Tx for Transplant Pt

I was wondering if anyone could tell me if the HCV tx dosage for a transplant patient is usually the same as everyone else.  The reason I am asking is, I treated 2 years ago, SVR (yeah)....however, my brother who is a transplant patient is going through treatment now.  He is 200 pounds and has only been on 600mg Riba until today which is the 8th week when the doctor told him to go to 800mg.  His peg has been 135; the doctor did NOT increase this.  His viral count started at 21 million and is now 9 million.  He wants to get rid of this virus but at the low dose we are both wondering if that's possible.  Any thoughts????

We are both Geno 1A.  His transplant was 18 months ago and he is already at stage 2, maybe 3.

[BThompson4]

I just completed 72 weeks of treatment as a geno 1a and 210 lbs starting weight, viral load unknown except that it was greater than 3.5 million pre treatment.  Did 150 mcg peg intron and 1200 mg riba.  Apparently, the sides can be worse post-transplant.  Your brother's dosage seems low.  It took me 22 weeks to become undetectable; I doubt with your brother's dosages that I ever would have been undetectable.  His viral load drop is not nearly great enough if it is an eight-week drop.  I assume he is seeing a transplant center hepatologist?

[kcmike]

Hi, I was transplanted in 1-05'.  I completed tx in september of this year.  I to started at 600mg of riba but only for weeks 1 & 2, that was the protocol of the clinical trial.  Week 3 it was increased to 800mg and stayed there throughout tx.  I weighed 140lbs and my riba was weight based (about 12mg p/k).  I would think 1200mg would be your brothers weight based dose.  Perhaps he is having some trouble with his hgb.  If it is his hgb, is he taking a form of epogen?  The 135mcg of peg sounds like weight based peg-intron according to my math.  

There are 8 or more post-tp patients who post on this forum who will all probably have the same opinion.  Up that Riba now!  If your brother is to have a two log drop by week 12, he will need alot of help.  Good news though he is responding.  He may if he doesn't reach UND by 12 weeks have to extend tx.  Let us know why the doc has him at such a low dose of riba if you can.

kcmike

[kcmike]

Hi BThompson, how the heck r' ya doin?  Congratulations on pulling the complete course of 72.  I'm 11 weeks post of my 48 week sentence.  Doin fine and enjoying life, damn even work feels good!  

kcmike

[seabean]

Thank you for responding.  My brother is treating with his transplant doctors.  Yesterday the dr. said he was not really up on treatment of HCV, he was a surgeon.  

I don't know why the doctor has him on such a low dose.  Every time he goes to the dr., he says he forgets to ask the doctor.  We live in different cities, so we usually keep in touch by phone.  After yesterday's phone call and update on doctor's visit, I was really p*ssed off.  What is this dr. doing.......why bother taking the medication at all, if it's not the right dose to become UND.  I told my brother that he was never going to reach UND at 12 weeks and he said he was raising his dosage on his own, but did not know what strength.

His hgb is low, but the dr. said it wasn't too bad.  My concern for Dave (brother) raising his meds was harming his transplant.  But, if you weighed 140lbs. and took 1200mg of Riba, then I don't think he will have any problems with it.

What is the recommended dose of Pegasys for 200 pounds?

Thanks again.
Judi

[mikesimon]

I too am a transplant recipient - June 2000. I am SVR since June 2004. I have seen a lot of transplants treated with low dose ribavirin and or interferon and especially at the start of treatment. I am in agreement with the opinion that his ribavirin dose is likely too low to be effective. I think there is a general reluctance to treat us transplants with full doses because of tolerability issues and the risk of cytopenia.

From: http://www.medscape.com/viewarticle/560940_1
"The major reason for dose reductions is cytopenia, seen both at baseline in many transplant patients and as a direct result of therapy. Use of growth factors to prevent this problem is not uncommon. Another problem in the transplant patient is renal insufficiency, limiting the use of ribavirin on account of its associated risk of hemolytic anemia."

Though it is a difficult road he's facing, it can be done and I wish him the best of luck.

Mike

[jmjm530]

I defer to Mike on any transplant related issues, but will say that his viral response is insignificant at week 8. Using non-transplants as a guage, unless something is changed soon, I doubt he will have much chance of an SVR. Given his weight, as a non-transplant he would be on full dose Peg and 1200-1400 mg/day or ribavirin.

[mikesimon]

I know you've seen the articles on ribavirin plasma levels in renal compromised patients and this can be a post transplant issue and especially with Prograf, which is nephrotoxic. So there might be a higher ribavirin level than we would expect by looking at dosage alone. I too suspect that his dose is not adequate but, I am never absolutely sure about that in a patient where renal insufficiency might be an issue. Mike

[jmjm530]

Yes, lots of concerns and complexities. It's unfortunate that his brother is treating with someone who is admittedly "not really up on treatment". Maybe it's time to get an outside consult with a doctor who is up on tx protocols and has some experience with transplant recepients. I assume you're referring to the "Lindahl" articles on dosing ribavirin based on renal function, and that potentially would be critical. Too bad we don't have riba serum testing (HPLC) in this country, but a good clinician should be able to have some idea of an optimal riba dose by first measuring renal function and then watching the hgb curve very carefully. Doesn't seem that is what's happening at all.

-- Jim

[seabean]

Thank you very much for your responses.  I will give him your replies and advise that he seek out another opinion.  I have read your threads many times and felt that you would know as much as anyone.  I just hate to see him treating if it's not enough to become SVR.

Thanks again.  Happy Holidays to all!!!

[mikesimon]

My surgeon treated me and I believe he knows as much about HCV and treatment as do the "experts" whose articles and studies I read. So, I would be troubled a little  because, if he isn't up on HCV treatment, I would hope that they have a hepatology department associated with their transplant center where presumably they would have doctors who are up on HCV treatment. My center has a large hepatology department but I stayed with my surgeon because I respect his knowledge tremendously and he was already heavily invested in my success. And additionally, I told him I would send him fruit every month for the rest of my life. I just ordered his 2008 fruit supply so he'll know that I'm still breathing - I wrote that on the card just to be sure. I recommend fruit very highly for these types of gifts, by the way.
Mike