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[mrvacation]

I am 52 year old white male, genotype 2.  I have completed 19 of 24 week pegasysus+ribasphere 1200 milligrams/day treatment.  I have experienced hypothyroidism, and I started taking Levothyroxine 0.05mg/one a day on Jan.24.  I sprained my hand and the doctor gave me Naproxen 500mg/one twice a day, and I took this med Feb. 2 and 3.  On Feb. 4, I felt stomach pain and nausea all day at work, and had diarrhea beginning Feb. 4 at night, and have had this plus terrible stomach pain and gurgling ever since.  Doc had me start on Prilosec OTC for 6 weeks, and discontinue the Naproxen on Feb.5 as well as Immodium but have had no relief from diarrhea or stomach pain yet.  I was unable to take either ribasphere or Levothyroxine on Feb. 5.    Doctor insinuated that the 2 days of Naproxen could be source of my stomach problems, and could have caused an ulcer, which Prilosec is to treat.

I was undetectable at week 12, and my Jan.27  labwork indicated the following exceptions:
WBC          2.6         Normal 4.0-10.5
RDW         15.3        Normal 11.7-15
Mono         14.0        Normal 4-13
Neutrophils(ABS) 1.4 Normal 1.8-7.8
Glucose     103         Normal 65-99
ALT            59          Normal 0-55

I should say that I work in a hospital, and know that I could have picked up a virus, but did not have any fever.  
Due to this diarrhea and painful stomach, I am thinking I cannot make myself take the ribasphere for the remainder weeks.  Has anyone else had this stomach pain and what remedies did you have?  

[mrvacation]

Thank you both for all your help. Talk to you soon. I feel good these days with just 4 weeks to go. Good luck to all.

[CoWriter]

Way to go!  If you cxan keep your fasting blood sugar below 100 that is wonderful.  But make sure you don't skip meals.

Co

[bajawoman]

I was undetectable at week 12, and my Jan.27  labwork indicated the following exceptions:
WBC          2.6         Normal 4.0-10.5
RDW         15.3        Normal 11.7-15
Mono         14.0        Normal 4-13
Neutrophils(ABS) 1.4 Normal 1.8-7.8
Glucose     103         Normal 65-99
ALT            59          Normal 0-55
___________________________________________________
seems like a very fast turn-around from your last labs above less than a month ago,  with glucose of 103  makes me wonder if you fasted before your last blood work?

But whatever, it is great news! and the Loss of 8 pounds in just Two Weeks Way to Go

Balanced diet and Excercise seems to be all you need!!  but I suppose it wouldn't hurt to continue to watch the problem with lab work follow up

In my opinion You do not need metaformin if diet and excercise works but Co can answer for herself  Just thought I would jump in and comment

I am taking my labs monday for insulin and glucose after being  on a diet since dx with IR
I purchased a book from amazon "the insulin-resistance diet " It arrived last week a recommendation from Bandman Great Book for all you Insulin Resistant folks

The formulas for eating in the book  are very good for lifetime support of eating healthy  and balancing protien carbs and fats in every meal and snack and never letting your body get into a starvation mode eating 5 meals a day is mandatory of well balanced small meals and the importance backing up everything Co has told me all along  

The book really explains the mechanics of how the body uses food and how to turn off your body's fat making machine


I am hoping too my lab reports come back in normal range and diet was able to turn it around  if not I can consider to take a helper drug like metaformin  

You are an inspiration being proactive and doing something good for yourself to correct the problem that was working against you

Good Luck with your journey toward SVR


Baja

[mrvacation]

Updated , since we last talked I found Sugar Buster Book. Started on low sugar diet, exercise and 90 oz h2o day. Lost 8 lbs. Got 20 week labs WBC 2.4( 4-10.5); Monocytes 16( 4-13 )neutrophils absolute 1.1 (1.8-7.8 )  Glucose 90 (65-99). Everything else normal. Is this better for my insulin resistance problem?    Would Metformin do better?                                    

[CoWriter]

Several small studies (one done with 4 and another with 8 obese, diabetic females) have shown a decrease in TSH while taking Metformin, but no symptoms from it.  The effect goes away once the Metformin is stopped.

Considering that interferon already damaged his thyroid and he's been taking Thyroid medication since Jan 24, the worst that can happen is that he would have to increase the thyroid medication a little while he's on the Metformin.

Doctors don't seem to realize that many of the people who are now insulin resistant will eventually end up becoming diabetics and they will have to use Metformin permanently.  Metformin is the medication most frequently used for diabetes. Metformin treatment is associated with a decrease in mortality.  It's even safe to use it in the elderly.  And you can prevent the gastrointestinal problems by starting with half dose and increasing to full dose after a few days...and taking it with food.  

It is so frustrating....I figured once a couple of studies came out showing that insulin sensitizers increased SVR, things would change.  But I forgot that hepatologists don't treat diabetes...and GP's aren't used to testing or treating IR (some are still using the term "borderline diabetic" and using sliding scales).  Insurance companies will refuse to pay for endocrinology consults for something like IR.  

Since Jan 2008, HIV patients are routinely tested for IR....and they use Metformin for lipodystrophy....so why is it so hard for HCV patients to get anything done?

Co

[mrvacation]

Dr said I reviewed the information presented and he said you will need to confer with your internist and/or endocrinologist in this regard.  

[desrt]

About the same way a peashooter 'synergizes' with a canon. To talk about Metformin 'side effects' to someone on IFN would be laughable - if the whole subject of medical professionals ignoring 'borderline' blood sugar readings wasn't so serious.

[zazza]

"There are of course side effects associated with Metformin as all medications, the most common of which are gastrointestinal and some potential for thyroid, specifically TSH, issues."

How does this synergize with the impact interferon has on the thyroid?

[CoWriter]

"With a single fasting blood sugar of 103 and no other supporting data or monitoring"
--------------------------

You have more than that.  You have .....

Pre-treatment Glucose 104
12 week glucose 103 (same as 5.7 mmol/l)
HOMA of 3


A HOMA is an insulin resistance test.  It's a formula that uses the results of a fasting blood sugar and a fasting insulin.

(FASTING BLOOD SUGAR in mmol/l  X  FASTING INSULIN divided by 22.5)

So with a blood sugar of 103 (same as 5.7 mmol/l), that means that your insulin would have to be 12 to get a HOMA of 3.  And an insulin of 12 is high.  And a HOMA of 3 means you're insulin resistant.  And according to the American Diabetes Association, a fasting blood sugar of 103 is considered pre-diabetes.  Results between 100 and 125 are considered "Impaired Fasting Glucose"

"Nearly one in four adults over the age of 25 has either diabetes or a condition known as PRE-DIABETES (in which blood glucose is higher than normal but not high enough to be diagnosed as Type 2 diabetes).

There are two conditions that fit into this category. One is called Impaired Fasting glucose (IFG) and the other is Impaired Glucose Tolerance (IGT).

IMPAIRED FASTING GLUCOSE is defined as glucose levels of 100 to 125 mg per dL in fasting patients.

Impaired Glucose Tolerance is defined as two-hour glucose levels of 140 to 199 mg per dL on the 75-g oral glucose tolerance test."


I would still talk to your doctor about it.  You only have a few weeks left of treatment.  Expecting you to loose weight to reduce the insulin resistance at this stage is unrealistic.  They should have told you to do that months before starting your treatment.  

Co

[mrvacation]

I asked the nurse today by e-mail if the Dr.would put me on Metformin for rest of my treatment, this is what she said: I seriously doubt that. He would refer you to either your PCP or an endocrinologist for an opinion or if he felt there was an indication.With a single fasting blood sugar of 103 and no other supporting data or monitoring (such as a glucose tolerance test and/or Hemoglobin A1C) I know that he would not prescribe any medication of this sort. His first recommendation still would be diet and exercise in combination with a low glycemic or low carbohydrate diet.  There are of course side effects associated with Metformin as all medications, the most common of which are gastrointestinal and some potential for thyroid, specifically TSH, issues.

He has not been in the office today---but as I said, I will go over the articles sent and let you know what he has to say in this regard.

[CoWriter]

Please let me know what your doctor says.

Co

[can-do-man]

SORRY wrong thread

[can-do-man]

I hope people don't get the ideal that 80-80-80 rule is something they should follow. Your GOOD hepatologist does not recommend this. Not much difference then dose reducing to me. And that is also something not recommended unless its that or stopping tx. Thats why they put us on rescue drugs so we can stay on FULL dose all the time.

Rocker, ever wonder on them palms why they worry about the excact times we take the boceprevir but only ask how many riba we take for the day? As long as we take the full dose of riba in a day it does not need to be 12 hours apart. It has been suggested to me at least 6 to 8 hours apart is fine.

[nygirl7]

what are my chances for svr ? 5'6" weight 188 white male hypothyroid homa of 3 biopsy dated 7/2/07 grade 2-3 stage 2. do i have a prayer?

I don't think that your doseage is correct - .05?  I went hyper then hypo- started on .75mcg and then it was upped .88.

What was your TSH level?  first mine was 0.0 then it went to 6.2 in just 3 weeks however taking the Syntrhoid (non-generic form of the levo) it has been kept perfect at about .6

That's why I'm wondering at .05 - the dosage should be the same even if it's the other drug and that seems extremely insufficient to do anything?

[mrvacation]

Thanks for all the info I will talk to my Dr. today.

[CoWriter]

And do NOT stop taking the Ribavirin.

Co

[CoWriter]

It jumps right out at you, doesn't it?  

Good job!

Co

[CoWriter]

Sorry, I hit "enter" too soon.  As I was saying.....

Insulin resistance (being insensitive to insulin) causes the pancreas to make extra insulin....so you end up with hyperinsulinemia (too much insulin),

And high levels of insulin make the interferon (which is used to treat Hep C) ineffective.

This comes from the Gomez-Romero study and says when you add insulin to interferon, it makes it ineffective......


"interferon alpha blocks HCV replication. However, when insulin (at doses of 128 microU/mL, similar that seen in the hyperinsulinemic state) was added to interferon, the ability to block HCV replication disappeared"

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



So what happens now?  The good news is that you already cleared.  The fact that you had genotype 2 is in your favor.  However, I wouldn't want to risk relapse.  I would talk to the doctor and show him the information I gave you.  Show him that having a fasting blood sugar higher than 100 lowers the success rate.....


"Having a fasting blood sugar higher than 100 lowers SVR"  

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


And ask him whether he would be willing to put you on Metformin for the remainder of your treatment.  Medications like Metformin decrease insulin resistance.  They're
"insulin sensitizers".  In other words, they help make the cells in your body more sensitive to insulin.   Studies have shown that using meds like Metformin increase success rate.....and the other study I posted on my previous post will show him that Metformin is considered safe for use on patients with Hep C.


(from AASLD meeting Nov 2008).....

"In Chronic Hepatitis C (HCV), Pretreatment with Thiazolidinediones (TZDs) or Metformin Decreases Insulin Resistance (IR) and HCV Viral Load and Increases Early Virologic Response (EVR)."

M. Adler, J.L. Matloff, A.S. Boxer, H. Han, M. Vachon, D.C. Carriero, D.T. Dieterich, , Mount Sinai School of Medicine, New York, NY; M. Vachon, D.C. Carriero, D.T. Dieterich, Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY;

Background: Chronic HCV is associated with increased incidence of insulin resistance (IR), which leads to a lower rate of sustained virologic response (SVR) following treatment with peginterferon plus ribavirin (IFN + RBV). Romero-Gomez et al. reported an SVR rate of 32.8% in genotype 1-infected patients with IR (HOMA-IR > 2) compared to 60.5% in those without IR. In addition, IR is associated with increased liver fibrosis and is characterized by a higher viral load, two other independent risk factors for decreased response to treatment. A recent study showed 0/5 EVR in patients with IR who were given a TZD at initiation of IFN + RBV. It is unknown if therapeutic intervention to improve insulin sensitivity prior to anti-viral treatment increases response to HCV treatment. Aim: To evaluate the effect of treatment with TZDs or metformin on IR and viral load prior to IFN + RBV and the impact on EVR. Methods: IRB-approved, we retrospectively reviewed charts of patients with chronic HCV from a liver clinic in our center. We included patients with IR treated with either metformin or a TZD for at least 3 months prior to initiating IFN+RBV. We compared HOMA-IR, HCV viral load, liver enzymes and BMI at baseline, after treatment with an insulin sensitizer (IS), and at week 12 of HCV treatment. Results: 17 patients met inclusion criteria. 10 were co-infected with HIV. The average age was 52.2 years, and 82% of patients were genotype 1. 11 patients were treatment-naïve to IFN+RBV. The mean stage of fibrosis was 2.7 on Metavir score in 12 patients. 11 patients received a TZD and 6 received metformin. The mean HOMA-IR decreased from 7.99 to 6.06 after treatment with an IS to 4.60 at 12 weeks of IFN + RBV. There was a significant mean decrease of 0.52 log in HCV viral load on each patient after treatment with an IS (p<0.01). An EVR was achieved in 12 patients (71%). The mean ALT value decreased from 86.2 at baseline to 72.5 (p=0.02) after treatment with an IS to 34.1 IU/L (p=0.01) after 12 weeks of IFN + RBV. BMI significantly decreased from 27.9 to 26.8 kg/m2 (p=0.02) following treatment with an IS. Conclusion: The use of a TZD or metformin improved insulin sensitivity prior to treatment with IFN + RBV. The baseline viral load, a risk factor for decreased response to treatment and until now referred to as an unmodifiable factor, was also significantly lowered. This intervention allowed a 71% rate of EVR in a population of mono and co-infected patients, the majority being genotype 1. This small pilot study suggests that targeting insulin resistance prior to treatment may enhance the chance of response to traditional treatment for chronic HCV.


As I said before, I think the fact that you had genotype 2 is in your favor.  Don't start looking at this as an "I am doomed" sort of thing but more as someone (Baja) coming in on time to tell you what to do to remain clear.  Metformin will be like insurance.

Best of luck to you,

Co

[CoWriter]

Glucose 104, HOMA 3

That makes you a pre-diabetic, which means that you're insulin resistant (insensitive to insulin).

Insulin resistance is a strong predictor of non-response.   However, it is more so for people who have genotype 1.  You are lucky that you have genotype 2 which tends to respond better




J Hepatol. 2008 Jan;48(1):28-34.

Insulin resistance and response to therapy in patients infected with chronic hepatitis C virus genotypes 2 and 3.

Poustchi H, Negro F, Hui J, Cua IH, Brandt LR, Kench JG, George J.
Storr Liver Unit, Westmead Millennium Institute, University of Sydney and Westmead Hospital, NSW, Australia; Digestive Disease Research Centre, Shartati Hospital, Medical Science/University of Tehran, Iran.

BACKGROUND/AIMS: Obesity is associated with impaired treatment responses in chronic hepatitis C. The aim of this study was to determine the relationship between the insulin resistance frequently seen in obese subjects and sustained virological response to anti-viral therapy (SVR) in patients with genotype 2 or 3 infection. METHODS: Eighty-two patients were studied; 59 received interferon/ribavirin while 23 received peg-interferon/ribavirin. RESULTS: The overall SVR was (77%). Patients with a SVR had lower mean serum insulin (10.7+/-0.8muU/ml vs. 22.2+/-4.9; P=0.03), fibrosis stage (1.9+/-0.1 vs. 2.7+/-0.3; P=0.007) and insulin resistance measured by the homeostasis model (HOMA-IR) (2.5+/-0.2 vs. 6.1+/-1.5; P=0.03). Age, gender, ethnicity, alcohol consumption, treatment regimen, viral load, portal activity and steatosis did not influence the SVR. By linear regression, body mass index (P<0.001) and fibrosis stage (P<0.001) were independently associated with HOMA-IR. After adjusting for fibrosis stage, patients with HOMA-IR of <2 were 6.5 times more likely to achieve SVR than those with HOMA-IR2.

CONCLUSIONS: Even in treatment-responsive genotypes 2 and 3, high HOMA-IR is associated with a reduced response. Improving insulin sensitivity may be a useful adjunct to anti-viral therapy in these individuals.




Assessing Hepatotoxicity of Thiazolidinediones (TZDs), Metformin, and/or Statin Therapy in Chronic Hepatitis C (HCV) Patients

H. Han, A.S. Boxer, M. Adler, J.L. Matloff, D.C. Carriero, M. Vachon, D.T. Dieterich, , Mount Sinai Medical Center, New York, NY;

Purpose: Patients over the age of 40 with Hepatitis C (HCV) have a three-fold higher prevalence of Type 2 diabetes (T2DM) than those without HCV. In addition, glucose abnormalities are associated with a poorer virologic response in chronic HCV patients. Attempts to improve insulin sensitivity prior to or during combination pegylated interferon and ribavirin therapy may result in a higher rate of viral response to HCV treatment. The aim of the study is to assess hepatic safety of insulin sensitizers such as TZDs and metformin, and/or cholesterol lowering agents like statins when used in patients with chronic HCV, prior to HCV treatment. Methods: IRB-approved, retrospective chart review from 2002 to 2007 of patients at a liver clinic in our center with chronic HCV treated with at least one of the study medications. We examined variations in ALT, AST, GGT, HDL, LDL and total cholesterol, triglycerides (TG), HbA1C, and calculated HOMA-IR at baseline and after 3 to 6 months of therapy. The Student T-Test was used to compare pre-treatment and post-treatment parameters. Results: Fifty-two patients (73% males, ages 36-68), of which 32 were on TZDs, 14 on metformin, and 6 on statins, were included for analysis. Compared to the pre-treatment, the post-treatment group evidenced a decreased trend in all biochemical parameters except for TG and HDL cholesterol. There was a statistically significant (p<0.05) decrease in calculated HOMA-IR from 7.37 (8.28) to 2.40 (0.87) after 3 to 6 months of treatment, and HbA1C declined from 5.44 (1.11) to 5.29 (0.82) %. ALT, AST, and GGT levels improved from 83.56 (82.47) to 65.92 (46.04) IU/L, 78.44 (66.76) to 65.77 (42.11) IU/L, and 139.48 (132.60) to 136.84 (202.38) IU/L, respectively. Total and LDL cholesterol also showed a trend downwards from pre-treatment (167.63 [37.69] and 82.65 [29.73] mg/dL, respectively) to post-treatment (162.55 [35.16] and 77.86 [27.21] mg/dL, respectively). TG and HDL values trended up from 163.85 (97.52) to 171.04 (127.99) mg/dL and from 49.59 (17.91) to 49.93 (19.99) mg/dL, respectively. There was no significant change in BMI from pre-treatment, 28.38 [5.72], to post-treatment, 28.04 [4.24] kg/m^2. No patients discontinued medications because of liver-related side effects. Conclusions: The decreasing trends in ALT, AST, GGT, and total cholesterol with the use of TZDs, metformin, and/or statins demonstrate the relative safety of these agents in HCV patients. The significant decrease in calculated HOMA-IR with insulin sensitizers given before HCV therapy may indicate a role for them in improving treatment response in HCV patients. A randomized study is underway.

[jmjm530]

let me add a little to the above. As stated, Pepto-Bismol does not contain aspirin and most certainly will help and upset stomach. that in fact is what the product is prescribed for. that said aspirin apparently does share some components with aspirin and for that reason *might* be contradicted on treatment because of its possible effect on platelets. I say possible, because I don't know if Pepto-Bismol would necessarily lower platelets, especially if only used a day or so for an acute upset stomach. as I stated in my second post of this thread, B. Pepto-Bismol should be run by a Dr. who hopefully will be able to weigh the benefits versus possible risks in regards to platelets.

[jmjm530]

Pepto Bismol DOES NOT contain aspirin and is, and has been, quite specific for irritated/upset stomachs.

http://www.pepto-bismol.com/pepto-bismol-faq.php#faq12

[CoWriter]

Peptobismol contains aspirin.  You don't give aspirin to somebody with an irritated stomach.  Plus it makes the stool black and people worry about it being GI bleeding.

Co

[bajawoman]

About CoWriter
she has not been around much lately but maybe you can go to her page and leave note or PM with your blood info and ask for help or suggestions but really you should print out the links about insulin resistance and speak with your doctor about this as it is definately a proven issue with tx and SVR very best of luck to you and there are aids to help when I tx is Alinia and Metaformin and sups won't do it without.Which was recommended by HR when I had my fibroscan as a MUST
baja

[mrvacation]

Please let me know what you think.