Timing of PCR tests following EOT?

[stee1head]

Geno 1b, VL 1.6 mill, mild stage 1. UND at 12 weeks. Pegasus 44/48 tomorrow (180) Riba (1200). I have been on the transfusion rollercoaster since mid August. The Aranesp was finally doubled after 12 weeks of shot. GI wanted to reduce Riba, but I told him no way. Now I have had 16 units of cells on this ride. The increased Aranesp has seem to slow my Hemoglobin drop, to about 1.1/week the last 2 weeks. I realize from reading this forum that I should have hade PCR tests more frequently during my treatment. I don't want the same mistake being made now that EOT is near. Do I need a PCR before treatment ends? I am afraid I could have had a breakthrough and never known it. I read somewhere that I should have one 5-6 days after my last treatment. Then I figure tests at 4,12, and 24 weeks. Does this seem reasonable. Thanks in advance for any replies. G

[mremeet]

steelquote: "Do I need a PCR before treatment ends? I am afraid I could have had a breakthrough and never known it. I read somewhere that I should have one 5-6 days after my last treatment. Then I figure tests at 4,12, and 24 weeks. Does this seem reasonable."

You definitely should have the most sensitive test available prior to EOT (2 IU/ml is the sensitivity of the tests jim alludes to above), and since you have 4 more weeks to go, I'd try to be tested right away and at least 2 more times prior to wrapping things up. Also, if you're that worried about relapsing then you might even want to consider extending tx another 4 weeks or so while continuing to frequently monitor PCR results. That way, if you do have a VL that is flickering in and out of undetectability you'd be more likely to catch it (and perhaps extend tx longer and/or add alinia etc). Plus you'd be buying more SVR "insurance" by doing so. If extending tx is a no go, especially in consideration of your hard fight with anemia (and the transfusions), then practically speaking worrying about your VL's anymore is superfluous. Also, frequent testing at precise intervals after you complete treatment (prior to 12-24 weeks) will do you no good unless you intend to re-initiate treatment and go a LONG distance afterwards. If re-initiating treatment is a non-starter, then the only thing it will provide for you is peace of mind, or the lack thereof, depending on the results.

Lastly, there have been a few recent threads about tapering off of IFN after the conclusion of a full course of the drugs, instead of simply abrubtly stopping as is commonly done in most of our treatments. Although it is not known for sure if tapering off of IFN will enhance odds of SVR-ing, there are theoretical arguments that suggest this may be true. Firstly, tapering IFN after EOT extends the window of antiviral efficacy, especially considering that riba has such a long halflife (i.e. riba's effects will persist for weeks after stopping it). This is actually pretty important in my view, especially in regards to geno 1 treatment where the odds are not very good for tx success. There are almost certainly a significant number of geno 1 patients who stopped tx at 48 weeks and were on the every verge of achieving SVR, but they snatched defeat from the jaws of victory right at the eleventh hour by stopping when they did. Continuing on, even in a gradually decreasing dose regimen, could make the difference in snuffing out those last hanger-ons for a surprising number of people.

Secondly, the body actually produces its own interferon and when it has been heavily dosed with synthetic IFN for a prolonged period of time, it significantly curtails its own production of IFN. When the synthetic IFN is abrubtly cut off, there is a period of time where the amount of IFN within the body drops to levels well below what would normally be found in a chronically infected HCV patient who is not undergoing treatment. It is during this period of time that IF there is still virus present, even if at extremely low levels, the body is especially susceptible to the re-emergence of the virus. This may be how some (or many) people end of relapsing after EOT. It takes time for the body to restart it's interferon production, and the abrupt cessation of synthetic IFN immunologically leaves it out in the cold for a period of time before it has a chance to kickstart and re-establish its own IFN production/regulation. By gradually tapering down the synthetic IFN dosage over time, you allow the body to get it's own IFN production going so that there will won't be that window of immunological nakedness that there otherwise would be if the IFN was simply chopped off at EOT. This is why it has been theorized that tapering the IFN dose down at EOT in a gradual manner may help to prevent relapse in those who are very close to achieving SVR, but just aren't quite there at the very end. A sort of coordinated hand-off between synthetic treatment provoked responses and the natural immune system responses instead of simply throwing the baton down on the ground at EOT.

[stee1head]

Thanks for your timely response.

G

[jmjm530]

Yes, an EOT test will help differentiate between viral breakthrough and relapse, in case there is no SVR. Have blood drawn for your EOT test as you would with a regular viral load test. In this case, it would be six days after your last Peg injection. Further testing at week 4, 12 and 24 weeks post treatment is a very good schedule. As to the test itself, I suggest you use the most sensitive available.

Three very good tests are:  (1) "Heptimax" by Quest Diagnostics;
(2) "HCV RNA TMA QUAL" by Quest Diagnositics; and
(3) "Hepatitis C Virus (HCV), NGI QuantaSure™, Quantitative, PCR" by LabCorp.

The first and third test will give you an actual number, should you be positive, while test #2 will just say either "virus detected" or "virus not detected".  At this point not sure a number is that important, and should you be positive, they could always run a quant with the same blood if you want. I've taken both of Quest's tests and now only use test #2. One of our contributing doctors here talks favorably about the LabCorp test.

Good luck,

-- Jim