JmJm, Cholesterol levels?

[gauf]

If low level Cholesterol is a sign of impending relapse, I may have something to worry about....

Cholesterol 94 100-199 mg/dL L
HDL Cholesterol 28 >45-  mg/dL L
VLDL Cholesterol 13 6-40 mg/dL  
LDL Cholesterol 53 60-129 mg/dL L
Fasting Time 12  -  hrs  

Last time it was checked was 10 years ago and is about the same.  Any thoughts.

[nygirl7]

Not that it matters but my cholesterol / triglycerides were perfect before treatment and after 72 weeks now is a huge problem.  Of course I don't believe I changed any habits pre-tx (obviously during treatment not eating would affect that low number) but - I did SVR with a huge change in my cholesterol numbers and obviously I was two geno 1s.

Just trying to throw i an optimistic note there even though scientifically it doesn't mean anything.

[jmjm530]

Good estimate. Again, I'd run all my stats (including those viral load numbers) by Dr. Dieterich in the Expert Forum for his opinion on whether 48 is the magic number or not. He's appears to be a very bright guy and I don't think you could spend 20 bucks (or whatever it costs) any better.

-- Jim

[gauf]

Don't know what my triglycerides are. I don't know if I am an RVR or not. I had a PCR at 3 weeks and showed >50 and <650. At week 7 had an ultrasensitive PCR which showed UND <5. I figured UND around wk 6, but is possible was UND at wk 4 or 5.

[Bobby1952]

    I believe that low cholesterol is fairly normal for us G3's. My cholesterol level was between 90 and 110 for the last 10 years. When I finished tx 11 months ago I had my cholesterol levels checked again twice and it shot up to 175 both times. Of course I achieved SVR so the Liver was healing. Hoping the same for you.

Bobby

[jmjm530]

I argued the point once that the relationship between low cholesterol and lowered tx response was solely due to liver damage, but I believe there may be a study out questioning that, i.e. that other factors may be at play indpendent of liver damage. Someone would really have to dig the studies up and take a look. Not sure if it's been pointed out in this thread but the "bad" cholesterol (LDL) shares the same receptor sites as the virus which may factor into all of this.

-- Jim

[geterdone]

Have you considered going back, from which you had begun? Two weeks prior to the start of the taper there may be an option if you so chose to retest the rockets if meds are available before reentry. Week 46 1 ¼ INF 1400 Riba, Week 47 1 ¼ INF 1600 Riba, Week 48 135 INF / 1200 Riba, then sliding scale from there, that is if you are going to do just the 48 and of course what your doctor recommends :)

Geterdone  

[JennyPenny]

Don't forget that cholesterol is made in the liver and the more fibrosis one has, the lower the cholesterol is likely to be. I don't believe it is any more a predictor than is stage of fibrosis.

[CockSparrow]

Forgot to mention whats your Triglyceride level

CS

[jmjm530]

Thinking a bit more, because you're a geno 3, the week 4 test might even be more important as most geno 2's and 3's RVR. So because of your stage 4 status -- and no RVR -- maybe extension beyond week 48 is warranted although I have no studies to base this on. Sorry for my vacillation but I'm much more versed on geno 1 studies.

What I would do in your shoes is research more the ideal treatment length for someone with your stats.

You might start with this article in the excellent "Nature" mag which unfortunatly you will have to pay for

http://www.nature.com/ncpgasthep/journal/v2/n12/full/ncpgasthep0337.html
( since I recommended it please PM me the full-text LOL)

I'd also post a question to Dr. Dieterich in the expert forum with all your stats and treatment history and request his best estimate for treatment length.

-- Jim

[CockSparrow]

With G3s and your cholesterol is low prior to Tx then your cholesterol will rise during Tx.
The reason for this is as your VL drops the viral induced steatosis also reduces.

However just because G3 steatosis is seen as viral induced doesnt means that metabolic causes of steatosis dont play a part.

Your cholesterol is a lot higher than mine.
So my guess is you cant read too much into your cholesterol levels
as your steatosis could be metabolic more so than viral.

In other words your steatosis is more like a G1s.
CS.

[jmjm530]

I must apologize because I forgot you were a genotype 3. Assuming you treated the requisite 24 weeks the first time before you relapsed, then yes, 48 weeks should be adequate the second time. The 72 week extension I recommended would hold for a geno 1 in your position who relapsed. Keep up the good work!

-- Jim

[HectorSF]

Nice journal. Good detail.

I agree with Jim. I think he really focused on the critical issues affecting your chances of SVR. The key factor was your viral response at week 4. Since you weren't a RVR the only variable at this point is duration. So I would extend. (Easy for me to say!)

Here are some comments about genotype 3, relapse rates and treatment duration.

"Chronic Hepatitis C
Strategies for Optimizing Current Treatment and the Potential Impact of Emerging Therapies"

Michael W. Fried, MD
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina

Mitchell Shiffman, MD
Virginia Commonwealth University Medical Center
Richmond, Virginia

MODERATOR
Emmet B. Keeffe, MD, MACP
Stanford University School of Medicine
Palo Alto, California

Medical Crossfire
Release Date: February 12, 2007

Dr. Fried ,“Although broad recommendations are important, it is clear that genotype 3
patients do not respond as well as genotype 2 patients; there is a higher relapse rate in genotype 3 patients. Even among genotype 3 patients, those who have more steatosis, a higher viral load, or more advanced fibrosis, are more likely to relapse.”
“Dr. Fried, let us say you are treating a genotype 3 patient with cirrhosis,” proposed
Dr. Keeffe. “What do you do?” Noting the dearth of good prospective evidence, Dr. Fried nonetheless indicated that he would extend therapy in carefully selected patients. “If the patient is tolerating therapy well and is having a good response, I will definitely think about extending the duration of therapy in the genotype 3 patient who has other negative prognosticators like cirrhosis or steatosis. This approach is somewhat anecdotal, but—” Dr. Fried stopped speaking and observed, “Dr. Shiffman, I see you are shaking your head.” “The data show that rapid response predicts the rate of sustained response,” countered Dr. Shiffman. “If a patient has a rapid response, it does not matter what their degree of fibrosis is, and it does not matter what their weight is. If a patient has a rapid response, the SVR rate is 90%. It is critically important to measure that. If I see that, even in a genotype 3 patient, I treat for 24 weeks.” “As Dr. Nelson said in his earlier comments, the RVR should be incorporated in the algorithm,” interjected Dr. Fried.
“Yes,” agreed Dr. Shiffman, adding, “On the flip side, as Dr. Nelson said, if the
patient does not achieve RVR at week 4, then treat longer using the principles that Dr. Nelson outlined.” “By the same token,” remarked Dr. Fried, “I do not believe that there are any good data to suggest longer treatment will improve the sustained response.” Dr. Shiffman confirmed the point, commenting, “There are no prospective data looking specifically at nonrapid responders in genotypes 2 and 3 to see whether a longer duration is useful. That study needs to be done.”

Relapse rates in genotypes 2 & 3 that don’t achieve RVR.
http://www.natap.org/2007/DDW/DDW_11.htm

“Dr. Bailey also noted that predictors of treatment outcome in genotype 3 patients (but not genotype 2 patients) included baseline viral load and Metavir fibrosis score. Liver disease was also a predictor of outcome for genotype 3 patients, with 47% SVR for those patients with cirrhosis (75% in patients with minimal fibrosis)”.
http://www.pslgroup.com/dg/216e2a.htm

Best of luck!
Hectorsf

[copyman]

I will check out your journal.

Best of luck my friend, you are a true warrior.

[gauf]

Oh yah, I am onboard with that. All in my journal.

[copyman]

i would not look at your cholesterol test as a predictor of anything. Especially since they are about the same as 10 yrs ago.

On another note, do you have a plan in place to taper off the tx drugs? I would seriously consider tapering off.

[jmjm530]

Yeah, treatment *****, and extension suck even more :) But the general principle is that if you didn't respond the first time, then juice up tx the second time. But if you responded and relapsed, then extend the second time.

In your case you did the former on round two (juiced up treatment) and while nothing wrong with that, it's only addressing the response issue and not the relapse issue which is your issue.

If you doc doesn't go for extension, I'd get another consult with a hepatologist of course as they tend to understand the more agressive regimens.

-- Jim

[gauf]

Riba 1600 first 4 weeks, 1400 next 3 mos, currently at 1200. Sx not too bad this time so will discuss extending with the doc. (sigh) thanks Jim.

[jmjm530]

Forgot to ask what kind of doses you're on this treatment round. Depending on your doses, you could reasonably cut back a bit after week 48 to mitigate side effects if that is an issue.

[jmjm530]

I'm assuming you were still detectible at week 4 and became UND at 6 using a very sensitive test, hopefully down to 5 IU/ml or at least 50 IU/ml?

Like yourself, I was also UND at week 6, but treatment naive and stage 3. While two of my consults thought 48 was enough, my treatment doc actually wanted me to extend, probably to 60 or 72 and I ended up compromising with 54.

Your case is different, however. I do understand you've added some goodies like Alinia to your treatment, and also lost signficant weight (probably the best news) but you're still a stage 4 who failed his first round of treatment. But the way you failed is important, you responded (did you test at week 6 the first time around?) like this time but then your relapsed. This by itself suggests extending the next time around so history doesn't repeat itself. Add to that your histology and I think there's a very strong case for extension. Of course, a lot depends on how you're handling treatment, but if nothing extraordinary is going on, I would give serious thought to 72, or perhaps shoot for 60 and then see how you're doing. You've invested a lot at this point, and you have a lot at stake here.

-- Jim

[Andiamo1]

Low cholesterol is more closely tied to the level of compensation with regard to liver function - not viral load.

Best,
Eric

[gauf]

UND around week 6. Not extending.

[jmjm530]

In terms of prediction, I think your viral response will trump any pre-treatment predictors. When were you UND this time around? If not UND at week 4, have you considered extending considering your stage 4 status?  As far as cholesterol, yes, low LDL cholesterol is a neg pre-tx predictor, but cant be looked at in a vacuum. You can see the finish line now. Be positive.

All the best,

-- Jim

[gauf]

P.S. last tox 180 pegintron weekly and 1000 Riba.

[gauf]

I have 7 weeks to go of 48. I did respond to last tox. Only checked at wk 12 (UND) and eot. <50.  IR not an issue starting this tox due to diet and exercise. I discussed IR with NP, but my glucose looks good so they said don't worry about it. I am still stage 4 compensated.