take it with food.  If you take it on an empty stomach then always take it on an empty stomach.  
----------------------
I think this type of instructions, commonly found with many drugs, is more for safety as opposed to the efficacy. It also might produce more consistent results of the trial setting, were the instructions may have originated. But in terms of SOC not uncommon for riba to be reduced, then increased back etc. because of let's say hemoglobin levels. And because of long half-life, the curve is probably a lot smoother than with some other drugs. I haven't heard anyone recently -- although yes I've seen it in print -- say their doctor told him to take riba on an empty stomach. Again, I think it was because they were looking for even levels in a trial setting and not really giving it a bit more critical clinical thinking.

as to your comments on IR, always informative. Thanks. and as I said before, I think we're in agreement that IR has to be dealt with prior treatment also I still think the first line is diet and exercise is these IR drugs do not come without risks. But here's my question. You commented several times a diet during treatment could be a problem in terms of IR. My first comment, is that many of us, I'd say the majority of us, do not have IR going into treatment. Nor do we develop IR during treatment. Let's face it, were closely monitored for least we should be. Therefore, have always contended, as has my liver specialist, that in a sense you eat to survive on treatment, but no sense the overall lack again. As to the diet of those that have IR going into treatment, by your stats, they really don't have much of a chance anyway, so not sure if dietary changes during treatment will make much difference. In short, I just think this notion that one should eat "healthy" during treatment because of IR is not really grounded in science of SOC treatment. And again, on a personal note, I ate a lot of fat on treatment my metabolic panel's were never better. last point, and forgive the rambling because I'm using force recognition software which makes editing are difficult, the so-called high-fat diet that some people are putting down, is really not that much different than the diet I have a feeling most people here each anyway -- at least based on all the threads about desserts cookies etc.. The average American diet, and this place is probably representative here, is a very high-fat diet. So when you tell people to take rebbe with a high-fat meal, it's probably not that much more fat than the average American eats.

[jmjm530]

"t will make much difference. In short, I just think this notion that one should eat "healthy" during treatment because of IR is not really grounded in science of SOC treatment."

should have read...t will make much difference. In short, I just think this notion that one should eat "healthy" during treatment because of IR is not really grounded in the practical realities of SOC treatment"

[justme53]

I read this thread early morning with lots of interest (Co-sent you a PM too)

I'm just catching up at home since my pc is down at work, but wanted to throw these q's out there for feedback.

1. Is it too late to get accurate readings on a FBS, HOMA and A1C now that I'm on tx?

2. Is it too late to start Metformin if I can get an Rx?

3. How practical is it to invest in a home Glucose monitoring kit?

4. Jim addressed diet practicalities on tx, how important is this as long as nausea and    other appetite issues don't come into play.

I'm sure there'll be more, but I need to get back to the office. Thanks in advance, Pam

[epiphiny]

Just to clarify, I did not make the decision to reduce my riba, it was made by the doctors as I was in a trial.  Their call not mine.  I requested it be increased when my hb went over 10 at week 8.  Since then I have been on the same dose ever day.  I believe I have been as consistent and compliant as any one could,

Do you all really think that changing the amount of fat I eat with each riba meal truly has such a clinical significance that it will drastically alter my serum levels to a point it could be dangerous? If so then fat must therefore increase absorption.  If not, then this is dead conversation.

I think that this has gotten blown somewhat out of perspective here but I would like to thank you all for your concern and well-meaning advice.  It occurs to me that I am reaching the last mile of this marathon and as much as I hate to admit it, I am starting to hurt and crumble.

Believe me, I will just continue to take the pink pills at the same time each day, take my shot every Friday and continue to pray for SVR and the day this is over.

Respect to all.

Epi.

[jmjm530]

yes, taking riba with a high-fat meal does increase absorption. and yes, I'm sure the "perspective" has been lost in a few of these threads, as people run with things as they like. Riba and its dosage is not the be all and end all of treatment. That said, it does have a significant impact in many cases, you just have to review the literature.

[CoWriter]

"My first comment, is that many of us, I'd say the majority of us, do not have IR going into treatment."
--------------------
It depends what you mean by "the majority".  All the new data says 50% of HCV patients are insulin resistant and one study said up to 70%.


"Nor do we develop IR during treatment."
---------------------

Yes, you do.  Interferon induces insulin resistance in the first two weeks of treatment.  It's a transitory effect and it's not known how long it lasts....or whether it would make IR worse if somebody already had it.

From the Gomez Romero study....

"In healthy volunteers, insulin resistance could be detected after the first injection of interferon alpha. Besides, in patients with chronic hepatitis C interferon alpha induces insulin resistance in the first two weeks, mainly owing to a decrease in hepatic glucose uptake. This effect has been related to the proinflammatory repertoire of cytokines induced by interferon. However it is a transitory effect because insulin resistance was not found at month three of therapy or the end of therapy"

http://scielo.isciii.es/scielo.php?pid=S1130-01082006000800006&script=sci_arttext


"Let's face it, were closely monitored for least we should be."
----------------------

In my dreams you are!  Come on Jim, if they were closely monitored people like justme53 wouldn't have been put on tx with a fasting blood sugar of 120.... CockSparrow wouldn't have gone twice through tx being IR....or Gauf, bandman or Susan or a multitude of them.  And all the people who say they crave sweets during tx would be getting checked for IR.


"In short, I just think this notion that one should eat "healthy" during treatment because of IR is not really grounded in science of SOC treatment"
-------------------------

Surely you didn't just say that.  Your voice recognition program must have typed the wrong thing.


"Therefore, have always contended, as has my liver specialist, that in a sense you eat to survive on treatment,"
---------------------

Here's what a panel of hepatologists say......

http://www.hcvadvocate.org/hepatitis/About_Hepatitis_pdf/1.1.1_Living_With_HepatitisC/SIDE_EFFECTS.pdf

"Some patients may notice a marked improvement in their condition if they could assume better control of their diet. Dietary improvements would not only improve health but might also retard the progression of fibrosis in many patients."

""From the patient's point of view, Interferon caused not just weight loss but also cravings for cheese, dairy and sweets, which are the worst things to have during treatment".

Another doctor answers, "Nobody is compelled to eat cabbage".


They're laughing because HCV patients crave fat and sugar during tx.  The interesting part is that they're not seeing the big picture.  Craving sugar screams insulin resistance.  And they're the ones that are supposed to "monitor you closely".


"yes, taking riba with a high-fat meal does increase absorption. and yes, I'm sure the "perspective" has been lost in a few of these threads, as people run with things as they like. Riba and its dosage is not the be all and end all of treatment. That said, it does have a significant impact in many cases, you just have to review the literature."
-----------------------------
When you tell people to take their Riba with a high fat meal you're not trying to increase "absorption".  You're trying to increase DRUG LEVELS......based on one study that said that fat increased the level of Riba after a single dose, not multiple doses.  So you really don't know what happens after multiple doses and fat.  And it's being done without telling the doctors.  Because I have never seen people suggest that they ask their doctor, "Is it okay if I take my Riba with a high fat meal to increase the drug levels?"

Bottom line, telling people to take their Riba with fat to increase the drug level is like telling people to take more Riba without a doctor's order.  You're braver than I am.  I would not want the responsability for doing that.  Especially now that hepatologists are starting to rethink using Procrit because of the new black box warning and recommending dose reductions instead.  So if the Riba+fat makes them too anemic, they may not have Procrit to fall back on.

One last thing.....

NRTI's (nucleoside reverse transcriptase inhibitors) can cause insulin resistance....and Riba....is an NRTI.

Co

[CoWriter]

1. Is it too late to get accurate readings on a FBS, HOMA and A1C now that I'm on tx?

You can get a fasting blood sugar done.  And HOMA is a formula that uses the results of a fasting blood sugar and a fasting insulin....so that can be done.  I wouldn't recommend doing a HgA1c if you're anemic.  The test uses hemoglobin so if you're anemic, it will give you a false low result.

2. Is it too late to start Metformin if I can get an Rx?

The studies using Metformin had the patients start it either 3 months before starting the treatment or at the start of the treatment.  You're at 5 weeks of treatment...that gives you 7 weeks to clear.  Metformin works quickly.  I would say it's worth asking your doctor.  

3. How practical is it to invest in a home Glucose monitoring kit?

What would you use it for?  To see if your blood sugar has improved.  But you haven't changed anything.  In think checking all the time would just stress you out.  


4. Jim addressed diet practicalities on tx, how important is this as long as nausea and  other appetite issues don't come into play.

Carbohydrates will raise your blood sugar....and that will cause your pancreas to produce large amounts of insulin.  That's what you want to avoid.  So cutting way down on carbohydrates and increasing the protein will help.

Other things that will help:

1.  Have 5 or 6 small meals a day instead of 3 large ones.  When you have a small meal, it will turn into a small amount of sugar and your pancreas won't produce as much insulin.  

2.  Do not skip meals.

3.  Make a schedule for your meals and stick to it.  Breakfast should be as early as possible to prevent your fasting blood sugar from going higher.  Space your meals and snacks evenly.  For example:

Breakfast 7am
Lunch 11 am
Snack 3 pm
Dinner 7 pm
Bedtime snack 10:30pm

4.  To lower your fasting blood sugar, have a bedtime snack HALF HOUR before bedtime.  So if your bedtime is 11pm, the snack should be at 10:30pm.  The snack MUST BE PROTEIN so it will last you all night.  Let me explain why.....

During the day, you have meals....and the food turns into sugar.  So there's always sugar in your blood.  But at night, you go many hours without eating....and your blood sugar goes down.  When the liver notices, it will give you a bunch of the sugar it had saved.  And that will cause your fasting blood sugar to be high.....120.

(that's why diabetics have a high fasting blood sugar and they can't figure out why, since they haven't eaten in many hours).

So you have to fool the liver into thinking that you have sugar and don't need more.  Protein will last you all night, so the liver will see that and won't give you extra sugar.  However, if for your bedtime snack you have cereal, it will only last you 2-4 hours and after that, the liver will start giving you sugar.  

Remember, it's only a snack, not a meal....so a piece of low fat cheese, some nuts, or tuna will be enough.

It will lower the fasting a few points...not below 100....but it's better than nothing.  

5.  Avoid fruit juices.  Choose fruit that has lots of fiber instead....like an apple (serving size is the size of a tennis ball.  To prevent your blood sugar from spiking up, don't eat the fruit by itself.  Have some protein with it....like some nuts.  

6.  Avoid caffeine.  It raises your blood sugar ALL DAY and even worse, it raises the insulin level more than the blood sugar.  

7.  If you smoke, try cutting down.  It raises the insulin level.  


I know....I'm no fun.  But you want SVR and so do I.  Let's go after it.

Co

[zazza]

"Therefore, have always contended, as has my liver specialist, that in a sense you eat to survive on treatment,"

Anyone who has had the experience of doing tx themselves knows this is true. There is knowledge about tx that only those who have done it have.

[justme53]

I really thought my diet was good prior to tx, with the exception of fruit intake, but I need to rethink my eating habits in finer detail, I guess.

I'm not sure where to go from here...except for now to get to week 12 and see what the PCR shows. I talked to my Dr. last Friday and they are considering me a slow responder based on my double dosing and a 1.34 log drop at 4 weeks. They will recommmend stopping tx at 12 weeks if no UND or at least a 3 log drop. I didn't ask what my options would be because I really want to focus on finishing these last 5-6 weeks in hopes of becoming UND. I just can't lose that focus right now.

In my mind, I will not tx again without time getting my glucose, insulin levels under control...with or without helper drugs. I've got too much stacked against me as it is.

[bajawoman]

In my mind, I will not tx again without time getting my glucose, insulin levels under control...with or without helper drugs. I've got too much stacked against me as it is.

EXACTLY my thought too  I was lucky enough to have paid attention to CoWriter and CS and others on the forum who advised just that

to be aware of the situation going in and HR who all respect here also agreed to NOT go into tx if at all possible without getting IR under control and when on tx to use Metaformin and Alinia to aid in reaching SVR

Sups recommended before tx to keep the IR under control along with eating good food before tx and on tx  as his theory which HR follows is
"our bodies of made of cells and we need to replace the cells with the foods we eat"

It all makes very much sense to me  
You do not have to be a doctor or a scientific person to see the logic in the matter of IR

I am sad when I hear of non responder or relapse or not achieving SRV especially in young basically healthy people  and all for the reason they seem to jump into tx without prior testing to see their position with IR and other issues Depression etc which cause a negative response to tx

being well informed and proactive way to go

good luck to you

[CockSparrow]

Zazza - "Therefore, have always contended, as has my liver specialist, that in a sense you eat to survive on treatment,"

Anyone who has had the experience of doing tx themselves knows this is true. There is knowledge about tx that only those who have done it have.
---------------------------------

Yeah. Guess what advice i followed last Tx.
I can assure you i wont be doing it again.
Eating to survive is asking to relapse or worse.

I will be eating to avoid IR this time.

Zazza - There is knowledge about tx that only those who have done it have.
Doesnt make it good advice though.

There is knowledge about Tx that those who NR have.
Tx failure is a good teacher.

CS

[zazza]

There is knowledge about tx that extended tx'ers have as well. My kids thought I had anorexia during tx. I was happy there were things I could eat.

I understand that IR is an issue non-responders have to deal with. But I consider myself lucky that this discussion was not on board before I treated. One less thing to worry about, and obviously I did not need it to SVR.

As you know I too have been touched by relapse, although it was not my own. That scream of anxiety made the blood in my veins freeze to ice. I do know of your struggle to conquer your non-response. I wish you luck.
Za

[jmjm530]

Just want to reinterate what Zazza says, above. Another way of saying it is that you can't become SVR if you can't finish treatment, and that is the situation many of us find ourselves in, i.e. interferon-induced anorexia where we have to eat to survive.

Knowing what I do now, if I was IR going into treatment (I was not) I would take appropriate measures prior to treating as well as during treatment. I do not pretend to be knowledgeable enough as to whether diet alteration during treatment would be part of that plan.

So where I come out is that if you don't have IR, then yes, you eat to survive. If you do have IR, then you follow the advice of a liver specialist who is monitoring you.

To suggest, as has been done by at least one person in the past, that someone will develop IR on treatment because of eating a high-fat diet IMO is not good advice, and not the advice that my doc, or other docs have given their patients and I would hope no one would take it upon themselves to eat a low fat diet on treatment based on what is posted here. If your doctor who is monitoring your treatment suggests such, that is an altogether different story.

FWIW my metabolic panel on treatment was the best in my life because of the effect interferon had on my metabolism. So again, if someone had told me to cut out the fats during treatment I have no doubt I would have had to drop out from wasting instead of achieving SVR.

CS, I wish you the best moving forward and hopefully addressing your IR issues will give you the SVR you deserve.

-- Jim