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Uncaring nurse practitioner

I had a battle with my husbands nurse practitioner.  He is very anemic and she does not want to deal with it.  He sleeps 16 hours a day.  We have yet to see a Dr.  Hep C was found by his primary Dr when he had his yearly physical he tested him without his knowledge.  We have no idea why but are glad he did.  My husband is 65 and on Medicare.  His Dr sent him to a gastrologist who said he needed an infectious disease Dr .  We only have 2 groups of Dr's in our town.  So we have only seen the nurse practitioner and never the Dr.  It is like pulling nail to get a copy of his blood tests and even worst to find out his viral load.  After asking her the results  today she told us he was not tested 2 weeks ago.  I informed her he was and she argued with me and finally whispered undetectable I asked her for a copy of the labs and she said I would have to get it from the nurse. This is very hard for me.  My husband is a fit hard working man.  We have been married for 46 years and I have never seen him like this.  He was told to take over the counter iron.  His stomach is already upset and hurting.  It seemed like when we were on insurance from his work we got treated a lot better.  When we went to Medicare it is like we have a label cheap pay or something.
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Avatar universal
Great points. I agree with can-do, this particular APRN is not knowledgeable if she is prescribing iron for anemia due to Hep C meds. In addition to being an older guy, if his hgb was high to start with, say 14, a drop to 10.1 could produce symptoms of anemia w/o technically being anemic, and iron is the wrong advice.
Adv
Helpful - 0
Avatar universal
    Because your husbands HGB has had a drop, it does produce fatigue.  As time goes by, usually our bodies adjust to the lower HGB somewhat.  Also, your husband is an older guy.
   The fact that he isn't out running around, is actually safer, fro his heart health, etc. After he is finished with these meds, his hgb will go back up, and he will get his energy back again. Have hime hang in there, and just keep careful watch,.
   Also, I have no idea why they think he contracted the Hep C recently,
or why his Doctor tested him, without even mentioning it...it seems strange indeed.  Most people that havent had a history of I.V, drug abuse, contracted Hep C from surgical procedures before 1992, because the medical profession didn't know about it before then, so didn't sterilize the surgical intruments properly, to avoid cross contamination.
   You should write down some questions to ask his Dr, one of them being "why do you think he contracted Hep C recently?"
Helpful - 0
Avatar universal
One thing for sure is this NP is not up to speed on treating Hep-C, having him take Iron pills for his anemia is wrong and can be dangerous... That alone tells me they need somebody else over seeing his treatment. He is not anemic because of iron deficiency but that seems to be how she is treating him.

Treatment
There are two approaches for treating hemolytic anemia: ribavirin dose reduction and use of a growth factor hormone (erythropoietin) to promote red blood cell production. (It should be noted that HCV treatment-induced hemolytic anemia cannot be treated by eating iron rich foods or taking iron supplements.)
----------------------------------
What is iron deficiency anemia?
Iron deficiency anemia occurs when your body doesn't have enough iron.

What causes iron deficiency anemia?
Iron deficiency anemia is caused by low levels of iron in the body. You might have low iron levels because you:

Have heavy menstrual bleeding.
Are not getting enough iron in food. This can happen in people who need a lot of iron, such as small children, teens, and pregnant women.
Have bleeding inside your body. This bleeding may be caused by problems such as ulcers, hemorrhoids, or cancer. This bleeding can also happen with regular aspirin use. Bleeding inside the body is the most common cause of iron deficiency anemia in men and in women after menopause.
Cannot absorb iron well in your body. This problem may occur if you have celiac disease or if you have had part of your stomach or small intestine removed.
-----------------------------------------
Asle brings up some good points about depression. That could very well be a problem he is having and should be looked at.  

Helpful - 0
Avatar universal
Actually, that can vary widely from state to state and from practice to practice. Because of the advanced practice training at APRN'S are required to receive and because they can and do specialize in areas (e.g. Hepatology), some APRN's practice in physicians' practices, but some practice individually. Their licensure and certifications allow for either and they are regulated by their own board. Specific regulations are determined by state boards and may vary significantly from one state to another.
Regardless, it is important for the OP's husband to advocate for his health by finding out his stage of liver damage, requesting the results of his 4 wk PCR, and receive proper management of his side effects and treatment for his Hep C, whether it's with a M.D. or with an A.P.R.N.
Advocate1955
Helpful - 0
2059648 tn?1439766665
As advocate 1955 stated - advanced practice registered nurse/nurse practitioners  work under the supervision of a doctor.  Let the doctor know you are having problems with the A.P.R.N./N.P.  I'm sure your not the only one.  Clearly, the A.P.R.N. is lacking professional conduct.  



Helpful - 0
Avatar universal
I think it's important to note that Nurse Practitioners do go through a significant amount of training and rigorous coursework, they earn a license to practice within a specific scope, and they are certified to diagnose, order tests, interpret results, treat, and prescribe. Many have advanced degrees as well: B.S., M.S. and higher. My husband's hepatologist sees him twice a year, between Hep C treatments, to monitor the state of his liver or to make recommendations regarding new treatments, but it is her A.P.R.N. (N.P.) who directly manages his Hep C treatment, makes adjustments to treatment, makes decisions about treatment, and prescribes meds related to treatment and managing side effects. She's knowledgeable, practices within the scope of her specialized training, and is highly responsive to us and invested in and committed to my husband's care during his 3 treatments. Of course we can see his hepatologist any time we wish, but based on 6 yrs of direct care by her N.P. during treatment, there has never been a need. A N.P. is qualified to manage Hep C treatment if they have been properly trained to do so. My concern in your case is not the N.P., it is the training and supervision she/he has received and is receiving within the hepatologist's practice. If, however, he/she is a R.N., and not an A.P.R.N., then he/she was practicing medicine without the proper licensure by making those statements.
I would try to switch to another hepatologist who supervises and is better aware of the training of his/her A.P.R.N.s.
As has already been stated, the hgb is fine, but should be monitored more frequently since he is approaching mild anemia. Fatigue and sleepiness is an expected side effect as well. If you think he might be experiencing depression or anxiety, that should be reported and treated.
Advocate1955
Helpful - 0
4950316 tn?1394184585
I notice your husband is sleeping 16 hours a day, and is not interested in dealing with things.
Has he had a history of depression? These medications can aggrevate negative thinking and depression. And it is imperative to deal with this. Not only do the meds knock you around physically, which can make you depressed, but a past history is also a sign to watch for this. An urgent referral to a psychologist through your liver team may be required.
I notice that you are not being supported by your medical team. As others have mentioned, even having to travel a few hours for proper care is worth it.
Please keep coming back with any concerns and changes to your situation. we are here to help where we can.
Helpful - 0
4113881 tn?1415850276
"A recent study suggests that patients infected with genotype 3 who have cirrhosis are 10 times more likely to relapse following treatment with conventional or peginterferon plus RBV than those without cirrhosis [57], a finding consistent with the results from the trial by Hadziyannis et al. and described below. If data from cirrhotic patients infected with HCV genotype 1 are extrapolated to those with other genotypes, it is likely that longer treatment duration may be beneficial in reducing relapse in genotype 2 and 3 patients with cirrhosis. However, this remains to be established in prospective clinical studies."

Optimizing response by reducing relapse rates in patients with HCV genotypes 2 and 3

There is evidence that patients with HCV genotype 2 or 3 and higher baseline viral load have lower rates of SVR and higher relapse rates after 24 weeks of treatment than those with lower HCV RNA baseline levels [55], and that, in patients without RVR, the lowest rates of relapse are obtained with 48 weeks of treatment and a higher RBV dose [11]. Whether increasing treatment duration would help reduce relapse rates in patients with high baseline viral load requires further evaluation.

Although patients with genotypes 2 and 3 are generally considered to respond similarly to treatment, there is also some evidence to suggest that genotype 3 patients have lower SVR rates and subsequently higher relapse rates than genotype 2 patients [32]. An analysis of data from the WIN-R trial of peginterferon alfa-2b also demonstrated higher SVR rates and lower relapse rates in genotype 2 infected patients compared with genotype 3 (72%vs 63%, and 5%vs 10%, respectively) [56]. It is possible that genotype 3-infected patients would benefit from longer treatment duration and/or higher RBV dose compared with genotype 2-infected patients; however current data supporting this comes predominantly from retrospective analyses and requires evaluation in prospective clinical trials.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759987/
Helpful - 0
4113881 tn?1415850276
Hello,

I went back and re-read your old thread that you posted a week ago.

http://www.medhelp.org/posts/Hepatitis-C/Husbands-rx/show/1966509#post_9230315

Your husbands lab values seem to be normal for someone on treatment. I know its alarming at first glance but almost everybody on treatment had or has lab values similar or even lower.

You didnt post your husbands HGB last time but I will tell you my HGB was the same as your husbands even 1 month post treatment with no intervention. This seems to be normal although it does seem your husbands care is sub-standard to say the least.

His PLT raised from 103 to 123 and his WBC  went from 2.5 to 2.2 All these values will fluctuate during treatment. It is important to be under the care of a doctor that actually treats patients with HVC...not a doc who just did the required training but one who is actively treating the disease. You said there are no Hepatologists in your town and the Gastro referred you to the ID doc. I know your husband is in the middle of treatment but if possible, research doc in neighboring towns to find one experienced in HCV. I popsted an excerpt in your last thread regarding ID docs. I will copy and paste it again in the event you didnt read it:

Here's an excerpt from "Hepatitis and Liver Disease" by: Dr. Melissa Palmer

"During the course of their two years of training in infectious diseases, some infectious disease specialist have little exposure to patients with viral hepatitis. On the other hand, some infectious disease specialists receive a great deal of exposure to patients with viral hepatitis during the course of there specialty training. Thus, the level of expertise among infectious disease specialist in diagnosing and treating viral hepatitis varies greatly."

Its important to get appropriate care because in many cases when the lab values get to low, in inexperienced doctor will stop treatment rather then utilize rescue meds like Procrit or Neupogen. You dont want to find yourself in that position. Like I said in the other thread, I treated with an Infectious Disease doc and found myself in a similar scenario needless to say my doc at least was open to my suggestions and was available when need be. It sounds like your doc is very hard to contact which is very bad. Even on medicare you can see another doc with a second opinion. You may have to get a referral from your PCP but if you do the leg work and find a decent doc, it shouldn't be to hard.

There are many things wrong with your husbands situation. He is a genotype 3 who have very high relapse rates. Knowing the condition of his liver BEFORE treating is very important and can act as a predictor to his response. Based on age, liver condition, IL28B genotype, RVR status etc...your husband may benefit from a longer treatment duration OR even waiting for the new medications to come out.

Basically, without overwhelming you...please do whatever possible to find a new doc that is actually treating patients with Hep C. Additionally, it would be wise to ask your NP for a FibroSure test. (If you can get it while treating) It is a blood test that is supposed to be able to diagnose Fibrosis. Since your husband did not have a biopsy and he cant while treating, this test may be his only option. The test can however be flawed but its better than nothing. Its important to get some idea of his livers condition.

Also, if I read correct, your husband was UND at 4 weeks? This is very good. He has a very good chance of curing the disease if this is so.
Keep fighting for your husbands care and read as much as you can about HCV so you can make informed decisions regarding his treatment.
Helpful - 0
2059648 tn?1439766665
Ok!  The Nurse Practitioner is a Nurse.  Make an appoint to see the doctor.  The doctor is the Nurses supervisor.  Nurses work for doctors.  I have excellent insurance and every now and then you I have had to stop and say I would like to see the doctor now.   I has nothing to do with your ability to pay.
It has a lot to do if you will except a nurse practitioner to see you.  I have had to ask to see the doctor on more than one occasion.  I believe I have maybe 3 or 4 times.  You might have to wait longer to get an appointment.  That usual follows.  But I can tell you...things get down to business after seeing the doctor.  This has happened every time I have asked to see the doctor.  It is the doctor who gives permission for you to obtain copies of your lab work.  It is the doctor who has the final say and it is the doctor who is responsible for telling you the results of your lab work....not the nurse.  You need to see the doctor.

DWBH
Helpful - 0
Avatar universal
Is there a Hepatologist (liver specialist) in your area? Or even if you have to travel a few hours to a city with a teaching hospital.
You need to RUN from where your husband is currently being treated. The 2  things that are alarming are not ever seeing a doctor and the fact they told your husband to take iron. This alone tells me they know nothing about Hep C treatment.
You have taken the first step to being pro-active by posting here. Now it is time to change doctors !
Best of luck
Helpful - 0
766573 tn?1365166466
At the risk of sounding crude, do not let the people at the doctor's office jerk you around like that and make you feel like a nuisance for copies of labs that are your husband's to begin with. If you are supposed to get them from a certain nurse then be sure to obtain her contact info ask is she will fax, email or copy your hubby's labs. It might be a hassle the first few times but ensuring your husband has his labs at the appropriate intervals and reviewing the data is crucial.

I learned so much from the people on here. Yes, your hubby's Hgb is OK now but he is sort of at the threshold where if it continues to decline some type of intervention may be necessary.

Best of luck and let us know how he is doing :)
Helpful - 0
Avatar universal
Can-do is right. I believe that hgb 10.1 is just above the line for anemia in men. Do you know what his hgb was before treatment? Sometimes big guys can really have symptomatic anemia even if they aren't below 10.0, because they nay have started fairly high (like 14.0 or so). Taking iron won't help and may harm. I suggest resting, walk slowly w him so he doesn't fall, and ask for another cbc next week. If he falls under 10.0, Procrit will help as can-do said. But he's not in danger. Fatigue and weakness is to be expected w treatment.
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Avatar universal
Your very welcome, hang in there.........
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Avatar universal
Thank you, I feel better.
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Avatar universal
From the CBC you posted his blood counts are fine, It's his HGB number that one goes by for being anemic. And while his is somewhat low at 10.1 it is far from danger levels. As a matter of fact it is what one would expect during treatment at 10 weeks. She said he was undetected do you know at what week that was?

Being your husband is genotype 3 his odds a very good that he will beat this, I guess they didn't do a biopsy? Normal treatment times for someone that is not cirrhotic would be 24 weeks.

I would suggest they do a CBC at least every 2 weeks and if his HGB falls below 10 you ask that they give him Procrit as taking iron is not going to help and is not good for him...... I am not sure how they can guess that he is newly infected unless he had been tested in the past, and yes there is a unfair stigma with Hep-C and it is wrong.... Stay on their case, demand answers, we have a member here that goes by Actingbrandnew who was also a geno 3 and can guide you along, he knows just about everything there is to know about that genotype....... As for now your husbands numbers are ok so try not to stress this to much. I will shoot a PM to acting and I am sure he will get in touch here with you...... Just remember everything is going to be fine.
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Avatar universal
He is genotype 3 and has been on the shot and pills 10 weeks.  His anemia is based on his blood tests WBC 2.2  RBC 3.11 HGB 10.1 HCT 30.1 PLT 123 RDW 17.3 MPV 10.1 Bands 0  I am at a loss what to do. We are with a large group of Dr.s and if you see one you cannot just go to another one.  For many years I worked as home health aid and picked up a lot of training from the Hospice nurses. I do not like what I see happening with my husband.  We were told that he probably was newly infected when we started and he has no idea how he contacted.  It seems like you are a dirty dog with Hep C.  I really think the money is not there for medicare patients so you are not given the time or effort.
Helpful - 0
Avatar universal
Your husband is not getting proper care and is very important that he does, it doesn't sound like she knows what she is doing. Viral loads are very important and need to be done at the correct times. When you say he is very anemic what are you basing that on? Another thing is he should NOT be taking iron for this. If he is anemic it is because of the meds and it is important that it is dealt with the proper way.

What genotype is he? And what meds is he on? I cannot stress enough how important that he gets the proper care..... You pay for the blood tests and they have to give them to you, without numbers, how long he's been treating, what genotype and meds it is impossible to answer much.

Once again this is serious stuff and I cannot stress enough how important this is..... Wishing you both the best
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