Prednisone Discussion

[meki]

Could you guys go into some info on prednisone and HCV?

I've read a few places that it can cause HCV to accelerate - or something similar to that.
I would love to hear what you guys have to say.

Specifically interested in Ms Ockert and mremeets info on the subject --- and very interested in personal experiences.

Just FYI - I'm asthmatic so have had to take Prednisone almost once a year since I was 12...

We're having a rash of "hay fever" pollens, etc. --- which of course, brings my lung functions down. I am a little concerned - and have been combating the issue without hitting prednisone this year - which is remarkable in helping...

BUT... I'm currently only 3 months SVR. So... What are the risks if I take Prednisone now? I didn't take it during TX --- because -- well heck -- don't think I left the house much to get air pollens... LOL!

I'd like some discussion on it --- whether or not backed up by fact.

I'm learning that sometimes personal experience is MORE than fact --- or any reference.

Because NOWHERE --- nowhere on any of the pamphlets from any of the doctors --- did they mention lasting side effects... nowhere did they say that side effects were common --- it was "MIGHT HAPPEN"... as if it were a worse case scenario.

So I don't trust anything by itself anymore  --- I take their "FACT" info --- and put it in with personal experiences -- and then I make up my mind.

But I don't see anything anti-prednisone.

Now --- it's y'alls turn to tell me what you think about it.

Super Thanks in advance -- you guys are excellent folks... Superbly excellent.

Meki

[debnevada]

I have had a couple of situations come up that could have used some steroids on board so I'm interested along with Meki. My internist is VERY against giving me steroids for anything but I don't know where the science is on this either.

We await your wisdom

[meki]

Elaine - how's Nick doing? Been meaning to ask.

Sorry about your mother - interesting about the steroids and thank you for sharing.

Deb - I'm thinking about steroid usage for my ribs... Something has to stop them from popping.

____|____   the sternum piece up to my neck feels like I have to pop a flipping knuckle every day --- it is very uncomfortable. Especially if I cough. Or sit with my shoulders forward for too long. Well - guess what hayfever does to asthmatics... LOL! Cough city.

But --- the good point of all of this is --- these are my last sides...

I'm losing my brain fog - little by little... I still have aches and pains --- but they are merely a whisper of what they were... and my vision is getting better - My tendons feel almost normal --- a little stiff --- but not like 4 months ago... And my lower back is feeling able to move... I can eat --- everything tastes good -- and I'm in a great mood almost all of the time now.

I have energy.

So --- I'm a little worried... because if the pollens keep up --- I'm going to need something. And I'm a little scared to have to go through all of that again.

Meki

[pigeonca]

I'm asthmatic too - have been ever since I was a kid.  I usually get one or two really bad attacks each year, and this past year was no different.  Needed prednisone shots, along with the six day program of pills in smaller and smaller doses, once during treatment and once since finishing tx.  I became SVR on the 4th week, and remain so 4 months after quitting.  So I guess the prednisone didn't do any harm.  

The people I know who have complications with steroids are using it on a daily basis or close to that.  Once or twice a year doesn't seem to bother me at all.  I also take an asthma controller, Q-Var, which is a steroid.  Took it throughout tx, twice a day.  Also needed steroid skin creams, again throughout tx.  I wouldn't worry about it.  Asthma is no picnic either.

[EarthMan]

Taken together, this body of literature supports the notion that corticosteroid therapy increases HCV RNA titers in all patients and may result in serious morbidity in some. We have therefore attempted to avoid their use, if possible, when treating UC in HCV-infected individuals, favoring 5-aminosalicylic acid or sulfa compounds when viable. If corticosteroids are used in this setting, we are careful to taper the dosage very slowly to below 10 mg/day in order to minimize the possible rebound effect of serum ALT. A similar strategy is used when reducing the dosage of corticosteroids in cancer chemotherapy for patients with chronic hepatitis in an effort to avoid disease reactivation or flare.[8]

http://www.medscape.com/viewarticle/413634

[mremeet]

The comments you read were probably in regards to taking prednisone while actively infected with HCV. Prednisone is an immunosuppressant so it reduces the intensity of your immune system while you're taking it. This can make you more likely to succumb to both bacterial and viral infections. Or, if you are already infected with a virus like HCV, it will increase your viral load, viral activity and probably the rate of liver fibrosis (although I don't have a study offhand to confirm that part). From memory, I think Kalio was taking prednisone or some other steroidal medication for a prolonged period time before knowing that she had HCV. Also, I don't think she was an alcoholic or a big drinker and yet she ended up with cirrhosis. So it appears as if the prednisone had accelerated her HCV disease process. Hopefully she will stop by and clarify, my memory is still a little fragmented right now so take this with a grain of salt until she explains for herself what happened.

But since it looks like you've got your SVR now, the use of prednisone should not cause the same problems for you that a chronically infected HCV patient might experience in the sense of increasing viral activity and the subsequent rate of fibrogenesis. However, be forewarned there's been a lot of talk (and fear) on this forum about the so called occult or low level persistent viral presence supposedly detected in the liver cells and PBMC (blood cells) of long term SVR patients. And because this may be true, it's thought that taking immunosuppressants like prednisone after achieving SVR might trigger a relapse. Much is made of two supposedly "confirmed" cases of SVR patients that had relapses after being given massive doses of immunosuppressants (I believe it was solumedrol). But this theory that active, viable HCV virus exists in our bodies at very low levels long after we SVR is controversial. It isn't fully accepted in the scientific community yet, and there are only a few studies that suggest this is true. There may be flaws in their detection methods or there may be something else going on that simply makes it appear there is viable virus hidden away in our livers after SVR. Plus a whole slew of reasonable questions have not been conclusively answered, like "if there's viable virus inside our bodies, why doesn't it simply become a full blown (re)infection again?" and "Considering that an SVR status has been proven to be extremely durable and long lasting in the vast, vast majority of those that achieve it - if there is viable virus in their bodies after SVR-ing, why don't we see people relapsing after (1) experiencing a significant challenge to their immune systems (via cancer, HIV etc) or (2) after taking immunosuppressants like prednisone and/or solumedrol (or any of the lesser steroidal meds like nasonex, clobex etc)?" This particular question is especially compelling considering what a large number of SVR patients there are now in the world. And if you consider how often and common steroidal med use is (for things like allergies etc) amongst ordinary people (including SVR's), along with the fact that there is a sizeable subset within the HCV SVR community that are old, and/or have experienced significant challenges to their immune systems (via cancer, HIV etc), and/or have taken very large doses of immunosupressants in order to control a serious health issue (like a transplant rejection or becaue of an autoimmune condition). Considering the people within this subset must number into the thousands upon thousands, and yet...we just dont see relapses. SVR durability remains nearly 100%, and there are very reasonable arguments to be made that can readily explain away the teeny bit of "relapsing" we do see (mosty in the sense of reinfections via chronic IV drug use, or by people who were mistakenly identified as SVR in the first place). So with all of this said, it certainly seems clear that prednisone usage (especially mild/moderate usage) after a confirmed SVR status is achieved will not lead to reinfection in the vast, vast, VAST majority of those that take it. (and the reason that may be true is simply because the virus has been effectively and permanently ERADICATED)

Lastly, remember that prednisone does have significant side effects whether or not you are SVR or have never been infected with HCV. But if you have a good doctor that knows you are SVR and a serious allergy or health condition that warrants its use, then in my opinion I wouldn't avoid taking it if I really needed it. Although speaking for myself, I would not take it until at least 6 months post tx (unless you desperately needed it), just to make absolutely certain the cooties were gone for good before tempting fate by tuning down your immune system with prednisone so soon after stopping treatment. But generally speaking, rest assured there are a large percentage of SVR people out there that are using steroidal creams/shampoos (which are absorbed into your body and do have an immunosuppressive effect) for rashes, and/or are using steroidal nasal sprays for congestion, and/or are taking steroidal inhalers for asthma, and/or in rare instances have used strong steroidal meds like IV solumedrol to suppress a serious allergic reaction (like from a bee sting). And yet they do so without relapsing en masse.

[mremeet]

Oh yeah, forgot to mention that I also took very large doses of prednisone during my treatment. I took it early on during the most critical phase of viral clearance too (starting at about week 6). And then after taking it for nearly a month, I even got a big juicey shot of solumedrol, which as stated above is a very strong immunosuppressant that's in the same class of drugs as prednisone. I also took even more prednisone after that. It was an immunosuppressive buffet for awhile there, and a buffet right smack in the most critical part of viral clearance. I had also stopped the VX950 and cut back on ribavirin during this period of time too. And yet I have remained UND since week 2 of treatment all the way up to my week 6 post tx. With any luck my 12 week pcr will be negative too (go in for that next week). Anyway, as you can see even for someone knee deep in treatment, large amounts of prednisone/solumedrol does not necessarily portend rebound or relapse.

[mikesimon]

I agree that almost every thing you said. When you said: "and the reason that may be true is simply because the virus has been effectively and permanently ERADICATED" I think you may have gone just a bit too far. The word "eradicated" suggests absolute elimination of every HCV virion and I do not believe that has been conclusively proven. I don't personally believe that 100% eradication occurs with all SVRs...or maybe even most. But, I do believe that SVR has been shown to be durable for at least as long as we have been watching SVRs. -What would the longest be - 20 years maybe? And I agree that low to moderate dosed steroids do not present a quantifiable risk. So basically we agree on everything but "complete eradication" and I will confess that I have used the term often before I had reason to question the notion.  Mike

[mremeet]

I think you may have slightly misinterpreted my statement as quoted above. I said "and the reason that may be true is simply because the virus has been effectively and permanently ERADICATED." In other words, "and the reason that MAY [emphasis added] be true is simply because the virus has been EFFECTIVELY [emphasis added] and permanently ERADICATED."  By "may" I wasn't suggesting it was an incontrovertible slam dunk (especially considering the remaining content and context of my previous message which contains qualifications concerning the ambiguity on the subject), it's just a possibility (and a strong one in my view). And by "effectively" I meant that even if the virus does persist in some manner, shape or form in long term SVR's, effectively it's behaving as if it's been eradicated.

[Whrose]

very well said.
i had multiple corticosteroid joint injections during IFN/riba tx. this was followed by low dose prednisone for arthropathy. i had held svr status 8 months post. still waiting for 'the year'. i also know a friend who developed pulmonary sarcoidosis after 12 months SOC(geno1) and took high dose prednisone EOT and reached SVR.
i am now on TNF inhibitors which are warned to exacerbate dormant infections including HBV and TB.  i gave much thought to this course of treatment due to the occult studies. i know of one friend also on TNF meds and has held her SVR status. my liver doc said they will not effect my SVR. pharm co also states there is no evidence for reactivation of HCV. rheumy says he doesn't know.
my point is this. if occult strands of HCV is present and replicating then by this theory i may see a reactivation of HCV or at the least occult infection.  i plan on close monitoring my SVR status and will ask for the value of testing for occult HCV presence.
perhaps others on immunosuppressive therapies especially our liver transplant recipients will come and share their insights.

[Whrose]

read your comments again about prednisone and although this med has many sides i am not aware that it increases fibrosis, due to its anti-inflammatory effect. this i will research evidence for. do you recall articles that support this statement?

[Whrose]

my last comment should read "i am not aware that it(prednisone) increases fibrosis, from my understanding it actually reduces fibrosis by its anti-inflammatory effects." i understand you were uncertain of your statement, but would cause you to search for evidence to support this because i can not find any that does.

[GrandmaA]

A friend of mine who had Lupus and HCV became undeteable with INF/RIBA but then her other doctor gave her prednisone and the HCV came back and she had to treat again. SHer liver specialist told her she can never take prednisone.

[mremeet]

My statement about prednisone possibly exacerbating or accelerating fibrogenesis only applied to people who are actively infected with HCV, not for SVR's. The reason this might be is because it increases viral loads and viral activity. But like I said, I don''t have a study offhand to reference that proves that the increased viral activity corresponds directly to an increased rate of fibrosis (although one might exist alread). I just think one infers the other, and also mentioned what happened to Kalio as an anecdotal example of how this might have happened. On the other hand, prednisone can definitely be used to prevent and perhaps even reverse fibrosis in those with autoimmune hepatitis (AIH).

[desrt]

A year or so ago I had concerns about my family doc's practice of giving me the occasional bump of cortisone for pain or pneumonia. The only documented case I know of someone regaining a viral load after being undetected for several years was someone who had been given a massive dose of coticosteroids. (This person later became undetected again and I believe they also may have had some questionable earlier undetected results.) It was mikesimon who pointed out this case involved a 'bolus' dosing of steroids, something most of us never see under normal circumstances.
Thanks again to mike for this information. If I ever again truly need to use steroids, I'll do so feeling much easier about it.

[jmjm530]

All studies seem to suggest that SVR is extremely durable. If your worry is that Prednisone is going to bring the virus back, I'd venture that most authorities would tell you to stop worrying.

-- Jim

[wyntre9]

I was on prednisone for 3 to 5 years when allergies and asthma were out of control.

When i finally started allergy injections most of the problems went away.

I've seen pics of myself while i was on prednisone and it wasn't a pretty sight - moon face, swelling, puffiness, weight gain.

I've often wondered if all that time on prednisone either exacerbated or sped up the hep-c.

The last time i was on it for an extended period was between 1993 t0 1996.

oh, and btw, the riba rage is very similar to the roid rage i used to get from the pred.

wyntre

ps - i've also read you should try to avoid steroid while on TX but sometimes there's no other solution....

very

[meki]

"From memory, I think Kalio was taking prednisone or some other steroidal medication for a prolonged period time before knowing that she had HCV. Also, I don't think she was an alcoholic or a big drinker and yet she ended up with cirrhosis. So it appears as if the prednisone had accelerated her HCV disease process"

Thank you for that... It makes a lot of sense...

I was just commenting in another thread - prior to HCV DX - they thought I had cancer (due to massive symptoms and signs) - and determined I had an enlarged liver, blah blah blah ---- but still did not recognize the HCV.

I'm geno 3a - and believe to have had it only 10 - 11 years. I have damage to the liver that does not make sense to me --- when I hear of people who have had the disease for 20 and 30 years not having any symptoms other than tiredness... And having very small amounts of liver damage after that amount of time.

I do realize however, that each person reacts differently based on genetics.

But I didn't drink very much throughout my life (just never liked the hangover feeling - so it was once in awhile --- not a party girl)  - I did take prednisone every allergy year when asthma got bad...

So thank you for that info.

I won't freak out --- I suppose now - what will be will be.

Wyn: "I've seen pics of myself while i was on prednisone and it wasn't a pretty sight - moon face, swelling, puffiness, weight gain. "

LOL - yeah - me too... me too. sigh... especially the moon face.... LOL!

[MrsOckert]

Sorry for taking so long to get here.  I don't come as often as I used to.

I read a study from Spain that suggested prednisone was responsible for Hep C relapse in a patient that was SVR for 8 years.  3 weeks after ending TX I was prescribed prednisone for my lung problems.  I WAS very concerned about taking it, but what do you do?  Keep the SVR and die from lack of breath?  

Sure enough at my 6 month PCR I was a relapser.  Tried to get PCR sooner, but doc refused, he was a "this is the way it's done" doc.  Wouldn't go outside the box.

Everyone I know (granted not a lot) that has taken prednisone (or some form of it) has relapsed.

[mremeet]

When you say "Everyone I know (granted not a lot) that has taken prednisone (or some form of it) has relapsed." What do you mean by that? And when you describe yourself as relapsing (and apparently lay it at the feet of prednisone), can you describe the sequence of events (i.e. the timetable) that preceded that relapse? SVR is usually only inferred/confirmed at the 6 month post tx UND PCR. So how do you know the prednisone caused your relapse if you took it prior to reaching the accepted threshold of 3-6 month for SVR?

[meki]

Mrs. Ockert - I would love any details you could provide.

I'm currently using albuterol daily (x3 - dependent on reaction of allergies and pollens - much less like 3x weekly during winter) I also take daily 10mg  Singualair tablet and inhale Advair diskus 1x nightly 250.

So I'm doing ok right now -- but those are steroidal compounds (correct?).

And I've had a few days where it was close... I had to tap up on the benedryl and keep myself on them for a full week... (Let's just say - brain fog and benedryl do not go hand in hand... It's like walking around with a waterballoon head... LOL!)

So --- I'm concerned about needing the Prednisone --- I stayed off it, so far..

AND --- let's add on top of that, I have a "cracking" (like when you crack your knuckles) in the rib cage sternum area, that has been suggested for corticosteroid shots.

I'd really like to get some personal info - before I just go for it on the docs whim...

I'm learning that it's important to ask others before jumping head first into things --- because perhaps... we as a conglomerate have much more information combined - than they do singularly.

LOL!

I'm learning...

So - please - if you have anything --- details --- and thoughts --- or just opinions - I'll take them.

Meki

[Whrose]

i usually do not rebut others important information and or experiences but after many visits here i have come to appreciate your loving sense of humor and wonderful support you give to others and i can see Mrs Ockert's statements have worried you.

i disagree with her suggestion that prednisone caused relapse in the people she knows. i do not put down her experiences but do not believe this as a fact.  it does not make sense to me due to the many people who have taken this med and reached SVR and held it. if prednisone caused relapse as she describes, my goodness it would be BIG LITERATURE listed as a contraindication for those with hcv and SVR. the truth is it is not contraindicated.

i too had alot of anxiety when i took it during tx and after SVR. i am still on it, and although i look forward to coming off it have really benefited the therapeutic effects.

please ask your liver doc HIS opinion as he is the medical expert on this and is responsible for the good advice he gives to you.  use your wonderful sense to not take extreme examples of inconclusive literature as the truth.
hugs

also MrsO.....please do forgive my contrary opinion. i wish you the best!

[desrt]

First of all, I don't think any of those things you listed are actually steroids - they are all the next generation, non-steroidal alternatives. Second, if you read my post above, the person I referred to is the only known case *maybe*, it was a life threatening situation involving an IV dose of steroids many times larger than most people will see over the course of a lifetime adminstered all at once, and the person later became undetectable again.
One case out of probably tens of thousands.
Maybe.

I'm not a big fan of steroids but pneumonia or severe inflamation (inflammation) is even less desirable.

[meki]

Cool - thanks you two! Very much --- I'm not horribly freaked out about it... But I am kinda holding back now --- afraid to take anything that might take away the SVR!

OK- maybe not afraid - but kind of very cautious.

Thank you ALL for every piece of info and opinion you've given.

Meki