odds after skipping one dose inf

[runsincircles]

  I'm 2b and und since week 4.  I've taken 18 of 24 peg shots and skipped this last one (19).   My ANC has been dropping quickly from week to week recently so dr put off this weeks peg shot.  Says we'll do weekly cbc to determine whether I take it each week.  Since I was a high risk case and have unexplained seizures for the last 2 years I'm not gonna argue this one.  I also have a depressed/anxious 11 year old to take care of and I've been at her school and dr alot lately.  I'm still taking riba.  Will my chances of success lower with each shot and how much?  Are these shots just "skipped" or should I ask about making them up?  I'd also like to know what happens if I get an infection at this point.  Can I take antibiotics or will I end up in the hospital with an ANC of 604?  I know alot of you have said I should change dr's but I think erring on the side of caution is best in my case and with medicare I don't think I could get switched in less then a week.  I appreciate all the support I get from you guys and I'm so glad I can come here to get get others opinions and knowledge.

[desrt]

From the two trials cited in Can-do's link:


Using weight dosed Peg-Intron and weight dosed riba -

"In an analysis of all RVR patients treated per protocol, 91% of those who received 14 weeks of therapy achieved SVR, compared with 95% of those treated for 24 weeks. The difference of 4% fell well within the pre-determined 10% margin needed to show inferiority, allowing the researchers to conclude that 14 week treatment was non-inferior to 24 weeks..........
The relapse rate was highest among participants older than 40 years, those with genotype 3, and those with a high baseline viral load. However, prolonging treatment from 14 to 24 weeks did not reduce the relapse rate substantially for any of these groups."





Using flat dosed Pegasys and flat dosed riba -

"The overall SVR rate was significantly higher among genotype 2 patients treated for 24 weeks rather than 16 weeks (91% vs 82%).......Relapse rates were significantly lower among people randomized to 24 weeks of therapy vs 16 weeks, both overall (6% vs 15%; P < 0.0001) and when participants with genotype 2 (5% vs 17%)"


"In an editorial accompanying Singal's meta-analysis, Donald Jensen from the University of Chicago Medical Center attempted to make sense of the conflicting findings from studies to date of shorter treatment durations for genotype 2 or 3 patients."


I can think of a couple things that might explain the conflict.

[pooh55811]

"More recent studies doesn't seem to agree with the one desrts posted that said, " In patients with genotype 2 and RVR, 12 weeks of therapy with peginterferon-alpha and ribavirin is recommended." "

I agree Can-do-man. The 7 page med scape article was pointing out the higher relapse rates with the shorter treatments as well.

[can-do-man]

More recent studies doesn't seem to agree with the one desrts posted that said, " In patients with genotype 2 and RVR, 12 weeks of therapy with peginterferon-alpha and ribavirin is recommended."

SUMMARY: A shorter 12 to 16 week course of pegylated interferon plus ribavirin is not as effective overall for people with chronic hepatitis C virus (HCV) genotypes 2 or 3, according to a meta-analysis and 2 recent international trials. However, abbreviated treatment may be a viable option for selected patients with rapid virological response at 4 weeks, low HCV viral load, and inability to tolerate longer therapy.

The overall SVR rate was significantly higher among genotype 2 patients treated for 24 weeks rather than 16 weeks (91% vs 82%, respectively; P = 0.0006). The difference for participants with genotype 3, however, did not reach statistical significance (90% vs 84%, respectively; P = 0.1308). Among patients with low baseline viral load (HCV RNA <400.000 IU/mL), SVR rates with 24 or 16 weeks of treatment were also statistical equivalent (95% vs 91%, respectively; P = 0.2012).

http://www.hivandhepatitis.com/hep_c/news/2010/1026_2010_a.html  

[pooh55811]

This is a 2011 article on treating Genotype 2 (and 3) patients. It is seven pages long. You may have to register for the site but it is free. The article is definitely worth reading, especially in your situation.

http://www.medscape.com/viewarticle/739955

[desrt]

http://www.ncbi.nlm.nih.gov/pubmed/17040112

" In patients with genotype 2 and RVR, 12 weeks of therapy with peginterferon-alpha and ribavirin is recommended."

[desrt]

At this point doing more tx is simply doing everything possible to achieve SVR. The odds of an RVR geno 2 staying undetected with 12 weeks tx are almost as good as 24 weeks and even better if you completed 16. Though your probability of getting a bacterial infection aren't any higher with low ANC, if you do catch something, it's going to be harder to get rid of.

[mzkity]

Don't know how to say this. It is what hector says "do you want to do this again". He said it to me!! I didn't want to do this again. I switched doctors. And you can go to a teaching hospital. And also believe most accept Medicare. My nephew was treated for his hep c at a teaching hospital. At the very least as idyllic says, second opinion can't hurt. I know it's so hard with kids. But I'm wishing you the very best.

[Idyllic]

To me erring on the side of caution is getting a second opinion.

Truly ultimately what matters is that you understand the implications of each action (or inaction) that happens. Your doctor's assessment of SVR after skipping your Peg is what I would go buy since he knows your medical background and treatment history.

[HectorSF]

The proper protocol for absolute neutrophil count is
ANC <750 cells/mm3 - Reduce to 135 mcg
ANC <500 cells/mm3 - Discontinue treatment until ANC values return to more than 1000 cells/mm3. Reinstitute at 90 mcg and monitor ANC.
(Also Neupogen can be given to manage ANC levels. But it is only experienced and knowledgeable doctors that know when and how to use Neupogen).

Your ANC should NOT have been stopped! It should only have been reduced. Apparently your doctor is unaware of proper treatment protocol which is list on the drug label itself. As you can see it is only when ANC goes below 500 that interferon needs to be stopped. It is sad to see another patient improper treated and have their treatment success put in jeopardy because of ignorance on the doctor's part.

In general it is known that every time you don't take your peg-interferon you are reducing you chances of SVR. There are too many variable to measure statistically. There is a possibility that there is remaining virus and without interferon boasting the immune system to fight it you could have the virus come back during treatment (breakthrough) or after stopping treatment (relapse).

An ANC of 604 is not dangerous unless you have other health issues that would be affected by a low ANC. I doubt that seizures have anything to do with ANC. Depression certainly doesn't.

'what happens if I get an infection at this point.'
ANC levels and infection are NOT related. There has never been shown a connection between ANC levels and rates of infection in treating hepatitis C patients. Besides your ANC is not low enough to have any serious affects.

If you doctor is going to continue to manage your treatment improperly I would find another doctor ASAP as he/she is setting you up for failure. Most major teaching hospitals accept payment from Medicare and they have the most educated gastros and hepatologist in the community. Do you really want to have to do treatment all other again because of your doctor's incompetence? The choice is yours of course.

Good luck to you!
Hector