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Avatar universal

Incivek week 4 VL back

Detected at <43.  

Doctors are pleased.  I was looking at frijole's spreadsheet and looks like the majority end up clearing when <43 at 4 weeks.  Is that what you all are seeing?

David
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446474 tn?1446347682
Another informational paper on post transplant treatment of HCV.
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"Immunosuppression, Liver Injury and Post-transplant HCV Recurrence
From Journal of Viral Hepatitis"
S. Ciesek; H. Wedemeyer

Posted: 01/17/2012; J Viral Hepat. 2012;19(1):1-8. © 2012 Blackwell Publishing

http://hepatitiscresearchandnewsupdates.blogspot.com/2012/01/immunosuppression-liver-injury-and-post.html
...
"Treatment of HCV Re-infection After Transplantation"

"As long as no potent drugs or neutralizing antibodies are available to prevent HCV recurrence after liver transplantation, re-infection can still be treated with a combination of pegylated interferon alpha and ribavirin. However, the efficacy of this treatment is limited mainly by the poor tolerability in liver transplant recipients, and thus SVR rates are lower than in immunocompetent nontransplanted individuals.[12] Overall, SVR rates after liver transplantation for HCV genotype 1 infection are around 25–30%.[53] Furthermore, prolonged therapy seems to be required even in patients infected with the easier to treat genotypes 2 and 3 and extending antiviral therapy for more than 48 weeks might prevent virological relapse in many patients.[54,55] IL28B genotypes of both the donor and the recipient are associated with response to PEG-IFNa-based treatment after liver transplantation, and determination of the IL28b genotype may therefore be useful in clinical practice to decide which patient should receive antiviral therapy.[27] Importantly, successful treatment reduces liver-related complications in recurrent HCV infection.[56]

Even though interferon alpha can be beneficial for many patients, it has to be considered that antiviral therapy can promote rejection especially in the early phase after transplantation.[57] Thus, liver transplant recipients receiving standard antiviral therapy need to be monitored for acute cellular rejection and chronic ductopenic rejection. In addition, de novo autoimmune hepatitis may develop and immunological phenomena may even occur after treatment has been stopped. As the clinical course of HCV infection is largely influenced by co-factors, it is of particular importance in liver transplant recipients to avoid co-morbidities including ischaemic-type bile duct lesions and liver steatosis.

The use of the novel NS3/4A protease inhibitors seems to be limited in patients after liver transplantation as it has been shown that telaprevir increases tacrolimus blood levels by approximately 70-fold – precluding its use outside of clinical trials.[58] Co-administration with telaprevir also affected cyclosporine exposure and cyclosporine half-life, but to a lesser extent. No data on drug–drug interactions between calcineurin inhibitors (CNI) and boceprevir are currently available. Clinical trials are under way to determine the safety of efficacy of triple therapy of hepatitis C in liver transplant recipients. Whether combinations of PEG-IFNa with other NS3/4A protease inhibitors or with calcineurin inhibitor-free immunosuppressive regimens are feasible remains to be determined.

Currently, more than 100 novel HCV inhibitors are under preclinical and clinical investigation. These can broadly be divided in direct antiviral agents (DAA) and host factor targeting antivirals (HTA).[59] While DAAs target the virus directly and include NS3/4A protease inhibitors (first & second generation), NS5B polymerase inhibitors and NS5A inhibitors, HTAs target essential cellular factors like cyclophilin A, microRNA122 and CD81 antibodies. Disadvantages of some but not all DAA classes are that they are not effective against all HCV genotypes and that viral resistance is anticipated to become a major problem. HTAs may show broad activity across HCV genotypes and pose a higher barrier to drug resistance in comparison with DAA.[16] It is expected that some of the novel drugs will reach the market in 2015; however, none of the new anti-HCV drugs are currently being evaluated in HCV-infected liver transplant recipients. The ultimate goal will be to introduce safe interferon-free combination therapies without significant drug–drug interactions leading to cure from HCV infection within a limited time frame."...

..."Conclusion"

" Prevention and treatment of HCV re-infection after liver transplantation remains a major unsolved clinical challenge. HCV-positive patients have poorer long-term outcomes after liver transplantation in comparison with patients with other underlying liver diseases. While treatment with pegylated interferon alpha and ribavirin can cure up to one-third of HCV-positive liver-transplanted patients, there are many promising drugs in clinical and preclinical development targeting either the virion or essential host factors. Strategies to prevent HCV re-infection include neutralizing antibodies or drugs targeting cellular HCV entry factors. Unfortunately, it will take at least several years until most of these drugs will reach routine clinical practice. Immunosuppressive medications may alter the course of hepatitis C after transplantation but conclusive data on the use of distinct regimens for HCV-infected transplant recipients are lacking. Thus, almost 30 years after the approval of the first calcineurin inhibitor and 23 years after the discovery of HCV, the optimal immunosuppressive strategy in HCV-positive liver transplant recipients still remains to be defined. However, acute rejection episodes and the need for steroid boli should be avoided as steroid bolus treatment is associated with reduced graft and patient survival and increase HCV infectivity."

Cheers!
Hector
Helpful - 0
Avatar universal
The doctors plans are as far as I know to keep the same regimen of half-doses since things are progressing in the right direction.  He's very cautious to avoid a rejection.  I'm right there with him on that.  A rejection is bad for multiple reasons but one of those is the patient has to start treatment from day 1 again.  See what I mean about being bad.  Don't think my rear end would appreciate that at all.

Yes, I had not heard of anyone being on prograf yet.  It goes way up with the PIs.  I was on prograf a while back but tolerated CsA better.  I'm down to a pretty low dosage of even CsA.  Would have to start skipping days to go lower.

Was getting labs twice a week but going to go to once a week.  Will get another PCR quaint at 8 weeks.

Thanks for comments and information.
Helpful - 0
190885 tn?1333025891
i might check it out at  5 weeks just to know when you get und.....i was <43 at 4 weeks....billy
Helpful - 0
163305 tn?1333668571
No harm at all,
I'm aware that other people read these posts, and I sometimes try to clarify things for those who may read them in the future.

Good luck:)
Helpful - 0
Avatar universal
Thank you, certainly agree about generalized statements from tranx patients.I  wasn't trying to generalize, I of all people am not remotely qualified to give any advise. Was trying to paint my picture,  and over stepped into general areas solely unintentional  and apologies to all. I assure you no harm intended. Thank you for posting!!!
Helpful - 0
163305 tn?1333668571
You are the only person I've heard of doing the triple tx post tp who wasn't switched from prograf to cyclosporin.  Maybe now, we know why.

I'm post tp, did SOC and did not require extra labs or reduced dosages until well into tx.

My impression is that the triple tx is still too new for tp patients, to make generalized statements.

To find Frijole's chart, go to her profile page, and look at her photos.

Good luck with your tx.
Helpful - 0
Avatar universal
Hey Bill, I too am post liver tranx and on triple therapy . I was told that Vic was the only treatment (48weeks) used in tranx patients because of maintaining immunesupressents. The Vic played havoc on my progragh. I was on daily labs for almost a week. Finally settled on a 3x a week doses for progragh. All stable now. The post liver transplant patient requires a lot of labs,  and reduced  ribavirin and interferon doses. How do I find Frijoles chart? Can't seem to locate. Trying to put a picture together about my chances of und at 12 weeks, and SVR is been a challenge. My beginning vl and my 4 week vl was cut by 80%, but not und. My 8 week # is 8-01-12. My alt and ast are in the normal range. Thank you for posting!!!!
Helpful - 0
446474 tn?1446347682
David here is some more info of the low accelerating -dose regimen (LADR) treatment you are on from EASL.

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"Low accelerating dose individualised duration treatment regimen for recurent HCV post liver transplantation" Apr 19, 2012

Introduction: Treatment with pegylated interferon and ribavirin is poorly tolerated post liver transplantation (LT) with significant side-effects. A low accelerating -dose regimen (LADR) has been used in patients pre-LT on the waiting list.

Aim: To retrospectively evaluate the efficacy of an individualised duration, LADR for the treatment of recurrent HCV post-LT.

Method: 28 patients were treated at our centre between April 2008 and June 2010. A LADR was used, with initiating antiviral dosages individualised by the treating physician. Treatment duration was determined by : patient tolerance, virological response, presence of advanced liver disease and previous treatment response. Treatment duration was extended beyond 48 weeks when a sustained virological response was felt to be less likely with a 48 week treatment duration.

Results: 15 patients (54%) had genotype 1 disease, 11 (39%) genotype 2/3 disease and 2 (7%) genotype 4. 7 (25%) had histologically advanced recurrence ( F>3 ISHAK). Initiating doses of ribavrin varied between 200 and 1200 mg/day (mean dose 600 mg). Dose reduction of ribavirin was needed in most patients and EPO support in 61%( n=17). The mean duration of treatment was 42 weeks. 53% (n=15) discontinued treatment prior to the anticipated end of treatment date, 66% (n=10) of these demonstrated inadequate virological response and 33% (n=5) discontinued because of significant adverse events on treatment.11 patients received treatment in excess of 48 weeks. The average treatment duration in this sub-group was was 61 weeks. 63% (n=11) of the extended treatment subgroup discontinued treatment prior to 72 weeks.

The mean haemoglobin decrement in the first 8 weeks on treatment was 2.68 mg/dl. On average, the Hb nadir was seen at 23 weeksf treatment. 3 patients required a blood transfusion whilst on treatment. 11/28(39%) attained an SVR overall. In the extended treatment subgroup, 55% (n=6) attained an SVR.

Conclusions: Extending HCV treatment duration beyond 48 is feasible in the post-transplant population and may benefit more difficult to treat groups. Treatment initiation at low doses may help to moderate the onset of on-treatment anaemia and convert it into a late phenomenon on treatment, allowing for a more lenghty period of antiviral exposure.
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http://www.multiwebcast.com/easl/2012/international.liver.congress.2012/18353/

The latest info on treating post TP patients with HCV.
Hepatology 2012
Standard Therapy of Chronic Hepatitis C Virus Infection
Markus Cornberg, Svenja Hardtke, Kerstin Port, Michael P. Manns, Heiner Wedemeyer

Download the entire book (PDF, 546 pages).
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Patients after liver transplantation

HCV reinfection occurs in almost all patients after liver transplantation. While the course of hepatitis C in liver transplant recipients was believed to be rather benign in the late ‘80s and early ‘90s (Boker 1997), HCV has led to a more rapid progression post-transplant in recent years (Berenguer 2005, Neumann 2004) with cirrhosis within the first 5-10 years in 20-30% of patients. HCV definitely takes a more rapid course post-transplant than in immunocompetent individuals and treatment needs are obvious. Antiviral therapy of HCV may be started before transplant to prevent reinfection of the graft. If this approach is successful, reinfection can be prevented in two-thirds of patients (Forns 2003). However, treatment with IFN/RBV is poorly tolerated in individuals with decompensated cirrhosis with a high risk for infections and this approach is feasible in only a minority of patients (Everson 2005, Forns 2003). Preemptive treatment within the first 4-6 weeks post transplant has been disappointing with SVR between 5% and 33% for different regimens including IFN monotherapy and IFN/RBV (Terrault 2003) (my hepatologist). Studies using PEG-IFN/RBV reported an SVR of 26-48% (Carrion 2007, Dumortier 2004, Neff 2004, Roche 2008, Rodriguez-Luna 2004). Treatment duration should be at least similar to non-transplanted patients considering early viral kinetics and the HCV genotype. However, bone marrow toxicity, depression, and rejection are limiting factors that require aggressive management (e.g., growth factors) (Rodriguez-Luna 2004). The ribavirin dose may have to be adjusted since many patients have some degree of renal insufficiency. Interestingly, the risk for IFN-induced graft rejection seems to be higher if ribavirin is not used. BOC and TLV are currently being evaluated in patients after liver transplantation. Besides adverse events (anemia, neutropenia), drug interactions with immunosuppressive drugs need to be considered. For example, TLV increases levels of tacrolimus by approximately 70-fold (Garg 2011). In conclusion, patients with established graft hepatitis should be treated with PEG-IFN/RBV, but at this stage, BOC and TLV should not be used in transplant patients outside clinical trials. Whether reinfection can be prevented by currently developed DAAs will have to be addressed in future studies.
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http://www.flyingpublisher.com/9002_13.php


Hang in there you are responding well.
Cheers!
Hector
Helpful - 0
1815939 tn?1377991799
It's great to hear you are <43 at 4 weeks. Congratulations!

Yes, it seems that most of us who were <43 at 4 weeks did clear the virus by the next VL test (my next test was at 8 weeks and I was UND at 8 weeks). We have to do 48 weeks, though.

Keep us posted.



Helpful - 0
Avatar universal
Being you have been on reduced dose do to TP I would think they would be very pleased... Whats their plans moving forward? Wishing you the best.
Helpful - 0
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